100+ Tips for Doctors on Call (Part 2)

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[Part 1 is here. The following post initially appeared in The Efficient MD. It demonstrates the unexpected power of blogs and Twitter for soliciting advice from large groups of people with specialized knowledge.]

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

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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MD, FACP, FASN

Dr. Schwimmer's blog explores the intersection of medicine, new technologies, and the Internet.

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