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Medscape Grand Rounds for June 30

Today is June 30, 2009. Which means, if I’m correct, that tomorrow is July 1st. And July 1st is the day that, all across the country, recent medical school graduates begin residencies in their assorted specialties. An amazing time, indeed! I remember it well. Standing around in a suit, listening to lectures, trying to figure out who was really smart and who was more like me. None of us knowing, by a long-shot, what we were embarking upon.

My friend Brad, an attorney, says of his years as a cadet at the Citadel, ‘It was a terrible place to go, but a wonderful place to have gone.’ He doesn’t mean it ironically…not completely. What he means is that, it was hard and miserable at times, but he’s thrilled that he did it. He looks back with pride and wonder on his accomplishment as a graduate of one of the most stressful college environments in America.

Residency is like that. I wouldn’t exactly want to do it again, but now and then I allow my self the vanity of saying, ‘wow, that was hard and you did it…and did it well.’

So, what can we say to all of those beginning their journeys? That was the topic of my Grand Rounds. And the submissions have been outstanding, and varied. Thanks for all of that. Thanks for taking the time to impart some wisdom and guidance to the folks starting their residencies tomorrow.

I’ll finish my intro with my own advice. I’ve been dinged for going on too long in my Grand Rounds. I won’t do it today. I’ll prattle on with my own insights some other place, some other time. For now, I’ll just offer a few little guidelines for all of those PGY-1 lambs, off to the slaughter.

1) It’s going to be hard. Deal with it. The less you whine, the more you will be loved and trusted. Learn to be strong, learn to power through your fatigue. And remember that it often takes more energy to avoid work than to just do it.

2) Do the right thing. Ethically, professionally, morally. Be the one everyone can count on to do the right thing; however hard it may be.

3) Humans, to paraphrase Blaise Pascal, are glorious and wretched. Capable of nearly angelic goodness and demonic evil, they will both thrill and disappoint you. Be neither too judgmental nor too naive. And remember that you, dear ones, are human as well.

I sit here, 19 years later, 16 years of practice under my belt, my wife and four children nearby, and I think back to that day, to that time, and all I can say to all of those young men and women is: ‘God bless and keep you. God give you wisdom and strength, from this day forth and always.’

May I present, Grand Rounds!

From Duncan Cross, some excellent, candid advice about how to treat patients from someone who is a patient. His main point is the difference between clinical and social problems. Well said, Duncan!

http://duncancross.net/2009/06/the-clinical-and-the-social/

Dr. Rich reflects on the madness of physician organizations efforts to ‘make the nurses behave,’ . As always, his insights are well considered and practical. Young doctors listen closely; nurses are a huge part of your professional world, so understand the conflicts and learn to work within the system as it evolves.

http://covertrationingblog.com/primary-care-in-america/on-making-the-nurses-behave

Barb Kivowitz at ‘In Sickness and in Health’ points out that illnesses affect couples, not individuals. Please consider both factors in your evaluation and treatment of patients. An excellent, and often overlooked, point. Couples aren’t two, but one!

http://insicknessinhealth.blogspot.com/2009/06/what-would-you-like-to-say-to-future.html

Kerri Sparling at sixuntilme reminds us of the fact that our patients are people first, not diseases, entities, products, target audiences or anything else. See Kerri and her friends in Philly for a lovely reminder.

http://sixuntilme.com/blog2/2009/06/the_faces_of_the_philly_meet_u.html

Clinical Cases and Images blog reminds us to write for ourselves, not for anyone else’s benefit (even Twitter and Facebook ‘use’ those who write for them, in a sense. We should share our unique perspectives by independent blogging.

http://casesblog.blogspot.com/2009/06/twitter-and-facebook-will-not-replace.html

Practical advice comes from Laika’s Medical Blog; using PubMed!  Thanks for the excellent tutorial for new residents and their instructors.

http://laikaspoetnik.wordpress.com/2009/06/30/10-1-pubmed-tips-for-residents-and-their-instructors/

David Harlow at Healthblawg tells residents to recognize that patients have a right to their own health data. Can’t argue with that; but some folks act like it’s somehow too secret even for the patients. Let your patients have their information! And don’t fight it.

http://healthblawg.typepad.com/healthblawg/2009/06/a-declaration-of-health-data-rights-cant-argue-with-it-but-its-only-a-first-step.html

From Chris at Man Nurse Diaries, a great reminder that science can coexist with the needs, even the desires, of the human beings who are our patients.  Even in the world of the C-section, eh?

http://mannursediaries.blogspot.com/2009/06/give-breech-chance-canada-reverses-c.html

Chris also directs us to this excellent related article at scienceandsensibility:

http://www.scienceandsensibility.org/?p=239

Follow this advice at The Cockroach Catcher: Challenge ideas, don’t be afraid of things new, different or unorthodox. Some of the best of our medical history was a challenge to the status quo.

http://cockroachcatcher.blogspot.com/2009/06/old-new.html

From Rita Scwab at Supporting Safer Healthcare, this piece on credentialling. Doctors, you may not be there yet, but read closely and pay attention. You’ll need to know all of this sooner than you can say ‘code blue.’

http://www.supportingsaferhealthcare.com/2009/06/back-by-popular-demand-the-ugly-truth.html

Though residency doesn’t often teach doctors about business, here is some useful advice to tuck away. Small practices can work and thrive in these days of large corporate medicine.

http://www.healthbusinessblog.com/?p=2412

Sometimes, we get what we ask for, then regret it. Henry Stern at insureblog says to young physicians, ‘beware of a Canadian-style of transparency in healthcare.’

http://insureblog.blogspot.com/2009/06/transparency-canadian-style.html

http://haloscan.com/tb/hgstern/894321934377798843

Wisdom from the American College of Physicians: Pagers…aaagggh!

http://blogs.acponline.org/acphospitalist/2009/06/sorry-doctor-i-paged-wrong-resident.html

Have you ever been paged when you weren’t on call? Oh, that’s right, you just finished medical school. The paging horrors have only just begin! Read on for more stories on paging the wrong doctors!

http://archinte.ama-assn.org/cgi/content/extract/169/11/1072

While you’re sorting out those false pages, start learning to be cost-effective. It’s an important part of good medical practice. Read more from the ACP on this relevant, timely topic.

http://www.kevinmd.com/blog/2009/06/acp-embracing-a-culture-of-cost-effective-health-care.html

Alison at shootuporputup says, to all young physicians, smart is good, but attitude is crucial. No question about it!

http://www.shootuporputup.co.uk/2009/05/08/let-me-manage-your-expectations/

Walter and Faith at highlighthealth address benefits of self-directed vs. group health intervention in heart disease management.

http://www.highlighthealth.com/research/tackling-heart-disease-together-or-alone-the-behavioural-science-of-self-management/

They also remind me to mention the following important points:

Grand Rounds can be followed via email or RSS feed:

http://feeds2.feedburner.com/GrandRoundsBlogCarnival

An aggregated feed of credible, rotating health and medicine blog carnivals is also available:

http://feeds.highlighthealth.net/HealthAndMedicineBlogCarnivals

Wise beyond his years, this insightful post by a third-year medical student suggests it might be a good idea for residents to strive to understand the system, and it’s problems, even as they learn to practice on the humans the system treats.

http://medicalpastiche.blogspot.com/2009/06/what-would-you-like-to-say-to-future.html

At Other Things Amanzi, future physicians can read about how horrible humans can be to one another, and how delightful peace and order really are. Don’t be surprised by the depths of human depravity.

http://other-things-amanzi.blogspot.com/2009/06/bell-bottoms.html

Heck, I’m always behind. Now that I’m blogging, I realize I don’t have a smartphone to stay up-to-date. Always a day late and a dollar short. Still, those of you on the leading edge will find this piece useful.

http://www.medicalsmartphones.com/2009/06/best-smartphone-operating-systems-for.html

Here is my submission for Grand Rounds. Better late than never? Understand if I am too tardy to submit.

Reality Rounds submitted, ‘How to Survive the Big House.’ I couldn’t open the link, so I pulled this one from her blog. I think it’s very relevant to residency. What do you do when you can’t help What do you do with the guilt? Thanks for the painfully honest post.

http://realityrounds.com/2009/06/22/guilt/

Not all residents are whipper-snappers. Some have children or, gasp, teens. Here’s some advice from healthline.com on how to handle your teens and their dating habits. I wonder if it’s applicable to residents and their dating habits? Maybe residency directors should pay attention here.

(http://www.healthline.com/blogs/teen_health/2009/06/when-teens-start-dating.html)

Living as I do in the land of all things stinging and biting, where my bathroom is constantly inhabited by wasps and my yard by hornets, this is relevant stuff on venom immunotherapy in insect stings.

http://allergynotes.blogspot.com/2009/06/venom-immunotherapy-reduces-large-local.html

A few more ‘non-blog’ thoughts:

Some excellent advice from a pharmacist who has experience with residents. Read closely, young doctors! Might save you some embarrassing moments.

I’m a pharmacist and work both inpatient as an ICU pharmacist and relief work as a community pharmacist. For the new residents, I have some tips to make their lives and mine a bit easier:

1. Find a pharmacist and ask questions if you’re not sure of anything about a drug. We won’t tell your attending or chief resident. We also know you are brand new and are willing to try to make your life easy.

2. When we call to clarify or change an order, please be polite. We know you are new and try to be polite to you and we’re sorry its late and you are tired, but this order doesn’t make sense. We are even polite to your attendings, who are not new. Lets all be polite!

3. If you don’t have a DEA number, you cannot order discharge medications or medications for anyone outside of your institution. The reason is insurance companies identify the prescriber by the DEA number. So, be sure to write your discharge rxs with your name and some notation “covering for………” This could be your attending or chief resident. Your hospital’s DEA number only works WITHIN the hospital. Most states do not allow institutional DEA numbers for use outside of the institution. This is a really hard thing for new residents to get. Patients get frustrated since they need their insurance to pay for it & we need to call you (by that time, you’re off call) or someone who has a DEA number who knows the patient.

4. Most hospitals have “closed” formularies. That means they use one PPI, 1-2 ACE inhibitors, a few cephalosporins, etc… However, that doesn’t mean Aciphex is covered on the patients insurance plan – which also has a closed formulary. It would be helpful for you to write choices for us – Aciphex 20mg, Prevacid 30mg, Protonix 40mg qd depending on insurance coverage. That goes for nasal sprays as well – Flonase, Nasonex, etc…

5. Insurance companies are cranking down on expensive medications. If you’re starting a pt out on new therapy, use the generic first – try the ACE inhibitor before you go to Diovan. Likewise, try a generic statin rather than Lipitor. It interrupts therapy when I get the discharge & the drug is not covered. I need to send a request to the PCP for a prior auth before they even get the discharge summary of the pt.

6. Please don’t try to write rxs for yourself or your family. I can’t fill them and its a bad habit to get into. When you arrive at your new location, bring me your wife’s BCP rx or your husband’s albuterol rx and I’ll transfer it from where you had it filled in medical school.

7. Above all, try to have fun. Pharmacists often have time to at least share last nights basketball scores or some TV show – come by our pharmacy (we have lots of them all over the hospital) and you might even find food!

And finally, we close with a bit of advice from my friend, Dr. Billy Campbell, a family physician in Westminster, SC, and true Renaissance man:

You can read his bio, and learn about his other business, Memorial Ecosystems, here:

http://www.memorialecosystems.com/AboutUs/Bios/tabid/109/Default.aspx

1) You are learning a lot more than content (the latest on how to treat this or treat that) and physical skills. In the old days, they talked about the “art of medicine”, but what I am talking about includes more than dealing with the vagaries of patient compliance and things like insurance and regulation…it also includes developing a systematic approach to managing information, and a little voice that says “are you sure?” A total lack of self confidence can be paralyzing, but self-confidence is certainly over-rated, and in super-abundance can be lethal.

2) Avoid caduceus wear (socks, ties, t-shirts, hats, underwear, tattoos, etc.). Not only is it tacky, it tends to reinforce a Johnny-one note approach to life. It is important to have a life outside of medicine: family, church, organization, hobbies, etc.

3) On the other hand, medicine is not just a job so you can make money to do things in your “real” life. It has to be a part of your life in a way that few other jobs could ever be. If you do not love it you need to become an administrator. Treat your patients and co-workers respectfully. Patients are not enemies who keep you away from the things that you love. Try to have fun, and keep a sense of humor (even occasional cynicism can be healthy-just don’t dwell there).

4) If you hear an “wise elder” earnestly say “There are no uninteresting patients, only uninteresting doctors”, spend as little time as possible with him. He probably has on a caduceus thong

Well, that’s all we have for today.

Best wishes to all of the new residents!

Edwin Leap, MD, FACEP

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23 Comments

Barbara K.

2009-06-30 09:45:45 Reply

An excellent Grand Rounds! You picked a fascinating topic. Thanks for including my post.

rlbates

2009-06-30 12:13:44 Reply

Excellent advise!

Dr Am Ang Zhang

2009-06-30 13:16:31 Reply

A fine job for the nextg generation of doctors. Thank you Edwin for including my post.
The Cockroach Catcher

hgstern

2009-07-01 20:08:30 Reply

Excellent job, Edwin!

Thanks for hosting, and for including our post!
 

Roger

2009-07-11 12:53:02 Reply

PGY-1 Here. Thanks for the great grand-rounds.

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