Blog | 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.