100 Precepts for My House Staff: Part 2

June 9, 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. . . . ” 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 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.

70 Don’t stop thinking about what ails your patient.

71 Know that unitary diagnosis, eg, for falls, is less common than multifactorial diagnosis. Remember that poor safety awareness is often a major element in falls; this cannot be studied with a Holter monitor nor corrected with a bed alarm. Check pulse and pressure in lying, seated, and standing positions to see if there is an element of orthostatic hypotension in any person who falls; if the pulse fails to rise with a fall in BP, autonomic dysfunction is present.

72 Know that delirium is an acute brain dysfunction whose hallmark is a disorder of attentiveness: either too distractible or hypervigilant. Ask me for a paper.7

73 Know what the Mini-Mental State Examination (MMSE) is, the Clock Drawing Test (CDT), the geriatric depression scale (GDS), the FAST scale, and the Global Deterioration Scale.8-10

74 Familiarize yourself with all the options on the CODE order drop-down menu and the even fuller list on the advance directive worksheet that I will provide you. Don’t fail to include a CODE order on any admission.

75 Whenever we have a CODE discussion with a family, update the computer order and write a CODE STATUS note as an intervention. Please allude to the worksheet. Make sure the family leaves the meeting with a photocopy of the completed worksheet in hand (the social workers are very gracious about making such a copy at the conclusion of such a discussion). Counsel the family to photocopy it and to provide any future facility with copies for the director of nursing, nurse manager, primary nurse, physician of record, social worker, and administrator to optimize the chance that it will be honored, though one can never guarantee this.

76 Know that many of your instincts/algorithms about how to respond to common clinical problems, eg, colonoscopy for evaluation of heme-positive stool, will need to be revisited and individualized with each patient on this unit.

77 Get comfortable with prescribing morphine. Ask me for a paper. Throw out the 1940s black-and-white movie image of “She is under morphia, and it’s only a matter of days.” Use opiates when they are the best choice. Don’t undertreat pain with tramadol when the patient needs an opiate. Put in parameters to prevent overdosing. When you prescribe opiates, always include standing doses of analgesics and PRN doses; the usual PRN is 15% of the scheduled 24-hour dose.11,12

78 If you are starting a patient on opiates, anticipate and enhance the bowel regimen. A stimulant such as senna will likely help; the standard dose is 8.6 mg by mouth daily, more if needed. You’ll overshoot rarely and you will avoid trouble often.

79 Get good at bowel medicines, especially polyethylene glycol solution (MiraLax), 17 g in 200 mL of water or juice. Ask me for teaching or a paper.13,14

80 Protect our frail patients: Always prescribe Lactobacillus if you start an antibiotic prone to cause Clostridium difficile–associated disease, eg, a cephalosporin, a quinolone (formerly a safe choice but now a leading risk), a penicillin, a tetracycline, or clindamycin.15-17 Do the same if you inherit a patient who is on such an antibiotic but has not had Lactobacillus added. Continue Lactobacillus for a week beyond the end of the course of antibiotic.

81 Don’t give antibiotics for asymptomatic bacteriuria.18 On day 1 ask me for a paper on asymptomatic bacteriuria to help you discern the difference.

82 If the patient has had an Escherichia coli urinary tract infection or even asymptomatic bacteriuria due to E coli, consider use of cranberry capsules for the long haul; they prevent adhesion. Resistance does not develop.19,20

83 If the patient has a catheter in the urethra, learn about and talk to staff about iatrogenic hypospadias.21,22 Make sure that traction on the penis is avoided. Ask for help in how to tape the catheter to the leg.

84 If possible, take the Foley catheter out soonest: it is a ticking time bomb for urosepsis, and an unstoppable source of chronic colonization with progressively more resistant uropathogens.23,24 It also harms both self-esteem and mobility. In 1988 the “king of urinary tract infection” called the urinary catheter “the leading cause of nosocomial urinary infections and the most common predisposing factor for preventable gram-negative sepsis in hospitals.”25 It’s still true.

If in doubt about urinary retention, get some post-void bladder scans in the first days after removal of catheter to be sure of adequate emptying. If in doubt as to what volume is acceptable, look it up and then talk to me.

85 If the patient has had a distended bladder, leave the catheter in long enough to decompress it and restore detrusor tone. If despite this the patient is not emptying the bladder properly, consider whether tamsulosin would restore better ability to void. If the 0.4-mg starting dose at bedtime does not accomplish this, consider raising it to the maximal, 0.8-mg, dose.

86 Know why tamsulosin is an α-blocker preferred in aged patients over doxazosin and terazosin,26 namely that it is selective for α1a-receptors and thus less prone to cause orthostatic hypotension at least at its lower, starting dose.

87 Learn what the 2003-updated Beers criteria are.27 Don’t use drugs from the list. If you find patients who are taking them before admission, strongly consider stopping or tapering them. Talk to the pharmacist. Talk to me. If puzzled or stuck about such a drug, call the physician or APRN who originally prescribed the drug and talk to him or her. Sometimes an exception is appropriate.

88 Recognize that information drop-off as patients cross from one locus of care to another is lethal. Do your part to gather as much information as possible on new admissions or those who have not come accompanied by adequate information. Get on the phone. Call the physician’s office. Talk to the office nurse-usually that is the key person. Routinely provide me with the name and fax number of the primary care physician and any key consultants: I will add it to the medical portion of the discharge summary, thereby increasing the likelihood that this summary will reach them and serve a function; otherwise it is an empty exercise in paperwork-and we already have too many of those.

89 In using collateral history sources such as old charts, know their limits as well as their convenience: an error once ensconced is never omitted. Just because somebody’s typo bestowed the nonexistent Von Schmerzbach’s disease on your patient in 1963 does not mean he has it.

90 In asking family members and caregivers for symptom and behavior reports, know that they may minimize or exaggerate or both, depending on their beliefs and on what they think the patient needs.

91 Recognize that all patients have peaks and valleys in cognitive performance. Best understanding of patients requires awareness of both as well as of the “mean elevation above sea level.” Use this image to understand why family members sometimes believe a loved one deteriorated massively when we think not, or that a medicine was calamitous when our observations suggest otherwise.

92 Participate in creating a sound, value-adding medical portion of the discharge summary, not rehashing geropsychiatric information that is in the psychiatrists’ portion, nor listing medicines, doses, and other information that will appear on the W-10, nor laboratory results that can be photocopied if critically related to active pathological processes. Rather, tell the story of what happened, what new problems arose, what old ones flared, what got better, what major changes in medicines were accomplished and to what results, how the BP fared, whether the fingerstick glucoses remained mostly in target range. Be complete and concise. Full sentences are not mandatory; clarity is.

93 Go easy on fingerstick glucose measurements. Most patients here do not need them 4 times per day; or need 4 times per day only for a few days. Then careful review by us usually leads to dose adjustments and a drastic reduction in fingerstick checks.

94 Don’t use sliding scales of regular insulin or at most, use them for a couple of days. They represent playing catch-up forever. Modulating dosing of basal or prandial medicine based on ongoing review is much more rational than giving an endless series of one-time supplements.28

95 Own your own education. Read every day. Go see patients. Don’t write the most minimal and generic note you can, but rather stretch yourself. Don’t treat this as a job. It is a noble and learned profession and a calling.

96 This rotation is lovely because it has no call and no weekends. But it is not a vacation. If you treat it as one, and make your principal focus getting out at 4 PM, you’ll gain nothing; you’ll misrepresent life as an attending, which is never that controlled in any specialty. Even the people with procedures, who sound very well compensated to internists, eg, ophthalmologists, orthopaedists, dermatologists, work very hard nowadays.

97 Believe it or not, most of your career will be as an attending and you won’t be a house officer forever. My hope is to provide you toolbox items that will serve you well now and also then.

98 Don’t abuse me or any other teacher: don’t confuse our work ethic and love of imparting, and of going to the bedside together, with a paucity of other pressures or with entitlement on your part. Reciprocate: take good care of the service; show you care about the patients and that they are neither objects nor means to you; don’t leave tasks for me that you can do competently. If I have to function as house officer to fill a vacuum so that patients are properly treated, I will do so, for the patients are why we come to work each day. But in that case I certainly won’t expend additional effort to be the teacher as well. You’re welcome.

99 Do your best to follow these leads. Then expect to receive strongly positive feedback.

100 More important, by utilizing these precepts you will employ your power and your effort to best purpose: you will serve and grow and learn, which are some principal lifetime tasks of every physician. Others include maintaining idealism, sustaining one’s spirit, and participating centrally every day, actively and not with an asterisk because you are too busy or too tired, in the lives of the people who love you and who underpin all the good that you do.

 Read part one of this article.




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