Thank you for putting the nurses at the head of your original list 🙏 For any of you inpatient MDs (grizzly attending included) out there: many new-onset “mysterious” Afibs (barring other morbidities) resolve after the unglamorous bowel movement is made happen. Damned be the dilt and/or amio gtts. If only anyone would ask and listen and hear closely the answer : “ Five days ago, seven days ago, ten days ago”. Do not rely on other clinicians’ documentation (“last BM -yesterday”)- So, your advice from the second list is paramount. Therefore, plz have your interns 2.0 always (if not contraindicated) have a QD SUPPOSITORY ORDERED, and require your interns 2.0 to MONITOR the administration => outcome. And be amazed! 🤝🌿☺️
Great article and spot-on. My only comment would be an addition to item 4. Before you order a diagnostic test, ask yourself: How will the result change my plan of management? If it won’t, regardless of result, it is a waste of resources. (e.g., ordering bone density on a patient already on maximal anti-osteoporosis treatment.) -Smokey Stover MD, MMM (ret)
This piece was beautiful. It nailed it. I remember once teaching another nurse how to make an initial visit. While one nurse assessed and cared for the patient, I sat back with the new nurse and told her to take advantage of this spot. Look at her skin: color, etc. Her legs- they are edematous. Listen to her breathe and speak. Smell. Does she smell musky, ethereal, etc. Finally when you get to be next to her, touch her. Abdomen hard, soft? Edema pitting? Listen to the patient, family, care givers as they relate the H&P of this person. Despite their limited medical knowledge, somewhere in their descriptions you'll hear exactly what you need to hear. The forest is your patient, the trees are what the patient is and where you find her diagnoses.
I would add "Don't always believe the computer." But maybe that goes under your Gaming advice. I think young people rely too much on what the computer tells them. Watch one of them use GPS. They do not look around them, they just follow the map. I have found in accounting many practitioners input the data and believe the answer they get is correct. But tiny changes to the data can come up with very different answers. This is the same in medicine. Every person is different and the computer can only give the answer for the average person.
Priceless advice. Brilliant comparisons. I also advised, look at the patient FIRST, process, only then look at the numbers. Who/what is telling a richer “story”?
Every single time, in a teaching hospital, the Rx was the rock-bottom protocol irrelevant of the patient’s PRN demand Hx, tolerance and pain levels, VS be damned...
Lovely piece Adam! 👏 They say you can't really give anyone advice, but I think words of wisdom from the (gender-neutral) masters are appreciated by our apprentices, especially when they ring true like yours!
I love your original list even more than your new list. These wise words signify what my fellow residents at a top Internal Medicine residency nearly 30 years ago knew and practiced. We worked hard, took care of our patients, listened and learned from those that knew more than us (almost everyone) and each other, and partied and supported each other outside of the hospital. My fellow residents are still some of my best friends though we are spread throughout the country. Striving for excellence and fulfilling our purpose was just part of our telos. It was exhausting and hard, but absolutely necessary for the wellbeing of our patients current and future. We did not have to be taught these values. We just needed to learn how to practice Medicine, and that is what we did. My, how the attitudes have changed.
There’s nothing I can add that others haven’t said regarding the importance of this list for providers. As a PATIENT, however, I wish every one of my specialists would read this (I might present it to my PCP and other docs with whom I personally worked while doing addiction and chronic non cancer pain).
I have said it before to you; having you as a doc would make life easier / I’m so glad you are out there helping others learn your skills.
I will add that humor is absolutely essential!!! I do all I can to make folks laugh who take care of me at my own expense. Rule #62 is the most important “rule” of recovery. Thanks for all you do.
I know what you mean, but the word "whining" often reveals a mindset in older professionals that undermines their effectiveness as a teacher/mentor. I find more empathy and good coaching reduces the normative distress in most learners. A few do need some tough love on their attitude problem.
This is so good. I am a medical massage therapist, so only very tangentially related to healthcare, but I even got a few takeaways for how I can improve my client contact. These are really good ideas for a lot of people.
I did "midnight rounds," in person in training and at least by phone when I was in Family Practice. I focused on the nurses' curent concerns and also on what would scare everyone at 3 AM.
Smart! Excellent! And thank you for sticking close with RNs ☺️ Nurses know the docs who do that (not many of them), and we ALWAYS do timely interventions ❤️🌿🤝
Dear Doctor,
Thank you for putting the nurses at the head of your original list 🙏 For any of you inpatient MDs (grizzly attending included) out there: many new-onset “mysterious” Afibs (barring other morbidities) resolve after the unglamorous bowel movement is made happen. Damned be the dilt and/or amio gtts. If only anyone would ask and listen and hear closely the answer : “ Five days ago, seven days ago, ten days ago”. Do not rely on other clinicians’ documentation (“last BM -yesterday”)- So, your advice from the second list is paramount. Therefore, plz have your interns 2.0 always (if not contraindicated) have a QD SUPPOSITORY ORDERED, and require your interns 2.0 to MONITOR the administration => outcome. And be amazed! 🤝🌿☺️
Great article and spot-on. My only comment would be an addition to item 4. Before you order a diagnostic test, ask yourself: How will the result change my plan of management? If it won’t, regardless of result, it is a waste of resources. (e.g., ordering bone density on a patient already on maximal anti-osteoporosis treatment.) -Smokey Stover MD, MMM (ret)
This piece was beautiful. It nailed it. I remember once teaching another nurse how to make an initial visit. While one nurse assessed and cared for the patient, I sat back with the new nurse and told her to take advantage of this spot. Look at her skin: color, etc. Her legs- they are edematous. Listen to her breathe and speak. Smell. Does she smell musky, ethereal, etc. Finally when you get to be next to her, touch her. Abdomen hard, soft? Edema pitting? Listen to the patient, family, care givers as they relate the H&P of this person. Despite their limited medical knowledge, somewhere in their descriptions you'll hear exactly what you need to hear. The forest is your patient, the trees are what the patient is and where you find her diagnoses.
I would add "Don't always believe the computer." But maybe that goes under your Gaming advice. I think young people rely too much on what the computer tells them. Watch one of them use GPS. They do not look around them, they just follow the map. I have found in accounting many practitioners input the data and believe the answer they get is correct. But tiny changes to the data can come up with very different answers. This is the same in medicine. Every person is different and the computer can only give the answer for the average person.
Priceless advice. Brilliant comparisons. I also advised, look at the patient FIRST, process, only then look at the numbers. Who/what is telling a richer “story”?
Great advice
The PCA advice...
Make sure you are not parsimonious about the Rx.
Every single time, in a teaching hospital, the Rx was the rock-bottom protocol irrelevant of the patient’s PRN demand Hx, tolerance and pain levels, VS be damned...
I really DO hope that my docs think this way.
It is outstanding.
I think that we can use this list when dealing with many other things too.
What in our life has brought us to this point, and is this where we desire to be?...
What can we do to change what doesn't make us happy with this particular outcome?...
I realize that I need to think many thing through with much more thoroughness.
Love that. Thanks. Adam.
Lovely piece Adam! 👏 They say you can't really give anyone advice, but I think words of wisdom from the (gender-neutral) masters are appreciated by our apprentices, especially when they ring true like yours!
I love your original list even more than your new list. These wise words signify what my fellow residents at a top Internal Medicine residency nearly 30 years ago knew and practiced. We worked hard, took care of our patients, listened and learned from those that knew more than us (almost everyone) and each other, and partied and supported each other outside of the hospital. My fellow residents are still some of my best friends though we are spread throughout the country. Striving for excellence and fulfilling our purpose was just part of our telos. It was exhausting and hard, but absolutely necessary for the wellbeing of our patients current and future. We did not have to be taught these values. We just needed to learn how to practice Medicine, and that is what we did. My, how the attitudes have changed.
There’s nothing I can add that others haven’t said regarding the importance of this list for providers. As a PATIENT, however, I wish every one of my specialists would read this (I might present it to my PCP and other docs with whom I personally worked while doing addiction and chronic non cancer pain).
I have said it before to you; having you as a doc would make life easier / I’m so glad you are out there helping others learn your skills.
I will add that humor is absolutely essential!!! I do all I can to make folks laugh who take care of me at my own expense. Rule #62 is the most important “rule” of recovery. Thanks for all you do.
Thanks so much Jim.
Adam
Great list and I add that these should be lifelong practices.
Maybe one more :spend less time whining about yourself and more time thinking about the fates of your patients.
Well OK,that would not go down so well but you know what I mean.
I know what you mean, but the word "whining" often reveals a mindset in older professionals that undermines their effectiveness as a teacher/mentor. I find more empathy and good coaching reduces the normative distress in most learners. A few do need some tough love on their attitude problem.
yes, as i said that would not go down so well.
Might not go down well but I do agree...
Excellent post and it rings true for me. I know residents don’t have time to read, but that the books “How Doctors
This is so good. I am a medical massage therapist, so only very tangentially related to healthcare, but I even got a few takeaways for how I can improve my client contact. These are really good ideas for a lot of people.
Great to hear. Thanks so much.
.
Used to be 1400hrs+ knife to skin here. Now less than 1/3 of that. Anyway lists are a large component of what we’re about, day to day. Thanks.
Good list.
I did "midnight rounds," in person in training and at least by phone when I was in Family Practice. I focused on the nurses' curent concerns and also on what would scare everyone at 3 AM.
Smart! Excellent! And thank you for sticking close with RNs ☺️ Nurses know the docs who do that (not many of them), and we ALWAYS do timely interventions ❤️🌿🤝