• Rob Orman

53. The Five Fears of Scott Weingart

Updated: Aug 30

Scott Weingart is arguably one of the most influential and polarizing physicians on the planet. He is not one to mince words and often comes across as definitive in how he describes his practice of medicine. What people don't realize, he says, is that his clinical care is often guided by fear, not bravado, ego, or machismo. In this episode, Scott breaks down his five fears when it comes to medical practice and thinks that those who seek to follow his advice should take these fears into account before acting.

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Guest Bio: Scott Weingart is an emergency physician who went on to complete fellowships in Trauma, Surgical Critical Care, and ECMO at the Shock Trauma Center in Baltimore. He is currently chief of the Division of Emergency Critical Care at Stony Brook Hospital and a tenured professor of emergency medicine at Stony Brook Medicine. He is best known for his podcast on Resuscitation and ED Critical Care called the EMCrit Podcast; it currently is downloaded > 400,000 times per month. Scott is the author of multiple books including Emergency Medicine Decision Making and the Resuscitation Crisis Manual.

This episode is in support of the I AM ALS. I AM ALS was founded by Brian Wallach and his wife Sandra shortly after his diagnosis at the age of 37. He was given 6 months to live, and now 4 years later he is leading a revolution to find a cure. People often refer to ALS as rare, which is not really so. The lifetime risk is around 1 in 300. Since Lou Gehrig was diagnosed 80 years ago, available treatments have been shown to extend life a mere 3 months. I AM ALS supports research, legislation to fast track therapies, and provides critical resources to patients and caregivers. ALS is relentless, and so are they. The question is no longer if we'll find a cure for ALS, but when. This is an underfunded disease and every little bit makes a difference. We will match donations to I AM ALS up to $5000 -- get started here on our Stimulus Donation Page. And for your daily dose of positivity, follow Brian on Twitter.

We discuss:

The distinction between carrying fear and being afraid [06:50];

  • Good doctors carry fear with them. Those who don’t carry a healthy dose of respect for the risks of their actions can be dangerous.

  • Fear should be your friend. It should be one of many internal voices that you listen to and to which you decide whether you want to regard or ignore.

  • Fear should not be your limiter. “If fear is your primary internal theme, then you're afraid. And that's a problem.”

Delayed sequence intubation (DSI) as an example for how healthy fear can keep things safe in the emergency department [09:30];

  • Link to EMCRIT episode on DSI.

  • People who learn about DSI and misapply it (not appreciating the nuance and risks in an individual scenario) can have adverse outcomes.

“Fear is beneficial. It happens for a reason. Everything we have in our heads is evolutionarily beneficial for the most part. The benefit of fear is it allows you to predict the evil sh*t that's going to happen and avoid it.”

The importance of embracing the idea that sick patients don’t take a joke [13:40];

  • The sicker the patient, the less room you have for error. Be very careful.

Scott’s fear number one: lawyers [15:15];

  • This is a healthy fear as long as you use it the right way. Shared decision-making and good documentation help to keep this fear positive.

  • It’s a bad fear if it prompts you to practice defensive medicine and do things that patients don’t need or want (such as order unnecessary tests or procedures).

  • When you document, be sure to show that you thought of the life-threatening diagnosis and why you did not think it was the cause of the patient’s complaint.

A common fear that Scott does not personally experience: being an imposter [21:00];

  • This is the inner voice that says negative things about your performance and capability of getting the job done.

  • Scott’s mindset has always been to assume that his baseline skill level at anything is zero until there is external calibration. With this cognitive assumption, he has never had an inner voice speaking negatively to him.

  • In emergency medicine there are plenty of opportunities to externally calibrate your skill set (eg. following up on patients to see if your diagnosis was correct or keeping a log of your first-pass intubation success rate).

Fear of Monday morning quarterbacking [28:10];

  • This is a useful fear to have because it allows you to foreshadow what you're going to experience tomorrow and the chance to fix the situation today.

  • While Monday morning quarterbacking can yield strategies for improvement when done in a positive fashion, it can also be done badly and be an opportunity to serve insults.

  • “The fear of Monday morning quarterbacking should drive your documentation more than it drives your practice.” And if you can anticipate what the Monday morning quarterback is going to harp upon, it should drive you to take actions to have the appearance of due diligence.

Fear of procedural complications [33:15];

  • Procedural complications can be prevented by breaking them down into distinct micro skills that can be individually mastered.

  • No matter how adroit one is at procedures, having a certain level of fear of the potential complications is healthy. That fear makes you question whether the procedure is truly necessary, or whether it would be safer done in another setting such as the OR.

  • “This fear has never stopped me from doing something that's indicated, but it has stopped me from doing things that weren't indicated.”

“Many of the safe emergency physicians have a negative inner inner voice. They're fearful of the complications, because they don't think they're good enough. That's somewhat healthy. There's another group that thinks they're the master of everything with no external calibration. Those people are dangerous.”

How Scott Weingart is not a jerk. He’s an acquired taste. [41:35];

Scott’s final fear: a patient dying on his watch [46:55];

  • This fear puts Scott in his flow state. It motivates him to “play a much better game” than he would otherwise.

“This fear of death winning is the most healthy fear of all. It crystallizes everything and makes me think at a different level.”

And more.

Shownotes by Melissa Orman, MD

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