Do you view your medical school and residency training the same way I see mine? I think I received really good training and education in the clinical knowledge base (e.g. which tests and drugs are useful in pneumonia) but really poor training and guidance into how to get the job done efficiently and organize my career. My problem was an inability to separate the good and bad advice about organizing my work; I essentially tried to follow all advice.
An energetic ENT attending who really seemed to care about students and trainees told me during my third year of medical school that failure to palpate the floor of the mouth on every new patient was a failure to do an adequate exam, not just on the ENT service but also on every patient in the hospital. While less dogmatic about it, he also encouraged documenting the presence or absence of a Darwinian tubercle. So I was determined to do these things—on all patients. No shortcuts for me!
But on my next rotation a few weeks later, I noticed that none of the neurosurgery attendings palpated the floor of the mouth on their patients. I stopped doing it routinely not long after.
By the time I was a resident, I was catching on to the fact that, like the ENT attending, my superiors were sometimes providing misguided, or even bad, advice. Meanwhile, I got a little better at knowing the difference. If I didn’t hear the same advice from multiple people, I gave it much less credibility. But if enough different people gave me advice, I typically accepted it as well-founded and tried to follow it.
Bad Advice: Keeping Up with the Literature
There must have been dozens of people who told me that the best strategy to keep up with the medical literature was to pick one, maybe two, medical journals with original scientific research and read all the articles in every issue. So that is exactly what I tried to do.
But after a few years, I decided that “pick one journal and read every issue” was bad advice. I think it is a poor way for most doctors in community practice to keep up with the latest and most important information. How many of us can really understand the strengths and weaknesses of study design and statistics? For example, outside of those who spend their career writing and analyzing original research (and are proficient in the complex and counterintuitive statistics they contain), how many of us have been able to make sense of all the conflicting studies of perioperative beta-blocker use? Outcomes of these studies vary a lot. So what should we do in clinical practice?
Better Advice: Keep Up with Literature
I finally concluded that in the pre-Internet era, the best way to keep up was to let academicians and researchers study the original research articles and write review articles, editorials, and letters to the editor. These seemed to pay much greater dividends in improving my clinical practice.
The traditional literature sources I’ve relied on for these kinds of articles are the New England Journal of Medicine, Annals of Internal Medicine, and the Cleveland Clinic Journal of Medicine. The latter is my favorite; it provides concise articles written to address very focused questions that come up all the time in my practice.
Since the arrival of the Internet, there are so many more ways to keep up with literature other than just deciding which journals and articles you’ll read. I’ll leave it to others to provide thoughts about that.
Get a Gimmick: Good Advice?
It was a tradition in my residency that at the end of a month “on the wards,” the attending (who rounded with us seven days a week for the whole month) took the whole team out to lunch or dinner. I think this once-common tradition has largely disappeared as a result of both the residency work-hour restrictions and attendings usually staying “on service” for only a couple of weeks, rather than the whole month. Right? (I’d love to hear from someone at a place where the attending-led, end-of-the-month team social event is still a common practice.)
On every such occasion, I would ask the attending, “What do you know now about ensuring a good career as a doctor that you wish you knew when you were a resident?” A number of the attendings didn’t seem willing to give it much thought: “I dunno,” most would say. “Maybe just make sure to leave time for nonprofessional activities like regular exercise.” Others gave generic advice: “Be sure to keep up with the literature.”
But one successful GI attending surprised me. When asked to provide career advice, he said, “Get a gimmick.” This is not what a young and idealistic trainee wanted to hear. A gimmick sounds like cheating or taking a shortcut.
He went on to explain that he meant that focusing only on being a good doctor for the next patient on your list, although it might be the most important thing you can do, might not be enough to keep your career interesting and energizing. So he advocated for finding an additional special interest, such as becoming a super-expert in a particular disease (e.g. you’re the snakebite expert at your hospital) or becoming a quality-improvement (QI) expert for your institution.
I’ve since fully embraced this idea and consider it among the best pearls of wisdom I’ve collected in my career. But “gimmick” is probably the wrong word choice; maybe it’s better to just say that you should get a special interest.
It would be best if you are the only one, or one of only a few, who pursues an area of interest at your institution. It can be rewarding to be the “go-to guy” for certain issues. And it might even lead to invitations to speak on the topic elsewhere, additional compensation, etc.
For nonacademic hospitalists, most of us will see our direct-patient-care activities as the core of what defines our career. I do many things other than patient care, but when I’m asked by a stranger about my occupation, I almost always end up talking about being a doctor who takes care of hospitalized patients. But my non-patient-care activities, my “gimmicks,” have been vitally important and satisfying components of my career.
If I were an attending at an end-of-the-month dinner with my team, I would talk with them about the value of developing these additional interests as part of a healthy and balanced career. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.