1. Cover your patients

It was my first year of practice. One day I saw a new patient, a 25-year-old man with hemorrhoidal pain. My nurse told him to disrobe and put on a lap sheet. When I entered the room, I was surprised to see that the young man was sitting on the exam table, naked from the waist down. The lap sheet sat neatly folded on the table behind him. I was so unnerved, I dared not look below his neck. I completed the history and physical exam, wrote a prescription, answered his questions, then fled the room.

I have since figured out what to do in this situation. I grab the sheet, unfurl it and place it across the patient’s lap while saying something like, “Here you go! You forgot this!” or “Let’s get you covered up!” Then the visit can proceed without great psychic discomfort for the doctor.

You might think me a bit dense for not thinking of this solution earlier, but it had never happened to me before. At any rate, this situation is easily defused with a simple gesture.

2. Never guess who the other person in the room is

I did learn this in medical school, but no one ever warned me about it. I was a third-year student assigned to do an admission on a young-appearing man. His companion was a gray-haired elderly woman. I introduced myself and then asked the woman if she was the man’s mother. He just about split his gut laughing while the woman glared at me and tersely announced that she was his wife. Whoops. I apologized profusely but the damage was done, and she hated me from then on.

The solution is simple. Even if you think you know who that person is sitting next to your patient, never, ever take a stab at it. My stock phrase which never causes me trouble is “Are you family?” or “Are you related?”

Sometimes I hear an indignant “I am his wife, of course!” when I might have guessed daughter or sister or mother. Better to be seen as dim rather than insulting.

3. The attendings you thought were old and out of touch were (mostly) not

When I was a senior resident, I am embarrassed to say that we made fun of some of the older attendings. We considered ourselves very knowledgeable and thought that some of those old goats were practicing medicine from the last century. We even had a famous story of one doctor who was about 60 at the time. One of his patients coded and “Dr. B” ran into the room after the residents had started the resuscitation. The following conversation ensued:

Dr. B: “What’s going on?”

Resident: “He arrested and is in EMD.”

Dr. B: “What’s EMD?”

Resident: ”Electromechanical disassociation.”

Dr. B: ”What’s that?”

Resident: “When there is a rhythm but no pulse.”

Dr. B: “Oh.”

Dr. B then left the room. We residents chortled about that one forever. How did Dr. B not know about EMD? (EMD is now known as PEA – pulseless electrical activity.)

In retrospect, as I have advanced to about the age that Dr. B was when we were finding fault with him, I think he was actually a fine doctor who just didn’t run codes. Those older physicians from my residency days had a lot of knowledge and expertise to offer their patients.

4. Acknowledge your patient’s death

When I was in training, some of my patients died. When that happened, I felt bad, but I never contacted surviving family members. Then in my second year of practice, my father died. Our family received an outpouring of support. I took great comfort in knowing how many people loved and respected my dad and how they took the time to show it.

I was suddenly horrified to realize that I had not done anything when my patients died. Shortly after my father’s funeral, I called an elderly patient whose husband had died a month earlier. I told her how sorry I was about her husband, who was also my patient. She replied, “I have been waiting for you to call me!” I cringed and apologized. She forgave me and continued as my patient until her death a few years later.

What I have done since then is to call the surviving family member, attend the funeral, or send a condolence card. I let the family know that it was a privilege for me to serve as their loved one’s physician.

5. Do not let patients coerce you into practicing bad medicine

This goes for inappropriate prescribing of antibiotics, opioids, and benzodiazepenes, and ordering unnecessary MRIs and other tests. It is hard not to please a patient when they are pushing for something that is clearly not indicated. But remember it is just bad medicine.

6. Rules of residency

a. Never pass a bathroom. (If you hold your urine too long, you will suffer acute urinary retention when you someday have surgery.)
b. Never run when you can walk. (You will arrive breathless to the code and will be no good to anyone, especially the patient.)
c. Never stand when you can sit. (You have to conserve your energy when you are working long hours.)
d. Never skip a meal. (I started missing meals as a resident and was rewarded with killer migraine headaches. It’s not worth it.)
e. Always sleep at the first opportunity. (You never know when you might have another chance!)
f. Piss and pus must come out. Corollary: Never let the sun set on an undrained abscess. These are my surgery attending’s rules of surgery. Never forget these.
g. The only reason not to do a rectal exam is if the patient doesn’t have a rectum or the doctor doesn’t have a finger. Corollary: If you don’t put your finger in it, you will put your foot in it!

Annette Chavez is a family physician.

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