Sometimes we try to distill long experience into words, whether aphorisms or full paragraphs. Rilke’s wonderful prose poem expresses this very well in the part that begins, “For the sake of a single verse, one must see many cities, men and things. . . .”1 While medicine has only some features in common with poetry, what reverberates is the wish to impart an affecting draught of beauty or wisdom or insight, in the case of poetry, after many years and decades of immersion in life; and I here offer some fruits of long observation and participation “hip deep” in clinical care and in the teaching of residents.
I have taught pathology and physical diagnosis and now internal medicine and geriatrics for decades. It’s time to write down some principles that I hold most dear. The purpose is to articulate insights and behaviors that are both useful for the learner and important for any practicing clinician to know and to perform. I hope to hand out this listing when I orient new house staff on my unit, to supplement rather than replace personal contact; I count on a role in training additional physicians and nurse practitioners for decades to come.
Why share the precepts with the readers of CONSULTANT, most of whom are not residents or trainees? Simply in the hope that even if just a few of these represent helpful formulations, they provide a service. Of course I hope that persons of kindred outlook, often self-described as “old-time clinicians,” will find resonance and support in the philosophy and values expressed. Some readers may find the tone preachy, judgmental, or self-righteous. I hope not. To say “I know the difference between right and wrong” is not the same as saying “I think I’m better than others.” These precepts do take a stand, and they represent core values. Our values and morals evolve continuously. So do the means by which we put them into action. Many clinicians contribute to medical education. If other teachers can employ some of these ideas, that will fulfill my intent.
Some comments and practices will doubtless strike the reader as simple, local, and particular. That too is the humble and genuine nature of the places we work and the people we are and those we look after. The physician-poet William Carlos Williams said, “No ideas but in things,” expressing a thought akin to this2; William of Ockham, a medieval philosopher whose ideas permeate Umberto Eco’s novel The Name of the Rose, formulated a similar notion.3,4 I trust that any reader will freely adopt any item by changing “Tuesday” to “Monday,” or whatever else is needed. [Any reader is welcome to download the text from the CONSULTANT Web site, www.ConsultantLive.com, and modulate it for best fit with her or his practice and teaching situation.]
These 100 do not drain the cup of my clinical maxims. But it seemed that if one went on too long, one would sacrifice any pleasure that a reader might take in them. And if that meant they were not put to use—at a minimum as the subject of vigorous debate—I would have just filled up printed pages rather than making a contribution, however infinitesimal, to the bedside care of patients. Heaven forbid: we are all far too busy to indulge in such an exercise. The editor has wisely split this work into 2 parts that appear in consecutive issues, lest the discussion go on too long all at once. [Precepts 1 through 50 were published in the April issue, starting on page 270.]
51 Gaining confidence and competence are equally vital elements in professional growth. If the nurse asks you a question about which you are unsure, give your opinion and acknowledge uncertainty; feel free to ask others for input. Nobody loses face. If I, for instance, corroborate your opinion, you gain confidence and credibility. If I disagree, these things are not diminished, you learn something, and we serve the patient jointly.
52 Attend treatment planning meetings on Tuesday and Friday at 11:30 AM; you will hear a great deal. Team will be very deferential, to me if you say nothing, and to you when you speak up. Please ask questions, but not of the ilk, “What is the dose of sublingual nitroglycerin?”
53 Dump the old outdated, hurtful posture that the doctor is the center (or that the internist can answer for the psychiatrist). We are a team. Don’t cover everything yourself.
54 If a patient refuses to talk, or to be examined, be simple, be creative, but don’t be a bully; a second try at another time is often the best means of getting the information you need without going to war. Pick your battles. Sometimes it is a great idea to decide that the patient should win a battle. Families too, as long as the patient won’t be ill-served by acceding to their wish.
55 If others interrupt you every 5 minutes for non-emergency items, please tell them, “I can’t get to that right now; please let me complete what I am doing,” and when you have completed it, make sure to go seek the speaker out and to respond to the query.
56 Teach yourself more about the computer. It can save much time and effort but only if you take the trouble to gain more than minimal competency.
57 Check your mailbox in the department of medicine at least twice daily.
58 Check the laboratory fax in the department of medicine at least each morning between 10 and 11, and each day at 2:30 PM by which time all routine results are expected to be in. When you find laboratory reports on behavioral health hospital unit patients, read them, initial in lower right corner, take any action, eg, ordering next warfarin dose and writing a warfarin anticoagulation note. Turn them in to behavioral health hospital unit staff. If you need to discuss them with me but they are not an emergency, make a copy or make yourself a note.
59 Routinely write an “MD/APRN brief note” except for full admission “history and physical.” Always write descriptive notes; don’t use a lot of the tick-off options in an “h and p.” Sequence your write-ups logically. Cover one problem at a time, so the reader won’t get confused or overwhelmed. Proofread your write-ups. Fix spelling and grammar errors. Have pity on the reader who may depend entirely on your words.
60 Bill your notes as “Hospital, medium complexity follow-up” unless they are admissions; our attentions to our patients on this unit are always at least that complex. This is a hospital unit, not a skilled nursing unit, so a “nursing facility/nursing home note” billing code will always be erroneous; the people from health information systems (medical records) will pick this up and ask me about it, based on the cycle of information review, long after you have graduated from the unit, and I will waste time correcting it. This is only a wise choice if you loathe me and wish to strike a blow from outside my immediate reach.
61 Type in diagnoses at the bottom of the bill; don’t use the tick-list for diagnoses. List only diagnoses that are justified by your note: just mentioning hyperlipidemia as a preexistent condition does not justify billing it. An easy way to get the diagnoses on the bottom without having to do any extra keyboarding is to name in lettered list format the problems you’ll discuss at the start of the assessment piece, then copy-paste to the billing area, then go back and expound. Never put dementia first unless you have seen the patient purely for that problem. Ask me for a demonstration if you don’t understand.
62 Write the same note, but bill as a “courtesy visit” and skip putting in diagnoses, when no attending has seen the patient or is going to see the patient with you that day; or when you are writing about a thought/ follow-up that has not included seeing the patient; or when you want to talk about a laboratory or an intervention, without having seen/touched the patient that day. In the “physical examination” portion state directly, “Patient not seen today.”
63 On any patient on warfarin, on admission and with each follow-up INR, write a warfarin anticoagulation note; learn how to save time with this by using “document spreadsheet.” Also write an order for the next INR on the date corresponding to the one you stipulate in the warfarin anticoagulation note. If clinically safe, avoid ordering follow-up INRs on weekends or holidays: the moonlighter then is swamped with other duties and needs one less task.
64 Don’t order NSAIDs, including COX-2 selective agents (also known as coxibs).5 They equal GI bleeding in our patients, and they can cause lethal hyperkalemia6 as well as renal failure.
65 Don’t change the psychiatry medicines: the geropsychiatrists do that. How would you feel if they changed our digoxin orders? I like to keep pain medicines as Medicine orders, but sleep medicines can go either way.
66 If I don’t give you a paper a day to read or to add to your files, ask for one.
67 Don’t assume that just because another MD diagnosed it or ordered it, it is correct.
68 Don’t assume that laboratory and imaging results are always right. They are not.
69 Don’t throw away your clinical findings when they conflict with technology.
1. Rilke RM. The Notebooks of Malte Laurids Brigge. Herter Norton M D, trans. New York: W W Norton & Company, Inc; 1968:26-27. The passage in full reads: “I think I ought to begin to do some work now that I am learning to see. I am 28 years old, and almost nothing has been done. To recapitulate: I have written a study on Carpaccio which is bad, a drama entitled “Marriage,” which sets out to demonstrate something false by equivocal means, and some verses. Ah! but verses amount to so little when one writes them young. One ought to wait and gather sense and sweetness a whole life long, and a long life if possible, and then, quite at the end, one might perhaps be able to write ten lines that were good. For verses are not, as people imagine, simply feelings (those one has early enough)—they are experiences. For the sake of a single verse, one must see many cities, men and things, one must know the animals, one must feel how the birds fly and know the gesture with which the little flowers open in the morning. One must be able to think back to roads in unknown regions, to unexpected meetings and to partings one had long seen coming; to days of childhood that are still unexplained, to parents whom one had to hurt when they brought one some joy and one did not grasp it (it was a joy for someone else); to childhood illnesses that so strangely begin with such a number of profound and grave transformations, to days in rooms withdrawn and quiet and to mornings by the sea, to the sea itself, to seas, to nights of travel that rushed along on high and flew with all the stars—and it is not yet enough if one may think of all this. One must have memories of many nights of love, none of which was like the others, of the screams of women in labor, and of light white, sleeping women in childbed, closing again. But one must also have been beside the dying, must have sat beside the dead in the room with the open window and the fitful noises. And still it is not yet enough to have memories. One must be able to forget them when they are many and one must have the great patience to wait until they come again. For it is not yet the memories themselves. Not till they have turned to blood within us, to glance and gesture, nameless and no longer to be distinguished from ourselves—not till then can it happen that in a most rare hour the first word of a verse arises in their midst and goes forth from them.”
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