Clinical Guide The Nerd's Guide to Pre-Rounding Table of Contents Part 10. Team Management for the MS3 Here’s a few suggestions for helping yourself in dealing with team dynamics. Logistics. First of all, make sure you introduce yourself to ALL team members, not just docs but also NPs, pharmacists, social workers, translators, etc.—anyone who rounds with your group. Every team member is a potential ally who may help you. So be friendly, know everyone’s name, and use it. This also applies to nurses staffing wards your patients are on. Also, have a card for recording your R1, R2/3, and attendings’ pager numbers. I also make a point of noting down my residents’ I.D. code numbers (called the "CHN number" at SFGH). These codes are needed on order forms for labs and studies, and I usually have an opportunity to collect them during the course of work in the first week or two, and jot them down where I keep pager numbers. Residents and attendings like it when you fill out forms for their sign-off with the codes already filled in; it shows you’re paying attention. Note that you ARE allowed to write orders, as long as they’re co-signed by an intern or resident. Talk to your team about how they want to manage this. Also, if you do write orders: Check every med order you write against your Tarascon’s Pharmacopeia or Epocrates—even when you’re SURE you know the prescription. Wrong med orders are a common cause of bad events. Great Expectations: Soliciting Feedback. Make it a habit, soon after joining a team, to speak to your evaluators. (Those are usually your attending and senior resident, and not your interns, but this varies, so check with your program director.) Let them know what your personal goals are for the rotation, and find out what their expectations are for you. Also, during the first conversation, tentatively suggest picking a date, about half-way into the rotation, when you would like to meet with them to discuss how you’re doing on the clerkship. On busy services, they may not want to set a time and simply ask you to come find them when the time arrives. Initiating this conversation demonstrates a high degree of professionalism, which, as explained above, will help you in areas you wouldn’t even expect. Gauging Your Team, or Knowing When to Tread Lightly. Unfortunately, skills such as being able to accurately read when your resident is too tired to answer questions, or whether an attending is rather formal or someone who appreciates a good joke, is not something that can be imparted with advice. I’m not even sure if it can be taught. But I can tell you that people who can read their team members in this way—that is, who demonstrate emotional intelligence—are going to fare better than those who cannot. "Yes, Virginia, There is Such a Thing as a Stupid Question." Related to the above, but more substantive: While in lecture we were assured constantly that there are no dumb questions, this is not necessarily true on the wards. Specifically, I make it a policy never to ask questions about basic information I could glean from a textbook. Why annoy your superiors with such questions when you can educate yourself on the issue—and maybe learn some things your attending had forgotten? (And by the way, if you ask such questions, you will likely be told, "Good question. Why don’t you look it up and let us know tomorrow?") When I ask questions, I try to make them about the resident’s clinical judgement—something I can’t learn from a book—or about my patient’s particular case. Examples: Not, "What kind of murmur do you hear in a patient with mitral stenosis?" but rather, "What do you find works the best to elicit the murmur when you examine a patient with mitral stenosis?" Not, "What drugs will we use for Mrs. Gonzalez’ AMI?" but rather, "How will Mrs. Gonzalez’ renal failure affect our choice of drugs for her AMI?" While asking questions can be a way to demonstrate interest in your patients’ problems, be careful to follow the above advice. I had one friend who, while sitting around with her resident on call, asked a lot of basic questions about anti-arrhythmics—a topic that, frankly, even most attendings find a little complicated. My friend thought she was demonstrating an interest in her patient. Her resident, instead, cited the conversation in his evaluation, as evidence of her "poor fund of knowledge." (All together now: Oooof!) The lesson: Never ask basic questions of a superior, when you can check a book. In fact, by reading up, you may be able to ask smarter questions and come off as more informed than your intern! The Rest of the Team. Sections 4 and 5 of this Clinical Guide describes the various members of the physician team, but keep in mind that you will be working with many members of other health professions on your teams, in the clinics and on the wards. Some of them could be crucial allies. Briefly: Nurses: The first commandment of clerkships: Nurses can be the medical student’s best friend. I think it’s wise to befriend the NP’s on your team, if there are any. They are usually the best teachers, esp. in physical exam skills, and are often friendlier than the doctors. Ward RN’s can also be very helpful in keeping you informed about your patient—so make it a point to meet them and communicate with them regularly. Ward nurses spend more time with your patient than you do and may notice things you do not. Social Workers: Again, these folks are important to know about. Especially if you have a patient with "dispo" issues - homeless, frail elderly, psych issues - the social worker will be key to finding a safe and efficient discharge plan. On some services, in fact, teams have social workers or nurses whose only job is to ensure secure discharges for the patients. PT/OT/ST: Physical therapists will assess patients’ crude motor skills, such as how they’re walking and if they’re at risk of falling. Occupational therapists assess more fine-motor, ADL (Activity of Daily Living) type skills, such as being able to cook a meal, groom, etc. Speech therapists not only analyze problems with speech production, but may also be able to assess whether a patient is at risk of choking or has "airway issues." Patient Care: Their Cats Will Thank You. Students often feel uncertain about their role on the doctor team. I think it’s important to remember that students have more time with the patients than do residents or attendings. Thus, you are the "fingers" of the team—which means you are the "human touch" in patients’ medical care. Don’t forget this, and don’t think that just because you don’t see residents spending time chatting with patients, that you shouldn’t do this. Good residents will explain to you that even though they don’t have time to do those things, they support your doing them and even expect you to do them. One of my patients, a lady with mesenteric ischemia, had post-surgery complications and wound up in the CCU. She had no family or friends nearby, and being on a ventilator, couldn’t talk. She had been a journalist before retirement, as I had been before med school, and we bonded about both being writers. Anyway, the evening after she woke up in the CCU, I stopped by to read to her. (Walt Whitman, to be exact.) The sight of a "whitecoat" reading to his patient was apparently surprising—the visiting nurse actually asked me if I was her relative! "I’m just her medical student," I explained. I may have felt a little awkward, but it meant something to her, and I’m glad I did it, because she never left that hospital. Another one of my patients, a lady with pneumonia, was very anxious to leave the hospital. When I probed a little, she told me she had three cats at home and no one to feed them. So, I borrowed her keys, stopped by the house, and fed the cats. My residents all chuckled about this, but hey—who else was gonna feed her cats? If my mom was in the hospital with no one to feed her pets, I’d hope some nice medical student would do that for her. Do these things. It matters. And students can do them better than the rest of the team.