“Old school” is difficult, but doable for teaching attendings. While prioritization is the key, having a basic framework will help.
Here are my personal keys:
1. Sit at the bedside and retake the history of present illness on those patients in whom taking the history is clearly a key. For example, someone admitted with presumed community acquired pneumonia should have a short history including fever and perhaps night sweats and possible rigors. We should retake the history carefully.
2. In the same patient we should do a careful lung physical exam, and then demonstrate any positive findings to the team.
3. We should look at the chest x-ray with the team, and discuss whether it looks consistent with the diagnosis.
4. If we agree with the diagnosis, we should state clearly why — what illness script are we using and how does the problem representation match that illness script.
5. If we have doubts about the diagnosis, we should state clearly why — and then work with the team to develop a diagnostic and therapeutic strategy.
A major key in this style is thinking out loud. The team should always understand what we are doing and why. The team should be first asked what they would like to do, and endorse when possible, but explain why not when you disagree.
In addition to we have several more bedside manner opportunities each day. We should make certain that the patient understands the plan for the day. We should deliver news — good or bad — with the team observing. Then we should debrief with the team — discussing the skills used and critiquing the performance. Sometimes we do not do a good job, and we should admit it and help the team understand what went wrong.
Old school in my mind requires explicit demonstrations of history taking, physical diagnosis, thought process and bedside manner.
We can and should demand that we strive to become old school attendings. I understand the reasons that many do not do this, but I cannot think of a good reason to avoid doing the proper type of teaching. It might be more difficult, but it is so important that we must adjust and give our patients the best trained physicians.
Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.
