Thursday, September 25, 2008

100+ Tips for Being On Call in the Hospital

Several weekends ago, while seeing nearly fifty patients in the hospital, I asked readers of this blog and my followers on Twitter a question: "What advice do you have for physicians on call?"

The question hit a nerve, and the result was over a hundred tips from a dozen different physicians. Some are directed at residents, others at attending physicians. Some tips apply to the daytime, some apply to 3 o'clock in the morning. Some tips are unrealistic. Some are thought experiments. Some tips might make your day go quicker, and some will purposefully slow you down. Some tips might improve the care of your patients, some might make you more mindful, and some might help you reconnect with the reasons you became a doctor in the first place.

There’s bound to be something here you'll find useful.

Thanks to everyone who generously contributed their advice, including Doctor Anonymous, Theresa Chan (Rural Doctoring), Jen McCabe Gorman, A. Mangla, Mark Johnson, Nephron129, Huck, and several anonymous physicians.

Addendum: For the most recent version of this page to which you can add your own advice, visit The Efficient MD Wiki.

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Drink more water. Does staying well hydrated affect your performance? In the rush to see patients, it’s easy to forget the simple things, like drinking water. Try drinking at regular intervals — say, every three hours. Set a timer to go off every three hours, and drink at least eight ounces of water. You might discover that this improves your mental acuity and performance.

Get outside at least once a day. Vow to get out for at least five or ten minutes every day (weather permitting, of course). Staying in the hospital too long can make anyone claustrophobic. Look at the horizon. Breathe the outside air. Get a fresh perspective.

Make a game of remembering names. Attempt to memorize as many of your patients’ names as you can. You may be one of those people born with the skill of instantly remembering names. Most of us aren’t so lucky, and we have to work hard at it. It’s a skill worth improving. Try memorizing the names of all the patients you see. One method is to say the persons name aloud to them (“Hello, Mr. Jones.”), Repeat the name three times to yourself, then focus on an unusual feature of the patient and connect this feature to the person's name.

Walk more quickly. Try walking 25% faster than you otherwise would. Observe the effect on the rapidity of your thinking.

Take the stairs instead of the elevator. If you need to walk up or down two flights, ditch the elevator and use the stairs. Extra credit: buy a pedometer and aim for 10,000 steps during the day.

Nap. If you feel sluggish in the middle of the afternoon, experiment with taking a 15 minute nap. (This is long enough to refresh you without causing you to fall into a deep sleep.)

Time yourself. Set a specific time to spend with each patient: say, 5 - 15 minutes with a follow up patient, and 30 minutes with a new patient. (Use a watch with a vibrating alarm, like the Dakota Vibe.)

Use a tally counter. Keep this in your pocket and record the notes you’ve written, or the times you’ve done something correct, or the small tasks you’ve accomplished. Aim for 100.

Connect with other people who are on call with you. There’s a certain friendly familiarity that comes with being one of the few people working in the hospital. Also, you may need them for consults, and they may need you.

Pay attention to your breathing. While walking in the hospital, quiet your mind and focus on the breath. Try to maintain your focus and concentrate only on the breath.

Refine one part of your physical exam. For ten patients in a row, pay particular attention to how you perform one part of the physical exam. Do a complete cardiac exam, or pulmonary exam. Do it the same for each patient. Analyze your technique.

Track down the coffee. Better yet: Find out who makes the coffee. Make friends with them. Quickly. Same with charge nurses. (Jen McCabe Gorman)

Maintain eye contact. Make a conscious attempt to keep your eyes focused on the eyes of your patients. Don’t look away. Occasionally switch from eye to eye. Maintaining eye contact tells your patients that you are paying attention to them. It’s easy to forget this and look at our list, or at the part of the body we’re performing the physical exam on — anywhere but the eyes.

Ask questions. Find out patients' backgrounds. Dr. Faith Fitzgerald has a story that she tells about a group of residents who purposefully presented to her “the most boring person on their team,” an utterly unremarkable old woman. After some questioning, Dr. Fitzgerald discovered that this woman was actually one of the last survivors of the Titanic. Everyone has a story. It’s easy to lose site of patients’ humanity when you’re rushing through the hospital on call. For at least a few of the patients you see, ask a question. Try to find out something about them. What have they worked as? Where do they live? What is interesting about them? Ask one question of each patient, like “Where have you worked in your life? Where have you lived?”

Do everything when you can. Eat when you can, sleep when you can, pee when you can. (Rural Doctoring)

Eat a Cliff Bar. Doctors notoriously are too involved with taking care of others to take care of themselves. We ignore our own bodies. We may be hungry or thirsty, but are rushing too quickly to pay attention. Midway through the morning, when you may feel yourself losing steam and are maybe slightly hungry, try having a snack. Something small, like a Cliff Bar. See if that gives you an extra boost of energy.

Get to the hospital ridiculously early. Wake up at 4 or 5 AM. Getting in early has advantages — it’s easier to concentrate and accomplish tasks if there are fewer people around. However, typically morning labs are not available until late in the morning or early in the afternoon, so this strategy may require you to check labs again. (If you haven’t slept much, getting in early works best when combined with a nap.)

Reevaluate your gear. Your day will be much more pleasant if you have the right equipment. Ever use a pen that didn’t write smoothly and felt awkward in your hand? Ever use a stethoscope with poor acoustics? These little things may not seem like much, but if you’re examining a lot of patients and if you’re required to write a lot of notes (assuming you’re not using an EMR), little things matter. Having the right gear can make the difference between being frustrated and relaxed at the end of the day.

Lie down whenever you can — even if only for a minute because it might turn into an hour. (Rural Doctoring)

Count stairs. Sometimes you'll be too damn tired to pay attention; wakes you up. (Jen McCabe Gorman)

Consciously write less. Make ever word count. Be sure to include the pertinent parts of the history, the pertinent positives and negatives, but be aware of the subtext to your notes — you are trying to establish in the reader’s mind your argument for a specific diagnosis or plan. For more on this idea, see Developing Clinical Problem Skills by Harold Barrows.

Consciously write more. As an experiment, imagine the worst possible outcome or potential diagnoses for some of your patient. How have you excluded these diagnoses? Take some extra time to convince the reader that your discarded diagnoses are not the correct ones and that further tests are not needed.

Don’t get distracted. "Being on Call can be overwhelming especially if you have to see over twenty patients. I usually get my list of patients in the morning and then geographically I make a 'plan of attack,' and then I go full steam ahead. Try not to chat with people although it can be tempting. Staying focused on the patients and their issues rather than what you want to do when you leave the hospital really makes my speed remain fairly contstant. There is nothing so novel here that you haven't heard before — make yourt plan of attack, stick to it, focus on the work without getting distracted." (A. Mangla)

Change your pen. If you’re used to a ball point pen, switch to a roller ball. If you’re used to a roller ball, try an inexpensive fountain pen or gel pen. It’s amazing what the difference of a pen can make in your mood and your writing. (If you write most of your notes electronically, obviously this advice doesn’t apply.)

Learn to recognize when people are sick. For residents: “If you think a patient has a chance of ‘crumping,’ ‘lay eyes’ on the patient early in the night so when you’re called at 2 AM you have a reference to compare to.” (Mark Johnson)

Say one encouraging thing to everyone (if possible). “You’re doing better.” “Your kidney function is improving.” “Everything looks stable.” It’s often difficult for patient’s to tell whether they’re improving or not. Even simple words of encouragement can lift someone’s spirit.

Respect the nurses. “Respectful interactions with RNs is key to survival. Rudeness results in bodies found in ditches.” (Rural Doctoring)

Don’t wear a watch. Does not looking at the clock make you faster?

Take a deep breath. If you become short tempered with patients or their families because of stress, catch yourself. Relax. Sit down.

When encountering complex differential diagnoses, use a mnemonic. For example, VINDICATUM: Vascular, Inflammatory, Neoplastic, Drug, Iatrogenic, Congenital, Autoimmune, Trauma, Unknown/Idiopathic, & Metabolic. For new patients with uncertain diagnoses, use this mnemonic.

Choose your rounding time carefully. “Certain period of the day are more conducive to rounding. 8AM is notoriously hard because the nurses are signing out and there is no workspace available. Family visiting hours, usually from 10 am until the early afternoon, can be tough too if you have a lot of patients to see. If you only have a few patients to see, this is probably the best time as you can take the time to explain things to the family and patient together. Like another person has written, avoid socializing.” (Anonymous)

Make sure your pager is on. Don’t laugh. (Doctor Anonymous)

For each patient, ask: how am I getting them closer to discharge? What’s the plan? How am I getting them to their goal of being well and out of the hospital? (Or failing that, how am I making them more comfortable, etc.)

Review ACLS. For residents: “Scan the CPR/ACLS protocols for about 90 seconds each AM while walking into the hospital in AM to refresh.” (Mark Johnson)

Normalize your patients. At some point during their hospital stay, most patients should be normalized. In the rush to manage more complex problems, this is easily overlooked. Normalization means turning a "patient" into a "normal person." This is accomplished by removing intravenous lines and catheters, stopping unnecessary medications, not drawing labs daily, getting people out of bed, and planning for discharge. A patient who is otherwise doing well may stay in the hospital for weeks (or even die) because of a complication like line sepsis, urinary tract infection from a catheter, or deep venous thrombosis. Sometimes, these complications may be prevented by early and aggressive normalization.

Take a stairway or elevator you’ve never used before. Many hospitals that I’ve worked at have multiple elevators and stairways, many of which I’ve never used. Experiment with using them.

Consciously relax. Doctors are often at their most stressed when on call. Ever few minutes, relax your facial muscles. Let your shoulders drop. Before seeing each patient, relax yourself.

Wake up early post call. For residents: “Set your alarm in AM for plenty of time to wake up & get a fresh cup of coffee (even if it means less sleep) prior to AM rounds.” (Mark Johnson)

Always give patient and their families the benefit of the doubt in any interactions. Presume that if they’re acting upset, or hostile, they have a reason. It may always not seem like a good reason to you, but presume it’s there. Try to see the reason. It’s surprising how often hostility melts away with a small amount of human kindness and empathy.

Avoid socializing. Recognize that being on call is a time that you need to get work done and socializing is not your goal.

Consciously socialize. Recognize that being on call is a time when you can deepen your relationships with other doctors.

Group your tasks. Similar tasks should be performed together. Rather than examining patients, checking labs, and writing notes, try doing each of these tasks at once — for example, examine all patients on the floor, check all labs for all patients, then write as many notes as you can. If you use this technique, be sure to ensure accuracy by writing small notes to yourself on an index card or on a note template so you don’t neglect to write down significant physical findings.

Triage. While it may be tempting to start at the top of the hospital and work your way down, or go from one floor to the other, it’s a better idea to see patients who are sick or require decisions early. That way, you’re less likely to discover that someone is unexpectedly sick at the end of the day. Of course, it’s better to see a few patients at each nurses station — it’s inefficient to constantly criss-cross your way through the hospital floors, returning to places you’ve already been. There’s a balance between seeing patients efficiently and seeing the most critical patients first.

Experiment with breaks. Take a five minute break every one to two hours. Athletes understand that for sustained peak performance you must take breaks. If you keep going at top speed for the whole day, you’ll burn out.

On an index card or PDA, write down everything you don't know. One of the best ways to learn more and learn efficiently is to keep a list of things you don’t know. Whenever you encounter a clinical question that you don’t know the answer to, write it down on an index card or PDA. (Assuming you don’t need to know the answer right then — if you do, by all means, look it up.) At the end of the day, devote some time to looking up the answer to every clinical question you have using a resource like UpToDate.

Have a printout of every patient you are covering in your pocket. "Keep to do list with check boxes next to each items. Write down tasks to be done at a particular time. For example, check labs on Mr. X, Mrs. Y, and Z at 2200. Keep commonly used numbers on the sheet or handy in your pocket (other residents, cardiology fellow, common hospital floor numbers.)" (Mark Johnson)

When “cross-covering” a patient, write down everything you do. (Mark Johnson)

Reevaluate your templates. Being on call is a stress test of the system.

Bring your favorite foods from home. “I bring 2 bottles of water and 2 sodas each weekend call. I like to bring ~6 sandwich bags of sliced cheese, crackers, nuts, carrots, dry cereal to snack on throughout the night, also a few chocolates makes the night.” (Mark Johnson)

If you’re staying overnight, stuff a call bag. One resident’s call bag includes a medical book, non-medical book, travel-sized deoderant, toothbrush, toilet paper, fresh pair of scrubs, undershirt, and underwear for the AM. (Mark Johnson)

Carefully choose your pocket resources. For residents, consider Massachussets General Hospital’s “Blue book,” Tarascon’s Internal Medicine/Critical Care, and Tarascon’s Pharmacopia. (MarkJohnson) I also liked On Call: Principles and Protocols.

Treat your call day just just like a regular work day. “I go through my same routine. I don't come in later, but rather at my usual time. I avoid nurse signout time (7am at our hospital) and I start with the most critically ill.” (Nephron129)

Write as you talk on the phone. You may often be put on hold or on a phone call which doesn’t require your full attention. Make productive use of this time. Write notes, check labs, or do other activities. The general principle is that there should be no downtime unless you want it.

Knock on the door (or the wall) before entering patients’ rooms. Even when you’re at your most harried, be polite. Patients will appreciate it, and when you do have time, being polite will be second nature.

Write standing. If you find that your energy is flagging, or that you your notes are overly lengthy, experiment with writing standing up.

Always keep a stack of business cards handy. Good advice generally, but especially while on call. You never know when a new patient or physician will ask for your card.

Find that zone of maximum benefit. Avoid defensive medicine, too much writing, and too much testing. The curves for you and for your patient are different.

Be kind. Say kind words to people who can't understand or hear you because they are unconscious. (Sometimes, they can hear you.)

Watch your body language. Face patients. Smile. Don’t rush. Don’t hunch your shoulders.

Have your fellow pre-round on everyone. Then come in at 8. (Huck)

Change up your routine. Start at a difference place in the hospital. Write with a different pen. Consciously alter large or small parts of your usual routine.

Some institutions film you. Be aware of how you appear. (Anonymous)

nephron129 said...
The best piece of advice for weekends on call came from one of my mentors. The people who are the most bitter are those who think that just because it's a weekend that somehow they can still make plans to attend some event in the early afternoon.
I try to avoid socializing but I also try to recognize when I've hit the wall and I need a break. I try to take 10-15 minutes to recharge in the late morning and then again in the early afternoon. It sounds silly but getting nourishment is important too. If you remember back to your intern days, you usually had a snack in your pocket or at least knew where the food was on the nursing units.
Just some thoughts.
Anonymous said...
MAKE SURE YOU KNOW WHERE THE PATIENTS ARE IN THE HOSPITAL:
WE HAVE A RATHER LARGE HOSPITAL. IT'S IRRITATING, AND TIME-WASTING, TO GO TO THE ICU TO SEE MRS X, ONLY TO FIND THAT SHE'S JUST BEEN TRANSFERRED TO THE REGULAR NURSING UNIT -- USUALLY THE ONE YOU WERE JUST AT -- WHICH IS THE EQUIVALENT OF 2 BLOCKS AWAY. SOMETIMES, EVEN THE PHYSICIAN SIGNING OUT TO ME MAY NOT KNOW THAT HIS/HER PT HAS BEEN OR WILL BE TRANSFERRED.

WE ALSO HAVE A TERRIBLE HOSPITAL EMR WHICH ITSELF MAKES IT HARD TO FIND PATIENTS, SO WE HAVE TO BE SURE THAT SIGN-OUTS AND CONSULTS GIVE US PATIENT'S EXACT FULL NAME. EG IF I WERE TOLD (ON THE PHONE) TO SEE A HARRISON BROWN, BUT HE'S REALLY HARRISON BROWNE, THIS EMR SYSTEM WOULD SIMPLY TELL US NO HARRISON BROWN IN SYSTEM -- OR WOULD GIVE US INFO ON WRONG PT.

FINALLY, MAKE SURE THE PT STAYS IN THE ROOM WHEN YOU'RE ON YOUR WAY. TELL NURSES TO VERIFY HE'S IN HIS ROOM AND KEEP HIM THERE. I'VE SOMETIMES GONE TO SEE A CONSULT (IN THE A.M.) FOUND, UPON ARRIVAL, THAT PT WAS DOWN AT MRI AND WOULDN'T BE BACK FOR AN HOUR, AND HAVE THEN HAD TO COME BACK LATER IN DAY (OR EVENING) TO DO WHAT I INTENDED TO DO AT 8 A.M. KEEP PT IN ROOM; THEY CAN DO THE MRI OR WHATEVER AFTER YOUR EVAL, UNLESS IT'S REALLY URGENT.
Huck said...
"Check in with your significant other EVERY call-night, set aside a time to talk, or at least text saying when you will call. They are lonely, and you get so busy that you can easily forgot.

Things I would like to implement
- "Jott" notes to myself to keep todo list on iphone
- Carry the hospital's cell phone (I found it took bulky, and phones are about everywhere)
- however if you do a lot of "page & run" its great to be able to page to cell phone, the uber-busy neurosurgeon residents are great @ this"
Theresa Chan (Rural Doctoring) said...
Physical survival on call

* Before call, determine food strategy. Some hospitals have horrendous food, residents almost always know where to call for delivery, etc. but bring food if you want alternatives/healthier stuff to eat.
* Sleep when you can:
o Even if you only have 5 minutes, it might turn into 20 minutes or an hour
o Don't be picky about where you nap--call room might be far away from where the action is. Nothing wrong with napping on a loveseat, 2 rolling chairs, the floor...
o Don't sleep on top of your pager if it is on vibrate mode, you probably won't feel it.
* Caffeine is helpful up to a point but drinking plenty of water or Gatorade is better for the long haul. You won't feel as seedy/sick after you get off call.
* Choose good shoes. Your feet will ache after being up for 24+ hours. Running shoes are good for some, clogs for others. Make sure they have good support and shock absorption. Some people wear TED hose.
* Bring a toothbrush. You will feel more human after freshening up.
* Bring Artifical Tears. Eyes feel weary and dry in the hospital at 0300.
* Apply deodorant before call. Please.

Call Team Strategies

* Before calling the attending/cardiologist/nephrologist, etc., page the rest of your team to see if they have to speak to the same person. Saves redundant beeps and attendings will be less grumpy as a result.

Cross-cover

* Have signouts on you, whether electronically or on paper. Make sure signouts are complete when you receive them.
* If there are labs to check on signout, make sure you check them. Also make sure the resident signing out tells you what to do with abnormals.
* If you're cruising around the wards/units, you might as well check in with the charge nurse to see if there are any questions/PRNs needed so you don't get beeped as soon as you leave. Similarly, if you get called to one ward, ask "Does anybody else need to speak to me?" before you get off the phone.
* Expect the most floor calls as soon as a new admission gets to the ward.
* Have strategies for the most common calls: fever, low/high bp, agitation
* Be nice to RNs when they call, but be clear about the info you need for specific questions, so they will learn to have that info ready when they call in the future. For example: if they are calling about hypertension, ask: has it been this high before? what meds is the patient on? HR?

Admissions

* In ER, write down vitals, labs, meds, allergies and look at ECGs/XR before you see the patient if possible
* Get the old chart. (Hopefully you have EMR and this won't be a big deal.)
* Don't automatically accept the ER attending's diagnosis
* History-taking: Get the big picture, then zoom in on details
* At first you may feel you need to write your H&P before you write orders, but take time to develop a running idea of the orders you need as you interview the patient. It will actually save you time in the future.
* Don't forget PRNs. Think about the poor schmo you're going to sign out to after call is over.

When you don't know the answer/what to do

* Talk to your senior resident
* Look stuff up in your favorite resource. Find one broad resource and stick to it. (I use UpToDate).
* Go look at the patient again
* If the issue is whether to do the LP/paracentesis/thoracentesis in the middle of the night, you're better off doing the procedure and getting the data then trying to justify not doing it the next day. When it come to paracentesis/thoracentesis, you can do a small-volume diagnostic tap at least [I can write up some instructions one day, or maybe your program already teaches residents how to do these.]

Prioritizing

* When on call, you're going to have multiple nurses, attendings, patients pulling your attention in 1,000,000 different directions. Get used to it. It doesn't get better after residency.
* Process requests/questions by urgency:
o Patient status deteriorating?
o Order or study needs to be done now or else you'll lose the opportunity to get essential data?
o Cranky attending on the phone and you need to speak to him/her?
* If none of the above are true, and if the situation will not create an irreversible calamity, it is far better for you to finish what you're doing right now, assuming it can be finished in 15-30 minutes or less, than it is for you to be pulled away and leave a task unfinished. What you want to avoid is having a dozen loose ends all around the hospital.
* Group tasks: if you're checking labs on the computer, take a second to run your list and check all the outstanding labs at once. Ditto radiology. Ditto dictations--once you're on the phone, get 'em all done.
* I cannot emphasize this enough: Dictate the same day you see the patient. It is painful at first but your life will get much better if you can get in the habit early.
Want to contribute your own advice? Please leave a comment.

Image Credit: Fractal Hospital, Flickr

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