I did a consult a while back on a patient who had cancer. She was old. She was dying. And when I was reviewing her records, it said she was a "poor historian."
When I walked into her room she was sitting up in her chair, eating her breakfast, alert, oriented, and completely conversant. She was, in fact, an excellent historian. She just spoke a little slowly, and her story was kind of complicated.
What had happened? There are a couple of possibilities:
1. Maybe last night she was really out of it when she came up to the floor. She's old, it was late, and maybe she wasn't very cooperative.
2. Maybe the resident did a crappy job.
3. Maybe the resident figured that he/she would be getting outside medical records and would be able to figure the non-emergent issues out then, rather than spending hours with this woman overnight while the pager went off over and over again.
4. Maybe it's just easier to write "poor historian" than to admit that you didn't have time to take a detailed (i.e. hour long) history. Maybe the attending would have chewed the resident out if they'd just said, "I didn't have time to get the full story last night, but I can today. Sorry." I don't find that hard to believe, actually.
My guess is that it was either 3 or 4 or both.
I can completely relate to this. Sometimes when I do a consult, I don't know what's important because I am still learning. I don't have time to go through every single study that has ever been done on the patient and read about every single admission. Part of learning to be a good doctor is learning what is important and what is not. But sometimes when you're learning, you mess that up. And then it sucks to say, "I don't know" over and over when you're presenting. It's embarrassing, and you get yelled at sometimes.
Pro: You never mess THAT up again.
Con: You might be inclined to cover up errors or bluff in the future.
And this is a problem in medicine. We are overstretched, and sometimes we can't do everything we need to. It should be ok to say you didn't have time to do something. You shouldn't have to be afraid of appearing lazy or incompetent for admitting that. A culture that doesn't allow for this seems to me like it would lead to worse care in the long run. People need slack so they can learn. So they can do a good job.
Thoughts?
3 Pearls of Wisdom:
or she was delirious because she's old, has cancer and it was late at night....it's sometimes shocking the improvement that some sleep will make.
Yeah, except that I really doubt it in this case.
Sundowning...or not.
I understand the entire notion of not having enough time, having a pt take forever to tell you their history, and excusing yourself once you've gotten enough, not returning, and writing that the pt either has a "complicated past history" is a "poor historian" or other such items in the H&P to relieve me the pressure of going back and trying to get the info from the pt. It's often easier to just read other's reports and come to that understanding.
And no, you shouldn't be afraid to admit you were being paged away in all directions - but attendings forget, or didn't have that kind of experience we have now (as I've come to find that very old guys didn't actually have pagers and were overheaded instead with less frequency than we get) and get upset. That's one of the reasons there's caps on admissions for interns and residents in many places. To help ease their burden in order to help with learning.
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