Tips for New Docs?

[Cinematographer]

#TipsForNewDocs began trending on Twitter earlier today:



And here is some of the advice from the medical community to all soon-to-be interns:






I was interested to see if the resident/attending members of this subforum had any EM-specific tips to add. Thoughts?

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[Angry Birds]

As an ER doctor, when you hear hoofbeats, you should first think about and rule out hippos. Hippos will kill your patient the fastest, before horses and zebras.

 

[StephBee]

As an ER doctor, when you hear hoofbeats, you should first think about and rule out hippos. Hippos will kill your patient the fastest, before horses and zebras.

Those damned hippos. I knew my childhood was teaching me to fear them. They're just always so.....hungry!


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[Angry Birds]

i used to say rhinos instead of hippos but then my wife, who knows a lot about animals, told me that hippos are in fact more dangerous

 

[Petypet]

 

[WilcoWorld]

This is more of a tip for EM PGY-2's who want to pick up their speed, but...

Respect the ABD's of the ER - Always Be Discharging

 

[shoal]

those horses are cruel too. seen so many horrible traumas. never trust a horse

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[deleted245139]

This is more of a tip for EM PGY-2's who want to pick up their speed, but...

Respect the ABD's of the ER - Always Be Discharging

I'll offer a modification... Always Be Dispo'ing. Haha. Great movie

 

[RustedFox]

1. Everybody lies.
2. See rule number one.
3. Dispo is king.
4. It is more important what the patient does not have than what they do have.
5. Wearing sunglasses in the ER is 98% sensitive for the presence of at least one Axis II disorder.
6. Every female between the ages of 6 and 66 is pregnant until proven otherwise.
7. Tubal ligations and hysterectomies do not exclude pregnancy.
8. Don't ask a question that you don't want an answer to.
9. Abdominal pain gets two exams documented on the chart.
10. Chest pain gets admitted unless you have a damn good reason not to admit it.

 

[Perrin]

All patients lie. Prisoners always lie. (We served all the surrounding prisons and jails)

Talk to the family. They sometimes have useful information.

 

[Angry Birds]

All patients lie. Prisoners always lie. (We served all the surrounding prisons and jails)

Talk to the family. They sometimes have useful information.

HouseMD aside, the truth is actually that patients have little important to say.

Patients don't know what the hell they are talking about. History--the most overrated part of an assessment.

 

[Zebra Hunter]

HouseMD aside, the truth is actually that patients have little important to say.

Patients don't know what the hell they are talking about. History--the most overrated part of an assessment.

"...and my doctor recently stopped prescribing me norcos for my back pain, and I am needing a new pain doctor. Also, my feet have been smelling weird for 2 weeks. Also, I had 1 bowel movement in the last 2 days and I normally go once a day. Oh, and btw, my friend is wondering if she should come here to get checked out for mono because she said she had a fr..."

"Okay ma'am, but what does any of that have to do with the abscess on your arm?"

 

[erasthrowaway328382382]

HouseMD aside, the truth is actually that patients have little important to say.

Patients don't know what the hell they are talking about. History--the most overrated part of an assessment.

Haha, I love how this is the exact opposite of what we are taught as med students.

 

[hoot504]

It's not overrated but you can't expect nuanced, insightful, or generally even accurate responses. If you're taking the history right, Yesses and Nos should comprise about 98% of the words out of the patient's mouth.

 

[gro2001]

Haha, I love how this is the exact opposite of what we are taught as med students.

I think that it might have been somewhat true a couple of generations of physicians ago (though probably not as true as we used to believe prior to EBM), around the time our more venerable med school profs were starting out. Part of the reason history is so unreliable is that even when it's two native English speakers talking (which is more rarely the case now than in the past), there is such a diversity of microcultures and microdialects that we can't be nearly as sure we mean the same things the patients do when we use a particular word. Even apparently simple words like "numb", "dizzy", "sharp" and "dull" have a greater variety of meaning than we would expect to different people, something neither physicians nor patients are typically aware of. This is compounded by people moving around and being exposed through media to unexpected and unpredictable microdialects. Compare this to the physician from the 1950s who likely grew up and went to school in the same area as he is practicing (and the same area his patient grew up in and lives in), and is much more likely to understand the nuances of the patient's words.

 

[goodoldalky]

Beware the unreliable history. I swear this happens once every 6 months. Someone brings me an EMS or triage EKG that's a STEMI. I run to see the patient, "Sir, tell me about your chest pain!"
"Oh, I don't have any chest pain."
"You don't?"
"No."
"Why are you here?
"I don't feel good."
"But your chest doesn't hurt? No pain at all?"
"No."
"How about tightness? Discomfort?"
"No, I don't have any tightness or discomfort."
"Sir, it looks like you are having a heart attack. Are you sure you aren't having any pain, tightness, discomfort, anything going on at all with your chest?"
"Well, it feels like there's an elephant sitting on my chest and I feel like I'm going to die, but it's not pain or anything."

 

[gro2001]

Beware the unreliable history. I swear this happens once every 6 months. Someone brings me an EMS or triage EKG that's a STEMI. I run to see the patient, "Sir, tell me about your chest pain!"
"Oh, I don't have any chest pain."
"You don't?"
"No."
"Why are you here?
"I don't feel good."
"But your chest doesn't hurt? No pain at all?"
"No."
"How about tightness? Discomfort?"
"No, I don't have any tightness or discomfort."
"Sir, it looks like you are having a heart attack. Are you sure you aren't having any pain, tightness, discomfort, anything going on at all with your chest?"
"Well, it feels like there's an elephant sitting on my chest and I feel like I'm going to die, but it's not pain or anything."

Another favorite of mine in the same vein was when I ask how long a symptom lasted, and I get the response indicating that it lasted "a minute". Eventually I figured out that to a surprising number of people "a minute" means "unspecified amount of time lasting between a minute and several weeks". When I started confirming by tapping on my watch and saying "You mean like a minute minute?" a scary number of people would say "No, I mean like..." and would then state the actual amount of time they meant.

A patient can also deny "numbness" only to add that "It's not numb, I just can't feel it."

 

[coachB]

Beware the unreliable history. I swear this happens once every 6 months. Someone brings me an EMS or triage EKG that's a STEMI. I run to see the patient, "Sir, tell me about your chest pain!"
"Oh, I don't have any chest pain."
"You don't?"
"No."
"Why are you here?
"I don't feel good."
"But your chest doesn't hurt? No pain at all?"
"No."
"How about tightness? Discomfort?"
"No, I don't have any tightness or discomfort."
"Sir, it looks like you are having a heart attack. Are you sure you aren't having any pain, tightness, discomfort, anything going on at all with your chest?"
"Well, it feels like there's an elephant sitting on my chest and I feel like I'm going to die, but it's not pain or anything."

It seems pretty clear here that the issue is not that the history is unreliable or unhelpful. In fact, it sounds like it could be quite helpful. The issue is the way you go around trying to obtain it, asking leading specific questions instead of letting the patient tell you what is going on.

 

[The White Coat Investor]

One EKG begets another.

 

[Angry Birds]

1. Never ask a headache patient if it is the worst headache of their life. Rookie mistake to do that.
2. Never ask about chills or rigors.
2b. All vomiting is projectile, according to patients.
3. If you get a pan-positive review of systems, try to break it by asking "does your hair hurt?" It will have comedic effect for yourself, if nothing else.
4. Color of sputum (aside from hemoptysis) is not relevant. Who cares if it is yellow-green or greenish-brown? It's a medical student question to ask.
5. Power of persuasion: "I am going to give you a very powerful medication for your pain, and I'm confident it will help a lot."

 

[EDParallax]

Beware the unreliable history. I swear this happens once every 6 months. Someone brings me an EMS or triage EKG that's a STEMI. I run to see the patient, "Sir, tell me about your chest pain!"
"Oh, I don't have any chest pain."
"You don't?"
"No."
"Why are you here?
"I don't feel good."
"But your chest doesn't hurt? No pain at all?"
"No."
"How about tightness? Discomfort?"
"No, I don't have any tightness or discomfort."
"Sir, it looks like you are having a heart attack. Are you sure you aren't having any pain, tightness, discomfort, anything going on at all with your chest?"
"Well, it feels like there's an elephant sitting on my chest and I feel like I'm going to die, but it's not pain or anything."

Excellent point.

1. Remember the above goes double if your patient speaks English as a second language. "Numb" "dizzy" and "bad feeling" are all synonyms for STEMI/stroke/impending doom if you're not careful and take face value all the time.

2.

A. ASSUME NOTHING
B. BELIEVE NO ONE
C. CHECK EVERYTHING




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[gutonc]

Another favorite of mine in the same vein was when I ask how long a symptom lasted, and I get the response indicating that it lasted "a minute". Eventually I figured out that to a surprising number of people "a minute" means "unspecified amount of time lasting between a minute and several weeks". When I started confirming by tapping on my watch and saying "You mean like a minute minute?" a scary number of people would say "No, I mean like..." and would then state the actual amount of time they meant.

A patient can also deny "numbness" only to add that "It's not numb, I just can't feel it."

Not in EM but when I ask how long a symptom has been going on I immediately qualify it with "has it been hours, days, weeks, months or years?".

 

[shoal]

Not in EM but when I ask how long a symptom has been going on I immediately qualify it with "has it been hours, days, weeks, months or years?".

need to add seconds and minutes in EM.

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[RustedFox]

Another favorite of mine in the same vein was when I ask how long a symptom lasted, and I get the response indicating that it lasted "a minute". Eventually I figured out that to a surprising number of people "a minute" means "unspecified amount of time lasting between a minute and several weeks". When I started confirming by tapping on my watch and saying "You mean like a minute minute?" a scary number of people would say "No, I mean like..." and would then state the actual amount of time they meant.

A patient can also deny "numbness" only to add that "It's not numb, I just can't feel it."

Allow me to translate: "A minute" really means: "I can't be bothered to actually take responsibility for myself; that's what you're there for. Furthermore, I won't be helpful because I'm too lazy to cooperate, instead... I'll be as obfuscatory as possible so as to exculpate myself from years of irresponsibility and self-neglect."

 

[DeadCactus]

A minute is pretty common slang for a long period of time...

 

[EskimoFriend13]

Don't forget the important skill of getting the patients to stop giving you history. I'm always astounded by how oblivious patients seem to be to the fact that I am actively backing out of the room.
Tip for beginners: if you are going into a room with a patient you know to be long-winded, have a buddy page/call you if you're still stuck after 5 min.

 

[meatbolus]

Some people just want a work note. If you are struggling to figure out just WHY your patient is in the ED, it's worth asking/offering.


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[da8s0859q]

Some people just want a work note. If you are struggling to figure out just WHY your patient is in the ED, it's worth asking/offering.


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Had this happen awhile back. Bunch of random, vague complaints in a not-sick person. Finally unearthed the fact that he wanted to be tested for Zika.

 

[HLxDrummer]

As an ER doctor, when you hear hoofbeats, you should first think about and rule out hippos. Hippos will kill your patient the fastest, before horses and zebras.

This is going to be a stupid question and I hope it is not rude/offensive: Why does it matter if you are an EM doc or FM doc? If a patient comes to your clinic or the ED and say they have X complaint, shouldn't it be worked up the same? If they came in via EMS I could see if being a little different because they were worried enough to call 911, but a lot of people go to their PCPs for acute visits just as a lot of people go to the ED for chronic problems.

Don't get me wrong, I'm all about looking for red flags and ruling out badness, but I do that no matter the setting (Just an MS4).

 

[gman33]

This is going to be a stupid question and I hope it is not rude/offensive: Why does it matter if you are an EM doc or FM doc? If a patient comes to your clinic or the ED and say they have X complaint, shouldn't it be worked up the same? If they came in via EMS I could see if being a little different because they were worried enough to call 911, but a lot of people go to their PCPs for acute visits just as a lot of people go to the ED for chronic problems.

Don't get me wrong, I'm all about looking for red flags and ruling out badness, but I do that no matter the setting (Just an MS4).

It's not a stupid question, but the setting does matter.

If I see a patient in the ED, i have one chance to get it right.
I don't have the option of telling them to come back tomorrow or next week and see me again (not totally true in reality).
Plus the fact that they are seeing me means their PMD has failed them in many cases.

For the most part, I honesty don't care to find the cause of their complaint.
I just want to make sure it's not something bad that needs hospitalization or immediate intervention.

If their CP is from GERD. I don't care. The PMD should care because that could go on to become barrett's and then CA.
But that eval doesn't need to happen today.

 

[sawboned]

Don't start an encounter with, "what brings you in?". Often the patient will respond with I don't know - (wtf) you tell me - that's why I'm here!

Reference your state of the art electronic record and how you will review their history, if you haven't already. Do this before asking about their past medical history - and that you want to hear it from them too.

Don't ask if they've had fevers. They may respond frustrated, I don't know they just took my temperature (stupid)! Ask if they've had fevers at home as far as they know.

Don't ask if they drink. Ask if they drink beer, wine or liquor... A lot of patients don't consider beer a 'drink'.

When you tap, push or prod attempting to elicit tenderness, apologize that it might hurt before doing so.

The 99th percentile heart rate for a 1.5-year-old child is 150. 160 less than 1yo and 140 for a 2yo - 3yo.

Be very very wary of discharging a patient with tachycardia.

If they clearly fit the pattern, rock it out. If they don't fit the pattern don't force it to fit and avoid anchoring bias.

Provide all the benefit of the doubt. Patients with mental illness have a higher overall mortality than those without.

If in doubt tube, tap and drain.

When overdosing on adrenaline, use combat breathing.

Talk to every patient as if you are truly on their side. Excluding psychiatric patients look warmly into everyone's eyes. Everyone's. Doesn't matter what you think or feel about them, become them for the moments that you are interacting with them. Emergency medicine really is theater in some ways. Be all in when you are on stage.

When you feel like screaming or crying because of a nasty interaction, painful error, overwhelming task saturation and the like know the shift will-eventually-end. Stay present and just keep going. Embrace that everyone, everywhere occasionally gets a bloody beat down. Some days the ED just wins and we lose. Reliably, your next shifts will be more likable. (If this fails to occur, find a new shop.)

If your note automatically goes to the patient's primary tell the patient that you will send their doctor a personal note about their visit today.

Conclude every visit with a pause and a sincere, "do you have any other questions". Your mind will be screaming to exit the room but it will ultimately save time and energy to conclude in this manner. Doesn't matter how messy the encounter might have been, as in many things, it's all about the resolve.

 

[shoal]

sawbond awesome post

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[Arcan57]

If you're moving to an area with a significant percentage of non-English speaking patients and have an on-site interpreter, it's worth it to ask how the local population phrases certain symptoms. It won't make you competent to communicate in the other language but it will help you understand the ones that do speak some English better. Fever especially can be tossed around as a non-specific feeling of lack of wellbeing and if you assume it means an elevated temperature your work up may completely miss the chief complaint.

"Do you have any medical problems?" will rarely lead to a correct and complete answer. I know it seems like no PMHx simplifies things, but don't accept the easy no. "Do you take any medicine on a regular basis (anything herbal or over the counter)?" "Do you follow with a doctor for any conditions?" and finally "Have you ever experienced this before?" will all uncover medical hx that you'll look like an idiot for not successfully obtaining. If the historical item really matters, it's worth asking in at least two different ways to pin it down. I'm not talking ROS questions but occasionally the exactness of the hx really matters. CVA onset if within the window, past abdominal surgeries with an abdominal complaint,etc.

 

[jgauger]

Don't start an encounter with, "what brings you in?". Often the patient will respond with I don't know - (wtf) you tell me - that's why I'm here!

Reference your state of the art electronic record and how you will review their history, if you haven't already. Do this before asking about their past medical history - and that you want to hear it from them too.

Don't ask if they've had fevers. They may respond frustrated, I don't know they just took my temperature (stupid)! Ask if they've had fevers at home as far as they know.

Don't ask if they drink. Ask if they drink beer, wine or liquor... A lot of patients don't consider beer a 'drink'.

When you tap, push or prod attempting to elicit tenderness, apologize that it might hurt before doing so.

The 99th percentile heart rate for a 1.5-year-old child is 150. 160 less than 1yo and 140 for a 2yo - 3yo.

Be very very wary of discharging a patient with tachycardia.

If they clearly fit the pattern, rock it out. If they don't fit the pattern don't force it to fit and avoid anchoring bias.

Provide all the benefit of the doubt. Patients with mental illness have a higher overall mortality than those without.

If in doubt tube, tap and drain.

When overdosing on adrenaline, use combat breathing.

Talk to every patient as if you are truly on their side. Excluding psychiatric patients look warmly into everyone's eyes. Everyone's. Doesn't matter what you think or feel about them, become them for the moments that you are interacting with them. Emergency medicine really is theater in some ways. Be all in when you are on stage.

If your note automatically goes to the patient's primary tell the patient that you will send their doctor a personal note about their visit today.

Conclude every visit with a pause and a sincere, "do you have any other questions". Your mind will be screaming to exit the room but it will ultimately save time and energy to conclude in this manner. Doesn't matter how messy the encounter might have been, as in many things, it's all about the resolve.

Wow. I think I'll copy this to a word doc and keep it for periodic review. Thank you.

 

[sawboned]

Wow. I think I'll copy this to a word doc and keep it for periodic review. Thank you.

Very welcome. When you've got it down, come work with me

 

[WilcoWorld]

Don't start an encounter with, "what brings you in?". Often the patient will respond with I don't know - (wtf) you tell me - that's why I'm here!

Reference your state of the art electronic record and how you will review their history, if you haven't already. Do this before asking about their past medical history - and that you want to hear it from them too.

Don't ask if they've had fevers. They may respond frustrated, I don't know they just took my temperature (stupid)! Ask if they've had fevers at home as far as they know.

Don't ask if they drink. Ask if they drink beer, wine or liquor... A lot of patients don't consider beer a 'drink'.

When you tap, push or prod attempting to elicit tenderness, apologize that it might hurt before doing so.

The 99th percentile heart rate for a 1.5-year-old child is 150. 160 less than 1yo and 140 for a 2yo - 3yo.

Be very very wary of discharging a patient with tachycardia.

If they clearly fit the pattern, rock it out. If they don't fit the pattern don't force it to fit and avoid anchoring bias.

Provide all the benefit of the doubt. Patients with mental illness have a higher overall mortality than those without.

If in doubt tube, tap and drain.

When overdosing on adrenaline, use combat breathing.

Talk to every patient as if you are truly on their side. Excluding psychiatric patients look warmly into everyone's eyes. Everyone's. Doesn't matter what you think or feel about them, become them for the moments that you are interacting with them. Emergency medicine really is theater in some ways. Be all in when you are on stage.

When you feel like screaming or crying because of a nasty interaction, painful error, overwhelming task saturation and the like know the shift will-eventually-end. Stay present and just keep going. Embrace that everyone, everywhere occasionally gets a bloody beat down. Some days the ED just wins and we lose. Reliably, your next shifts will be more for likable. (If this fails to occur, find a new shop.)

If your note automatically goes to the patient's primary tell the patient that you will send their doctor a personal note about their visit today.

Conclude every visit with a pause and a sincere, "do you have any other questions". Your mind will be screaming to exit the room but it will ultimately save time and energy to conclude in this manner. Doesn't matter how messy the encounter might have been, as in many things, it's all about the resolve.

This post is SOLID GOLD (figuratively).

 

[WilcoWorld]

I end every discharge with "Remember, if you need us, we're here 24/7."

Sometimes it's more like "Remember, if you NEED us, we're here 24/7" and other times it's "Remember, if you need us, we're HERE 24/7" but that's always my closer.

 

[sum dude]

1) Find out why a patient is there during your history
2) Dispo patients before seeing new patients
3) When you go to a new place, no one cares what you did at your old hospital. Try your best to get along with staff, don't make waves. Stay humble and grounded. See rule #4
4) You can be smartest doctor in world--if you can't get RN's and techs to do what you want, you'll be an average doctor at best.
5) If you work for a non-CMG group and want to be in a leadership position, spend 6 months settling in, then find a niche where you can make it better. Work hard at it and others will notice--prove your worth and you'll climb the ladder.
6) Don't be a jerk

 

[Cinematographer]

1) Find out why a patient is there during your history
2) Dispo patients before seeing new patients
3) When you go to a new place, no one cares what you did at your old hospital. Try your best to get along with staff, don't make waves. Stay humble and grounded. See rule #4
4) You can be smartest doctor in world--if you can't get RN's and techs to do what you want, you'll be an average doctor at best.
5) If you work for a non-CMG group and want to be in a leadership position, spend 6 months settling in, then find a niche where you can make it better. Work hard at it and others will notice--prove your worth and you'll climb the ladder.
6) Don't be a jerk

Are 3 and 5 really advice for incoming interns? please see OP.

 

[Apollyon]

This post is SOLID GOLD (figuratively).

Thank you for your usual erudition, and NOT saying "literally".

 

[Renaissance Man]

Are 3 and 5 really advice for incoming interns? please see OP.

There are medical students who will undoubtedly show up to residency and do #3. And if 1/6 words of wisdom don't apply for 3 years, I think we will all be ok...Relax champ.

 

[tartesos]

Beware of these guys.


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[HooliganSnail]

A minute is pretty common slang for a long period of time...

Some people here are dating themselves, haha

 

[HooliganSnail]

This is going to be a stupid question and I hope it is not rude/offensive: Why does it matter if you are an EM doc or FM doc? If a patient comes to your clinic or the ED and say they have X complaint, shouldn't it be worked up the same? If they came in via EMS I could see if being a little different because they were worried enough to call 911, but a lot of people go to their PCPs for acute visits just as a lot of people go to the ED for chronic problems.

Don't get me wrong, I'm all about looking for red flags and ruling out badness, but I do that no matter the setting (Just an MS4).

I assure you, the fact that they arrived via EMS is in NO WAY correlated to disease severity. In my shop, it may even be inversely correlated....

 

[HooliganSnail]

Try NOT to order Etoh levels on the drunks, unless you are concerned about an actual toxic ingestion.

If their alcohol is 485, you're screwed holding onto this guy for 16 hours!

Clinically clear their sobriety. If they can talk without slurring their speech, and walk straight to the bathroom, then they have demonstrated CAPACITY and can be discharged to the waiting room, or the street curb, or wherever.

Also, don't kick out the drunks before 2 am or they will just go get more drunk.

Also, if you are overnight, it's always rude to leave your drunks for the day team. It's just common decency to kick out your drunks before shift change, kinda like flushing the toilet. ....

 

[Angry Birds]

Try NOT to order Etoh levels on the drunks, unless you are concerned about an actual toxic ingestion.

If their alcohol is 485, you're screwed holding onto this guy for 16 hours!

Clinically clear their sobriety. If they can talk without slurring their speech, and walk straight to the bathroom, then they have demonstrated CAPACITY and can be discharged to the waiting room, or the street curb, or wherever.

I've been told this by numerous people, but I don't necessarily buy it. You can just write in the note: "Patient is clinically sober at this time. We will not recheck a BAL because patient is a chronic alcoholic and lives at a baseline high level. If we wait till his level comes down to below the legal limit, patient will likely go into alcohol withdrawal."

Not that you necessarily need to order a BAL on all drunks, but I don't think it necessarily means you are stuck holding them for 16 hours.

Also, if you are overnight, it's always rude to leave your drunks for the day team. It's just common decency to kick out your drunks before shift change, kinda like flushing the toilet. ....

LOL

 

[WilcoWorld]

I've been told this by numerous people, but I don't necessarily buy it. You can just write in the note: "Patient is clinically sober at this time. We will not recheck a BAL because patient is a chronic alcoholic and lives at a baseline high level. If we wait till his level comes down to below the legal limit, patient will likely go into alcohol withdrawal."

Not that you necessarily need to order a BAL on all drunks, but I don't think it necessarily means you are stuck holding them for 16 hours.



LOL

Agreed, I don't hold drunks just for being drunk. If they're suicidal or homicidal or critically ill, than sure, I'll get 'em to stay. But if someone who's only problem is being drunk wants to walk out of the ED, I get out of the way.

 

[Tecmo Bowl]

Don't masturbate on patients....too soon?

 

[Angry Birds]

Don't masturbate on patients....too soon?

What's the NNT of this advice?

 

[Cinematographer]

What's the NNT of this advice?

That would be NNH in this case.

Anyone any documentation tips? Pretty anxious about it for some reason.