I have learned more from my failures than my successes. My current practice is a hybrid of academic and community sites, and I have worked in myriad community hospitals from busy ones to single coverage critical access hospitals. Each has its own challenges and lessons.

Emergency medicine residencies focus heavily on foundational knowledge, procedural competency, and professionalism. But we often learn real life, practical skills during our first years out of residency. I have learned much of this the hard way. Hopefully, they will make your first few years out a little easier.

1. BE EARLY, BE PREPARED, AND INTRODUCE YOURSELF

For your first few shifts at a new facility, introduce yourself to the nurses, consultants, and ancillary staff. If you are single coverage right off the bat, you need to be familiar with your facility’s OB, peds, and difficult airway resuscitation equipment and resources. Ask your charge nurse or medical director to walk you through it. You do not want to be fumbling through the pads or OB equipment during a critical resuscitation.

Arrive early, especially when relieving the overnight physician. Institutional culture varies, but it always goes a long way to relieve your colleagues 15 minutes early.

2. STAY CONFIDENT, BUT HUMBLE

You do not want to brag about your airway or central line skills just to be humbled by a difficult peds airway or angioedema your first shift. Medicine, especially emergency medicine, is a humbling profession. When you do have a challenging angioedema or case, I personally find it helpful to take a couple of breaths. I recently learned the power of fully exhaling instead of the typical “take a deep breath” advice. I now practice this routinely. Remind yourself that you know what to do. You are well prepared for this. Getting anxious will not help. Mind over matter. Lead your room well. Know your contingencies.

If the resuscitation does not go as well as you wanted, learn from it and move on. The past is the past. If you have a difficult outcome, it is helpful to know what risk management support you have at your hospital. Sometimes there is a risk management staff member on call to support you in navigating challenging outcomes, including your immediate documentation.

3. ATTENDING LIFE CAN BE LONELY, SO FIND YOUR COMMUNITY

For those starting a career in a new practice environment, it can be lonely at first while you nurture relationships. Residency sets you up for success from day one, but transitioning into a new job takes courage and time. Give yourself grace.

If you are a new grad, you may not have mentors reach out to you as often as when you were in residency. I felt this my first year out. Now that I mentor residents, I think of my recent grads all the time. I am wishing them well and reminding myself of how I felt in their shoes. However, I do not always check in with them as much as I would like. Reach out to your old mentors. Reach out to your peers, as they are likely facing similar challenges.

When I moved to a new city to start a new job, I thought a support system would form organically (and quickly), similar to residency. I learned that sometimes it takes effort and time to build a community.

4. THINK BEFORE YOU SEND THAT EMAIL, BECAUSE TIME BRINGS CLARITY

I have never regretted waiting to send a heated email. However, I have regretted many angry conversations and emails sent in the emotional flurry of frustration. Maybe you worked an overnight shift with broken equipment and decreased staffing ratios. Before you light up your medical director with a salty email or complain to your colleagues, sleep on it. Time will usually bring clarity to an initial visceral response.

5. YOUR MOOD IS CONTAGIOUS, SO CHECK IN ON YOUR EMOTIONS

The emergency physician sets the tone for the department. If you are grumpy in the department, everyone else will be. If I am returning to work after vacation or a few days off, my emotional battery is at 100 percent. If I am in the middle of a stretch of shifts, I must be aware that I am likely starting depleted. Add on the daily frustrations we all face during ED shifts: the challenging consultant, high volumes, time intensive laceration, etc. We are all human. If you find yourself drained, notice when it is happening and develop your own ritual or mantra to reset. For me, walking outside the ambulance bay for a few breaths of fresh air or walking to brew a coffee is helpful while I reset. You can spend months fostering a good rapport with your ED staff only to ruin it with a few minutes of anger or a harsh word.

6. GIVE YOURSELF TIME BEFORE YOU FORM AN OPINION ABOUT A NEW JOB

When you start somewhere new, give it a fair chance. Give yourself a year at a new place before deciding to move on. Keep an open mind. Try to learn its culture and norms. Don’t be the newbie who constantly refers to “how we did it at my last shop.”

7. DON’T WASTE SUFFERING

We all make mistakes. You will inevitably miss something. When you do, learn from it. Don’t allow yourself to waste that suffering. Learn and move on. You can become a better physician and person from handling failure with grace and a growth mindset.

When I see higher volumes or staff many APP patients, I am more prone to missing small details. My personal practice is that when I find myself seeing higher volumes, I purposely spend a few extra seconds re-reviewing the CBC, BMP, and vitals one last time before discharging.

8. IT’S OKAY TO SAY NO

Early on, it is easy get seduced by the dollar amount of an extra shift and pick up so many shifts that you are working more than you were in residency. Instead of thinking of the extra pay, I now look at extra shifts in terms of what I am trading away my time for. Is it worth it to me to miss dinner with my spouse or not spend time on hobbies that rejuvenate me?

One of the hardest lessons I have had to learn is to say no. Consider your bandwidth before agreeing to a new QI project or committee. Will it bring you joy?

9. FIND YOUR PRACTICE STYLE

I did not staff patients with physician assistants and nurses practitioners during residency, so this was a learning curve for me as a new attending. Working with nurses and physician assistants comes in many flavors. Sometimes you staff all their patients. Sometimes you staff none. Other times you sign all their charts whether you saw the patient or not. I can write an entire paper about the lessons I have learned from staffing NPs and PAs patients and signing their charts. My main lesson is: pay attention to the attestation you are using when signing the physician assistants and nurses practitioners. charts. If something doesn’t feel right, be more thorough, see the patient, ask for more information. Your medical license is undersigning the care. But remember, both you and the NPs and PAs both want the best care for the patient.

10. HAVE FUN, BECAUSE IT IS AN HONOR FOR PEOPLE TO INSTILL THEIR TRUST IN YOU

Remember to have fun! Emergency medicine is what you make of it. Take ownership of your professional identity and who you become over the next 10 years. You have worked hard to enter an honorable career that will challenge you, bring you perspective, and allow you time off and the opportunities to pursue different interests in and outside of medicine. I have never had a boring ED shift or the same shift twice. Stay positive. Enjoy being an attending and physician. Most importantly, be proud of yourself.

“A New Spin” is the personal perspective of the author and does not represent an official position of ACEP Now or ACEP.

Dr. Smith is assistant professor and assistant director of UME, student advising, and mentorship at the department of emergency medicine at Vanderbilt University Medical Center at Vanderbilt Wilson County Hospital.

Dr. Shenvi is an associate professor of emergency medicine and president of the Academy of Educators at the University of North Carolina at Chapel Hill.