Tuesday, December 7, 2010

Back on the inpatient service again

It's another week supervising the inpatient resident service for your intrepid academic family medicine blogger.

I find my inpatient weeks to be among my most demanding as an attending.  To do my job well, I need to:

  • speak with and examine every patient on the service daily
  • carefully review all lab, path, micro, etc data
  • ensure that each patient's plan of care is appropriate
  • review all resident documentation for quality and accuracy
  • facilitate daily team round patient care discussions
  • directly observe each member of the team (students, interns, senior resident) as they evaluate a patient 
  • provide feedback to each team member regarding his/her clinical performance
  • provide feedback to the senior resident regarding team management and leadership
  • discuss residency and career issues with any family medicine-interested med student
  • problem-solve challenging patient and family situations
  • problem-solve any resident/team cohesion issues (rare, but it has happened)
  • attend to each team member's emotional needs (any burn-out? need support after a tough case?)
  • ensure that residents are not violating work hour regulations
  • sign every H&P, progress note, and discharge summary - and document my own thoughts
  • and, of course, teach medical management of the inpatient
I'm sure I could come up with more, but those of you non-academic-medicine people probably get the idea.  :)

This week, I have the added pleasure of working with one of our faculty development fellows, helping to teach him how to do all of this...and, of course, supervise his efforts and provide him with feedback as well.

It's always a fast-paced and interesting week.  I really get rejuvenated by watching our outstanding residents grow while grappling with challenging situations.

One of our interns led a family meeting today for a patient who is on a ventilator and has made it explicitly clear that he doesn't want to live that way any more.

Another successfully built rapport with the initially intimidating mother of an adult son with special needs.

Our visiting medical student led a behavioral rounds interview with a patient admitted with hyponatremia (low sodium) and seizures likely caused by excessive alcohol intake.

And, the fellow and I today worked to build an alliance with a frustrated patient's wife, unhappy with the "condescending" (her descriptor) manner of the many care providers she has interacted with.  Her husband is obese, and she feels that he is being unfairly treated because of his size.  With a lot of validation, empathy, and summaries, we tried to give her a safe place to vent her fear and anger, and we worked with her and her husband to come up with a treatment plan agreeable to all.

From these and so many more moments, the ultimate challenge for me is choosing what to focus on as a teacher.  Every single one of these episodes is positively overflowing with teaching opportunities - pathophysiology (the processes in the body responsible for disease), diagnosis, management, and, so importantly, demonstrating caring for patients and their families during the terribly stressful time of being hospitalized.

There's only so many hours in the day, though, and only so much capacity to absorb and process information at one time.  Halfway through my third year as faculty, I am feeling much more comfortable with these decisions, but sometimes I still worry that I am neglecting something that should be important.  That my assessments of my learners will miss some important deficiency.  That we will all overlook some critical detail - or make some critical mistake - that could have devastating consequences for a patient.  I like to think that the worry keeps me on my toes, at least.

So, toes, rest up tonight.  Tomorrow's another big day...

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