Sunday, September 2, 2012

The advice I gave the housestaff and fellows

I just finished one of my two 2-week rotations on the Solid Tumor Inpatient Service for this academic year at Hopkins, and I spent some time with the fellow and each of the residents at the beginning of their rotation and then on my last day on service discussing my expectations for them and a review of their performance, respectively. Having spent most of my professional life in a non-academic setting, I haven't had much previous experience with students and trainees, so I can't say I am particularly skilled at medical education or the best techniques for assessment and review, even though I find the teaching opportunities of my job at Hopkins one of my favorite parts. So instead of giving them a detailed list of recommenations about how they can be smarter and more effective physicians, I simply told them things that I wish I had been told at that point in my training that would have really broadened my perspectives at the time - in other words things that took me far too long to learn on my own and came only as I matured during 20+ years as an oncologist.

Here's what I told them:
  1. You can't possibly spend enough time listening to the patient. Hospital rounds are admittedly a highly artificial and inefficient construct from both the learner's perspective and the patient's, but from the perspective of the person in the bed or the family sitting in the room, both highly anxiety-producing and often unsatisfying. I tried to tell them that even though our time in each room was short, we had to try harder to let the patient and family talk and not spend the time talking AT them ("Today you are getting a PICC line, then we start your chemo, then PT will see you and if you can walk we'll send you home and if not maybe to rehab, and we'll give you something for nausea if you have it which most people don't, and then the discharge planner will give you a list of your meds for home and follow-up appointments, and call us for any fever since it could be a sign of a serious infection, OK?" Usually not ok.) Pause, listen, ask if they understand or have more questions.
  2. Always try to solve one problem for the patient every hospital day or every encounter in the office. As physicians we often fail to understand how important it is for the patient lying in the bed to get the TV remote fixed or the disability form filled out, even when (to us) that seems far less important than treatment of their cancer.
  3. Remember that for most if not all patients with a cancer diagnosis in the hospital or at a visit with the oncologist in the office, they are having the worst moment of their lives. A community-acquired pneumonia while on FOLFOX or a first visit to discuss adjuvant treatment of a T1 breast cancer is routine for us, but it is most often an unspeakable horror for the patient in front of us. So give them a break if they are irritable, slow to understand, or "non-compliant."
  4. You can't possibly be detail-oriented enough. True of course in all of medicine particularly so in a data-intensive specialty like internal medicine or medical oncology. Most residents seem to get this, but occasionally I see lapses that are easily prevented.
  5. Do your part to creat a medical record that allows another person to see the story of the patient and his/her illness. I am trying to teach my trainees that while our electronic tools allow us to include all sorts of data and details in the daily progress note, too much cut-and-paste and mindlessly repetitive problem lists confuse the narrative, so they need to start learning the discipline of effective documentation now. I don't think very many of my colleagues spend much time talking with the housestaff about this, but I believe as attendings, mentors, and role models, teaching this is nearly as important as teaching pathophysiology.
  6. Even if you're tired, burned out, or overwhelmed, or even if this specialty doesn't interest you long term, always appear interested, enthusiastic, and eager to learn. I think residents forget that it is so easy for the senior people to identify the complainers and whiners, and those trying to get out of doing work.
  7. People judge your character by how you behave when you are under stress, short of time, conflicted, etc. Pretty true for all of us don't you think?
I must say that I have been pretty happy with the trainees I have worked with in the past few years at Hopkins. One of the most positive aspects is that largely they DO have a collaborative working relationship with the nurses and staff, and there does seem to be mutual respect. I don't think that really was the case in the 1980's when I trained, and it is with no small sense of regret and shame that I remember that I didn't often view the non-physician staff as partners in care. Here's to hoping today's young physicians figure out how to do the other things above a lot sooner than I did.

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