Archive for the ‘Communication’ Category

Medical school, internship, and residency are particularly busy times. If you’re a doctor in training or someone who cares about one, you can send a quick eCard to let them know you care.

They’re easy… they’re fast… and they’re free…

I just posted several ecards and this video tutorial showing you how to send them. Check it out.

Residency tips and pearls should be a little more accessible than having to ask all of the time. Especially because there are some questions people are reluctant to ask… like about stress. Here are some coping tips for internship and residency…

No baby yet, so I had time to address some questions… One question was posed (on a forum) about extreme levels of stress and anxiety in internship and residency. Here was my response. Some of these tips and pearls come from the free report you can signup for at the right (just put your name & email in there & follow the directions… easy-peasy). Some of the other tips & strategies come from RookieDoc members-only videos. And some of the others were specific to the questioner. Anyway, check out my response and let me know if it helps you.

Also, if you have a question for me, Just Ask.

What you have expressed is ultra-common. It is, by far, the biggest thing I deal with every year from May to about October. I give talks to and provide services for new interns… I’m not going to plug my stuff here, but I am going to give you some background and a little proof that it is common.

When I started internship, I came in pretty average or slightly below average. I felt like any minute I was going to be declared a fraud & that somehow this whole medical school thing was actually a mistake. I was also immensely fearful of hurting someone.

Because of those two things – harming someone & being declared a fraud – I was always the first one in… always the last one to leave… At night I was dreaming about my patients. During the day I had palpitations, fatigue, reflux, etc. And throughout the day I was dreading any situation in which I could be called on or humiliated. Now, I wasn’t paralyzed with fear and I did my best not to show it, but I was definitely burning out.

So much so, in fact, that there was an intervention. Two attendings pulled me aside and took me under their wings.

One & a half years later I was Resident of the Year, then Chief Resident, and now I hold a prestigious position at my institution. Now the unfortunate thing is that not everyone gets attendings to guide them through it all (despite the whole idea behind our training). The fact is, you’re right, many people do talk about specific interns behind their backs. Some even pigeon-hole them into categories and give them labels that stick with them throughout their training – passed from attending to attending.

So I started giving talks to new interns and started some web sites and services. In the process, I have interviewed or surveyed well over 1100 interns anonymously and as a coach/counselor.

And guess what? Most of them list those same two top fears that I said I had. (My surveys always ask for the 3 top fears… and these 2 are the most common) Fear of harming someone is always number one… and fear of being the weakest link or worst of your peers or exposed as a fraud – almost always number two.

So what you are feeling is more common than you think. Actually, it’s probably normal.

Now, is it as intense as you describe? Not usually.

Now, on to some things to help cope…

1 – You are not alone. You know when you’re sitting around with the whole team – the students, the interns, the residents, maybe fellows, and the attending? And you know when the attending starts throwing questions out to the group? At that moment, everyone is secretly hoping they’re not called on. Everyone is eager to blurt out an answer when they know it… because they want to be absolved from answering the ones they don’t know. (Incidentally, because of this fear, I always start with the students, then the interns, then the residents when I’m asking questions to my team)

2 – The 10-Year Litmus Test. Ask yourself, “10 years from now, will any of this matter?” And the answer is no. It will not.

3 – Strengthen Your Strengths. This might sound like an odd suggestion & maybe even unrelated, but it is not. Most people are worried sick about their weaknesses. But think about this… How are you going to stand out? How are you going to provide the most value to your program? How are you going to forge the career you want, that’s in line with your passions and goals? Do you think you will do these things by working on your weaknesses? No.

If you want to stand out… If you want the people around you to say good things when you’re not there… If you want to like the company you keep… and if you want to make an impact in your patients lives or even on the world at large…

Then you should strengthen your strengths. Provide value to your program and your patients and your fellow interns with the areas you are strong in. (Related to medicine or not)

4 – Compare Yourself To Yourself. Too many of us worry where we stand relative to someone else. Like you said, “i will compare myself to my class mates and convince myself that they are all so much better than i am”. You are comparing what you know of yourself to what you do not know of others. You have no idea what they are thinking… what their fears are… or even what attendings think of them… or the vibe that patients get from them… or whatever. The best comparison to make is “This is where I am now – am I better than a few months ago? And how much better do I want to become?”

5 – You Are Not At The End Of The Road. Just because you are a doctor doesn’t mean that you are done. You are not at the “end of your training journey”… you’re right in the middle of it. You’re in the middle of the process. Trust the process a little bit.

Thousands of interns have come before you and thousands will come after you. All have their strengths and their weaknesses. This process helps make those weaknesses into competencies (maybe even strengths depending on you and your program). But the ultra-successful ones will be the ones who leverage their strengths.

So trust the process and add value along the way.

6 – It’s All About Communication. It’s not about knowing the right answers or even ordering the right tests the first time around. Those things come with time.

The best doctors are the best communicators. (By the way, so are the best wives, husbands, parents, etc) More on this another time.

7 – Avoid Complainers – Steer clear of complainers. Complaining is infectious. And whining will get you nowhere.

8 – Avoid the backbiters.

9 – Laugh a little bit. Check out sites like GiggleMed.com’s Medical Humor Blog, Placebo Journal and Q-Fever. But find humor only in appropriate things related to work – not in individuals or demeaning things.

Anyway, I hope this helps.

I get hundreds of questions about residency training, internship, and the clinical years of medical school. Lately, it seems that I have been getting more & more questions pertaining to preparing for residency when you have babies at home.

Well, here’s one email response to such a question. This is Tip #29 from the Residency Tips Series.

If you’ve got a question of your own, just ask. (I will not publish your name or other personal identifiers unless you’re giving me a testimonial & you give me permission to use your name.) In fact, you can ask the questions anonymously if you want, but I won’t be able to get back to you unless you leave your email.

Anyway, on to Tip #29…

Hello

I received your question from the RookieDoctor.com site and I wanted to offer some insights.

(“I have an 11 month old baby, Would I be able to manage my work and my family?”)

First of all… congratulations on the baby

Is it possible to manage your work and your family with a little one in the house?… absolutely. However, it takes some planning and it will be a source of some stress at times.

My wife and I were in the same class in medical school. And we had a child at the beginning of our third year of med school, and another at the end of our internship, and yet another right before residency ended. So, we’ve dealt with a lot of the same things you are about to go through. That being said, your situation is unique to you.

The first thing would be to assess your support structure and your “allies”. Possible support includes your family, your spouse’s/significant other’s family, your spouse, close friends, your siblings, your parents. Again, I don’t know your situation. But, don’t assume that others are unable to help in some way. It may not be watching your child during the day or call-nights, but for some it may be as simple as picking them up from someone else’s house, or picking up diapers the next time they go to the store, etc. It will be difficult to ask for help in some cases, but you may just have to.

By assessing your allies, I mean people that you may not be close to right now, but can offer some support in some way. One ally might be an upper level resident who previously went through the same thing. They know the residency program you are in… they know who is easy to approach about this subject and who should never be approached… they know local resources… they may know of an attending that lets residents leave for family reasons, etc. You might say, well, I didn’t start yet and I don’t know these people. Guess what? A great resource for who is who is the department secretaries. They know the gossip. Ask them… “Has anyone recently gone through this program with a baby at home? I just need some tips.” You can also ask them, “What do you recommend?”

Another ally might be the chief resident… Let’s say you know your spouse has a particularly busy time of year coming up… you can ask for lighter schedule/electives around that time… Vice versa… if you know you’ll have more support at a particular time of year, then see if you can do your harder rotations during that time. Again, this takes planning. You’ll need to review your yearly block schedule and try your best to make arrangements as early as possible.

And the more stuff you have pre-packaged, the better. Let’s say you want to do a critical care rotation in December because you will have more support at home… well, look for someone that has critical care in December and ask them if they’d be open to switch (most would prefer not to have a call month near their holidays). If they are open to switching, then just mention that to the chief resident or whoever controls the block schedules. The less they have to do, the more likely you’re going to get what you want.

Another thing is… don’t waste any time. When you’re at work there is going to be downtime. You should take care of things you can during that time… you need to pay your bills, work on a presentation, arrange a doctor’s appointment, signing charts (if you have to dictate), filling out forms, etc. Surfing the internet, gossiping, etc are all completely a waste of time and will take you away from things that will free up time at home. Very important.

There are two very important things to prepare yourself for:

* Communication
* Guilt

Communication is of the utmost importance. Your non-medical family and friends (your support network) will not understand what you are going through. They won’t understand that even though you’re at the hospital or office a lot, you may have to come home and read or prepare a presentation, etc. They need to know this and they need to know why it is so stressful for you. And I mean a sit-down-heart-to-heart “Mom, I’m worried” “Honey, I’m scared.” etc.

Communicate with your co-residents and your chief resident. Apologize when you inconvenience someone. And don’t assume that you know the answer. You might surprised what happens when you just ask.

Guilt is probably the toughest. You will miss things like bedtime, bath time, important milestones, etc. You will have to deal with crying when you leave (your child and occasionally you).

I hope this is helpful.

Let me know if you need anything else.

Dr. Tori

I just posted another video to YouTube… This one is the second video in the RookieDoctor.com series on Residency Horror Stories. You might be wondering where the first one is… Well, it’s a little long and has some embarrassing information in it, so it’s only available to members. (Yes, even more embarrassing than this video.)

In this video you get to see how I screwed up telling someone that they were dying. Horror for me… but, good for you, because I extract several important lessons from this story for you. In fact, that’s the very reason I’m sharing these horror stories with you… You can take the good and leave the bad and it’s told to you in a way that you won’t forget… a story.

So please take this stuff with you through your clinical training years and apply it. You will be a better doctor for it and, of course, your patients will benefit too.

I would really appreciate your comments… You don’t have to tell me how much of an idiot I was, though I learned my lesson… Hopefully you learned my lesson too.

Anyway, let me know what you thought about the video and if you have any horror stories of your own. There’s many more where this one came from… but thankfully not all from me.

If you submit any stories about your training or someone else’s please do not include patient identifiers or institutional identifiers. Of course, if you do, I’ll remove them from the story and I will alter some of the details for the sake of anonymity and privacy. But if you share your stories, others might benefit from the lessons.

I’ve started a Residency Horror Stories series. The point is not to get you nervous about your training or being on-call or anything like that… In fact, it’s quite the opposite.

Most people think they learn best through experience. That’s true, for the most part… but there’s another piece of “experience” that is even more important than the experience itself… and that’s “the story”. We remember things as stories. We further ingrain the memory by retelling that story. And each time we retell it, there’s an opportunity to extract new insights from it and an opportunity for the listener to benefit from your story.

Now some of the medical establishment (the Old Boys Network) may be a little upset with me for saying this, but… the dry, factual version we often present on rounds is not always optimal.

Which one are you going to remember?:

THIS?:

49 year-old obese female with a history of type 2 diabetes and smoking who presented to the ER with severe chest pain, hypotension, and diaphoresis. Her EKG demonstrated 3mm ST segment elevation inferiorly. Cardiology was consulted and she was emergently taken to the cath lab. After a brief Vtach arrest requiring 260 Joules for return to sinus rhythm, her right coronary artery was successfully stented with two Taxus stents with good angiographic results. She was transferred to the CCU in stable condition with an intra-aortic balloon pump, IV heparin, Plavix, and aspirin.

THIS?:

It was my first week as a second-year resident and I was on-call in the CCU. I was called stat to the ER for a CCU admission that was described as a “49 year-old obese female with a history of type 2 diabetes and smoking who presented to the ER with severe chest pain, shortness of breath, and diaphoresis.” I was told that cardiology was consulted via phone & they recommended transfer to CCU after a VQ scan.

I went to see the patient & there’s a morbily obese lady lying in Trendelenberg, IV fluids wide open, heart rate in the 40s, and huge “tomb stone” STs on the monitor. I introduced myself and told her that we would take good care of her. She looked up at me and said, “Son, I’m gonna die tonight if you don’t do somethin’.”

I went to the ER doc and said, “This lady’s clearly having a huge RCA MI! She’s bradycardic, hypotensive, complaining of chest pain, & her EKG… well, look at it! We can’t send her to the unit with a VQ scan.”

He responded, “Well, I talked to the cardiologist on-call.” And I asked, “Well, are sure he understood what we’re looking at here? I mean, no offense, but sometimes it’s all in how we say it. I think you should call him back.”

Well, he did… the ER doc called back the cardiologist on-call and got screamed at… loud enough for me to hear it through the phone from about 4 feet away. “I said!… Admit to CCU and get a VQ scan!”.

He hung up. There I am, a new second year, one of my first nights with any kind of real responsibility and I’m disagreeing with the ER attending and the subspecialist. What should I do?

Well, there was no question… that lady said to me, “Son, I’m gonna die tonight if you don’t do somethin’.” So I did… I firmly asked the ER doc, “I’m not comfortable with this! Are you comfortable with this?!” He said, “No… No, I’m not.” So, I asked, “Well, how about TPA?” He paused… so I snatched the EKG out of his hands and ran 3 floors up to the telemetry floor. There was a cardiologist (from a competing group) and I shoved the EKG in front of him and said, “49 year old lady in Room 8 in the ER, tons of risk factors, heart rate in the 40′s, telling me she’s going to die… no labs back yet.”

He said nothing to me. He picked up the phone and called the cath lab. Together he and I wheeled her into the lab. While we were lifting her to the table, she arrested….

So which one are you going to remember? Which one will give you strength to do the right thing when the time comes. Both of those versions are true. I lived through it. More importantly, so did the patient, but not before her night got much, much worse. I’ll tell you the full story and the lessons learned in the second video for “Residency Horror Stories”… the first video will be in the next few days.

Do you have a story we can all benefit from? Tell us. Here’s the link again:

After a great response from those of you on my “new release priority notification list”, the RookieDoc Membership program is being opened to anyone that is interested. Here’s a short intro video to show you some of the things that are part of membership. If it sounds interesting or useful, click the link below the video to find out more.

The images of CDs, books, and DVDs in this video correspond to downloadable products.

If you could sit down with me and ask me any question about being successful in your internship or residency, what would it be? I’ll answer some questions on upcoming RookieDoc FAQs – these are occasional phone conferences for RookieDoc fans and members where I discuss a hot topic or answer questions.

Ask Me About Internship or Residency

I may not get to every question directly, but may be able to post important answers here, in special RookieDoc reports (PDF), on the RookieDoc Squidoo lens, or in the Audio Tips series.

By the way, the RookieDoc membership is undergoing some upgrades and will open to new members soon. Stay tuned. In the meantime, though, get your question in. Go ahead, click the link above.

OK. I had a sad, humbling experience on a trip to Wal-Mart last night. My wife asked me to return something and my daughter was/is sick, so I had to get a prescription filled. Not a big deal, right?

Well, three things… One. I am not a Wal-Mart guy. No offense to Wal-Mart Inc, but in my area the “customer service” there is quite pathetic. It is the type of place where those hilarious guys at Despair.com get inspiration. I have to consciously prepare myself to keep my mouth shut… suck it up… and move on.

Two. I am not a go-to-the-store-and-return something guy either. It’s just not me. I don’t like doing it. If I can get out of it, I will. (But if I’m wronged, I’m going full tilt – Better Business Bureau, letters to the home office, etc… just don’t make me return anything.)

Three. It’s the week after Christmas and the place is packed.

Anyway, I went.

There were no less than 40 people in line at the “customer service” desk (so naturally, I didn’t return anything . I briskly bobbed and weaved to get to the pharmacy pick-up line. I was number 16 in line. Ahead of me stood 15 uncomfortable-looking, elderly patients. Since 11 of the 15 folks did not have a smooth pick-up, I had plenty of time to stand there… to just watch and listen.

Here is some of what I saw and heard:

• The patients in line were elderly and uncomfortable standing so long.
• Most of the patients had even sicker-looking (in a chronic sense) family members sitting aisles away on empty shelves or in wheelchairs.
• While in line, these patients were cordial and patient, but as time went on, frustration and fatigue began to show.
• While they were waiting and becoming increasingly tired, several employees were walking out from the back talking about their break and why they need to take it now, “even though it’s busy”.
• Several patients were discussing “coming back out of retirement” just to be able to afford things for daily living.
• Several quoted the $4 prescriptions as the reason they were willing to withstand the “customer service” and the lines.
• Despite their interest in the $4 bargain, most (8) of them were unable to actually get the $4 drug… mostly because the way it was written.
• 11 out of 15 had issues with their scripts being filled at all – and not one of the 11 was given a solution that they could control… The staff blamed each issue on the doctor or the government – 8 on the doctor, 2 on the government (specifically Medicare Part D), and one on both.
• The second person in line (appearing to be in her late 70s) ended up being shouted at by the pharmacist, “Didn’t you read Medicare Part D?! Your doctor has to put the indication on your prescription! It’s not my fault! Go ask your doctor. We called, but your doctor is not getting back to us.”
• There was one employee who was visibly working her tail off to get the patients their meds before they even reached the counter. She walked out and asked each person in line their names and began trying to get their stuff 3, 4, and 5 people deep in line. No one thanked her. No one said, “Job well done”, at least in the 45 minutes I stood in line.

Here are some tips and pearls for interns and residents to take away from this experience:

• Small things on your part can make a humongous difference for your patients.
• Write the indication on your elderly patients’ scripts.
• Advise your patients to bring their discharge instructions with them to the pharmacy when they leave the hospital for the first time.
• If you are writing a narcotic, put your DEA number and spell out the number of pills to dispense.
• Try to avoid writing “Use as directed”… that doesn’t fly with some co-pays, Medicare D, and some discount programs.
• Choose the medications wisely… with cost being a huge piece to factor in.
• Ask your patients if they’ve ever had problems filling scripts before and what the nature of the problem was… too many to dispense, not covered by insurance, etc.
• Consider titrating doses before adding new classes, if possible.
• Keep an updated list of the discount meds available. And familiarize yourself with other discount programs (Target, Wal-Mart, Giant, etc).
• Get in the habit of writing the generic name anyway.
• If you get paged from a pharmacy outside of your hospital, it is probably regarding a patient you just discharged… Answer it promptly. That person who was just hospitalized is probably standing in Wal-Mart, or sitting off to the side waiting for a family member to fill their scripts.
• Write legibly.
• If there’s a discrepancy when looking at their meds and the meds you thought they were taking at home, ask the patient. Reconcile your scripts with their current meds.
• Be careful what you talk about in front of others. Sure, there’s nothing wrong with discussing where everyone wants to order from for lunch. But if you do that while a patient or their family is in earshot, you might really rub them the wrong way.
• Social workers and case managers know about these patients’ frustrations and potential problems… learn from them. Ask them for feedback. And appreciate what they do. (The insurance industry is like Wal-Mart on steroids.)
• When someone does something well, or goes a little further than they have to, tell them about it… thank them… let them know that it was appreciated.

Now, it is important to realize that when you actually do these things, you will not be praised. No one will thank you. No one will really notice. And that’s okay. It’s not about you. It’s about them, the patients.

And if you don’t think it’s about your patients, then quit health care right now… and go work at Wal-Mart. You’ll fit right in… probably best-suited for “customer service”.

And here are some tips for Wal-Mart and pharmacies, in general:

• Put some seats or benches for your elderly patrons. Be generous and be strategic. Put them in such a way that people can remain in line and remain seated if need be.
• Consider having a health professional (MD, DO, NP, PA, Pharm D, etc) that can write scripts for the edits and tweaks that someone else simply forgot… things like indication, quantity, etc.
• Consider having a looping video that explains procedures, policies, what’s needed, etc. so that people don’t have to wait in line to find out that they’re missing something.
• Keep track of all of the issues that prevent people from getting their scripts on the first trip up to the counter… use that list to get to the root causes… or at least publish it. If it is truly the doctors, then send the list to me, I’ll get it out there.
• Try to hire people that “own” problems, not the Me-Myself-and-I types that consistently shunt blame.
• Remind your workers that it might be viewed as a little inconsiderate to discuss their breaks while frustrated customers look on. Remind them to consider how they would feel.
• Tell your pharmacists that it is a very, very rare patient that ever “reads Medicare Part D”… In fact, I’ve never met one.

There’s my rant, but there are lessons in there, though. I learned a lot standing in line at Wal-Mart.

I made a short 7 minute video as a quick introduction to Twitter and how you can use it to get tips and strategies for your med school rotations, internship, and residency. Just click on the video image below to get started. You will need the most up-to-date QuickTime player (free version).

Developing good documentation skills can be a tremendous part of your training – with profound implications for your patients, the effectiveness of consults you request, your evaluations from attendings, and developing efficiency for your future work. I have been called several times, thanking me for my documentation – by malpractice lawyers, by risk management personnel, and once by the Chief of Medicine at another hospital – you would be surprised at the information that others find useful in your old notes.

Anyway, here are a few tips I extracted from the Documentation Module of the RookieDoc Members area… Let me know what you think in the comments below or through email.

1. Know who reads your notes – you may be shocked at how many people rely on your documentation. If you know who these people are and what they are looking for, you will be light years ahead of others in your program.

2. Write legibly – If you work in a hospital or office that does not yet use electronic records, you better write legibly. It can have a huge impact on patient care, lawsuits, and your evaluations from attendings.

3. Use bulleted lists – Most people scan notes to the parts they think are important. If you list things like Past Medical History, recent tests and studies, Past Surgical History, recent hospitalizations, etc as bullets in a list, it will make it much easier for people that read the chart after you. You will stand out and your patients will be better for it.

4. Indent consistently – when making paragraphs or headings, do it in a consistent fashion. Avoid writing everything in one big blob of a paragraph.

5. Consistent order of things – from note-to-note, stay consistent.

6. Refer to other parts of the documentation – It’s okay to write, “See Dr. Smith’s review of the CT results in his note dated 12/13″ or “Exam is unchanged from 12/12″ or “See #2 above”. A good example of “see #2 above” may be if you have to refer to a problem more than once… like renal insufficiency in it’s own section, and then also again under diabetes.

7. Ask for specific feedback – ask attendings, risk management nurses, and upper level residents to look at your notes and give you feedback. And don’t accept answers like, “They’re good. Keep it up.” No. Ask specifically, “Well, what could I do better? What should I work on?”