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Wisdom for Residents

Tonight, I am completing my first two week stint as the Neurology night shift resident at my hospital. For better or worse, I did not have any night float experience as a Medicine intern (plenty of long and painful on-call shifts, but no long consecutive stretches of nights), so these two weeks have been an interesting, exploratory experience for me. I have a total of two months of the night float rotation during my residency, so I have plenty more time to perfect my strategies for both maintaining the best possible patient care and making the best use of the time. I have picked up a few pearls that might help other residents who also will be filling this role:

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[1] The Plan and Pickup

As detailed in my last post, signout is an extremely important process and is the initial and primary means of high-yield information gathering for the night shift resident. Day residents are often tired and worn out by signout time, making it difficult to execute an effective delivery of all of the important details that a night shift resident covering all of the patients requires. Accordingly, it is the night shift resident’s job to ask the important questions when important information is left unsaid.

Of the many details that are valuable, I find that there is special significance in the day team’s plan of action for the patient. The night shift resident’s job is sometimes viewed as a “float” position where one simply tides the patients over until the next morning when active patient care can continue; the job in that case is very passive and only activated in reaction to new developments. Sometimes the team’s plan for the patient is glossed over during a signout process or even omitted. However, the night shift resident covers half of the twenty-four hour day, and much can be done during that time (albeit in smaller, discrete measures, given that the night shift resident is covering a much larger patient census). Sometimes medication titrations started during the day (e.g. for blood pressure control or diuresis) can be continued during the night. Sometimes a new therapy or plan started during the day shift might result in a less desirable outcome, requiring that it be reverted back to the original regimen during the night shift.

Inevitably, small details of care are omitted from signouts, whether intentionally or unintentionally. Nonetheless, the night shift resident can assess the team’s plan and pick up where they left off by following up on ordered studies, touching base with collaborating services or nurses, etc.

[2] The Preemptive Measures

Anticipation is a valuable skill. Being able to predict needs and requests can save valuable time. For example, at my current hospital, the order set for cardiac telemetry does not include a system to indicate whether or not the patient can leave the hospital floor without telemetry when being transferred to another part of the hospital for testing (e.g. Radiology). Residents have to manually type in a text order to give the nurses permission to release patients to the transport team. Accordingly, whenever I start my night shift, I look to see which patients are scheduled for overnight tests, determine whether it is reasonable for them to be off cardiac telemetry monitoring for a period of time, and then indicate such in the ordering system. Placing a few orders and touching base with nurses early in the shift helps prevent the potential slowing down of care delivery when one is dealing with multiple consults, admissions, codes and triggers, and other unpredictable developments.

[3] The PM Rounds

For me, there is great value in laying eyes on each patient. Unfortunately, the 8PM start time for my night shift is past the bedtime for many patients, so they are hidden behind curtains in dark rooms. Nonetheless, I make a concerted effort to locate all patients and mentally store an image of where patients are and what they look like (if I can see them). That way if something happens later requiring me to rush to the bedside, I know exactly where to find each patient. I try to lay eyes on the patients whose clinical statuses are more likely to change, and I examine the patients who are quite sick and are already changing in stability. With regards to examinations, I find that it is important to think about the patient’s pathology, their baseline examination, and the likely changes that one might see with the most likely complications. For example, a patient with a large cerebellar hemorrhage might develop brainstem abnormalities or depressed level of consciousness on examination, so that’s what I would look for as an indicator of worsening clinical status and a trigger for intervention.

[4] The Face Time

The geography of my night is unfortunately split between three locations: three floors in three different buildings, separated by a series of bridges and elevators. Furthermore, the Neurology floor is on the top floor of one building and the Emergency Department is on the bottom floor of another. Accordingly, I find it useful to split up my night into segments where I can minimize my migration from one section to another. Generally, I spend the first four to five hours of my twelve hour shift on the floor where most of my department’s patients are located. This is the start of the nursing shift as well, so there is more activity, more requests, and fresh pairs of eyes reviewing the orders and the patients themselves. The night shift is the best time to get to know the nurses in a hospital with regional admissions: there’s only one doctor on the floor, and that’s me! During those first few hours, I can be a useful resource to the nurses, both by providing some insight conveyed by the physician teams and by helping to facilitate the care ideas generated by the night nurses. Putting in this face time early in the rotation is quite valuable, too, because one develops relationships of trust with the nurses and can better triage requests and nurse assessments when brought to one’s attention later. After the floor patients quiet down, I usually migrate down to the call room which is closer to the Emergency Department where I can more easily set up camp, eat and drink, write notes, and run to either the floor or the ED as needed.

[5] The Quiet Place

Although the hospital is quieter at night (literally), there is still a cacophony of telemetry beeps, yelling and moaning patients, and chatter. A large part of a physician’s job is documentation, and writing well requires mental focus. For me, I can generate clinical documents much faster if I can find a quiet place, be this the call room, a quiet hallway, or an empty conference room. Finding a quiet space and making it a frequent stop during the night shift can help improve efficiency when the admission and consult notes start piling up. Some people prefer to work to music, so finding a room with a computer where one can play Pandora or an iPhone/Android on speaker can help facilitate the written work that needs to be done.

[6] The Energy Food

Shifting to the night schedule can screw up one’s gastrointestinal clock. I eat breakfast and dinner at the usual times, but I have switched lunch to a post-midnight meal so that I don’t have to wake up in the middle of my daytime nap to maintain my calorie intake. However, despite changing over to the night schedule with my meals, my stomach continues to growl constantly and loudly between 4AM and 7AM, or until whenever I can next eat.

The most important thing with regards to food and drink is to keep up one’s energy levels and hydration. As an on-call intern, I spent my on-call budget on a cache of Life Waters; I would keep four or five bottles in one of the physician conference rooms, and then I would down one bottle at a time to stay hydrated throughout the night. Now, as a night shift Neurology resident wandering between different floors and buildings, I keep close tabs on the water machines and on my supply of food (whether in my bag, locker, or the conference room fridge) so that I can snack throughout the night and stave off hunger and dehydration. Everyone has different preferences for on-call food: make it tasty and energizing!

[7] The Rally

Inevitably, fatigue ensues. With fatigue comes a loss of willpower and the onset of complacency. When the hours wear on and one is nearing the end of the shift (particularly in the 4-8 AM hours), it is important to buckle down and push through. Stretch, snack, or take a quick power nap to reenergize and refocus. The end is near: race to the finish!

Hopefully, these tips will be useful to those who will be doing the night shift, which is to say, virtually all residents now that the 16 hour work day restrictions have come into effect for interns. However, don’t be a night float and just muddle through through the night. Be a night rider!

Do you have other tips or strategies for surviving and adapting to the night shift? Please post your comments and suggestions below.

With the advent and evolution of work-hour restrictions, the importance of the signout as a learned skill and a necessary aspect of patient care has grown considerably. The signout or “pass off” is viewed by some senior physicians as a necessary evil (with the emphasis on “evil”), but as work shifts for residents become shorter and the population of hospitalists expands, it becomes ever more important to learn how to do a signout right.

What is a signout or pass off?

By its nature, it is:
[1] A temporary yielding of responsibility for a patient’s care to another physician.
[2] A process by which one prepares the covering physician to perform at maximum capacity as if he or she were the primary physician directing the care of one’s patient.

These two aspects of the signout are essential and intertwined; one cannot exist without the other. Some residents eagerly throw the responsibility for their patients at a fellow resident without adequately preparing them for anticipated or potential overnight complications. On the other hand, some residents overprepare their night shift colleagues, poring over every lab value and detail, while also signing in from their home computers to update electronic signouts and notes. The best strategy is to find the right balance of information transfer and a secure handing over of patient care responsibility.

Granted, it takes two to tango: signout requires both an effective transmitter of information and an actively engaged recipient. The person receiving the signout needs to know what questions to ask and needs to know when to jump in regarding a clarification or to keep things on track when the other resident starts to lose steam and digress.

What are the essential elements of the signout?

While some residency programs and hospitals are trying to standardize signout processes and even study their efficacy, the current process lacks standardization across programs and hospitals. Nonetheless, a few key details form the backbone of a solid signout. Signout can take a long time and is often interrupted by pages and requests, so the most important information that requires verbal transmission must be shared first.

[1] The Red Highlighter – “Which patients are the sickest? Which patients are changing in condition?”

Identifying the sickest patients alerts the on-call resident to the patients who need to be re-evaluated more frequently or who are most likely to have complications or changes in condition overnight. This helps the resident prioritize his or her time and also potentially evaluate these patients early during the shift so that reevaluations later can be compared to a baseline examination.

[2] The Code Status – “Which patients are DNR/DNI? Are any patients CMO?”

Night shifts in particular can be chaotic, and nothing is more chaotic than a Code. Accordingly, the algorithms underlying Codes are meant to provide order and structure for a situation where interventions must be rapidly delivered. However, not all of these interventions are desired by the patient, and so the Code Status must be the hand that stays the trigger finger in these cases.

Identifying patients who are “comfort measures only” and may likely pass during the shift helps the on-call resident prepare, particularly if he or she has questions regarding the cause of death (which will have to be documented and can be an ardurous process).

[3] The One-Liner – “Mr. T is a 43 year old man with a history of hypertension, coronary artery disease, and diabetes presenting with intermittent substernal chest pain for one day, most likely representing acid reflux.”

This skill is learned by medical students, but it still requires honing and perfection throughout residency and beyond. It is important to be able to convey key details of information in a compact amout of time and space. This includes age, pertinent past medical history, the presenting complaint, and the suspected diagnosis.

This is also a common area which can balloon in size and detail: the entire past medical history does not need to be conveyed, only the important aspects. Nonetheless, these details can be important, and it helps to provide some detail in a written version of the signout. For example, it helps to know the left ventricular ejection fraction for a patient with Congestive Heart Failure, that a patient with chronic renal insufficiency has a baseline creatinine of 1.6, that a patient with CAD has coronary stents, and that a patient with a prior left MCA stroke has residual right arm and face weakness.

[4] The Plan – “He is being ruled out for myocardial infarction and evaluated for other causes of chest pain.”

The “second line” following the one-liner should indicate what is being done for the patient. In particular, night shift residents are often called to the bedside to update patients and their families regarding the medical team’s plan of action because that is the time when family members are off work and can visit their loves ones in the hospital. This information also helps the night shift resident think about the direction of the patient’s care and potentially offer contributions in the form of suggested investigatory testing, additional history taking from the patient, or collecting collateral information from visiting family members. This can empower night shift residents to continue the work of the day time.

[5] The To-Do’s – “He has cardiac enzymes pending at 2000 and 0400.”

This part is a no-brainer. If there are specific tests to follow up or re-evaluations that must be done at a particular time, this should be communicated clearly and concisely. A plan of how to react to potential data points is also important here. For example, what should be done if the patient’s lungs have more crackles than before? What should be done if the patient’s blood pressure drops below a desired range?

[6] The Contingencies – “If he has recurrent chest pain, reassess, check his telemetry, and consider a repeat ECG. If his cardiac enzymes turn positive, call the Cardiology fellow and consider Heparin.”

Part of the day resident’s job is to anticipate potential problems or complications that might occur based on his or her current knowledge of the patient and the suspected disease process. This should accordingly be communicated to the night resident, and they should plan together how to react to these situations. In some places, these are called “disaster rounds” where the residents discuss worst-case scenarios and develop plans on how to deal with them.

This how-to guide should provide some structure and tips on how to make signouts systematic and effective. Signouts will continue to be a part of practicing medicine, wherever and whenever one is involved in patient care. Are there other aspects of the signout process not listed here that you believe are important to include? Has your program developed signout strategies that are particularly helpful or effective?

In a time when defensive practice conflicts with prudence and established practitioners bemoan the current state of the profession in light of a more glorious past, there are few consistent models representing the ideal physician for those training in the medical art. This is not to say that there are no heroes: there are numerous role models among practicing physicians and teachers. However, the medical field as a whole does not not cultivate an ironclad internal philosophy in the same way that one might find in a military academy or a successful company. Senior physicians might argue that the highly intellectual nature of medicine precludes a simplification of the core values underlying medical practice. However, all effective organizations have an infrastructure of core values that its members must aspire to and uphold at any cost. The medical profession’s core values suffer from adulteration by third parties that try to dictate how physicians should practice medicine and what doctors should be. If we cannot decide for ourselves the principles that we must follow, then others will, for better or worse.

We must know the essential qualities of an ideal physician. But where can we find them? Certainly not in popular culture. Physicians of the past had Marcus Welby; we have Gregory House and the fickle white coats of “Grey’s Anatomy.” But we also cannot rely on other external influences including our teachers (physicians who trained in a different era) and our patients. We must see beyond the nostalgia of our predecessors and the approval of our patients and their families to determine the true core values underlying the makings of the ideal modern physician.

[1] Excellence

The first measure of a great physician is excellence in clinical judgment: the accuracy of diagnostic methods, the thoroughness of approach, and the effectiveness of proven clinical decision-making principles. This obviously arises with the necessary prerequisites of intelligence, intellecutal curiosity, and well-developed logic and critical thinking skills. What follows, and is just as essential, is the ability to carry through the plans of action dictated by the clinical reasoning process, whether through coordination of care, the administration of pharmacotherapy, or the application of steel to the diseased body. Merely having good clinical reasoning and technical skills is not enough, however. The tireless compulsion to perform at maximum capacity is the true meaning of excellence.

However, always striving to deliver the best care possible should not be equated with ordering every test and calling every consultant. Rather, there is a careful balance between acting prudently and aggressively taking action.

[2] Compassion

A great physician enters this profession with a love for humanity. A great physician, despite the hardships of training and temptation of cynicism, never loses this love for his or her patients. Compassion is a core value of humanity as a species, and it is the primary fuel for the physician’s mission. For the modern physician, compassion represents the underlying emotional connection formed with each patient despite the bureaucracy, paperwork, and lack of time, and this connection is the fundamental basis for healing.

[3] Loyalty

The modern physician never works alone. Health care delivery, with the practice of medicine at its center, is reliant on teamwork. Loyalty means a great deal to the physician. It represents his friendship, support, and guidance of other care providers such as nurses and technicians. It represents the development of camaraderie within a specialty field among fellow residents and among physicians as a category. It represents respect for his mentors and teachers and the carrying of their messages and teachings to future generations. And it also represents the commitment to help fellow physicians see their mistakes and correct them in a supportive manner. (This last one, in particular, is incredibly important because past generations of physicians did a poor job of internal policing and correction, thus allowing the encroachment of outside parties who inevitably tend toward seeking punishment for mistakes instead of re-education or reform.)

[4] Fortitude

While our forebears wax poetic about the hardships of their storied early careers, it is important to understand that these comparisons are as based in reality as the practice of phrenology. The practice of medicine is constantly evolving and introduces many new challenges while attenuating others. Whereas physicians in the past may have worked longer shifts for more continuous stretches of days, they also did not have the same burden of paperwork, the complexities of care coordination, or even the complexities of addressing the wishes and perceived needs of patients (i.e. paternalistic care is much easier to deliver, but it is not better). Nonetheless, the underlying message is valuable: the willingness to persevere against hardship is a core value for physicians, because our jobs are not easy. We cannot give up once we have picked up the mantle for our patients. This is not to say that resident physicians should not complain about abuses and injustices or strive to make improvements in their lives, but often it is necessary to hunker down and push through the barriers, shoulder to the wall.

[5] Honesty

Last but not least, the practice of honesty is a core value of the modern physician. There are numerous occasions within the lives of a young physician when she is called upon to lie, bend, or obscure the truth: when a colleague makes a mistake but she must document her findings accurately and diplomatically, when a more senior colleague or attending physician comes to a conclusion that she does not agree with, or when it is requested by a family member or senior colleague that a suspected diagnosis not be revealed to an inquisitive patient. Nonetheless, there is no way to gain the trust of one’s colleagues and one’s patients if honesty is ever compromised. A forgotten exam maneuver should never be filled in with a fabricated finding. A question regarding the possibility of cancer as a possible explanation should never be sidestepped. The foundation of integrity is trust, and trust cannot be earned without consistent demonstration of honesty. A modern physician must be all of these things.

Do you have other ideas for core virtues modern physicians should have? If so, please write back in the comments section!

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