One of the things that’s most important when working in emergency medicine, or any aspect of medicine really, especially if you’re a student, is the level of initiative that you take when caring for patients.

This is the biggest problem that I have with students. If you are an active student out there, I’ve precepted about 50 different students in my career, so I get it. The problem is ubiquitous. It’s very rare that I have a student who doesn’t fall in this trap to some degree. There’s never been a student I thought that was great at this. The only people that are great at this are people who have been in the field for a while.

I want to save you from years of very sluggish growth with a tool called the ‘tell-ask.” What’s a tell-ask John? The tell-ask is a level of initiative that you should take cognitively with every single patient. If you’re a student, use this tool when you go on rotations. Using the tell-ask tool will help you grow 50% faster than your classmates.

The tell-ask goes like this. You tell whoever your supervising doc is or whoever you’re working with exactly what is on your emergency medicine SOAP note. Include your Subjective, Objective, Assessment and Plan.

Writing Emergency Medicine SOAP Notes

Here’s my problem. Lots of students are fantastic with their subjective. They get a really good HPI and they know all the components of the HPI. They have a good objective exam. With students, a lot of the physical exams are more academic, more academic than mine. They have all the little nooks and crannies filled in.

They’re great with subjective and objective, yet they suck at plan. They can’t put it together. You know why they suck at plan? They suck at their assessment and plan because fear is keeping them from using critical thinking in their practice of medicine. They’re afraid of looking stupid. They’re afraid of saying something and having the doc or the PA go, pfft, laugh at you, or think you don’t know what you’re talking about. Way too many providers prefer to live in the safety zone of ignorance rather than go for it.

Ladies and gentlemen, you are allowed to be wrong. You can’t have that fear prevent you from thinking critically and giving it a shot. Way too often I have people give me the subjective and objective, but they don’t really analytically think, so I don’t get an assessment and plan.

I have to stress this to you. If you want to be extraordinary, don’t just give the subjective and objective, give me the assessment and plan using the tell-ask.

Thinking Critically to Deliver the Tell-Ask

Here’s the deal. You give your subjective and objective and then you tell me exactly what you want to do with the patient. Let’s say it’s a head injury. “John, my subjective is blah, blah, blah, blah, blah. My objective is findings is blah, blah, blah, blah. My assessment is head injury mild. My plan is to send them home with head injury instructions. I don’t feel they need a CAT scan.”

That’s beautiful, that’s fantastic. Then I can critically, analytically think it through with you.

I would love a student to say, “John, subjectively I have a 56-year-old diabetic smoker with high cholesterol, who came in really bad indigestion. It came on all the sudden and they’re super sweaty. But it looks really bad. Their physical exam is normal other than their vital signs being up. Their blood pressure’s 180/100. Heart rate’s 110. So my assessment is GERD and my plan is to give them Maalox and send them home. Put them on a PPI. Is that okay?”

I’d go, “No, it’s not okay.” Clearly that’s not okay, but you’re way easier to fix than a student without the ability to use critical thinking in medicine and give me an assessment and plan. I can get you thinking right because I can show you how inaccurate that was.

You’ll see this with the nursing staff. You’ll know a good nurse. It’s not the nurse who calls and says, “Hey, John, Mr. Smith’s got a headache what would you like me to do?” I like the nurse to say, “Mr. Smith has a headache, I’d like to give him 650 of Tylenol. Is that okay?” They’re telling me what they want to do, but then getting my permission at the same time. That’s an advanced thinker.

As an advanced clinician, you have to be an advanced thinker. You have to think critically in healthcare, especially in emergency medicine. Don’t be a wimp. Don’t be afraid to make a mistake. That’s the only way you’ll really grow! Too many people have too much ego invested in what they’re doing because they don’t realize something. Medicine isn’t about me and it isn’t about you. Medicine is about our patients.

Guys, I’m saying this from experience. I’m saying this as a guy who’s a recovered egomaniac. I’m not saying I’m not completely fixed because I still struggle. I can tell you this though. I know that medicine isn’t about me. Medicine has always been about my patients. It’s not about me and it’s not about you.

Being wrong is part of the growth process. If your ego is so fragile that you can’t be wrong, you will struggle. You will struggle tremendously. Your growth will be slow. You’re going to make a lot of mistakes and when you make an ego-based mistake, you will defend it very aggressively.

Again, guys, I’m speaking from experience.

Don’t be afraid to be wrong; as long as you are talking to your doc, you have a safety net. You’re allowed to be wrong. You will learn better, because you won’t make that same mistake. You’ll be more on the ball.

The Five Levels of Tell-Ask

There are five different levels of initiative within the tell-ask tool.

  1. The first level of initiative is go into an emergency room and just sit in a corner, and you sit there until someone tells you to do something. Unfortunately, that’s what some people do. A horrible level of initiative.
  2. The second level is to ask if you can go see a patient. “Hey, can I go see that patient?”
  3. The third level is the tell-ask. You tell your supervisor, “Hey, I’m going to see this patient. Is that okay?” You have to get involved.
  4. The fourth level’s where you just do it, and then seek counsel immediately after.
  5. The fifth level is where you just do it. You just do it and you don’t even seek counsel.

Now, I’ve been a PA for 20 years and I’ve always worked critical access emergency medicine, so that’s really the level I’m used to functioning at. Most advanced practitioners don’t, nothing wrong with that. But the tell-ask has been a very valuable tool for my growth. It’s been very valuable when I’ve worked with students to get them to use critical thinking in their medical practice, beginning with their SOAP notes.

Again, you have to surrender your ego for the betterment of your patient. As a speaker, I realized something. When I have the privilege to share what I’ve learned with others, it’s not about me. It’s about the students. How can I optimally affect them? And I know all the docs, the PAs, the nurse practitioners that we have speaking for us at the Emergency Medicine Institute feel exactly the same way. We’re kindred spirits; our job is to serve without ego.

A really good social media post or podcast encourages a dialogue. The things I’m going to share with you, or guest speakers are going to share with you, are meant to encourage a conversation. Let’s carry this dialogue forward, okay? Let us know how this is working for you, especially if you work emergency medicine or any kind of acute present.

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