General Medicine Service Expectations

In my effort to always “make it count twice,” I share my expectations for students who work with me on the inpatient general medicine service. I expect this will be of enormous, or maybe even immeasurable, help to students and attendings everywhere.

You will be rotating with me on the inpatient general medicine service. These are my expectations for you. They are meant to maximize your educational experience while guaranteeing a high level of patient care. 

General

• I expect you to be the primary caregiver for your patients. I will do my best to look to you for updates.

• Of everyone on the team, you have the most time to spend with patients. I expect you to have the best grasp of your patients’ history of present illness, past medical history, and relevant social history.

• Never hesitate to go back to gather more information from your patients. Data from the history and physical exam are critical and free.

• Dress code

  • Men: It is safest to dress like me. If you need extra guidance, watch doctor movies from the 1950s.¹ 

  • Women: See above (and here).

  • Men and Women: It is fine to wear scrubs in the hospital but only when I won’t see you.

Conference Room Presentations

• Your presentations need to be complete but concise. I will not know the patients until you tell me about them. I need to know what you are thinking and why, but I also need enough information to enable me to question your diagnosis.

• I need your presentations to be concise. Hold back unimportant information, but be prepared to give me extra information if I ask you for it. I am likely to interrupt you midway through your second sentence.

• I expect you to present without notes. I, however, will be looking at the electronic medical record and will correct you every time you misspeak.

• Tattoos

  • I expect a description of all of your patient’s tattoos. A photograph is not an appropriate substitute because observation and descriptive skills are important.

  • I expect a brief story of the patient’s decision making regarding the tattoo and, on a scale of 5-10, their level of regret.² 

• I have some bizarre preferences. I prefer hematocrits to hemoglobins. I prefer vital signs presented as even numbers. Latin words (diverticulum) must should be pluralized correctly (diverticula). You have no way of knowing these preferences but I will hold it against you if you ignore them.³

• Do not drink coffee while you’re presenting. If you do drink coffee (because I do and you’ll want to model your behavior after mine), only drink black coffee. Fake coffee drinks, and those who drink them, irritate me.

• Do not go to the bathroom while we are rounding. If you absolutely have to go to the bathroom, don’t ask, just go, but make absolutely sure that it’s at a time that I will not be asking you questions.⁴

Bedside Presentations

• Never present findings that I can easily observe (sex, race, obesity…).

• Do not demonstrate any physical findings that will make the patient uncomfortable unless it is absolutely necessary. If it is necessary, assure that the door is closed and the minimum number of team members are present.

• Never examine the patient from the left side of the bed.

• When we retreat to the hallway to speak, please stand. Do not lean against the wall. I will lean against the wall because I am older than you.

• Keep your weight on both feet equally. I do not like when people lean on one leg. 

• There are issues that I consider “intern level problems” that I never want to hear about. These include, but are not limited to, constipation, hypokalemia, and pain control.

• If intern level problems progress to the point that they become attending level problems (bowel obstruction, symptomatic electrolyte abnormalities, opioid induced respiratory arrest) your grade will suffer.

Documentation

• Please complete your documentation promptly.

• Documentation should demonstrate your knowledge and clinical reasoning skills AND fulfill all billing requirements. 

• Notes should be written daily, no cutting and pasting.

• I will not read your notes.

Education

• When I have the time and energy, I will relentlessly question (pimp) you.

• Do not worry about these sessions, I do not expect you to be able to answer all the questions.⁵

• There will be no way to prepare for these questions as they will relate more to what I know than to what is relevant to the care of our patients.

• Whatever you experience during these sessions, it cannot be called “public humiliation or belittlement” because that would qualify as student mistreatment. 

• I will probably assign you to do a short educational presentation for our team. I will immediately forget that I have assigned this, so the work you put in will be wasted.⁶

• I am unlikely to give you any feedback at the end of the rotation. If I do, it will be, “You're doing a good job. You should read more.” This feedback will have no relation whatsoever to the grade I randomly assign you. I should not be held to account for this discrepancy.

Most importantly, have fun and learn a lot. I am sure we will enjoy working together. 

1. I recognize that all the doctors in these movies are middle aged white men. Use your imagination.

2. If a patient says their level of regret is less than 5, you need to query them more intensely as this can’t be true.

3. H/T Harry Neuwirth

4. It is impossible to predict when I will ask questions.

5. In truth, though, it will be hard for me to not judge you for not knowing things.

6. There is a small chance that I will remember, so it would be unwise not to prepare the presentation.

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