Chief to junior on rounds, sharply: “Don’t guess. You know or you don’t know. Guessing is making it up.”

Attending to senior during M&M: “You believed the pre-op H&P from the office chart? Don’t you dare do that on my service. Be more compulsive than that.”

A couple more months of witnessing this (and receiving my fair share of it, too), and I will be obsessive about details. Which is good. That’s what I admired about surgeons, and I still do. They are the people who have the least tolerance for any kind of avoidable error. You don’t know what the patient’s home medications are? Why not? Did you talk to the patient, to their family, call their nursing home, have records sent from the other hospital, call their family physician? Only if you’ve done all of that do you have an excuse for not knowing their meds and doses. You don’t know what the pre-op CT looked like? Did you dig through radiology records? Did you make multiple requests for records from the other hospital? Did you go through the attending’s office looking for the CD? Only then do you have an excuse for not knowing what the lesion looked like on CT. As for current labs, recent vital signs, and recent imaging, when those are available in a chart or on a computer, there can never be an excuse for not knowing those, or having them written down handy. Aspects of the physical exam? With the patient in a bed somewhere in the hospital, no excuse not to know every reflex, murmur, skin lesion, and scar. Especially if the attending is asking about it. (Maybe you don’t need to know all of them, but you’d better have figured out which ones of them are going to be relevant, and know those.)

Eventually, I’ll get tired enough of wasting my time and losing face in front of patients by going back to check on these things that I’ll remember to ask about everything and look at everything the first time I’m in the room. Then, I will really be a good doctor. For now, the only thing to do is to be obsessive about rechecking the details, so the seniors and attendings can’t find anything that I don’t know. After all, that’s what morning rounds are really about. Part of it is taking care of the patients, figuring things out early enough in the morning that we can get all the needed tests and procedures done before people go home in the evening. But at a deeper level, every morning is an exercise in obsession: how much detail can you find out, how fast, and present in how precise an order? Most surgeons aren’t born obsessive-compulsive; they practice hard to get that way.

This might sound ridiculous. But mistakes can kill. If you don’t notice a patient’s low potassium, they could have a fatal arrhythmia within a few hours. If you don’t notice that no one has put SCDs (compression boots) on the patient, they could die of a PE the day you want to send them home. If you don’t order the pre-op antibiotics, the patient could get a serious, if not fatal, wound infection. If you don’t notice a gradually increasing heart rate, the patient could die of anything from a heart attack to sepsis before you catch up.  (And this isn’t even mentioning details in the OR itself, which I have no idea about yet, but which I am sure are even more ominous.) You never know which detail is going to trip you up; so you have to know all of them.

About these ads