100 Precepts for My House Staff: Part 1

April 1, 2009

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.

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 a PDF of 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.

1 This is a unique opportunity. You will get a great deal out of it only if you put in commensurately. This unit is challenging, educational, and extremely important to me and to the others who work on it. Regard your time on it as a privilege. Maintain our high standards. Take pride and grow as a physician. These are among the toughest of patients; pediatric cancer patients, profoundly developmentally disabled persons, and those with advanced HIV disease come to mind as comparably challenging. Gain skills that will export well to the rest of your career: jump in with both feet.

2 Two of the many things you can expect to get out of this are to lose the fear of psychiatric patients, and the subliminal dislike of them that can trail in the wake of fear; and to gain skill in looking after the special needs of demented persons.

3 I expect you to arrive early in the morning, by 8 AM or better at 7:30 AM; see patients before I do. Take report first thing from the charge nurse. Be helpful. Know that everything you do or don’t do is important.

4 Be accountable. Know that I will write a detailed, careful, and rigorous review of your work which can be useful and sustaining, or otherwise. Your constituencies are the patients; their families; all staff; the clinicians who will resume care of the patient after he or she leaves our unit; and me; and yourself.

5 Open the chart electronically. Always read the admitting history and physical examination. Read the other MD/APRN notes, including the MD co-signature notes. Read the psychiatric admission note. Read all the orders. Read the nursing daytime notes. Read the daily psychiatrist notes. Use “care trends” to review the BPs, the pulse rates, and the fingerstick glucose measurements using “cardiovascular” and “nutrition,” respectively. Watch the weight for trend. Watch the temperature. Watch the I&O if appropriate.

6 I will round each morning at or before 9 AM. If you have class in the morning, come in beforehand (!) if need be, and as soon afterward as possible. On such days if I miss you in the AM, I will re-round, duties permitting, at 2 PM.

7 Be prepared. Don’t tell me that you did not see the patient. Don’t tell me you ausculted through clothing. Don’t tell me you palpated the abdomen with the patient in the wheelchair. Don’t embarrass yourself.

8 Don’t bluff. It amounts to lying, and lying is anathema.

9 Don’t be embarrassed to say, “I don’t know.” These are the most underused words in the physician’s vocabulary. Better still if you can follow up with, “But I will find out.”

10 You can never harm a patient by admitting ignorance, whereas you can do harm by pretending to possess information that you do not. Likewise by agreeing that a finding is there because I say it is: I too am fallible. Don’t be a yes-man to the emperor’s new clothes.

11 I have a great deal of other duty. Consider me unavailable except 9-10:30 AM and 2-2:30 PM. If I am not available, either determine that the issue can safely, painlessly await our next rounds, or get another attending to oversee you. Talk to the Fellow to determine when to make an exception. The other attending will also be very busy.

12 You are my personal ambassador. Act accordingly.

13 Wear a clean white coat. Dress like a leader because when you come on the unit, that is how you will be viewed regardless of how young you are, how low on the organizational chart.

14 Behave and speak like a leader: calm, polite, composed, poised. A foreign accent is no barrier to this. Skillful physicians come from everywhere. Careless speech undermines efficacy.

15 You don’t have to know everything to lead well (see #9, above).

16 I dare you to try to gain on me as a physician. The only way is to work harder (or better) than me, and I work hard.

17 My goal in working with you is not to steer you to a career as a geriatrician, rather to help you become better at whatever track you are following: internist, nurse practitioner, family practitioner, or for the few who so choose, geriatrician.

18 There is an infinity of lessons you can export and generalize to whatever patients you see in future, and in particular to other difficult patients such as the frail elderly.

19 Go see the patient. Sit down to interview-don’t loom over the patient. Get your hands dirty. Clean them afterwards. Be a hands-on doctor. Do follow- up and serial physical examinations. You don’t have to auscult the lungs each time if the issue is not cardiorespiratory. If you are doing a rectal, position the patient carefully and tell him or her before you touch and again before you enter.

20 At the end of any rectal examination, wipe the patient’s backside with clean tissues and tell him or her you have done so. You will diminish misery and humiliation more than you can know: the patient can pull back up the underclothing without soiling it and the hands.

21 Find the ophthalmoscope, gloves, lubricant, Hemoccult, BP cuff, and tongue blades in the clean utility room. Carry a penlight, reflex hammer, gloves, lubricant, pen, paper, a few alcohol wipes, two 2 x 2 gauzes, and 4 nonsterile tongue blades in the white coat you wear whenever you set foot on the unit: don’t waste time backtracking to collect a supply that you’ll need in the course of the week. Bring a clipboard or a PDA (personal digital assistant). Don’t make notes on scraps; that ensures loss. Above and beyond: carry a bandage scissors and spend less time removing Kling gauze; keep the scissors clean.

22 Look at wounds and be sure the nurse joins you for this, since she or he has to see it anyway, and in hearing and responding to what you recommend, the nurse may well offer observations and recommendations of utmost value that had not occurred to you; all will gain from the interaction. Describe even if you can’t name.

23 Don’t examine patients, not even the external eye, in the dining room. Use the Mom rule: “If it was my Mom, how would I like her examined in public?”

24 Learn to apply and remove the brakes on a wheelchair.

25 Learn how to help lift a patient (by the waistband, not the arm: don’t cause shoulder separations and rotator cuff tears in susceptible old people).

26 Learn how to turn chair and bed alarms on and off. Always leave them on when you are finished. Don’t leave a mess. Maid service was abolished on this unit 3 years ago.

27 Learn to go into the dining room and bring out a patient. Greet as many patients as you can by name.

28 Set limits: don’t spend 20 minutes trying to explain something to a demented person. Don’t attend only to those who noisily seek you.

29 Don’t believe the patient or the family who tells you that you are the only one who understands or who cares; these comments mean something very different from their overt content. If you don’t reject them, you’ll have much more emotional difficulty in rejecting the equally untrue assertions by those who call you the worst alcoholic doctor on earth, incompetent, too young, etc.

30 When you tell me a case, don’t replicate your writeup; I will read it. Tell me instead what you have found and what you’d like me to go over at bedside.

31 Know that I will ask you, “What did you learn?” with great frequency after we have seen a patient, and will expect you to have thought about this and to tell me something added to your bedside toolbox. Avoid dodging via a compliment to me. Don’t duck by pretending you learned the same thing that the trainee just before you uttered. Don’t be afraid: nobody will make fun of an odd answer; this is a very safe place to speak your thoughts bluntly.

32 The nursing staff, including the CNAs (certified nursing assistants), unit clerks, social workers, rehabilitation staff, and recreation therapist will work very hard to help you.

33 Learn their names. Address them by name and always state your name.

34 They are not your servants: be mindful of this. When they help you, it is a gift and needs acknowledgment. They often talk to me about how you treat them and how well you are doing, not to tattle but as colleagues who share the work of nurturing your professional growth.

35 Don’t sit anyplace reading the newspaper: even if you have a forced delay, it gives the message that you are letting others carry all the weight.

36 Carry a medical article in your clipboard and read it during a forced wait. Tell the nurse what it was about and how you will apply the information to help one of your shared patients.

37 That night at home, replace it with a fresh unread article.

38 If you run out of unread medical articles, ask why you are in this profession.

39 Don’t interrupt a nurse who is working, to ask her a question or to ask him for assistance every 15 minutes: they have much too much work of their own to baby-sit you. Batch your requests; expect the same courtesy applied to you. Think how you feel when you are interrupted every 5 minutes. I can be rock-sure that you have experienced such interruptions.

40 Don’t leave coffee cups. Don’t hog the computer. Don’t cut in if another member of the team is on the computer.

41 Don’t go on the Internet on a hospital computer unless it is to PubMed or Up-To-Date to answer an immediate question about a patient you are treating at that moment.

42 Don’t bring in your cell phone, or if you must, don’t turn it on.

43Do feel free to ask, politely, if the nurse can come look at something with you if it is difficult; or to ask the nurse or CNA to help you get a patient into or out of bed or into or out of clothing for examination.

44 If family is present, use it as an opportunity to enhance your understanding of the case and to update them. Don’t regard family as an enemy. Don’t lose patience because they have a lot of questions: it is just one patient for you, but the calamity of a lifetime for them.

45 Tell the family that you are a house officer. We are a teaching institution. This is normal. Good communication does not come exclusively from the attending physician. Never apologize for being a resident or a student. These are honorable estates without which attendings would become extinct in one generation. Families who ask that no trainee work with them fail in the social contract of medicine and of the teaching hospital.

46 When patient or family queries you based on 10 minutes’ search on the Internet, feel free to say gently, politely, firmly that information without context and without rigorous fact-checking is the bane of the Web. Our decisions reflect years of training and experience that cannot be replicated by doing a Google search.

47 If family is receptive, feel free to say, respectfully, that medical, psychiatric, nursing, rehabilitation and social work professionals bring three special elements to the conversation:
•Technical knowledge.
•Knowledge of parallel cases: even though each person is unique, one has insights from other human beings with similar problems that one has looked after.
•Objectivity: we are sad when our patients ail or die, but our hearts are not being wrenched forever because we are not losing the one and only father we ever had.
Then acknowledge that they also know what we cannot: a lifetime of contact; and profound personal connection, though our patients are precious to us.

48 If a family tries to imply that their money or ethnicity matters to you, think to yourself, even if you don’t say it, “I would try to do as good a job for Bill Gates’s mother as I would for a homeless man.”

49 Teamwork, teamwork, teamwork. Expect to have scheduled family meetings, and ad hoc telephone calls when there is a change of status, along with a social worker and/or a nurse, often with both; sometimes the charge nurse will participate, sometimes the nurse manager. Often I will. When the call is not about a deterioration, start out, “Hello, this is Dr Jones, from Hebrew Health Care, calling for Ms Smith. Is that you? Good, please don’t worry, I am just calling to provide you some updates and to gather some more information about your husband.” Wait 10 seconds for the panic and tachycardia of the recipient to lessen-way too many families are conditioned by experience to believe that a physician on the telephone equals a death or a calamity with ICU transfer. Then, “I am on the speaker phone with Nurse Kelly and with Ms Brown the social worker, so we can all hear you and contribute.”

50 If the nurse asks me a question in your presence, try to answer it; I will be very happy to be interrupted by you for this purpose. Insist on being a team member, not a visitor. (If you are merely a visitor, you are guaranteed to be unhappy and unproductive.) Don’t contribute passively to any staff member’s turning to me as the be-all and end-all. I ain’t, and it hurts our care.

Read part two of this article.

References:

REFERENCES:


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 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.”

2

. Williams WC.

The Collected Poems of William Carlos Williams

. Vol. 1 (1909- 1939). New York: New Directions; 1986:263-264; from the 1927 poem “Paterson,” lines 9, 27-28. Parts of this poem were reworked into Book One of Paterson (1946). See Paterson. New York: New Directions; 1963.

3

. Eco U.

The Name of the Rose

. Weaver W, trans. San Diego: a Helen and Kurt Wolff Book, Harcourt Brace Jovanovich; 1983.

4.

Haft AJ, White JG, White RJ.

The Key to the Name of the Rose

. Harrington Park, NJ: Ampersand Associates; 1987.