Blog | Monday, January 22, 2018

Ward attending notes to my younger self

Finishing my 38th year of internal medicine ward attending, I wish I knew then what I know now. I estimate the equivalence of at least 10 full years of ward attending, I think this meets the magic 10,000 hour number. Hopefully, these notes to myself will help some newly minted ward attendings. The job is quite difficult and multifaceted.
1. Understand the various responsibilities of the ward attending: Help your learners grow; make certain the patients get top notch care; be a good role model for the learners.
2. Stay healthy, both mentally and physically.
3. Never lose your humanity.

What distinguishes ward attending is teaching. While we have a great responsibility to our patients, we also have a great responsibility to our learners' future patients.

This week I did exit interviews and mid-month interviews with two students and three residents. When I do exit interviews, the learners also give me feedback. Over the years many learners appreciate that discussions of patients diagnoses and management include an understanding of why. Knowing why we do what we do is highly valued. Perhaps some examples would help.

A heart failure patient comes in with significantly increased edema. He tells us that the furosemide is not working as well as it previously worked. The discussion that follows should include an understanding of loop diuretic absorption as well as an understanding of diuretic resistance. Therefore, we must know how to diagnose whether the problem is furosemide absorption or loop diuretic resistance. If we do not understand how loop diuretics work and why they might not work, then we may not provide the most efficient solution to the patient. Understanding makes our task much easier.

A patient with COPD comes in dyspneic. Unless we understand the differential diagnosis of worsening dyspnea in a COPD patient, we may treat the patient incorrectly.

A patient comes into the emergency department with confusion. She has a serum sodium of 120. We need to understand why normal saline is an incorrect response. We need to understand hyponatremia causes, and the dangers of overly fast correction.

Internal medicine is very complicated. Our learners want to understand what to do and why. Therefore, as educators we have a responsibility to first learn and then share that learned understanding with our learners.

While doing that, we should show great respect for our learners. Therefore, we must give them graduated responsibility. Our first instinct to patient decision making should be to ask the team what they want to do and why. There are several ways to deliver care to our patients. When possible, let the team make the decisions so that they can grow. The attending's job is to protect the patient, so sometimes we must make the decision. But when we make the decision, we must explain why.

We should respect our learners, especially their time. Make rounds in a defined amount of time. Let the learners have time to do their jobs.

Get to know them as human beings. Help them maintain their humanity. Ask them what they did for fun on their days off. Share what you do for fun.

Treat patients with respect. Show your learners how to treat patients with respect, how to listen to them and how to examine them.

And when you do this job properly, your patients benefit and many future patients benefit. It is a wonderful, complex, important job. Work hard to make certain that your learners grow.

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 former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.