A Letter to Graduating EM Residents

By Gus M. Garmel, MD, FACEP, FAAEM, Co-Program Director
Stanford/Kaiser EM Residency Program 

With the current academic year coming to an end, graduation is just around the corner. Senior residents are likely to have many issues to face in the months ahead. In addition to completing their program requirements for board eligibility, those without staff or faculty positions will consider finding a position their top priority. For graduating residents who have accepted a new position, many things need to occur during this transition period from resident to attending physician. Not only is relocating and learning about the new position critical to success, but gaining knowledge that may not have been offered during residency training is essential. Many programs direct conferences for senior residents that tackle these complex issues; others do not. The graduating residents at our program have found this information particularly helpful. There is plenty of time to plan for the future position, as well as to integrate some of these concepts and knowledge skills into practice immediately. If the situation allows, request assistance from faculty at your training program before departing.


The title of the lecture presentation is “On Graduating.” The concepts presented are thoughts and wisdom that have benefited graduating residents who have put them in action. Certainly, differences for varying geographic regions and position competitiveness exist and must be taken into account when considering the information provided.


I. 6 C’s of graduating

  1. Compassion: You can’t have enough of this.
  2. Compulsiveness: It is important to balance this with efficiency.
  3. Caution (conservatism): This is the extra care you should take with difficult disposition decisions.
  4. Conflict resolution: An important skill to possess that many residents do not utilize much during training, but must be successful at in the attending role.
  5. Committees: By joining these, you become indispensable within your institution and are likely to learn more about the operations side of medicine in the process.
  6. Communication: You should always be clear, direct, professional, and never condescending in your interaction with others.


Compassion is not an infinite commodity; spreading compassion, empathy, and concern for others is something that should not be conserved. Remember, you can’t have or demonstrate enough of this.

Compulsiveness is an excellent quality for all Emergency Physicians, especially recent graduates. The ability to balance compulsiveness with efficiency is a skill that may take time to master, but is an important one to work on during the last few months of training.

Caution (conservatism) implies that extra care should be taken when making difficult disposition decisions, especially during your first shifts and first few months. Everyone practicing Emergency Medicine will make errors of judgment and send a patient home who has an adverse outcome; hopefully, this won’t happen to a new physician right after graduating.

Conflict resolution is an incredibly important skill to possess. As residents, it is possible that your supervisors handled the most difficult conflicts. This places new graduates at a distinct disadvantage, because conflicts (and their resolution) between nurses, staff, consultants, patients, family members, administrators, and insurance companies occur daily. Remember that conflict is generally not personal, and should not be considered as such during negotiations. Furthermore, conflict resolution is a difficult skill to teach. Ask an attending who is respected by the staff to share some of his or her experiences (and skills), if possible.

Committees offer new physicians the opportunity to become indispensable within the ED or hospital, as well as the chance to meet physicians from other departments. The time invested despite the inconvenience of coming to the hospital from home for one-hour at 8am or lunchtime is well worth it. Committee requests can be made to the chief or chair of the ED based on your interests, his or her needs, or the schedule. Important committees include the Quality Assurance/Continuing Quality Improvement (QA/CQI), Privileges & Credentialing, Emergency Medical Services (EMS), Clinical Care Guidelines, Constitution & Bylaws, or Medical Staff Social committees. There are a number of other committees to participate in if positions are not open on these. Finally, communication is an integral part of your skill set as a new attending physician.

Communications should be clear, direct, and professional, and never condescending nor demeaning. At all times, demonstrate sensitivity to others by your communication, language, and posture.


II. Areas for growth

  1. Charting and documentation
  2. Billing and coding
  3. Patient and family member satisfaction
  4. Clinical exposures
  5. Dictation
  6. Efficiency and patient movement (flow)
  7. Knowledge: use this time to study for written and oral board examinations
  8. Death-notification skills
  9. Supervision, including providing feedback
  10. Emergency Medicine ethics
  11. Political issues related to healthcare (esp. EM)
  12. Personal (mentorship may be extremely helpful)


Growth may be professional and personal, and will occur rapidly during the first months of your new position. Embrace this growth. Education will not stop simply because graduation has occurred. Consider reading not only Emergency Medicine literature, but “personal growth” literature as well. Books that have been particularly helpful to new graduates are listed at the end of this article. Furthermore, growth can occur with the development or enhancement of skills that may not have been offered during training, such as ultrasound, medical Spanish (or other languages), patient satisfaction, death-notification, Emergency Medicine ethics, time management, patient flow and efficiency, billing/coding, teaching/supervision, political issues, or dictation (if relevant). These areas commonly challenge new physicians, and improving these skills should help new physicians provide better emergency care. Growth is best accomplished with the help of a trusted mentor. There is a wealth of literature clearly describing the benefits of the mentor-mentee relationship, and the importance it has on professional and personal satisfaction.


III. Areas of common concern

  1. We did it this way (“I can’t believe you don’t do it this way too.”)
  2. Wanting to change too much too soon (give things some time)
  3. The honeymoon period is shorter than you think (“I didn’t know…” only lasts a few shifts, if that)
  4. Criticism of others (practice style, consulting patterns, etc., especially of the medical staff, known as the “private” attendings
  5. Schedule inflexibility
  6. Promptness for shifts (arriving late once is remembered far longer than arriving early twenty consecutive times)
  7. Lack of positive attitude (“fun”). This relates to “work wellness.” Don’t be a complainer.
  8. Learning to delegate (get comfortable with doing this, when necessary)

IV. Survival skills

  1. Arrive early and stay late
  2. Help out your colleagues whenever possible
  3. Be nice to as many people as possible (“kindness is contagious”)
  4. Demonstrate appreciation of your staff (not just nurses)
  5. Chart legibly (especially medication orders and discharge instructions)
  6. Meet with the billing company and chief early on for feedback
  7. Take all patient and nurse complaints seriously
  8. Assist patients and staff as often as possible (time-permitting)
  9. Be available to the scheduler for last-minute situations
  10. Make yourself indispensable
  11. Be a team-player
  12. Meet and get to know the (private) attending staff
  13. Attend ALL staff and committee meetings
  14. Malpractice claims and patient complaints happen to everyone. If you get a subpoena, notify your risk manager immediately. Do not discuss the case with your colleagues, as your conversation is not privileged and can be used in court.

V. Life skills

  1. Honor your commitments to family and friends
  2. Respect is only earned (not deserved)
  3. Get a hobby if you don’t have one
  4. Be financially prudent
  5. Hold off on major purchases until you are comfortable with your new position (and they are comfortable with you)
  6. Get professional help with financial planning and taxes
  7. Don’t be distracted while at work (carpet colors, mortgage options, car loans, etc.)
  8. Be aware that EM is a business to administrators (and to some physicians)
  9. Don’t stress over the little things, they happen to everyone


Remember, a career in emergency medicine is a marathon, not a sprint! Enjoy the positive things about our specialty, especially the privilege of providing patient care at the time when people need it most. It is too early in your career to focus on just the negatives of our challenging specialty, especially those you can’t change.

Congratulations on successfully completing training in emergency medicine, and enjoy your careers!

Suggested reading list:

  • Oh, the places you'll go - Dr. Seuss
  • Zen and the art of motorcycle maintenance - Robert Pirsig
  • The Tao of Pooh - Benjamin Hoff
  • Seven habits of highly effective people - Stephen Covey
  • Who moved my cheese? - Spencer Johnson
  • The four agreements - Don Miguel Ruiz
  • The precious present - Spencer Johnson
  • Don't sweat the small stuff - Richard Carlson
  • All I really need to know I learned in kindergarten: Uncommon thoughts on common things - Robert Fulghum
  • Success at life: How to catch and live your dream - Ron Rubin and Stuart Avery Gold
  • Tiger heart, tiger mind: How to empower your dream - Rubin and Gold
  • You can negotiate anything - Herb Cohen
  • The 100 simple secrets of happy people - David Niven