You thought residency was just going to be putting all your immense knowledge into practice? Think again! Well that the majority of the job, and then learning about the next best step, and the next, and the next, etc. etc. However, the idea of “practicing medicine” stems beyond taking a quality history and physical. It becomes about how to best develop rapport with your patients use that in a way to create treatment plans. It includes learning to have goals of care discussions with patients and families, and translating complex medical information into layman’s terms for any to understand. In particular, this post is going to pay close attention to the hand-off, which is one of the most sensitive times of the clinical work day. Depending on your residency, it happens at various times of the day. It means that when you’re leaving for the day, your colleague on call and night float team will need to understand your patients relatively well in order to provide quality care for acute issues.
Let me first address the idea of “acute” issues because as an intern, you are going to want to put out every fire for your team and neatly tuck away their patients for their ease in the morning. While you may be as gung-ho to do so, more often than not, it is about staying afloat in a raft with the Kraken viciously gaining upon you (I just watched Pirates of the Caribbean, so forgive me for the spoiler!). But in all honesty, many issues come up at unusual hours, from families wanting to talk at midnight and the possibility of a specialist consult. The art and craft of medicine comes in managing these calls, both to acknowledge whoever has made it aware to you and address it in a way that does not seem to “why are you calling me about this right now?”. I’ll have a separate post on non-acute issues and examples, but for now, keep this on your radar.
Now, back to my main point about hand off. We have attention spans of a goldfish, and knowing we have to get a sign out for some number of patients, that span is going to shrink, fast. So what you will be able to have to do is come up with the best one liner for patient, and make it clear if they are stable or a “watcher“, aka someone who might give you problems overnight and “WHY“. You should not by listing all their past medical history, just what you think is most relevant to their admission. So their history of left toenail fungus and paper cut in 1990, has got to go! Tell me what they presented with, what you are treating right now, and give me some legitimate what/if scenarios that are particular to this patient (i.e. whether I can diuresis further or not, does this person need BIPAP overnight, etc.). Sign out is a tenuous time for patients, so please do take your time, be thoughtful in your remarks, and ask if your colleague has any questions before leaving. Your written or typed hand off should be free of extra information. I prefer to highlight pertinent tasks to follow up on and what to do with those values too. Again, overnight is not the time to reinvent the wheel, but certainly present new thoughts to your day team, if you feel that will help management.
Here are some additional thoughts based on a brief search using “hand off internal medicine residency” as my search terms, Sources: