Common Sense

A Thick Skin

Issue: March/April 2020

Author: Andy Mayer, MD FAAEM
Editor-in-Chief, Common Sense


An essential skill for the wellness of any emergency physician is the ability to cordially and professionally interact with the doctors in person or on the other end of the phone whom we contact for admissions, consults, and follow-up. This skill is difficult to teach, but is essential for success from both a professional standing and wellness point-of-view. Each hospital staff has difficult and sometimes nasty consultants. Sadly, this is part of the terrain of emergency medicine and each of us needs to develop a path and strategy to be able to interact with the most difficult of consultants.

Like almost all emergency physicians, I enjoy reading Dr. Ed Leap’s column in Emergency Medicine News. I personally think he is able to most closely articulate the trials and tribulations of the average “pit doc” in an entertaining way so that important issues can be reflected upon while still maintaining some humor. His November column, “The 26-Year Intern,” speaks to the issue of our professional interactions with our consultants in his usual insightful and humorous way, and I encourage you to read or reread it and think about what he is saying. Each of us can immediately identify with all of the scenarios he relates in his column. Your own response to each of these scenarios is tempered by the individuals involved and where you are in your emergency medicine career and your own level of wellness.

Personally, I am close to thirty years into my emergency medicine career, but can still easily relate to his 26-year intern idea when I speak to some fellow or new attending on the phone who does not know me and feels entitled to treat me like an intern. We all know attendings who seem to obtain pleasure by torturing the poor ER doc on the phone. What is one to do? Your ability to prevent negative feelings after one of these painful encounters will play a significant role in your ability to have a successful career and is a useful marker for your longevity in emergency medicine.

How should we deal with these sometimes unpleasant, and at times demeaning, interactions? The title of this article reveals many emergency physicians’ main coping mechanism in this regard. A thick skin is a very useful tool. We all realize that many of our consultant’s angry or condescending statements really have nothing to do with us. These doctors are often just inappropriately directing their angry at us as a coping mechanism for their own frustration with what is going on in their own career or personal life. Maybe their dog died or simply the fact that they are a tired middle-aged surgeon with five elective cases in the morning having to come in at 3:00am for a less than pleasant case is simply overwhelming them. Their sleep deprived fog when you wake them up leads them to say things that are inappropriate and simply stupid. We did not ask the uninsured chronic pain patient to present to the ER at 2:00am. We are not responsible for EMTALA, medical staff bylaws, weekend call, or the other myriads of aggravations which can be thrown at a physician who is on their third spouse and facing huge college tuition bills or whatever malfunction is derailing their life. The tired emergency physician seems to them to be a perfect target for their misguided rage.

In these instances, having a “thick skin” is useful if you avoid internalizing this unjustified and misdirected anger. Taking those same negative feelings into your wellness bucket will eventually cause a leak. This of course is easier said than done and does not excuse the physician at the other end of the phone for their behavior. Individuals are responsible for their behavior and we need to do what we reasonably can do to correct this negative and wellness-killing behavior. Whether religious or not, the wisdom of the Serenity Prayer is something to consider.

“Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”

  • Reinhold Niebuhr 


The idea of turning the other cheek, as it were, can certainly become wearisome and I suggest developing other tools to deal with these unpleasant interactions. One of the best tools which I have found is the simple ability to become an actual person to the other members of your medical staff instead of just another unknown ER doc on the other end of the phone. This is certainly a challenge for locum’s doctors who often do not stay long enough at any one location to build these interpersonal relationships. However, for the rest of us, you might consider making positive steps to building relationships even if right out of residency. There is a lot of low-hanging fruit in this regard if you are willing to make even a little effort. Consider taking a few minutes before, during, or after a shift and sitting in the doctor’s lounge, cafeteria, or any location where fellow members of the staff gather to strike up a conversation and get to know some of your consultants. It is much harder for almost everyone to be disrespectful to someone they consider a friend or a colleague instead of a stranger. Consider attending staff parties, staff meetings, medical society meetings, and other social functions and you might discover some of the reasons your consultants seem to be so difficult. These reasons are sometimes that the person is simply unhappy and usually have little to nothing to do with you. Becoming friendly with them can lead to mutual respect and an increased willingness on their part to help you in the emergency department when you need it.

Another technique worth considering is a more direct discussion about these issues with a difficult consultant. A reality check for these difficult souls can be much more productive than you might think. I suggest you try and talk to your difficult consultants about some interaction which you witnessed instead of confronting them in the heat of battle. Taking them on the side when emotions are not high and talking about an interaction in which you were not personally involved more frequently leads, in my experience, to an “Oh, I didn’t realize” response from the difficult doctor. Confronting them when emotions are running high can lead to a throw down instead of a useful outcome. It is certainly more productive in my opinion than sending it to whatever official medical staff “quality improvement” process your hospital has in place. An informal private discussion is more likely to produce a positive collegial response than a possibly punitive process. There are certainly situations when the formal process is vital and the only solution but consider the more collegial approach and you might be surprised. Certainly many of us, particularly more youthful emergency physicians, might consider calling the grizzled old general surgeon on the side to discuss a delicate topic beyond their comfort zone. However, I suggest you try it and might very well be positively surprised with the result. If you just cannot do it, consider asking your medical director or a more senior member of your group to do it for you. Being collegial and right is a quick way for you to earn the respect of the more senior members of your medical staff.

I am a fan of Benjamin Franklin. His autobiography is one of my all-time favorite books. I have tried with varying success to take some of his advice. His tactic of asking an enemy for a favor had baffled me until I tried it. What might seem like a futile approach to improving a difficult professional interaction is now is accepted as the Ben Franklin effect.

Wikipedia explains below:

The Ben Franklin effect is a proposed psychological phenomenon: a person who has already performed a favor for another is more likely to do another favor for the other than if they had received a favor from that person. An explanation for this is cognitive dissonance. People reason that they help others because they like them, even if they do not, because their minds struggle to maintain logical consistency between their actions and perceptions.

You might consider trying this by asking one of the consultants you have the most trouble with for a favor. Of course, this seems hard but I have personally been pleasantly surprised with the results. This could simply be done by asking for their advice or counsel about a case or follow-up about a patient you cared for together. I would suggest going further whether it be advice about a school for your kids, an opinion about a neighborhood, or whatever. This makes your nemesis feel important and makes you a real person in their eyes. Almost certainly, the next time you wake them up, they will be much more polite and helpful. My personal best instance of this was when I asked a difficult general surgeon for help with a school project for my daughter. She and I went to his house and had a great interaction. Every call to him from then on started with him asking about my daughter. I was a person with a family.

I ask you to think about these ideas and the many more which you can use in an effort to improve our professional interactions. Maybe your skin will not need to be as thick. This will make that skin more resilient when the next psych patient calls you names which cannot be mentioned or a surgery resident gives you a totally inappropriate response to a consult. Having a personal relationship with their staff or a hospital administrator or whomever will make the next call much easier.


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