Since my first day as a resident—responsible for my own team of learners—I have begun every teaching rotation by walking into the workroom and calling a halt to the bevy of activity heralding the start of another day on wards. There is a new sheriff in town (me), and we are not running another differential without establishing a new working order: my 3 Rules—served with coffee and pastries, of course (equally important in my book).
Pulsating temples give away the apprehension trainees must feel as we walk down to the café, likely wondering what ridiculous demands this new preceptor is about to place on their already overburdened lives. But watching that apprehension transform into confidence and joy in their work is an experience that I have come to treasure.
Thinking that others might be inspired to develop their own rules to benefit their respective training environments, I would like to share mine.
1. There Is Always Time for Coffee and Chocolate
Nestled between the primary medicine wards at my training institution, our program office offered many things, but on an hourly basis, it provided 2 primary things: a coffee machine and chocolate. It was the perfect pick-me-up, minute-motivator, soul-soother, beckoned in those hectic moments when the inner wellspring starts to run dry. A warm sip cascading down to your toes, or sweetness slowly melting on your tongue, undeniably made the next task more efficient and enjoyable.
Medicine is often entrenched with a certain stoicism that celebrates the subjugation of natural bodily needs. Unfortunately, such self-inflicted mental and physical insults not only drain our morale and contribute to suboptimal performance, but they may also lead us to respond to our environments with unintended impatience and hostility. We all have had days where the intensity, and sometimes the joy, of our work subsumes hunger, thirst, and fatigue. However, we are all also familiar with individuals who insist that the day is bereft of time to address basic self-maintenance, and that suggesting otherwise is a sign of weakness or inefficiency. I am tempted to ask these individuals whether they truly think such a misguided display of heroism actually benefits anyone: their patients, their colleagues, or themselves. Rather, is this modus operandi not a paradoxically inefficient and unbecoming attempt at personal validation?
Current training environments, and the occasional self-righteous ideals therein, propagate this kind of behavior. My first rule offers a rebuttal by recognizing our undeniable humanity. “We are all adults,” I tell my team, “Mind your human dignity, for goodness' sake, and if you need to use the restroom, use it; don't raise your hand to ask me! If you are hungry, pause to eat something. If you need a mental break, sit back and talk about it with a team member. Be it your body or soul, pause and pay a moment's heed.” How can any individual be denied this right? The work we are rushing to do and the patients we are rushing to care for all will benefit from our optimization as persons. This validation of self, in turn, breaks down the barriers of hierarchy, fear, and self-deprecation that often encumber the learning environment.
So, yes, there always is time.
2. You May Do Whatever You Like, So Long as You Have a Reason
To me, this rule embodies the crux of clinical education. Prefilled electronic ordering systems bear the simultaneous genius and flaw of cognition-free ordering. Tests and procedures can be requested in seamless succession with a few clicks of the mouse, and even fewer clicks of the brain, often just to “follow up.”
Follow up on what? What is the reasoning behind burdening our patient with a needle, catheter, drain, blade, beam of radiation, or added medical debt? If you were a patient, would you not want your physician to have cognized this? Why admit to a specific floor; why check vitals at a specific interval; why order a third CT scan in 2 days? In their conception, each command bears a reason worth understanding, no matter how seemingly mundane. This exercise instills a self-reciprocating habit of reinforcing clinical decisions with thoughtful consideration. Not only does this benefit patients, but it also nurtures the development of individual, yet adaptive, thought patterns among trainees. This is the basis for the autonomy I am comfortable affording the members of my team. Give me a thoughtful reason, and autonomy automatically follows without loss of learning or oversight. If I disagree, I will share my reason, and we will develop a consensus to move forward.
While a separate discussion altogether, I also posit that socially conscientious, cost-effective, and legally sound care all start with the same diligent attention to clinical decision-making. The psyches of our future clinicians should not be molded to financial considerations. However, financial and clinical responsibility can be bridged by enlisting reasons for our decisions. In the same manner, rather than countering a projected legal offensive, we need to teach medicine to prioritize patients' best interests, the same principle medical law seeks to protect. Thoughtful medicine pursuant of the highest level of care obviates the need for defensive medicine.
In effect, this rule promotes thought-invested and confidence-building learning, and the provision of care that is patient focused, socially responsible, and legally sound.
3. Never Ever, Ever, Ever Panic
I have told my students in jest that, while missed physical examination elements are redeemable, I will fail them if I catch them panicking. There is no dearth of evidence describing the clouding effect panic has on judgment, decision-making, and motor coordination, and, most importantly, its effect on others. And for what? At the latest hour, in the direst of situations, there are multiple levels of expertise present throughout the hospital to offer support, including nurses, intensivists, hospitalists, senior trainees, and respiratory therapists. Most hospitals have dedicated code teams who materialize at the sound of an alarm, and often overtake care completely. The point is, one is never really alone and help is always present, if only waiting to be sought out.
There are, of course, situations that require us to think and act fast. That internal monologue should be transmitted by calm action and firm communication, not frantic movement and confusion. Here is a familiar example: a person suddenly drops unconscious in front of us. For all the dramatic effect, as medical professionals, the answer is simply … advanced cardiovascular life support: a series of defined steps (the first of which is to call for help), thereby bringing to action an entire team of support staff. It is a model of rapid, ordered action. Panic should not have a blind shot of entering the foray.
What I find most troubling is that when panicked, even calm individuals can act defensively, out of fear rather than reason, and can transmit emotions in ways they do not intend, frequently as anger or disrespect. This can not only disrupt team unity, but also sabotage the learning experience altogether.
The rotation is over, and I whisk each trainee away to a sunlit spot, where we can share our thoughts and experience. And I find myself inspired, just listening.
They acknowledge reignition of the sometimes flickering beliefs that drove them to pursue medicine. They describe never having experienced a rotation where they found as much space to make thoughtful decisions as part of a team and simultaneously develop a sense of independent confidence. They are grateful to rediscover their inner capacity for growth, while putting patients first. Astonishingly, they narrate to me the same moments of motivation that spurred these rules into existence when I stood in their shoes.
This is not an exaggeration, although it may sound like one. I credit my 3 rules. The only evidence I have for their efficacy is that the response is always the same. The rules promote an interpersonal dynamic that validates our capacity to grow and contribute as intelligent, well-intentioned adults. More simply put, these rules make work more fun for all of us. It is difficult to argue with 3 little rules that can do that!