Ary L. Goldberger - Becoming a Consummate Clinician: What Every Student, House Officer and Hospital Practitioner Needs to Know

Hospital Medicine: Current Concepts

Scott A. Flanders and Sanjay Saint, Series Editors

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Cover design: Michael Rutkowski

Copyright 2012 by Wiley-Blackwell. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey

Published simultaneously in Canada

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Library of Congress Cataloging-in-Publication Data:

Goldberger, Ary Louis, 1949

Becoming a consummate clinician : what every student, house officer, and hospital practitioner needs to know / Ary L. Goldberger, Zachary D. Goldberger.

p. ; cm. (Hospital medicine: current concept ; 3)

ISBN 978-1-118-01143-0 (pbk.)

I. Goldberger, Zachary D. II. Title. III. Series: Hospital medicine, current concepts ; 3. [DNLM: 1. Clinical Medicine. 2. Evidence-Based Medicine. 3. Interprofessional Relations. 4. Medical Errorsprevention & control. 5. Teaching Roundsmethods. WB 102]

610.73dc23

2012023634

For

Erin, Ellen, and Nicki

Annabel, Tabitha, and Quinn

and for Lexy

PREFACE

Youve had the usual busy day. Just finished seeing and writing up the last of six patients admitted overnight to your service (including one who had to be transferred to the ICU with sepsis). Sent in an application to the medical centers curriculum committee for a proposed new course, The Golden Glove: Defining, Detecting, and Eradicating Medical Errors. Late for a hospital committee meeting on the new quality initiative to improve care in postoperative patients.

When you return to your office, two of the 59 new e-mails in your inbox catch your eye. The first is from a third-year medical student who presents with the complaint that I feel disoriented and confused only one day after starting my medical clerkship. This note is not a request for a neurological consult but, rather, a distress signal from one of your mentees who has been touching base with you throughout her clinical years without any indication of prior problems.

The second e-mail, from a friend and colleague, says: Work and teaching rounds took four hours today! How can we teach students and house officers to present more clearly and concisely and how to frame a differential diagnosis?

This book is written for hyper-busy clinicians/teachers and their trainees who face these types of challenges related to apparent gaps between the world of the class and the world of the wards. Despite the best-intended efforts of courses with names such as The DoctorPatient Encounter, students and their preceptors often express the sense that essential but hard-to-identify components are missing from our training efforts. These missing links contribute to the types of frustrations voiced above. We have adopted the term interstitial curriculum as a way of defining selected necessary concepts and practices that seem to fall between the disciplinary cracks of contemporary medical education programs.

Throughout the book, we highlight these concepts with mini-case examples. Most are drawn from internal medicine; further, a cardiovascular bias will unmask the specialty orientation of the authors, but hopefully will not prove limiting.

The complementary processes of constantly rethinking assumptions, researching information, and reformulating basic mechanisms are fundamental to practicing all types of medicine successfully. Such processes also help to avoid potentially lethal errors and help to rigorously and compassionately advance the inseparable sciences of prevention and healing. These deep and multidimensional challenges are central to the ongoing pursuit of becoming the consummate clinician.

ARY L. GOLDBERGER
ZACHARY D. GOLDBERGER

ACKNOWLEDGMENTS

We wish to acknowledge our many students, colleagues, and patients over the years, and the many others who inspired this short book. Finding oneself adrift in a turbulent clinical sea midway through medical school is, to say the least, daunting. Finding others with similar questions and existential anxieties is therapeutic, but what we really want are the keys to the kingdom where medical house staff and residents seem to speak that mysterious dialect of clinicalese with high fluency, and possess apparently uncanny reasoning and communication skills. Having read the same textbooks, taken similar preclinical lectures, and passed similar exams, we wondered whether we had all inadvertently missed some extracurricular but essential mentoring sessions somewhere along the way. Could this bridging knowledge be restored?

The discovery that the classroom-to-clinic gap was more the rule than the exception became a prime motivator for writing the book. Many people played important roles, including students at Yale School of Medicine, University of CaliforniaSan Diego, University of Washington, Harvard Medical School, and University of Michigan.

A number of colleagues have read sections and have offered important critical reviews. Among those are our wives, Erin Fouch, M.D., and Ellen Goldberger, J.D., and colleagues, Tom Delbanco, M.D., Richard Schwartzstein, M.D., Vikas Sukhatme, M.D., Ph.D., Michael Volk, M.D., M.S., Colin R. Cooke, M.D., M.Sc., and Madalena Costa, Ph.D.