Promoting the Patient's Welfare

Persons surrender some of their autonomy and control when they become ill and enter the hospital.  Hospitalized patients are thus in a position of forced dependency, unable to avoid situations and personalities which they find unpleasant or frightening.  Indeed, they are often so ill and feel so helpless that they are unable to speak out against particular situations or practices which offend them in some way.

It is vital to your effectiveness as a physician that you appreciate your patients' predicament and seek to avoid any conduct that might be regarded by your patients as threatening, demeaning, or otherwise unprofessional.  Attention to the details of propriety and good taste in both conduct and appearance is essential, because some behaviors that would be perfectly acceptable outside the hospital may seriously damage the physician-patient relationship in the hospital.  While in the hospital all clinical clerks must wear white jackets and wear official name-tags above the waist.  Men must wear neckties, and no clerks should wear jeans.  Eating or drinking on rounds or in corridors is not permitted.  Displaying silent expressions of potentially controversial opinions (e.g. political buttons or badges) is inadvisable.

Your patients must know who you are.  You may have to introduce yourself several times to patients who are confused by their illnesses, somewhat disoriented by transfer to the hospital, or merely overwhelmed by the large number of new people they are meeting.  You should introduce and identify yourself as a medical student, not as "Dr....".

Showing courtesy and respect to patients is very important.  You must notify your patients in advance if they are to be visited by a group of physicians or presented in person at a conference to a group of physicians.  Patients' objections should be respected.  Knock before taking anyone into a patient's room, and introduce the patient and visitor. Exercise caution in bedside conversations, and avoid any language or behavior that might be stressful for the patient.  Do not address patients by their first names unless they have invited you to do so.

You should devote an appropriate amount of time to talking with the members of the family about your patient's condition and progress.  It is important to respect the privacy of the patient, so you should have permission from the patient before discussing his/her medical condition with anyone.  If you have questions regarding issues to be discussed with the family, review them beforehand with housestaff or attendings.  Conflicting reports to the patient or family from different members of the health care team can cause considerable anxiety; such problems can be avoided if the team is organized and communicating well.

Some patients will come to regard you as their primary physician.  You may be the person who spends the most time with the patient and who has explained most to the patient regarding his or her illness and management.  Still, some medical information is best communicated by people with more patient care experience than you possess.  Initial discussion of a serious or life threatening diagnosis (e.g. AIDS, malignancy), a confrontational suspicion (e.g. malingering, self-induced illness, psychosomatic disease), or a diagnosis with legal implications (e.g. job associated, limiting future employability) is a challenge even for seasoned clinicians.  Such patient interaction should be conducted only with members of the housestaff or the attending physician present.

There is increasing concern about issues of patient privacy.  You must exercise great care regarding your conversations in public areas of the medical center (i.e. corridors, elevators, lobbies, dining rooms).  Individual patients should never be discussed in a way that would permit their being identified by visitors.  Avoid joking references to patients.  Clinical discussions, in general, are inappropriate in visitors' areas.  If you have transferred identifying patient information to a personal digital assistant, please insure that it is password protected.  Likewise, note cards or flow sheets containing identifying patient information must be carefully guarded against loss or the opportunity for reading by outsiders.  Of course, you should not review the medical records of anyone for whom you are not caring, unless you are performing authorized (Human Investigation Committee approved) research.  Discussing individual patients with your family or friends should be undertaken, if at all, with great caution, always bearing in mind how you would feel if the patient were you or a family member.

Preventing Hospital-Acquired Infections

Keep in mind at all times the risk to your patients of morbidity and even death from nosocomial infections.  The laying on of hands is an important concept in medicine, but the health care worker's failure to wash hands (with a minimum rinse of 10 seconds) or to apply alcohol gel between patient examinations is a major mode of transmission of virulent pathogens from one patient to another.  If there is visible soiling of the hands, or if you have cared for a patient with Clostridium difficile infection, you must wash with soap and water, as the alcohol gel is inadequate.  Cleaning of the hands is required after contact with any object or surface in the patient's room. The stethoscope can also serve as a vector for nosocomial infections and the diaphragm and the bell should be wiped with an alcohol pad after touching a patient.  Prior to using the stethoscope on the rotation, and at periodic intervals thereafter, the entire instrument should be disinfected with alcohol pads, since organisms can live for weeks on a dry surface. 

Proper observance of special isolation procedures also helps limit spread of virulent organisms.  Signs on the door identify patients on isolation.  Isolation precautions on the patient's door must be read and carefully followed.

Health care personnel have become more aware in recent years of the risk of acquiring infections like hepatitis B, hepatitis C, and HIV/AIDS in the hospital.  Standard, universal procedures are designed in part for the protection of health care workers.  Be aware, however, that infections go unrecognized in some patients, and health care workers are advised to apply these precautions to all patients.  Such precautions involve instituting a barrier between the clinician and the patient's body fluids.  Wear gloves for procedures, such as venipuncture, that could result in contact with blood; and, wear masks, gowns, and eye protection during procedures that produce spraying (rare on Internal Medicine).

Health sciences students should not practice an invasive procedure on patients with a blood borne virus until their supervising teacher agrees that the students can perform the procedure with sufficient competence to proceed.

Certain exposures must be regarded as serious.  These include:  mouth, other mucous membrane, nonintact skin, or parenteral contact with blood or other potentially infectious materials such as semen, vaginal secretions, CSF, synovial fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid visibly contaminated with blood, or any body fluids in situations where it is difficult to differentiate among body fluids.  A student experiencing such an exposure should do the following:

1. Immediately wash the affected skin with soap and water for at least 10 seconds.  One should apply 70% isopropyl alcohol to open sores, cuts, or puncture wounds.

2. Flush contaminated mucous membranes for at least 30 seconds.  The mouth may also be rinsed with 1-3% hydrogen peroxide.

3. Make a note of the patient's name, hospital number, and location.  Do not question the patient regarding risk factors for blood borne diseases or antibody status.  The ward team should initiate no testing for such infections.

4.  Report the incident to housestaff or faculty supervising the clinical service.  Student Health will ask if this has been done.

5.  Page the nursing supervisor (pic #1523).  Student Health will ensure that this has been done.  The nursing supervisor will evaluate the exposure (over the phone) for ability to transmit HIV and send the student to Student Health or the Emergency Room depending on the time of day.  If transmission is not possible, the rapid test for HIV procedure will not be ordered. 

6.  Patient confidentiality must at all times be protected.  You must not discuss any aspect of the patient's illness or infectious status outside of the ward team.

PERSONAL ILLNESS

Students who become ill with a communicable disease during enrollment are required to immediately remove themselves from patient care activities and notify the attending, resident, and clerkship coordinator.