American College of Physicians: Internal Medicine — Doctors for Adults ®

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Thursday, August 15, 2013

Thoughts for interns and residents

[AUTHOR'S NOTE: Darilyn V. Moyer, MD, FACP, is Vice-Chair for Education in the Department of Medicine at Temple University. She also is the Chair-Elect of the ACP Board of Governors and a good friend. She sent this wonderful piece on respect for house officers.]

The Power of RESPECT (one of my favorite songs of all time)

1. Respect the Power of Words
Perform bloodless surgery with your brain and practice a thorough history and physical. Despite the explosion of medical technology over the past several decades, most diagnoses can still be arrived at with a thorough history and physical. The best doctors use technology to augment, not substitute, for clinical reasoning and judgment.

2. Respect the Inner Voice and Think Out Loud
Being able to articulate the clinical reasoning process for yourself and those around you allows you to think things through and teach everyone on your team. And you know what they say about teaching you never understand principles better than when you have to teach them!

3. Respect High Value Care and Debunk Daily and Labs and Studies
Remember the four questions of test ordering:
How will the test have a real impact in the big picture of care for this patient?
What are the possible side effects of the test including incidentilomas and long term effects of radiation?
Is there a more cost effective strategy?
What does the patient desire? (Please include this important principle in every decision you make every day).

4.Respect the Power of Repetition
Approach everything you do in a standardized, comprehensive methods-based model. Interpret ECGs? Rate, rhythm, axis, intervals, etc. Know the. ABCDEF of CXRs. Perform your physical exam in the same sequence each time to maximize comprehensiveness.

5. Respect the Team in a Critical Situation
Take a deep breath, watch your own heart rate during a code or rapid response and remember the ABCs. Be a great team leader if you are the first and most senior person on the scene. Look to your team members to think things through out loud with you. Your team includes the nurses and the other staff that might have valuable information on the clinical circumstances and changes in patient just prior to the critical situation.

6. Respect Every Member of Patient Care Team Everyday (this includes the patient!)
Speaking of nurses and other important team members, pull them into the room when you are rounding. Get their input and review what you are thinking and how you are figuring it out. When the rest of the staff feels engaged as team members, you will be amazed at how those specimens get collected! As a sidebar, remember that while physicians have years if postgraduate training, nurses only get a few months of postgraduate training. They want to learn too!

7. Respect Drug Allergies
Be meticulous about allergy documentation. What if your now comatose patient labeled as "Penicillin allergic" on presentation (no other details given) is diagnosed with a life-threatening infection for which a beta lactam antibiotic is the only choice? Get the details of allergies and make sure you document newly diagnosed allergies and their manifestations in the medical record (and on the patient's wrist with an allergy bracelet). Remember to report all suspected and adverse reactions to your central pharmacy as well. Heparin- induced thrombocytopenia is sometimes an allergy that "gets lost" in inpatient records.

8. Respect Anticoagulation and Antiplatelet Therapy
Many of the adverse events and near misses with patients involve some combination of these drugs, along with drug-drug interactions that prolong INRs, etc. Pay attention to other drugs and non-prescription agents that have potential to inhibit or augment other drugs the patient is on. Run, don't walk, to evaluate patients on these drugs that complain of HEADACHE or have a drop in hemoglobin! This principle also holds for someone who has thrombocytopenia.

9. Respect and Push Aside Distraction
I have seen many people at the computer ordering tests on one patient when important new information about another patient is brought to their attention. The natural stream of consciousness involves prioritizing the important new information so orders germane to the higher priority go in under the wrong patient. Always check and double check that it's the correct patient before you order!

And the most important rule of all ...

10. Respect and Trust Your Gut
Think the patient looks like they need the unit? They probably do. Apply the same principle for all patients and especially for inpatients not on unit services. When contemplating whether to transfer a floor patient to the unit, think of the as someone newly presenting to the ED. What level of care would you get for the patient? This type of thinking will get you out of the sense of complacency that can develop for non-unit patients and not appreciating their slow spiral downward.

11. Respect and Treat Every Patient the Way You Would Want Yourself and Your Family Members Treated
That principle speaks for itself.

And my final "Respect" mantra is: Stop, think, ask and respect your colleagues' opinions.

The best physicians are not those with encyclopedic medical knowledge but those who know when, how and whom to ask for help. I think I have more" go to" people and question decisions more with each passing year. Older, wiser or both? You decide.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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