40 years of ward attending

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Category : Medical Rants

January 1, 1980 I walked onto the 7th floor of the old North Hospital at the Medical College of Virginia to make rounds as the attending physician. I had spent much time there as an intern and resident, but now I had a new role.

As I reflect on 40 years and probably between 12 and 15 years of total time making rounds, I first feel fortunate that I quickly discovered that my vocation was also my avocation. Now while I have retired from administrative responsibilities, I still devote 3.5 months each year to rounding with students, interns and residents. And each rotation still brings out the same excitement of going to the bedside and trying to help patients, of exposing students to the wonder of internal medicine, of helping interns through that difficult year and of helping residents in the final year of their internal medicine journey.

When I started, I thought that I really knew what I was doing. On reflection, I had some excellent instincts, adequate knowledge and yet much to learn about leading a ward team. The job has changed dramatically over these 40 years, and hopefully so have I.

In 1990, I had the wonderful opportunity to spend a month at Stanford, learning about teaching from Dr. Kelley Skeff. To this day, he remains one of my heroes and important colleagues. He taught us how to evaluate our own teaching. He provided a structure of the attributes for successful teachers:

  1. Creating a Positive Learning Climate
  2. Organizing Control of the Teaching Session
  3. Communication of Educational Goals
  4. Promoting Understanding and Retention
  5. Evaluation of the Learner
  6. Providing Feedback
  7. Fostering Self-Directed Learning

To read more from Dr. Skeff

His insights and videos allowed us self-reflection. Under his guidance, we learned to strive for improvement and to critically evaluate our own teaching. I borrowed much from Kelley.

He transformed my teaching in many ways. The most important in reflection was that I began seeking ways to assess my own teaching through student, intern and resident feedback. I learned that experimentation was desirable for teachers – as long as one could adequately evaluate the experiment. Over the years my teaching has matured thanks to the patients, students and housestaff who have given me either direct or indirect feedback.

Teaching attending responsibilities have changed dramatically over the years. When I started we never wrote notes. Then we transitioned to brief notes for billing.

It took many years to developed my unique ward rounds teaching style. I am happy to argue that there is no correct teaching style, rather each attending physician needs to develop a style that works for patients, students and housestaff.

Medicine has changed dramatically over the past 40 years. We treated heart failure with digoxin and furosemide when I started. We had no HIV reported, no MRSA, nascent CT scanning and MRI, many fewer drug classes, and no billing requirements. Our understanding of pathophysiology has grown. Our ability to diagnose prior to autopsy is much greater, yet we likely make as many diagnostic errors now as we did then.

The research into what makes successful ward attending rounds – Using cognitive mapping to define key domains for successful attending rounds – further helped me understand what to emphasize and what to de-emphasize.

At the beginning I aspired to become a great clinician-educator although no one used that term. In the 70s and 80s (and for some today) most deans and chairs assumed that any good physician could teach clinical medicine. Today we are more clearly defining the value of great clinician-educators and hopefully insisting on quality (although this might be an aspirational hope).

So what do I know now that I did not know then. First, I have a much better personal understanding of my limitations. I know when to ask for help. Second, I have developed my best style. I allows start in the team room, discussing each patient, having the team tell me their plans. We often have a brief educational discussion of some aspect of the patient (dx, rx or something tangential). Once we all understand the general plan for the day, we go visit each patient. At the bedside I often am the “role model”. I repeat parts of the history when appropriate, repeat the high yield physical exam, answer patient questions, and make certain that the patient understands the day’s plan. I deliver bad news if necessary. Afterwards, we often debrief the team about bedside manner. Whenever we have images to view, we walk to the radiologists. I started doing this several years ago, and it has become extremely popular with the housestaff and students. It also helps us more quickly get to the proper diagnosis.

My advice to junior attendings:

  1. Read both linked articles
  2. Try hard not to micromanage
  3. When you disagree with the team, or when you are directing the plan – make your thought processes explicit – that is the number one wish of your learners
  4. Respect their time – always finish on time, even if you must see a few patients w/o the team
  5. Get to know the team members
  6. Ask team members what they did for fun on their off day
  7. Give feedback daily – both positive and formative – and label it as feedback
  8. Touch patients, sit down, learn who the patients are – your learners will emulate your bedside manner, so make it impeccable

I have left much out. Being an internal medicine ward attending is and has been my perfect vocation and avocation. I hope they let me reach 50 years.

Thanks to the many patients, students, interns and residents who have challenged me to be a better physician and a better educator. You have given me the great gift anyone could receive.

And on February 16th I go back on service for another 1/2 month. Looking forward to it.

Comments (4)

A masterpiece as always. Thank you, Uncle Bob. I hope you never retire.

So much wisdom and appreciation for students and residents. Another LARGE aspect of your career is the impact on the lives of patients, fellows, faculty/ practicing physicians. Few outside UAB may know that Bob was the 1st physician recognized with the UAB lifetime teaching award (description below). Bob, THANK YOU for inspiring so many.

“The Ingalls/Alumni Award is presented annually to a full-time regular UAB faculty member who, throughout his/her career at UAB, has demonstrated an outstanding commitment to teaching. To receive the Ingalls/Alumni Award, the faculty must be a former recipient of the President’s Award for Excellence in Teaching and have served UAB for 20 or more years as a full-time regular faculty member.”

Excellent post … educational/ inspirational as always. I for one miss your blog posts. Thanks for what you do.

Nice information based on the real experience in health care. Thanks for sharing such informative aricle.

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