Mastering the Art of Patient Care

Foreword
Preface
Acknowledgments
Contents
About the Author
Part I Building Your Medical Foundation
1 Medical School
1.1 The Early Years
1.1.1 The Cheat-Sheet Method
1.1.2 Study Questions
1.1.3 Keep Hope Alive
1.2 The Clinical Years
1.2.1 Feign Enthusiasm
1.2.2 Commit to the Rotation
1.2.3 The Price of Service is Scut
1.3 Final Thoughts
References
2 Becoming Fluent in Medicine
2.1 Oral Presentations
2.1.1 The Identifying Statement
2.1.2 The History of Present Illness
2.1.3 The Past Medical History
2.1.4 Medications
2.1.5 Allergies
2.1.6 Social History
2.1.7 Family History
2.1.8 Review of Systems
2.1.9 Physical Examination and Laboratories
2.1.10 Assessment
2.1.11 Plan
2.1.12 The Daily Presentation
2.1.13 Keep to Your Script
2.1.14 Know Your Patient
2.1.15 Practice Makes Perfect
2.2 The Art of the Note
2.2.1 Make It Make Sense
2.2.2 Brevity is the Soul of a Good Note
2.2.3 If You Write It, You Own It
2.2.4 Close the Loop
2.2.5 Useful Tips and Tricks
2.2.6 Cringe-Worthy Phrases
2.3 Final Thoughts
3 Your Career Path
3.1 Research
3.1.1 Pick the Mentor not the Project
3.1.2 Start More Basic
3.2 Giving Talks
3.2.1 Relevance: Consider the Audience
3.2.2 The Importance of Anecdotes
3.2.3 Punctuality is a Virtue
3.2.4 Make Your Slides Work for You
3.2.5 Practice, Practice, Practice
3.3 Choosing a Specialty
3.3.1 Process of Elimination
3.3.2 What Do You Love?
3.3.3 Who Inspires You?
3.3.4 Does Lifestyle Matter?
3.3.5 What Comes Next
3.4 Picking a Training Program
3.4.1 Volume
3.4.2 Autonomy
3.4.3 Mentorship
3.5 More About Mentors
3.5.1 Find a Role Model
3.5.2 Ask the Right Questions
3.5.3 Assemble a Cabinet
3.6 Final Thoughts
References
Part II Honing Your Clinical Judgment
4 Diagnosis
4.1 Read a Lot (of Notes)
4.2 The Highest-Yield Questions
4.2.1 What Are the Precipitating, Exacerbating, and Relieving Factors?
4.2.2 Have the Symptoms Been Getting Better, Worse, or Staying the Same and Over What Period of Time?
4.2.3 What Made You Decide to Come in Today to Discuss Your Symptoms?
4.2.4 What Are You Most Worried About?
4.2.5 What Have You Tried to Make It Better? What Prior Testing Have You Had?
4.3 Learning More Than What the Patient Says
4.3.1 Personality
4.3.2 Other Opinions
4.3.3 Location
4.3.4 Your (the Physician’s) State of Mind
4.4 Diagnostic Pitfalls
4.4.1 Orthopnea
4.4.2 Reproducible Chest Pain
4.4.3 Assessment of Mental Status
4.5 The Power of Observation
4.5.1 Walking in the Exam Room
4.5.2 Who’s with the Patient?
4.5.3 The Hospital Set-Up
4.6 Final Thoughts
5 Tests and Interventions
5.1 There is No Perfect Test
5.2 Bayes Theorem is Your Friend
5.3 Pitfalls, Outliers, and Trends
5.4 Duplication of Effort
5.5 Communicate the Urgency
5.5.1 Prepare the Patient
5.5.2 The Acute Recognition of a Chronic Problem is not the Same as an Acute Problem
5.5.3 Use Your Influence When Warranted
5.6 The Cases that Keep You Up at Night
5.6.1 Validation
5.6.2 Tempered Reassurance
5.6.3 A Plan with Managed Expectations
5.7 The Worst-Case Scenario
5.8 The Golden Rule
5.8.1 Contraindication Creep
5.8.2 Indication Creep
5.9 “How Can It Hurt?” is Rarely the Right Justification
5.9.1 Be a Humble Student of Clinical Trials
5.9.2 When in Doubt, Return to the Golden Rule
5.9.3 Bandaids versus Cures
5.10 Final Thoughts
References
6 The Art of the Consult
6.1 How to Call a Consult
6.1.1 Call Early
6.1.2 Have a Specific Question
6.1.3 Tell the Patient
6.1.4 Calibrate Your Concern
6.1.5 Save the Plan for the Consultant
6.1.6 Make Your Consultant Work for Your Patient
6.1.7 Know When to Push
6.2 How to Be a Consultant
6.2.1 Be Prepared
6.2.2 Be Specific
6.2.3 Be Timely
6.2.4 Be Part of the Team
6.2.5 Anticipate Questions
6.2.6 Know When to Sign Off
6.3 How to Work Together
6.3.1 Avoid Chart Wars
6.3.2 Pick Your Battles
6.4 Final Thoughts
Part III Establishing Your Medical Style
7 Good Habits for a Lifetime
7.1 Preparation
7.2 The Worst-Case-Scenario Game
7.3 Don’t Be Afraid of What You don’t Know
7.4 Checklists: Not just for Interns Anymore
7.5 Time Management
7.6 Be Nice and Work Hard
7.6.1 Choose Kindness
7.6.2 Reliability and Respect
7.7 Final Thoughts
Reference
8 Leading Your Team
8.1 Tough Transitions: Being a Leader
8.1.1 Second-Year Resident
8.1.2 First-Year Fellow
8.1.3 Attending Physician
8.2 Teaching
8.2.1 Streamline Rounds
8.2.2 Encourage Debate
8.2.3 Create Captains-Claim the Role
8.2.4 Don’t Micromanage
8.2.5 Rejoice in Trainees’ Successes
8.3 Learning
8.3.1 Look Things Up
8.3.2 Know the Right Questions
8.3.3 Experience Trumps Education
8.4 Feedback
8.4.1 Be Timely
8.4.2 Be Specific
8.4.3 Provide Context
8.4.4 Offer Strategies to Improve
8.4.5 Check in to Assess Progress
8.4.6 Positive Feedback is Important Too
8.5 Lead with Kindness
8.5.1 Protect Your Team
8.5.2 Don’t Just Make the Offer, Make a Plan
8.6 Final Thoughts
9 The Tough Conversations
9.1 The Emotion Behind the Question
9.1.1 Can I Trust You?
9.1.2 Am I Going to Be Okay?
9.2 The Patient Who is Angry and Frustrated
9.2.1 Protect Yourself
9.2.2 Step 1: Listen
9.2.3 Step 2: Reflect
9.2.4 Step 3: Make a Concrete Action Plan
9.2.5 Step 4: Circle Back
9.3 Leaving Against Medical Advice
9.4 The Patient Who Takes Too Long
9.5 The Patient Who Disagrees with You
9.5.1 Step 1: Identify the Problem
9.5.2 Step 2: Emphasize the Shared Mission and Medical Facts
9.5.3 Step 3: Allow the Patient to Make Their Own Decision
9.6 The Patient Who Wants a Second Opinion
9.6.1 Encourage Second Opinions
9.6.2 Learn from Being the Second Opinion
9.7 Practicing the Art of Saying No
9.8 Breaking Bad News
9.8.1 Step 1: Have a Concrete Action Plan
9.8.2 Step 2: Determine the Delivery
9.8.3 Step 3: Let the News Register
9.8.4 Step 4: Explain the Plan
9.8.5 Step 5: Make the Promise
9.8.6 Step 6: Circle Back
9.9 When You don’t Know
9.9.1 Honesty on Rounds
9.9.2 Honesty with Patients
9.9.3 End-of-Life Care
9.9.4 Step 1: Know All the Facts; Use Only the Ones the Families Need to Hear
9.9.5 Step 2: Frame Best-Case and Worst-Case Scenarios
9.9.6 Step 3. Explore the patient’s Goals, Values, and Preferences
9.9.7 Step 4. Make the Promise
9.9.8 Step 5. Come to Consensus
9.10 More Thoughts About End-of-Life Care
9.10.1 There Should be Grief
9.10.2 You Do not Have a Crystal Ball
9.10.3 Your Right Answer May Not Be Their Right Answer
9.11 Final Thoughts
Reference
Part IV Optimizing the Care of Patients and Yourself
10 The Patient-Physician Bond
10.1 Addressing Patients
10.1.1 Introductions
10.1.2 Patients with Dementia or Learning Disabilities
10.1.3 Unresponsive Patients
10.2 Managing Expectations
10.2.1 Hospital Standard Time
10.2.2 Discharge Planning
10.2.3 Side Effects
10.2.4 The Results of Tests/Interventions
10.3 Care Versus Service
10.3.1 Delays Are the Luxury of the Healthy
10.3.2 Trust the Experts
10.3.3 Know When to Expedite
10.4 The Person Behind the Patient
10.4.1 Embrace the Little Details
10.4.2 Ask the Follow-Up Question
10.4.3 Address the Little Indignities
10.4.4 Humor
10.5 Maintaining Homeostasis
10.5.1 Eat
10.5.2 Poop
10.5.3 Sleep
10.6 Final Thoughts
11 Being a Woman in Medicine (Men: Don’t Skip This Chapter!)
11.1 Navigating the Training Environment
11.1.1 Never Assume the Worst
11.1.2 Claim Your Role
11.1.3 Humor and Sarcasm Can Help
11.2 Motherhood (Parenthood)
11.2.1 What You Need to Successfully Parent as a Physician
11.2.2 The Right Time to Have Kids
11.2.3 Unfounded Fear 1: You Won’t Remember How to Be a Good Physician
11.2.4 Unfounded Fear 2: Your Baby Will Forget You
11.2.5 Unfounded Fear 3: You Will Never “Get It Together”
11.3 Navigating the Career
11.3.1 Your Priorities Are Right Because They’re Yours
11.3.2 Comparison is the Thief of Joy
11.3.3 There is More to Academic Medicine Than Research
11.4 Final Thoughts
Reference
12 Self-Care
12.1 Boundaries
12.1.1 Vacation Time
12.1.2 100% Care Does Not Require 100% Access
12.2 Patient Reviews
12.3 Grief and Mistakes
12.3.1 Separate Fault from Fluke
12.3.2 Distinguish the Unforeseen from the Expected
12.3.3 Accept that Control is an Illusion
12.3.4 Learn from Your Successes Too
12.4 Savor Your Victories
12.5 Find the Joy
12.6 Final Thoughts
Reference
13 What Covid-19 Has Taught Us (or Not)
13.1 The Myth of Zero Risk
13.2 The Road to Bad Outcomes
13.3 Disagreement and Covid
13.4 Final Thoughts
References
Afterword: The Joy of Medicine