The Role of the Senior Resident

The jump from the first two years of training into the Senior role is really what separates Emergency Medicine from most other specialties. Instead of caring for one patient at a time and just focusing on one problem, an emergency physician must manage the entire department; and simultaneously look out for multiple patients.

Carlo Rosen and Senior Resident, Holly

As an EM-3, this means managing the flow of the department, keeping track of 30 patients at a time instead of 5 to 10, and working with the resource nurse and attending to figure out how to optimize the limited space of the ED and if diversion is needed. Initially, the main challenge, especially in our high acuity, busy ED is to figure out how to track patients - which ones have I seen?; which ones have I received a presentation on from the junior resident?, and which ones have I discussed with the attending?

This of course occurs while EKGs are being thrust in front of you at a rate of several per hour and nurses, attendings, and junior residents are constantly asking you questions and calling you into patients' rooms, not to mention those critically important calls from the Stat Lab. This is really where multi-tasking comes into play, organization is key, and communication skills are critical. All of sudden, you have become the main problem solver for 30 patients, 10 nurses, and 3 junior residents, rather than just having to worry about your own 5 to 10 patients as an EM-2. It would be an interesting study to figure out how many decisions you have to make per hour and how many times there is a distraction that pulls you away from what you are doing. The other quality that is essential for the new senior residents is the art of negotiation and communication. It seems that suddenly, you are the final line of defense when a radiology resident needs clarification on why a CT is being performed, when a patient demands to sign out, or when a consultant doesn't understand why a patient must be physically seen. What we have tried to do with our Senior Resident supervisory role, is simulate for you what the attending job is. The goal is to make the transition to being an attending an easier one, and to actually teach you how to run an ED under the careful mentorship of our 36 outstanding attendings.

The jump to becoming an attending comes with the realization that you are "IT". There is no one standing behind you ready to take over the airway if you miss, do the procedure if you have trouble, remember that dose of medication if you forget, and offer advice about what work-up to perform. This is a major psychological transition. By the time you get there, you have the clinical and procedural skills, and presumably the confidence. Nevertheless, when you are walking from the garage to the ED for a night shift, realizing that you have minimal back up and will have to deal with major cases and problems by yourself, that is when a touch of fear sets in. Once you start the shift, and remember what you have been taught (hearing the attendings' voices in your head) and what you have been through over the past three years, you will thrive on the excitement of running an ED as an attending.