Tips for IM Attendings – Chapter 7 – Communicating Expectations

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Category : Medical Rants

The domain communicating expectations included a few concepts that do not fit as neatly.  These two were highly rated.

Stating expectations for residents/students (6)

Allow team some independence in decision-making (7)

The first concept seems obvious at first, but likely appears because it does not occur frequently enough.  As attending physicians we have the responsibility to make clear how we want things done.  That includes presentation style, daily reporting style and time expectations.

Although not explicitly included, many colleagues will ask the learners to express their expectations of the rounding process.

Independence in decision-making as a concept becomes a recurrent theme especially with residents.  As attending physicians how do we balance our patient care responsibility with resident growth.  My former chairman often used the term graduated responsibility.  Ask yourself if you really encourage residents to have appropriate independence.

Residents seek management without micro-management.  How do we avoid micro-management?

A few examples might help.

On day 5 of the patient’s admission, she complains of constipation.  Do you tell the intern and resident how to treat the constipation, or do you ask them to develop a plan?

Another patient has a potassium level of 2.5.  You look at the IV fluids and see D5/NS with 20 mEq KCL running at 100 cc/hr.  What do you do?

1. Tell the team to add 50 mEq instead of 20 mEq.

2. Ask the team what the potassium deficit is and then how fast you an safely replace potassium.

3. Ignore the subject

4. Yell at the team for putting “your patient” at danger of arrhythmias

One very highly desired attending physician uses these situations as an opportunity to “think out loud”.  If you teach the physiology and pharmacology, then the intern/resident team will make the right decision then and in the future.  They will believe that they had independence in ordering the potassium replacement.

This small and perhaps contrived domain really focuses on communication.  How do we as attending physicians make the learners involved and growing in a way that works well for patient care?  Do we teach them how to present, how to call a consult, how to keep us updated or do we just criticize them at the end of the rotation for doing a mediocre job?  Do we allow them to present their ideas on evaluation and treatment and then focus any criticism as a teaching opportunity?

This domain while small is a difficult one for many attending physicians.  Newly minted residents often have the same difficulty with these concepts.  Do they give the intern enough autonomy, but not too much?

Can we embrace the concept of graduated responsibility?  When we do, our learners grow faster and reach important milestones with our help and not despite our style.

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