Emergency Physician - Dr. Sonali Meyer

Questions About Speciality:

What percentage of your day is spent doing what?

• 35% direct patient/family interaction, 35% logistics (entering orders, answering questions from nurses/techs/unit coordinators/pharmacy, phone calls to consultants and admitting physicians, looking up patient's history), 20% paperwork (charting, dictating, signing transfer paperwork/informed consent paperwork/holds), 10% miscellaneous (procedures, sedations, answering ambulance calls, taking report from other doctors transferring patients in)

How many hours a week do you work?

• Full time with my company is approximately 31 hours a week, or 16-17 shifts a month plus meeting time and continuing medical education. Some places are a bit more.

Are you on call?

• Never. It's one of the best things about the ER schedule.

Do you work weekends / holidays?

• We work every other weekend and every other holiday. That's one of the worst things about our ER schedule. We also work about 1/4 of our shifts as overnights. Many of our other shifts are late evenings, ending at midnight or later.

Who do you work for? (i.e. self, another provider, a hospital)

• I work for a democratic group of ER physicians in the Twin Cities. We have contracts to staff 5 hospital ER's in the metro, plus at least 2 hospitals farther out of the cities. Our group also owns 3 urgent cares that we run entirely independently. We work with the hospitals whose ERs we staff, but we don't work for them. It's nice to be our own bosses and know that our chosen leaders are always working in our best interest.

What kinds of problems do you deal with?

• Patient problems, staff problems, administrative problems.

• Patient problems: lots of people come to the ER with the wrong expectations. They think we can fix their bronchitis overnight (it can take 4-6 weeks and no medicine will make it better faster, most of the time), they think antibiotics will make their viral cold better, they think narcotic pain medications are the answer to their chronic pain, they have seen two specialists about their problem who haven't been able to fix it and want us to fix it... Managing expectations is a big part of the job, as is patience, and understanding why people come to the ER. Usually, people who are in the ER for a "bad reason" (i.e. Something that's not an emergency) are there because they're afraid of something or have so much stress in their life they can't function. It's easier to deal with patient problems when you figure out the underlying anxiety behind it.

• Staff problems. Sometimes doctors disagree with each other. Sometimes doctors egos get in the way of doing the right thing for the patient. Sometimes a nurse doesn't understand why you want something done or the urgency of the situation. Most of these issues can be resolved with good, direct communication.

• Administrative problems. The job of the administration is to provide safe healthcare at the lowest possible cost. Financial pressures (paying for fewer nursing hours, expecting docs to see more patients per hour, things like that) can lead to some stress and resentment.

What do you do if you do not know something or how to treat a patient?

• I am so glad to work in ERs where there is always someone working with me. I've always got someone to bounce ideas off of or come see a patient I'm not fully sure about. We also have specialty consultants we can call 24 hours a day (cardiology, pediatrics, neurosurgery, etc). We've also got online resources to help us manage and diagnose problems that we're not very familiar with (basically an encyclopedia of health problems, diagnostic criteria, common presentations, complications, treatments, etc) called UpToDate. I can always call someone for help.

What was your residency like?

• Emergency residency programs are either 3 or 4 years. Mine was a 3 year program at Regions Hospital in St. Paul, MN. Most residencies are run out of academic centers (like universities) or large urban/county or community hospitals.

• Residency is hard-- you learn so much so quickly. But it's where all the theoretical learning from medical school is finally getting put into practice, so it all starts to make sense. Intern year is terrifying at first, but everyone gets the hang of it eventually. We got a lot of support from our faculty and fellow residents, so we never felt alone and weren't ever made to feel like we couldn't ask for help. We were also encouraged to take responsibility and ownership of our patients early-- the staff docs or older residents wouldn't just take over if a case was going downhill-- they would help you manage it yourself. The long hours are...long. An 80-85 hour workweek is tough no matter what, but I have never felt more competent than during my 3rd year of residency, managing the entire ICU for 24 hours straight. It's exhausting, but also really satisfying.

Do you think you sacrifice personal life for your profession? How do you balance the two?

• Medical training requires sacrifice. The hours during the 3rd and 4th year of medical school and during residency are so long and inflexible, that you're going to miss stuff. You'll miss some family events and birthdays and holidays and you won't have as much time for your hobbies that you used to. There is always wiggle room, though. If you choose a few priority things in your life, you can still devote time to them (hanging out with my husband, seeing friends, traveling during time off) and make your schedule around the most important things (traveling to visit my brother when he was ill, my dad's 60th birthday, etc). Some things will fall to the wayside for a while (reading for pleasure, playing tennis) but pick up when training is over. During training, though, you need to make sure to tank up your emotional reserves. All work and no play would wear anyone out. You NEED to take care of yourself so that you can take care of your patients-- there needs to be some balance.

• Part of choosing a specialty is not only choosing the subtype of medicine you want to practice, but also the lifestyle that goes with it. Clinic docs like family practice generally work a more regular 9-5 schedule, with holidays off. Surgeons start rounds at the crack of dawn, so they can get into the operating room early in the day. Not my jam.

• If you work in the ER, you have shift work (no carrying a pager or being on call EVER). It's very freeing. You work every other weekend, but get a lot of random free time during the week (good for running errands, traveling cheaply, hanging out with young kids if you have them). You don't have to be at work at 7am (or earlier-eek) every day and work a lot of late hours. The ER schedule gives me balance. I'm a night owl and working 9-5 never really worked for me. I value sleeping in and not having to carry a pager more than I value my weekends and holidays. I've got a lot of time off for traveling and hobbies. It's a trade-off that works for me and the life I want.

What is the best aspect of your specialty?

• The variety and the immediate gratification. Most specialties other than ER and Family Practice are split into pediatrics and adult practices. I still get to see both and I see anything that walks through the door-- no two days are alike. I get to solve the puzzle (what is the diagnosis?) and make a plan to fix it, all within a short period of time. The ER is a microcosm of everything in medicine.

What is your least favorite aspect about your specialty and/or medicine?

• A lot of what comes through the door is non-emergency stuff or vague symptoms with no cause. It's really satisfying to shock someone out of a dangerously fast heart rate, stitch up a big cut, or pop their shoulder back into place (that's the immediate gratification I was talking about). It's less satisfying to diagnose colds, deal with chronic back pain that I can't do much to fix, and do a bunch of tests for a vague problem (like dizziness) and have everything come back normal- and then telling the frustrated patient that there's nothing dangerously wrong with them and you can't fix their problem.

What is needed in your niche? (ie. what personality traits/skills? What specialties?)

• ER work is FAST. You have to be able to assess a patient and make a plan within minutes. If a patient is truly sick, you don't have time to sit and think about what's wrong with them, you only get a few seconds for diagnosis before you have to go about fixing it. Because of this, lots of ER physicians are "adrenaline junkies"-- elite athletes, skydivers, etc. I am NOT that. But I am calm in a crisis and am goal-oriented. I think those might be two biggest things you need to succeed in the ER.

How do you ensure value based care over volume based care.

• Part of working in the ER is dealing with volume. There is no getting around that. In a lot of ER's, your paycheck is at least partially based on the volume of patients you see. But there are different ways of dealing with that. The bottom line is that you always want to do the right thing for the patient.

• I would rather spend 10 minutes explaining to someone that antibiotics don't make a cold better than just prescribing the antibiotics and avoiding the fight, so you can discharge the patient faster and open up the room to see someone else. Sometimes you have to sacrifice volume for value.

• We just changed the flow of our ER to maximize value and volume. Low-acuity patients are seen in "intake" area where they are seen by a doctor as soon as possible and discharged from an internal waiting room after their tests are done. This frees up the actual ER rooms (with beds, heart monitors, etc) for the sicker patients, so they don't end up sitting in the waiting room forever. Everyone gets what they need, faster, and makes sure that the sickest patients get priority for rooms.

General:

Did you always want to be a healthcare provider (doctor/PA, etc.)

• Nope. Both of my parents are doctors. My mom was a 9-5 family practitioner and my dad was an OB-GYN with a private practice, on call 365 days a year/24 hours a day. Neither of those seemed like the lifestyle I wanted.

• I started out in arts administration, working in NYC, but realized that I'm not cut out for forging my way in the world without a path. I wanted a defined path to a stable career. I decided on medicine when I decided to do something that would be helpful in an apocalypse situation: graphic designer? Love it, but no. MBA? Definitely not. Medicine? Yep!

Is being a medical professional exactly like how you imagined it?

• Not exactly. I thought I'd be a clinic doctor because I was never comfortable in hospitals, but I fell in love with the ER. I understand now the frustrations and struggles that my parents always complained about. I'm constantly second guessing myself and feel like I could do better, but then I think back about things I've done-- saving lives! Making an elusive diagnosis! -- and am pretty proud of the skills I have. Also, both my parents were kind of alone in their practices and I am so thankful for the team aspect of the ER.

What are some regrets you have regarding your profession?

• I wouldn't change my specialty for anything. I still think I'm incredibly lucky to have found it and for the life I have. I just wish there were a "sense of accomplishment". With a lot of jobs, at the end of the day you can look back and see tangible evidence of a job well done: a successful show, a magazine put out by the deadline, a court case won, a paper published. In the ER there are always more people to see and as many happy patients as angry ones, so it's hard to remember to take a minute to reflect on the little daily accomplishments.

How would you describe the relationship between science and education to the actual practice of medicine?

• Medicine is science in practice. I was never big into bench research or clinical research. I don't have the patience for it and just want to know the answer right now. It is so great to see all of the hard science (Bernoulli's law! Biochemistry of hemoglobin) put to use every day to make clinical decisions for real people. Medicine is definitely an art, though. While chemistry and biology are generally pretty reliable, human brains and bodies rarely follow the "rules" and the rules are always changing. Research is changing the "rules" of medicine every day. Diagnosis and treatment are a moving target and everyone responds to things differently, so there are lots of gray areas. That's part of what makes it so interesting, though.

What would be the 2-3 best pieces of advice you could give students who are considering a medical career?

• Take some time off between undergrad and medical/PA school. Have some fun. Explore. Get your nose out of books for a while. There's no rush.

• Don't decide what specialty you want to work in before you actually experience it in real time. Have an open mind and you might be surprised at what you like and what suits you.

• Pay attention in anatomy!

What was the med school/PA school curriculum like?

• Med school curriculum is 2 years of book and lab learning, then 2 years of clinical rotations.

• The first semester was 4 hours of lecture every morning and 3-4 hours of anatomy lab every afternoon. In the next 3 semesters, anatomy lab was replaced by clinical observation, microscope labs (pathology, histology), and some other classes. All of these classes are HARD compared to undergrad. They are no joke. And since there are so many smart people in your class, it will seem like other people are just breezing through it (because they are) but feeling in over your head is very normal.

• Clinical rotations go through almost all the specialties, so you can decide what you'd like to do your residency in. There is quite an bit of flexibility in this, but it's usually best to try all the biggest specialties in the first 15 months, and save some of the "fun" ones, subspecialties, and things you KNOW you don't want to do until later in 4th year. Residency applications are due in fall of 4th year, so you should have a pretty good idea of what you want to do by then.

What would you want to see in someone who is joining your practice?

• I want to see residency grads that are humble-- willing to ask questions and admit when they are out of their depth. None of us know everything. We work as a team, and everyone is there to back each other up during the tough cases. There's nothing wrong with not knowing everything all the time!

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