Blog | Friday, August 7, 2015

The attending physician's job as role model

After 35 years functioning as a ward attending, I have had many epiphanies. When I started, my concept of the ward attending physician's job consisted of providing pearls to the learners. My brilliant lists (differential diagnoses) had the ability to overwhelm the learners. They would bask in my reflected glory. I understood the job so poorly.

These are the main points that I believe are essential for our role. As Stephen Covey often quoted, “Begin with the end in mind.” What is the end of ward attending rounds? The only unimportant person here is the ward attending physician. We must first prioritize patient care. Our first job is to make certain that the patient gets the best possible care, including making the correct diagnosis, recommending the best treatments and comforting the patient. We must make certain that the patient understands each day's plan and his/her diagnoses and why we recommend the treatments that we feel are best.

Our second priority is helping our learners grow. We want the third year students to grow into house officers. We want the fourth year students to grow further. We want the interns to master the details of patient care and making most patient care decisions. We want the residents to learn how to help the other learners and at the same time polish their own skills.

So what are the characteristics of the desired role model?
1. As our research has shown, we must first make our thought processes explicit and transferable. All learners with whom I have discussed this issue endorse it strongly. It is not our job to tell the trainees how much potassium to give, but rather to have them figure out the proper dose through understanding the deficit and the replacement constraints. As we have heard so many times, do not give a man a fish, rather teach him how to fish.
2. We must model desirable bedside manner. Too many trainees tell us stories about teaching physicians who do not connect with their patients or do not explain the patient's condition in a manner that the patient can comprehend. How can we expect our trainees to have excellent bedside (or chair side for outpatient encounters) unless we excel in this area? We should discuss the skills of excellent bedside manner with our learners and demonstrate them.
3. We must model comfort. We cannot cure many chronic diseases. We can improve our patients' quality of life. We can work to help the end-of-life process become respectful and less scary. Our words, our body language and our actions all have the potential for helping our patients. We must hone those skills and pass them on to our learners.
4. We must demonstrate excellence in history taking. Too many trainees have not yet mastered this important skill. How can we expect them to do a better job unless we should them how?
5. We must demonstrate physical findings. When we go to the bedside we should examine the patient for relevant findings and then ask the patient's permission to have everyone learn from them. The permission asking shows the patient that we respect them and sends an important message to our learners.
6. We must demonstrate medical humility. We do this in several ways. First, when we are not certain of a fact (drug dosing or duration, utility of a test) we should stop rounds and look up the information. Second, we must call appropriate consultations and make explicit what information we are seeking from the consultant.
7. Last, we should treat all the other members of the health care team with great respect. Too many physicians degrade other hospital workers. We should expect better from ourselves and our trainees.

I am certain that I have left out some important points. I would love to hear your thoughts about this issue. These ideas have grown over the past 15-20 years, often because of comments that learners have made about my role. I wish I had known this in 1980 when I first made ward attending rounds.

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 Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.