I have been a teaching attending for the last three and half years and I enjoy the daily interactions on the wards with the medical students and residents. I think the biggest challenge I run into on daily basis is how to get my residents and medical students to think like me.
Some may argue that this is not quite possible as I have more clinical experience and exposure to patients than the residents and that is the whole point of doing three years of residency. The training is to build up to that level of critical thinking. Also, it is a rather an uphill challenge for a 3rd-year medical student to know certain disease processes inside out and present the appropriate findings to the attending in a timely fashion.
Yet, I find these are the expectations we unconsciously set upon our medical students and the residents frequently, especially when it comes to evaluating their performances. We almost want them to function at a higher level than their year of training [i.e- for an intern to function as a 2nd-year resident, for a 3rd-year medical student to be 4th-year Sub-I] for us to be impressed by them on the rounds. If they are functioning at their year of training, our generic advice at the end of the block is to encourage them to read more. This piece of advice is not particularly helpful, but it is the most commonly dispensed advice we give to them both in-person and in our written evaluations.
I think there is a better answer here and it goes against our current approach. The biggest misconception in medicine is that gaining more knowledge is the way for our medical students and the residents to excel on the floors. That is not true as I frequently find that some of my senior residents will know much more about a specific topic such as vasculitis than me but I will be able to guide the patient care in a more efficient way. This is also NOT to say that foundational knowledge is not required as it certainly is needed to function as a doctor. I am by no means advocating for not going home and reading up on relevant patient topics. Yet, when on the floors, a good intern or medical student can be spotted when he takes a step back and looks at the whole big picture of patient care. He or she is able to identify the major obstacles in advancing day-to-day patient care and works immediately on resolving them. Let’s give an example here to put into practical terms:
Let’s imagine a 74 y.o woman with limited medical insight who presents to the hospital with a complaint of progressive shortness of breath and tachycardia and is diagnosed with acute PE in the ER. She, unfortunately, does not have insurance and is admitted to the hospital for heparin to coumadin bridging. An intern or a medical student will present the H&P to me in the morning and my mind is already clicking on relevant issues such as discharging the patient on coumadin with proper instructions, setting the patient up with coumadin clinic, and ensuring that the patient has proper social support to get her INRs checked regularly. Some might interject me here and say, “This is a job of a second-year resident to facilitate these issues and even prepare the interns and medical students before rounds for such matters.” My reply to that statement is good luck. The poor senior resident is already putting out fires in the morning from dealing with acutely sick patients to rapid responses to challenging patients. Or he is being called by consultants to put in a certain lab order or by radiologists for urgent findings on imaging studies from overnight. Where does the senior resident find the time unless he or she is having a slow day which I find is quite unusual at a busy hospital? Also, even if a senior resident prepares or coaches the interns or medical students on individual patients, isn’t it better to provide the framework instead so that the interns and the medical students can think on their own for such issues?
Here’s my approach and it is very simple: The medical students and the interns, even 2nd-year residents are advised to write a section called disposition as the last topic on their note after DVT prophylaxis. The disposition directly addresses the question of “What is keeping the patient in the hospital TODAY and what needs to be done for the patient to leave the hospital?” It allows or better yet, gives the intern a permission to take a bird’s eye view of the patient care for that day. More often not, interns are so busy dealing with day-to-day noise that they rarely take a moment to look at the big picture.
I have not come up with the genius idea of writing disposition and it is written commonly in ancillary staff’s notes [I bet your case management has it in his or her note]. Matter of fact, I was instructed in my residency to frequently write it and it is a tool which has always served me well. It wouldn’t be far-fetched for me to say that this approach has also saved the hospital ton of $$$$ as it has made a difference between a patient getting discharged on Friday afternoon or staying the weekend and leaving on Monday as a procedure such as PICC line placement could not be done over the weekend. [Experienced physicians will nod their head here].
I think our interns and medical students will find this “hack” useful and allow them to ask right questions to themselves to allow the patient care to move forward. If you are a physician of any level, I suggest you try it in your daily approach and see if it works for you.
