‘Our job is to rule out the scary’

Early careerist profile: An interview with Joran Sequeira, M.D.

Virginia ACEP recently shadowed Joran Sequeira, M.D. on her Monday evening shift, where we were able to witness an emergency physician at work on one of the busiest days for EDs nationwide. A graduate of New York Medical College, Sequeira completed her Emergency Medicine residency at the University of Virginia in 2016 and today is an attending physician and serves as an assistant director of the Memorial Regional Medical Center emergency department in suburban Hanover County, Va.

Sequeira, along with VACEP member Cameron Olderog, M.D., served in the first class of the 2016-2017 Virginia College of Emergency Physicians Leadership & Advocacy Fellowship, a program designed to develop and groom future emergency medicine leaders with mentoring, organization, education, advocacy, and involvement.

We spoke to Dr. Sequeira to learn more about her first two years as an attending emergency physician, her fellowship and ACEP involvement, and advice to residents on making it through the rigors of medical education.

VACEP: What led you to pursue a career in medicine?

Sequeira: I was always really interested in the way the human body works. I remember taking a high school anatomy course and loving the class; I thought it was interesting how the body naturally fixed itself. And though my parents aren’t doctors, I have some family who are physicians. They would always talk about their cases when we got together during holidays. That piqued my interests from early on. So I took some medical classes in high school and volunteered a lot at nursing homes and in hospitals. I was into geriatrics initially; I went into medical school thinking I was going to go into geriatrics.

At what point during medical school did you decide that emergency medicine was the path you would pursue?

It was pretty late, actually. I remember my first year in, I had printed out a list of all the different specialties. I had actually crossed off emergency medicine – physically crossed it off. I was into geriatrics because I liked that you really got to talk to your patients, build rapport, get to know them. And geriatrics has one of the highest job satisfaction ratings. But I’m kind of a geek when it comes to the science of medicine, and I found that there was a lot of medication management in geriatrics – and that it wasn’t procedurally challenging enough for me, personally. I wanted to be a bit more hands on. But I still do love working with older adults and remain interested in geriatric medicine, which is why I’m part of the ACEP Geriatric Emergency Medicine Section.

In my third-year pediatric rotation, we did a two-week rotation in the pediatric ER. It was so much fun, and I was surprised at how much I actually liked the ER. Then I asked if I could shadow some ER physicians on the adult side. I did, and realized I liked it more than general medicine. The fast pace worked with my personality, and every case you see is different. So I put emergency medicine back on the list. I loved every rotation in medical school and found that with emergency medicine I could do a little bit of everything.

I decided that very late in my third year. And was scrambling for away rotations for my fourth year.

Emergency physicians require knowledge in multiple specialties. What’s it like to have to know a little bit – or even a lot – across so many specialties?

Honestly, I am still learning, every single day. That’s another reason why I love emergency medicine so much is because it is constant learning. It’s a little bit intimidating, for sure. I remember in residency being very overwhelmed. Even when I was studying for boards, I was like, “Oh my, I have to know everything.” While a lot of it is just knowing the common pathologies, you need to detect the true emergencies and know how to act quickly. It’s knowing things like how to manage a difficult intubation or manage the pulseless, unresponsive patient. There are those cases that you still have to look up in the medical literature – medication dosages and rarer pathologies, for example. As long as you know the things that are time sensitive, that’s the key.

A lot of what we do is like trying to solve the puzzle. Sometimes as a hospitalist, you get the patient and you already know what is going on. But we have the luxury – and I honestly think of it as a luxury – to solve the puzzle. It’s fun. That’s why I like it so much. 

In internal medicine, physicians are trying to find out what is going on and what is the most likely cause. Whereas we approach medicine differently: ‘What is the scariest thing that this could be?’ Many times, people don’t understand why we’re ordering all these tests. Truth be told, we do sometimes order way too many tests, but our job is to rule out the scary. So when you hear, for example, that a person presenting with a seemingly GI issue like heartburn has a cardiac history, you still get the EKG and cardiac enzymes. You don’t want to miss a heart attack. So you test and look for more clues.

Residency allows you to gradually step into the role of an attending physician, but is there a moment when you fully recognize your independence to practice without oversight?

It’s definitely gradual. [During residency], supervising attendings do a great job of making you are more and more independent. So you are obviously watched quite closely during your intern year, but by the middle to end of your second year, you are already starting to gain a lot of independence. Then by the third year you are not only handling patients autonomously, you’re also learning how to look at things like patient flow. These are things you might not think are important when you are in residency, but are very much important in the real world. You have to know where the bottlenecks are happening, how you can change it, and make those changes on a whim.

I know flow is a huge issue in EDs, as we saw during our time with you. How are you working to improve patient flow, which translates directly into patient care?

Every ED is working on what can be done to make the flow better. Everything from the minute the patient is registered to the patient getting a bed upstairs. [At our hospital] we started doing a quick huddle, every two hours, in which one dedicated doctor meets up with the charge nurse, and the PAs, to discuss the state of the beds in the ER and upstairs, what’s working and what’s not, and our bottlenecks. We were having issues where we did not have enough beds to put people in – an issue that is happening all over the country. Because of that, we felt we needed to communicate with each other better. Coming out of residency, I didn’t realize how important communication was between all aspects of the ER.

You are on the front lines of many national healthcare discussions – fair pay, mental health, opioids. As an emergency physician, how are some of the healthcare issues that we are seeing across the country playing out at your level?

Lack of access to mental health resources is one that is so upsetting to me. I see people who are desperately trying to get help and just can’t in touch with a psychiatrist or get an appointment to be evaluated until months later. Thus, they are coming to us for help with their anxiety or depression. While we have some training in psychiatry, we are not equipped to start people on anti-depressants and anti-anxiety medications. Several of those are controlled substances and a lot of them can have pretty major side effects. That’s a problem.

Another issue is access to primary care. I have a couple of patients who have told me they have called around and no one is accepting new patients. Or their PCP is no longer taking their insurance. Or to see Pain Management it is $250 out-of-pocket because of changes with insurance companies. That is also frustrating to hear. I think primary care doctors are at their limit of seeing patients every day. The primary care doctors are obviously trying to build rapport and trying to spend time with the patients but then they are forced to race through them because they have too much on their plates.

The opioid crisis is real. Every single provider sees at least one desperate narcotic user during a shift. Our ER worked closely with our ED pharmacist to review the literature and come with alternatives to opioids, and making ordering them user-friendly for the providers. ACEP too has provided resources and also educational sessions at Scientific Assembly to educate providers. In addition to alternatives, we have also improved and updated our addiction and substance abuse resources. We heavily rely on care plans and Case Managers. In a time when drug-seekers are shopping around for opioids, we providers need to be consistent in saying “No.”

Balance billing is another hot topic that ACEP is passionate about, especially in educating the public and lawmakers. I’m still learning all about how parts of a patient’s visit can be in-network and others out-of-network, thus leaving a patient with a hefty bill.  VACEP has many smart people on the board with a variety of interests, including Todd Parker, who you can go to about all things balance billing.

How did you first get involved in ACEP?

I got involved in ACEP during residency. I’m interested in operations and health policy, so I joined just to learn: to find out about what we do on a political and lobbying front for emergency medicine, and learn more about the issues that pertain to our specialty.

I applied to the Virginia ACEP fellowship and ended up being in the first class. It has been a lot of learning and, yes, lots of sitting and listening, but my goodness, it is eye-opening just sitting and listening. Being involved in VACEP, you discover what’s going to happen before it happens. Another thing that I’ve found is that if you aren’t at the table, you truly are on the menu. Our lawmakers make decisions based on what the lobbyists tell them – whether it is patients, activist groups, insurance companies, or medical societies. If you aren’t present to educate lawmakers on why a bill could be dangerous for healthcare or patient safety, life-threatening laws could go into effect. It has been quite a worthwhile experience meeting my district representatives and senators or their legislative aids in Richmond or in D.C.

Tell us about your work in the fellowship, where you are working to create screening guidelines for mental health patients at state hospitals.

It’s still an ongoing project. When mental health patients come in with suicidal ideation, psychosis or mania, and are otherwise young and healthy, we are required by private and state hospitals to order a laundry list of labwork and tests. It makes no sense ordering EKG, Tylenol levels, thyroid function tests, or urinalysis on everybody if their history and physical exam doesn’t dictate it. How much money are we costing the patient and the system? Therefore, I’ve been working with the Virginia Department of Behavioral Health and the Community Services Boards (CSBs) to create medical screening guidelines for the emergency department. Within that, we also wanted to foster communication with the psychiatrist on the other end- there should be open to a discussion. Right now, these guidelines are for state hospitals only, but my hope is that private hospitals will follow suit.

What is your word of advice for someone starting out their residency?

It’s so important to talk it out with your co-residents.  When you have your doubts and emotions validated, you realize you’re not the only one with similar stresses and reservations. Everybody feels like they’re making stupid mistakes, that they shouldn’t be here, and that they are alone in this. Speaking to those in your class and those in years ahead of you can help you cope with those stressors and learn from them.

Joran Sequeira, M.D., is a physician with Emergency Medicine Associates and serves as an Assistant Director of the emergency department at Bon Secours Memorial Regional Medical Center.