Disclaimer: These are my personal expectations and may not overlap with other attendings. I offer them more as a learning tool to see what an experienced clinician considers good performance.
Work hard:
- Show up on time, don't leave until your work is done or handed off.
- Do what you say you are going to do, update your team when you make changes to the plan.
Take Ownership:
- Act like you are the main doctor taking care of this patient, and that all patient problems are your problems.
Medications:
We are internal medicine, we own the med list, and we are responsible for an accurate list for any of our patients. This responsibility is easy to dodge by simply importing the existing list, and since we often care for patients for whom we did not do the initial med rec, that means assuming the list is wrong until we have checked it ourselves.
- Double check the following home meds against pharmacy records or patient/family report.
- Anticoagulation
- Antiplatelet (clopidogrel)
- Diuretic
- Immunosuppressives
- Any other drug that is critical
Interacting with patients:
- Introduce yourself in terms of your role in the hospital in terms the patient can understand.
"Hello, I'm Dr. Stupple. I know you have seen a lot of doctors. I'm taking over from Dr. _____. I'm your main doctor right now. I'm on a team that includes Dr. _____. You have gastroenterologists and surgeons who are seeing you as well, so there's three teams. My job is to coordinate everyone."
- Be respectful of everyone. Patients that trigger anger and resentment are often the most vulnerable and suffering the most.
- Give them time to feel heard. Letting someone speak uninterrupted until they get out everything they want to say is maybe the most powerful way to communicate compassion.
- Explain to them what is happening and update them when things change. Ex- if you order a CT scan, tell them why it's happening rather than letting the nurse or transportation tech do it.
- Discuss medical issues at a 6th grade level of language and understanding.
- Speak with the healthcare proxy or close family once every day or two.
Nursing and other staff:
- Be respectful. Among other things, control the urge to be dismissive- when nurses are concerned, patient mortality reliably increases.
- Be approachable.
- Respond to pages quickly, regardless who they are from. It's easy to say you respect everyone, but actions speak louder. Responding quickly to pages tells the recipient that you value their concerns. Think how much you appreciate it when someone "important" gets back to you immediately. It's gold.
Workflow:
- Top priority is generally to call consults, then submit orders, talk to patients and families, and finally get notes done.
- Be skeptical of all incoming information. Double check important vitals, confirm history with the patient or close family.
- Don't dismiss incoming information. Treat emergencies and urgencies as such until you know they are resolved.
- Don't delay placing diet orders.
Presenting:
- Start with chief complaint or one-liner to orient the team. (This is an excellent habit because it teaches you to prioritize and summarize.)
- Save the discussion for the assessment/plan, don't editorialize the data.
- On rounds, take a guess at a diagnosis, list alternatives, and look for tests you could do to make things clearer. Don't obsess about trying to get the diagnosis right, just tell us what you're thinking, including "I don't know."
- Master the problem list. Have a problem for each medication the patient is on at home, including meds that are on hold, and each med in the hospital.
Master Level:
- Focus on solving problems for patients, rather than simply getting your job done. Ex- A patient admitted with CHF can be rapidly improved with IV lasix and tempting to discharge. But focusing on their problem of volume overload and frequent admissions, we can diurese them to their dry weight.
- Prioritize items that will impact care, such as delaying diagnosis and treatment or prolonging hospital stay. This requires good medical knowledge as well as....
- Maintain situational Awareness: Outmaneuver the bottlenecks, such as PICC lines and IV access, procedures, consents.
- Extend your plan all the way until discharge. Clarify what conditions need to be met before you will discharge.
- Speak definitively when you are definite about what you are telling them. Avoid using qualifiers like "we might have to do an LP" or "it looks like you might have bacteria in your blood stream."
Personal Extras:
- I avoid maintenance fluids. If a patient needs fluid, I make an estimate of how much and write to give that amount over a period of a few hours. Then I reassess and consider more fluids. Maintenance fluids are hard to know how much they received and can easily be forgotten about over a period of days.
- I never order colace since several RCT's show it doesn't work.
- With exceptions, I rarely alter patient's diet from home because their treatment should be tailored to what they usually eat, not a special in hospital diet.
