1. Severe acute pain should be treated aggressively, even if you don’t yet know the cause.
2. When you wonder why the patient is here for an apparently inconsequential problem, remember: We are in the reassurance business.
3. Often the parent’s anxiety is worse than the child’s illness. Direct your care accordingly.
4. Do not waste the patient’s time.
5. The patient is an autonomous human being who consults the physician but remains free to follow, or ignore, the doctor’s advice and recommendations.
6. It is hard to make an asymptomatic patient feel better.
7. Schizophrenics are not immortal; even these patients sometimes have serious physical illnesses.
8. The emergency department staff is perceived as all-knowing and all-powerful, solver of all problems – medical, psychological, social, and otherwise. This is a difficult reputation to sustain. Do your best.
9. If you believe God put you on this Earth to make others’ lives better, welcome to the team. If not, please find another line of work.
10. The patient defines the emergency. The triage nurse knows that some patients are better at this than others and has to sort them out.
11. Do not order tests that will not influence patient management.
12. If you order a test you shouldn’t have, and get a result you don’t know what to do with, ignore it.
13. Drug company–sponsored studies may produce meaningful results, objectively interpreted, with sound conclusions, but the odds are heavily against it.
14. There is no free lunch: Food and pens change prescribing patterns.
15. Always use the cheapest drug that will do the job safely.
16. When a patient is referred to the ED for what seems to be utter foolishness, it may turn out to be the right decision for the wrong reason.
17. Abdominal pain in the elderly is a catastrophe until proven otherwise; use “beyond a reasonable doubt” as the standard of proof.
18. If you cannot figure out what the patient is worried about, ask that question directly. You cannot assuage the patient’s worst fear if you don’t know what it is.
19. Neither be the first to use a new drug nor the last to discard an old one.
20. Write legibly. If others cannot read it, the time you spent writing it was wasted.
21. It is good to know guidelines issued by prominent organizations. It is better to know evidence-based guidelines. It is best to know the evidence.
22. Agencies like the Joint Commission, in attempts to improve patient care, sometimes create new problems that are worse than the old ones. They must be educated politely but firmly.
23. When families say they want “everything” done, remember: Not everything that can be done should be done. It is your job to know the difference.
24. Admitted patients belong in inpatient units. Their hallway is just as good as our hallway, and we have more patients waiting for a spot in ours.
25. Emergency physicians and nurses are doing God’s work. Obstacles in their path to performing that work must be removed. Anyone who builds such obstacles is the devil’s handmaiden.

Dr. Solomon teaches emergency medicine to residents at Allegheny General Hospital in Pittsburgh. He is a social critic and political pundit and blogs at www.bobsolomon.blogspot.com.