Mastering the Art of Patient Care

Foreword
Preface
Acknowledgments
Contents
About the Author
Part I Building Your Medical Foundation
1 Medical School
	1.1 The Early Years
		1.1.1 The Cheat-Sheet Method
		1.1.2 Study Questions
		1.1.3 Keep Hope Alive
	1.2 The Clinical Years
		1.2.1 Feign Enthusiasm
		1.2.2 Commit to the Rotation
		1.2.3 The Price of Service is Scut
	1.3 Final Thoughts
	References
2 Becoming Fluent in Medicine
	2.1 Oral Presentations
		2.1.1 The Identifying Statement
		2.1.2 The History of Present Illness
		2.1.3 The Past Medical History
		2.1.4 Medications
		2.1.5 Allergies
		2.1.6 Social History
		2.1.7 Family History
		2.1.8 Review of Systems
		2.1.9 Physical Examination and Laboratories
		2.1.10 Assessment
		2.1.11 Plan
		2.1.12 The Daily Presentation
		2.1.13 Keep to Your Script
		2.1.14 Know Your Patient
		2.1.15 Practice Makes Perfect
	2.2 The Art of the Note
		2.2.1 Make It Make Sense
		2.2.2 Brevity is the Soul of a Good Note
		2.2.3 If You Write It, You Own It
		2.2.4 Close the Loop
		2.2.5 Useful Tips and Tricks
		2.2.6 Cringe-Worthy Phrases
	2.3 Final Thoughts
3 Your Career Path
	3.1 Research
		3.1.1 Pick the Mentor not the Project
		3.1.2 Start More Basic
	3.2 Giving Talks
		3.2.1 Relevance: Consider the Audience
		3.2.2 The Importance of Anecdotes
		3.2.3 Punctuality is a Virtue
		3.2.4 Make Your Slides Work for You
		3.2.5 Practice, Practice, Practice
	3.3 Choosing a Specialty
		3.3.1 Process of Elimination
		3.3.2 What Do You Love?
		3.3.3 Who Inspires You?
		3.3.4 Does Lifestyle Matter?
		3.3.5 What Comes Next
	3.4 Picking a Training Program
		3.4.1 Volume
		3.4.2 Autonomy
		3.4.3 Mentorship
	3.5 More About Mentors
		3.5.1 Find a Role Model
		3.5.2 Ask the Right Questions
		3.5.3 Assemble a Cabinet
	3.6 Final Thoughts
	References
Part II Honing Your Clinical Judgment
4 Diagnosis
	4.1 Read a Lot (of Notes)
	4.2 The Highest-Yield Questions
		4.2.1 What Are the Precipitating, Exacerbating, and Relieving Factors?
		4.2.2 Have the Symptoms Been Getting Better, Worse, or Staying the Same and Over What Period of Time?
		4.2.3 What Made You Decide to Come in Today to Discuss Your Symptoms?
		4.2.4 What Are You Most Worried About?
		4.2.5 What Have You Tried to Make It Better? What Prior Testing Have You Had?
	4.3 Learning More Than What the Patient Says
		4.3.1 Personality
		4.3.2 Other Opinions
		4.3.3 Location
		4.3.4 Your (the Physician’s) State of Mind
	4.4 Diagnostic Pitfalls
		4.4.1 Orthopnea
		4.4.2 Reproducible Chest Pain
		4.4.3 Assessment of Mental Status
	4.5 The Power of Observation
		4.5.1 Walking in the Exam Room
		4.5.2 Who’s with the Patient?
		4.5.3 The Hospital Set-Up
	4.6 Final Thoughts
5 Tests and Interventions
	5.1 There is No Perfect Test
	5.2 Bayes Theorem is Your Friend
	5.3 Pitfalls, Outliers, and Trends
	5.4 Duplication of Effort
	5.5 Communicate the Urgency
		5.5.1 Prepare the Patient
		5.5.2 The Acute Recognition of a Chronic Problem is not the Same as an Acute Problem
		5.5.3 Use Your Influence When Warranted
	5.6 The Cases that Keep You Up at Night
		5.6.1 Validation
		5.6.2 Tempered Reassurance
		5.6.3 A Plan with Managed Expectations
	5.7 The Worst-Case Scenario
	5.8 The Golden Rule
		5.8.1 Contraindication Creep
		5.8.2 Indication Creep
	5.9 “How Can It Hurt?” is Rarely the Right Justification
		5.9.1 Be a Humble Student of Clinical Trials
		5.9.2 When in Doubt, Return to the Golden Rule
		5.9.3 Bandaids versus Cures
	5.10 Final Thoughts
	References
6 The Art of the Consult
	6.1 How to Call a Consult
		6.1.1 Call Early
		6.1.2 Have a Specific Question
		6.1.3 Tell the Patient
		6.1.4 Calibrate Your Concern
		6.1.5 Save the Plan for the Consultant
		6.1.6 Make Your Consultant Work for Your Patient
		6.1.7 Know When to Push
	6.2 How to Be a Consultant
		6.2.1 Be Prepared
		6.2.2 Be Specific
		6.2.3 Be Timely
		6.2.4 Be Part of the Team
		6.2.5 Anticipate Questions
		6.2.6 Know When to Sign Off
	6.3 How to Work Together
		6.3.1 Avoid Chart Wars
		6.3.2 Pick Your Battles
	6.4 Final Thoughts
Part III Establishing Your Medical Style
7 Good Habits for a Lifetime
	7.1 Preparation
	7.2 The Worst-Case-Scenario Game
	7.3 Don’t Be Afraid of What You don’t Know
	7.4 Checklists: Not just for Interns Anymore
	7.5 Time Management
	7.6 Be Nice and Work Hard
		7.6.1 Choose Kindness
		7.6.2 Reliability and Respect
	7.7 Final Thoughts
	Reference
8 Leading Your Team
	8.1 Tough Transitions: Being a Leader
		8.1.1 Second-Year Resident
		8.1.2 First-Year Fellow
		8.1.3 Attending Physician
	8.2 Teaching
		8.2.1 Streamline Rounds
		8.2.2 Encourage Debate
		8.2.3 Create Captains-Claim the Role
		8.2.4 Don’t Micromanage
		8.2.5 Rejoice in Trainees’ Successes
	8.3 Learning
		8.3.1 Look Things Up
		8.3.2 Know the Right Questions
		8.3.3 Experience Trumps Education
	8.4 Feedback
		8.4.1 Be Timely
		8.4.2 Be Specific
		8.4.3 Provide Context
		8.4.4 Offer Strategies to Improve
		8.4.5 Check in to Assess Progress
		8.4.6 Positive Feedback is Important Too
	8.5 Lead with Kindness
		8.5.1 Protect Your Team
		8.5.2 Don’t Just Make the Offer, Make a Plan
	8.6 Final Thoughts
9 The Tough Conversations
	9.1 The Emotion Behind the Question
		9.1.1 Can I Trust You?
		9.1.2 Am I Going to Be Okay?
	9.2 The Patient Who is Angry and Frustrated
		9.2.1 Protect Yourself
		9.2.2 Step 1: Listen
		9.2.3 Step 2: Reflect
		9.2.4 Step 3: Make a Concrete Action Plan
		9.2.5 Step 4: Circle Back
	9.3 Leaving Against Medical Advice
	9.4 The Patient Who Takes Too Long
	9.5 The Patient Who Disagrees with You
		9.5.1 Step 1: Identify the Problem
		9.5.2 Step 2: Emphasize the Shared Mission and Medical Facts
		9.5.3 Step 3: Allow the Patient to Make Their Own Decision
	9.6 The Patient Who Wants a Second Opinion
		9.6.1 Encourage Second Opinions
		9.6.2 Learn from Being the Second Opinion
	9.7 Practicing the Art of Saying No
	9.8 Breaking Bad News
		9.8.1 Step 1: Have a Concrete Action Plan
		9.8.2 Step 2: Determine the Delivery
		9.8.3 Step 3: Let the News Register
		9.8.4 Step 4: Explain the Plan
		9.8.5 Step 5: Make the Promise
		9.8.6 Step 6: Circle Back
	9.9 When You don’t Know
		9.9.1 Honesty on Rounds
		9.9.2 Honesty with Patients
		9.9.3 End-of-Life Care
		9.9.4 Step 1: Know All the Facts; Use Only the Ones the Families Need to Hear
		9.9.5 Step 2: Frame Best-Case and Worst-Case Scenarios
		9.9.6 Step 3. Explore the patient’s Goals, Values, and Preferences
		9.9.7 Step 4. Make the Promise
		9.9.8 Step 5. Come to Consensus
	9.10 More Thoughts About End-of-Life Care
		9.10.1 There Should be Grief
		9.10.2 You Do not Have a Crystal Ball
		9.10.3 Your Right Answer May Not Be Their Right Answer
	9.11 Final Thoughts
	Reference
Part IV Optimizing the Care of Patients and Yourself
10 The Patient-Physician Bond
	10.1 Addressing Patients
		10.1.1 Introductions
		10.1.2 Patients with Dementia or Learning Disabilities
		10.1.3 Unresponsive Patients
	10.2 Managing Expectations
		10.2.1 Hospital Standard Time
		10.2.2 Discharge Planning
		10.2.3 Side Effects
		10.2.4 The Results of Tests/Interventions
	10.3 Care Versus Service
		10.3.1 Delays Are the Luxury of the Healthy
		10.3.2 Trust the Experts
		10.3.3 Know When to Expedite
	10.4 The Person Behind the Patient
		10.4.1 Embrace the Little Details
		10.4.2 Ask the Follow-Up Question
		10.4.3 Address the Little Indignities
		10.4.4 Humor
	10.5 Maintaining Homeostasis
		10.5.1 Eat
		10.5.2 Poop
		10.5.3 Sleep
	10.6 Final Thoughts
11 Being a Woman in Medicine (Men: Don’t Skip This Chapter!)
	11.1 Navigating the Training Environment
		11.1.1 Never Assume the Worst
		11.1.2 Claim Your Role
		11.1.3 Humor and Sarcasm Can Help
	11.2 Motherhood (Parenthood)
		11.2.1 What You Need to Successfully Parent as a Physician
		11.2.2 The Right Time to Have Kids
		11.2.3 Unfounded Fear 1: You Won’t Remember How to Be a Good Physician
		11.2.4 Unfounded Fear 2: Your Baby Will Forget You
		11.2.5 Unfounded Fear 3: You Will Never “Get It Together”
	11.3 Navigating the Career
		11.3.1 Your Priorities Are Right Because They’re Yours
		11.3.2 Comparison is the Thief of Joy
		11.3.3 There is More to Academic Medicine Than Research
	11.4 Final Thoughts
	Reference
12 Self-Care
	12.1 Boundaries
		12.1.1 Vacation Time
		12.1.2 100% Care Does Not Require 100% Access
	12.2 Patient Reviews
	12.3 Grief and Mistakes
		12.3.1 Separate Fault from Fluke
		12.3.2 Distinguish the Unforeseen from the Expected
		12.3.3 Accept that Control is an Illusion
		12.3.4 Learn from Your Successes Too
	12.4 Savor Your Victories
	12.5 Find the Joy
	12.6 Final Thoughts
	Reference
13 What Covid-19 Has Taught Us (or Not)
	13.1 The Myth of Zero Risk
	13.2 The Road to Bad Outcomes
	13.3 Disagreement and Covid
	13.4 Final Thoughts
	References
Afterword: The Joy of Medicine