Exceeding Expectations?

One of the skills I am trying to develop as a relatively new attending physician is setting expectations and following up on them, whether it's the timely completion of notes or that I am almost always available whenever the team needs me. In residency I developed a 2-page document setting out a variety of such expectations that I share at the beginning of a rotation and that I periodically update. It includes a section entitled "Finer Points":

1. Identify yourself on the phone with your name and team every time you make or answer a call.

2. Use generic names for drugs.

3. Consider whether you actually need full daily labs on every patient: what are you looking for? Do you really need a differential? If labs are not drawn overnight, can you get them in the morning?

4. Remember you catch more flies with honey than with vinegar.

5. Always name the Outside Hospital (OSH).

6. Work together. Our common enemies are time, disease, and red tape, not patients, consultants, nurses, or families.

7. Strive not to be just a good clinician; strive to be a good, just clinician.

8. Wash your hands, especially before you eat.

9. You will make mistakes this month. I will make mistakes. Other practitioners will too. Patient safety should be priority #1. Education should be priority #2. Assigning blame doesn’t make the list.

10. Teach someone something new every day.

I was surprised but pleased to see that one of the medical students had cut out number 7 (now number 9 in the revised version), and taped it to the monitor of the computer he used in the workroom. It reads, "You will make mistakes this month. I will make mistakes. Other practitioners will too. Patient safety should be priority #1. Education should be priority #2. Assigning blame doesn’t make the list."

I would like to help create what the hospital wonks call "a culture of safety," or an environment in which trainees care less about their grade than about patient well being. One in which everyone feels comfortable acknowledging when they don't know something, or after they did something wrong. Fear or litigation is probably less important than fear of looking or sounding "dumb" in front of friends, colleagues, superiors, and inferiors.

This is one reason I insist that they "name the OSH," which to me has a derogatory feel. When a patient is transferred to us, it is easy to assume that the doctors at the other institution couldn't take care of them because of a knowledge deficit, as if better doctors work at large centers and lesser ones work at satellite locations. However, I think that (largely unspoken) assumption seriously underestimates our colleagues who could have many reasons for working not-here, and not-smart-enough probably doesn't make the list. It is equally if not more likely that they have correctly identified that the patient needs something they cannot provide. There should be no shame in recognizing one's own limitations. Not to mention that it shows the patients you respect _them_ if you refer to their local hospital by name. AND good history taking it is necessary for whomever cares for the patient after the packet of papers that came with them on transfer disappears into the black hole of the workroom. If the night team tells the day team to "follow up on blood cultures at OSH" but hasn't named the hospital...how exactly are they supposed to accomplish that task?

Finally, in its most recent iteration I included this bon mot: "Strive not to be just a good clinician; strive to be a good, just clinician." I wanted some way to indicate that I am trying to practice with anti-racist principles; but also that I care about sexism, ableism, ageism, anti-immigrant bias, and good stewardship of healthcare resources. Maybe I'll cut that one out and tape it to the monitor on MY desk as an expectation for which to strive.