100 Precepts for My House Staff: Part 1
100 Precepts for My House Staff: Part 1
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.]
| On Service
By Golder N. Wilson, MD, PhD
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.