Your favorite scripts/ phrases, frameworks, and other tips for new attending

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TrailRun

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Hi, wondering if anyone would share their favorite canned speeches or frameworks for patients such as when you don't think an intervention will help them, imaging not warranted, etc or any other tips. Starting as a new attending in a couple weeks and a little nervous. One attending in fellowship had some nice lines about 'the tools I have in my toolbox are not the right ones for you,' 'opiates really work best for broken bones and cancer, not this' and things like that. Luckily I'm at a non-opiate practice so that helps. But getting nervous about being solely responsible for patients, although I keep trying to remind myself that 'the patient is the one with the disease.'

Thanks!
 
I like:

“The juice ain’t worth the squeeze”

“It’s like pissin in the ocean”

“If it ain’t broke don’t fix it”

“If it hurts don’t do it”

“You can’t teach an old dog new tricks”

“Help me help you”

“You’re tougher than most”

“You’ve got a lot going on”

“You’re making me work for my money”

Some of these are in jest but most of these I use fairly often. Congrats on your first job, good luck and god speed my friend
 
TrailRun said:
Hi, wondering if anyone would share their favorite canned speeches or frameworks for patients such as when you don't think an intervention will help them, imaging not warranted, etc or any other tips. Starting as a new attending in a couple weeks and a little nervous. One attending in fellowship had some nice lines about 'the tools I have in my toolbox are not the right ones for you,' 'opiates really work best for broken bones and cancer, not this' and things like that. Luckily I'm at a non-opiate practice so that helps. But getting nervous about being solely responsible for patients, although I keep trying to remind myself that 'the patient is the one with the disease.'

Thanks!
Click to expand...
"They will never love you back."
"Secrets are like wounds. They fester until you let them out.”

"Elections have consequences."

"Write your Senator."

“If you don’t take a temperature, you can’t find a fever.”

“The delivery of good medical care is to do as little as possible.”
"We don’t always win. Sometimes we lose.”
"There’s a time for surgery and a time for martinis. This is martini time.”
“Pick me. Choose me. Love me.”
“Sometimes the hardest part of medicine isn’t the science, it’s the people.”
“The carousel never stops turning.”
“Sometimes it’s not medicine that saves lives — it’s changing the system that put them in danger.”
“It’s never lupus.”
 
“That’s a really good question for your PCP!”

“(If going in circles) Sounds like you need some time to think through these options, call the office when you are ready to take the next steps.”

“Does it hurt enough to try an injection to help that?”

“I like doing a great job of talking about one thing, not a bad job of talking about 3. Make a follow up and we can talk more about that.”

“Great question - I’m a pain doctor, not a (insert X, usually numbness) doctor. Don’t know the answer to that. You should talk to a X specialist about that.”

“I’m sorry, I don’t have any good options for you.”

For patients afraid of pain from injections “I’m a pain doctor, if I gave painful injections I’d be out of business. I’m a baby when it comes to shots for me so I’m really nice to other people. It will be boring”

For my staff:
“Patients have a “one free question” policy. Anything after that requires a visit.”

I don’t waste my time fighting a patient that wants imaging. If I really don’t think it’d help I just tell them “hey I don’t think that’s worth your money because of X, but I’m more than happy to order it if you still want it”
 
I don't refuse imaging. Comes of as dismissive or negligent if someone else orders and something shows up. Especially in our litigious society. Sometimes I will say something like:
"Happy to order but your insurance has strict criteria so you probably won't get approved and might get stuck with the bill".

Patients who push for procedures? Good problem to have. If you want to dissuade:
"Chances of success for this procedure, for your condition, are low, but happy to try".
"Happy to do it, but you don't fit the your insurance's criteria, and it can be expensive and there are potentially serious complications.."
"Every procedure has risks and benefits. If the potential benefits are low, as in your case, it's not worth the risks"
"We practice evidence based medicine, and there's not enough literature for me to be comfortable with that"

Patients with pathology but you can't fix:
"I've done all the procedures I know, maybe you could try another pain doc to get another set of eyes on you, or X,Y,Z".
"No treatment has 100% success rate" "Treatment failures happen, and while no one wants to think it'll be them, some will simply not respond"

Patients without much pathology:
"When I do procedures there has to be a target I'm trying to hit and there's no clear target on your MRI"
"I'm a spine specialist and my job is to see if your symptoms are from your spine, and based on your history, exam, and imaging, I can confidently say that your spine isn't the source. You might want to see..."

Opioids:
"With the opioid epidemic, there are strict guidelines we have to follow"
"The DEA frowns upon that, and I could lose my license, as other doctors have"
"We are a surgical and procedure based practice. We are not set up for chronic opioid management. State law requires drug tests, pill counts, etc, and we aren't set up to be able to adhere to those regulations, but other practices are [give options]"
"No one who gets addicted thinks they're going to get addicted. Your age puts you at high risk, so this isn't the best option"

You can see a few themes:
-come across as facilitative not obstructive
-blame insurance, guidelines
-patient needs to understand they have some skin in the game, especially financially and health wise
 
"I can do the procedure, and I do it quickly and make a little bit of money off you, but if you're my mother it would never happen."
 
Taking NSAIDs every day increases your risk of a heart or stroke by 31%. Except Diclofenac. That is 50%.
No show or deed-o? (I have a lot of very old patients)
I need more coffee.
Thanks everybody, I have been great, I am out of here. (as I walk out of room or suite)
Tip your nurses...
Free coffee with epidural.
Series of three means boat payment.
If you want to sht big, you gotta eat big (Larry Lobel)
Cerner, death by 1000 clicks.
I might be the worst doctor you will ever see.
How are you not dead yet?
You will feel a tiny prick- that's what she said.
As soon as we are done you will say, that was nothing- that's what she said.
I thought you would be bigger- that's what she said-no: you play pretty good for a blind boy.
 
One of my attendings gave me a pearl that has paid great dividends

when you expect disagreement about a treatment (esp opioids): Tell a pt what you RECOMMEND rather than what you are/are not willing to do. It is very hard to argue with an expert recommendations. "I do not recommend X for you, it is not a safe or effective option for your case"

Repeat phrase as needed

On a more humorous note pts will often ask you what they cannot do or should avoid after an injection. Feel free to make ridiculous suggestions and they will (usually) laugh. 90 yo pt after ESI: "Strictly no roller-skating or bungee jumping today", or tell a housewife (preferably in front of her husband), "it is very important that you do no housework or wash any dishes for at least a month"
 
When a hyperalgesic patient referred for minor injection is hollering and acting the fool:
“You’re doing SO good.”

My staff understands this is high sarcasm but I generally have a nice demeanor with patients, so the patient doesn’t seem to pick up on it. Saying stuff like that helps me from getting more annoyed.
 
Whenever a hyperalgesic patient screams out “oh Jesus” or “oh God” during a procedure I say “you can call me DOctorJay”.

When patients ask if their spine is “disintegrating” I tell them it’s just grey hair of the spine.

You can’t polish a turd.

We’re here to stomp out pain.

No surrender, no retreat.
 
DOctorJay said:
.

You can’t polish a turd.
Click to expand...
this is one of my favorite phrases of all time. I think I first heard it on beavis and butthead. I use it a lot when teaching the fellows, re getting things set up correctly the the start or bail, restart when needed.

My other:
Not my circus, not my monkey.
 
“Just because we can see something doesn’t mean it’s causing any problems” - to the patient with unremarkable imaging who is perseverating on their small disc bulges with no stenosis

“It’s called pain management, not pain elimination”

“You’re the only one who feels your pain. If your pain isn’t bad enough to deal with a quick needle poke, then that’s pretty good pain control” - to the patient with agonizing 24/7 pain who just can’t handle the torture of a 1 minute epidural injection so they refuse all procedures

“I’m an ability doctor, not a disability one.”
 
Last edited:
TrailRun said:
Hi, wondering if anyone would share their favorite canned speeches or frameworks for patients such as when you don't think an intervention will help them, imaging not warranted, etc or any other tips. Starting as a new attending in a couple weeks and a little nervous. One attending in fellowship had some nice lines about 'the tools I have in my toolbox are not the right ones for you,' 'opiates really work best for broken bones and cancer, not this' and things like that. Luckily I'm at a non-opiate practice so that helps. But getting nervous about being solely responsible for patients, although I keep trying to remind myself that 'the patient is the one with the disease.'

Thanks!
Click to expand...
“It’s called pain management not pain elimination for a reason”
Also one of the most important things is learning early who you can’t help. Tons of psych diagnoses, psych med allergies, “I hurt everywhere” tons of ER visits these are some of the signs. As Nancy Reagan said just say no.
 
Just before you give an injection: "This is another one of those times when it is better to give than to receive."

Wait a decade before this reply to the question how long have you been doing this? Since 8 a.m.
 
because this is what your insurance requires, so they can save boatloads and their ceos can buy yachts.


of course pain pills work. thats why they are good after surgery. but over time? they stop working. and you are left with a whole lot of constipation and other side effects.


the numbing part hurts the most. like a flu shot.


we dont determine disability here. we are here to get you as functional as possible and making you disabled means we arent even going to try.
 
This will feel better as soon as it stops hurting.

When doing a bilateral injection and moving to the second side: this should be easier, because I think I know how to do these now.

In response to how long it takes to get an injection scheduled: that buys me some time to watch YouTube and learn how to do the procedure.

I’m just a simple country doctor.

Not mine, but a retired doc right before ESI…A little prick behind you.

Are you doing ok? Great, me too.
 
before a shot

patient: im nervous
me: me, too. I NEVER do these shots...
 
cowboydoc said:
This will feel better as soon as it stops hurting.

When doing a bilateral injection and moving to the second side: this should be easier, because I think I know how to do these now.

In response to how long it takes to get an injection scheduled: that buys me some time to watch YouTube and learn how to do the procedure.

I’m just a simple country doctor.

Not mine, but a retired doc right before ESI…A little prick behind you.

Are you doing ok? Great, me too.
Click to expand...
glad to see I'm not the only one with corny dad jokes
 
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