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When I Become an Attending…

Based on the many observations and interactions with staff / attending / chief residents / consultant doctors during clerkship year. A list of do’s and don’ts I will try to follow one day… Hopefully I’ll look back at this post when I’m finished all the training and find it useful.

Patient Care … I will

  • Take care of Patients – my favorite preceptors were the ones who showed me how to interact with patients. They made sure they rounded on all their patients, answered all their questions and concerns in clinic, and that they were getting the best care possible.
  • See patients as people, not just as a disease – Simple non-medical questions like how was your day, where are you from, what do you do, etc is often all it takes to break the ice and help someone relax. I don’t want to become a doctor that refers to people as the gallbladder in bed 12.
  • Talk with Families – one of the hardest things I found as a student was talking to patient’s families, especially if the patient was nearing the end of life. Medical questions I could answer, but difficult questions like long term goals, personal directives, placement in homes, and what to expect from here on were often out of my scope. Apart from having limited medical knowledge, I was also not in a position to make these decisions and playing messenger between staff and families often created miscommunication.
  • Respect Confidentiality and Privacy – Simple things – closing the curtains when examining a patient, breaking bad news in a private place, not talking about patient information when others can hear (elevators, hallway). Small things that make a big difference.
  • Respect Patient Autonomy – Most doctors are quite good at patient centered care these days. Gone are the days of paternalistic care.
  • Be responsible for my patients – When you become an attending, it’s your name on the chart and you are ultimately responsible for your patients. I hated it when patients were TURFed around, trying to be sent to different services. When no one takes responsibility, the patient suffers in the end. I can count multiple times where our service consulted different surgical services who refused to see our patient because the surgical problem was in an anatomical grey-area zone. No one wanted to be responsible for the patient. In the end, we had to physically get all the different services to sit down and decide out who was going to take this very sick patient to the OR. You know the saying, “With Great Power…”

Education … I will

  • Always try to find teaching opportunities – My favorite preceptors loved to teach. Whether it was on core medical topics to how to be more efficient to procedural skills, they always found a chance to teach. As a medical student, you are there to learn. There’s only so much you can learn on your own too before you need the guidance of someone more experienced than you. Teach, Teach, Teach.
  • Teach at appropriate times – There is a time to learn and a time to get things done. A teaching moment at 4am in the ER after being up the whole night, not an ideal time. Teaching at the bedside on morning rounds, a better setting.
  • Have dedicated teaching time – I found the best times to teach was early in the morning before rounds, lunch, or in the afternoon when there was a lull. If you don’t set aside time for teaching, there might not ever be a time.
  • Teach Relevant Material – Going over cases you saw during the day or approach to common/emergent presentations makes sense. No obscure medical trivia.
  • Ask Questions to Educate – I can’t promise that I won’t pimp my students with questions. But I’ll try to do so in an appropriate manner, for purposes of education and not humiliation, and not in front of patients or other staff.
  • Teach at the Right Level – I hope I remember that medical students do know a lot, don’t belittle their knowledge. Similarly, some have knowledge deficits that need to be addressed. And a lot of how much students know is based on if this is their first rotation, middle of the year or late in the year.
  • Challenge students to improve – We had a staff cardiologist who would host ECG rounds once a week. We all sat down as a group of students, and he would hand us a stack of ECG’s. Each person was to interpret one ECG and was given 5 minutes to prepare. The ECG’s got progressively harder and I was nervous about being wrong in front of everybody, but as a group we got pretty good at reading them within a few weeks because we were challenged outside our comfort zone.
  • Give opportunities to students to excel – IV’s, lines, intubations, chest tubes, suturing, reductions. I really appreciate the time my preceptors took to show me how to do a lot of procedural skills. How else are we suppose to learn unless we try?

Teamwork … I will

  • Be available – Knowing that there is backup available and someone to call for help when needed makes a big difference. The worst I’ve seen is surgeons refusing to come in when a senior resident thinks there is need for emergency surgical management. On the other hand, pediatricians who answer their pagers in the middle of the night to review an admission. Granted, I also know surgeons who want to be called about their patients and pediatricians who just say admit everyone and wait until the morning.
  • Give students appropriate responsibility – students can’t learn if they’re never given a chance. I remember being quite bad at suturing at the beginning of the year, but as I got better at it, I got more chances to suture and close in the OR. Give students tasks they are comfortable with handling and trust them to do it. They will be more aware of the limitations and more keen to seek help when needed.
  • Not delegate tasks that weren’t meant for residents/students – Things like family conferences, deciding whether to admit or discharge a patient, important paperwork, there are stuff only the staff should do. Being a staff doc doesn’t mean your residents can do everything for you. Residents aren’t paid the big bucks, you are, and ultimately there are things only you can do.
  • Make the call for difficult consults – An example of a difficult task is consulting other services. Asking another physician to accept your patient should be a staff to staff conversation. Likewise, it often takes a staff physician’s request to get that emergent imaging scan approved. I have some bad memories of getting yelled at by consulted doctors for inappropriate requests, I was just following orders.
  • Set students and residents up for success – My preceptors would often start me with bread and butter cases, things every medical student should know. They would always handle the difficult patient encounters or drug seeking patients. As I got more comfortable with different clinical scenarios, they would give me more responsibility. They never threw me off in the deep end at the start. The good ones maximized my chance for success by giving necessary instruction and tips. I believe good doctors want to see their students go on to be good doctors too.
  • Treat students as part of the team – Listen to them, they might know things about the patient that you do not. They might be more up to date with new medications, diagnostic criteria and guidelines. Let them come up with a management plan on their own and then review it with them. Let them write orders on their own first instead of being just a scribe. You can always correct them afterwards. One of my preceptors said on the first day of my IM rotation, “don’t think you are just a medical student, but think and act like a resident, because one day you will be one and there’s no better time to practice being one with some supervision.”
  • Send the post-call resident/student home on time – There’s no reason to keep a tired, sleep deprived, hungry student on for another few hours when you have the rest of the team well rested and ready to work. Send them home earlier if there’s no work that needs to be tidied up.
  • Buy Coffee for the team – Coffee rounds made Monday mornings or slow days so much better. For a few bucks, it can lift the spirits of a team and students really appreciate the gesture.
  • Buy Lunch for the team – At the end of each rotation, I had some attendings who would take the team out for lunch or order in nice food. It made me feel appreciated and whenever it happened I left each rotation with a smile on my face and food in my belly. It’s strange how a free meal can completely change how you feel about a lot of things. Perhaps it’s cause as a medical student/resident you feel pretty broke most of the time.
  • Get to know your team – instead of being “Hey You…Medical Student over there,” I loved it when staff got to know you. Simple questions like where are you from, what do you want to do when you’re done school, any hobbies, etc.” It helped alleviate a lot of fears and nervousness when staff got to know you. As a result, I think I worked much much harder whenever I was acknowledge as a person. Oh, the strangeness of a medical student’s self-esteem.

Professionalism … I will

  • Be friendly to all staff members – Nurses, OT/PT’s, Porters, Unit Clerk, Residents, Medical students and more. Every person has a role in making the system work. As a doctor, you are in a position of power and I can see why it can be intimidating for other services when they interact with you. I don’t want my demeanor to be the reason why someone didn’t speak up when they saw something wrong.
  • Get to know people’s names – “Good morning Nancy” is much better than “Who’s the charge nurse today.” It’s well known that the nurses you work with can make it heaven or hell for you. Get on their good side and one of the easiest ways is by acknowledging them by addressing them by their name.
  • Say please, sorry and thank you’s – Just because you’re a head/neck/cardiothoracic surgeon, it doesn’t mean that you can be a jerk. Being well-mannered often speaks more about you then what you actually say.
  • Apologize when wrong – The best docs knew their limitations and when they were confident and when they were uncertain. I’ve been “corrected” a few times by stubborn docs who thought they couldn’t be wrong. I hope I don’t propagate the arrogant doctor stereotype.
  • Start on time – Everyone’s time is valuable, starting on time is an easy way to make sure everyone finishes on time.
  • Try to stay on time – Especially in clinics, it’s common to fall behind behind bookings. Making sure patients aren’t stuck waiting too long means a lot, even if that means skipping lunch, saving some charting for afterwards or hustling a bit.
  • Stay late if needed – If work needs to be done, it needs to get done. Don’t put off what should be done now because it’s inconvenient.
  • Don’t keep students waiting – Too much time was spent this year waiting to review a case or hand over information. It’s an unfortunate inefficiency in the system. I’ll try my best to minimize it.
  • Answer my pages/calls – No one likes getting paged (at least no one I know), but if I do get paged/called, answering within an appropriate time is common courtesy. I wouldn’t want to keep anyone waiting by a telephone. Playing phone tag sucks. Perhaps I’ll be like the younger attendings and communicate via text.

Random Tidbits … I will

  • Wear scrubs that fit – I’ve seen more attending ass crack (all male) than I would like.
  • Safety comes first – Dispose of my sharps, wear protective equipment, make sure others around me are safe too
  • Not put students on the spot – I hated when attendings pimped me in front of patients… especially when I didn’t know the answers. I’ll try to pimp not in a public place.

I apologize for the long post, I guess this post is more for me than for others. Hope I can look at this list several years down the road and become the attending doctor that I always looked up to.

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One Comment

  1. Paradocs
    Paradocs July 8, 2011

    Wisdom! I loved the Professional and Educational sections most. That is a lot of things, but like you said “with great power…”

    My my calculations you are going to be applying for residency soon… Could I humbly request your thoughts on the process of deciding what you want to do or what sold you on the programs you are going to apply for?

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