Medical students are often attached to the various services. They can provide a significant contribution to patient care. However, their work requires supervision by the surgical intern/resident who takes primary clinical responsibility. Subinterns are senior medical students who are seeking additional clinical experience. Their assistance is needed and appreciated, but again, close supervision of their clinical responsibilities by the intern/resident is mandatory.Outside reading is recommended, including textbooks, reference sources, and monthly journals.Eating is prohibited in patient care areas.Maintain patient confidentiality at all times.At conferences use only patient initials in presentations; and speak carefully and respectfully on work rounds.
1. Always be punctual (this includes ward rounds, operating room, clinics, conferences, morbidity and mortality). Personal appearance is very important. Maintain a high standard including clean shirt and tie (or equivalent) and a clean white coat. The day begins early. Be ready with all the data to start rounds with the senior resident or chief resident. Be sure to provide enough time each morning to examine your patients before rounds.
2.Aim to get all of your chart notes written as soon as possible; this will greatly increase your effi ciency during the day. Sign and print your name, and include your beeper number, date, and time. Progress notes on patients are required daily. Surgical progress notes should be succinct and accurate, briefl y summarizing the patient’s clinical status and plan of management. Someone unfamiliar with the case should be able to get a good understanding of the patient’s condition from one or two notes. Operative consent is obtained after admitting the patient, performing the history and physical examination, discussing the risks, benefi ts, and alternatives of the procedure(s), and having the patient’s nurse sign the consent with the patient. If you are unaware of the risks and benefi ts of a procedure, discuss this with the service chief resident. Blood transfusion attestation forms need to be signed by the counseling physician before each surgical procedure.
3. Arrive in the operating room with the patient and before the attending physician or chief resident. Make sure that the charts and all of the relevant x-rays are in the operating room. Make sure that the x-rays are on the x-ray view box prior to the commencement of the case. The intern or resident performing the case should be familiar with the patient’s history and physical exam, current medications, and comorbidities, and be familiar with the principles of the operation prior to arriving in the operating room. Make it a habit to introduce yourself to the patient before the operation. It is mandatory that the surgical resident involved with a case in the operating room attend the start of the case punctually. Scheduled operative cases do not necessarily occur at the listed time. For this reason, it is necessary to check with the operating room front desk frequently. Do not rely on being paged. Conduct in the operating room includes assisting with the preoperative positioning and preparation of the patient; this includes shaving, catheterization, protection of pressure points, and thromboembolism protection. The resident should escort the patient from the operating room to the intensive care unit (ICU) or the postanesthetic care unit with the anesthesiologists. The operating surgeon is responsible for dictating the case. The resident must record all cases performed. For cases admitted to the surgery ICU, a hand-over to the surgery ICU resident is mandatory.This includes discussing all the preoperative assessment, operative details, and postoperative management of the case with the ICU resident.
4. Signing out to cross-cover services must be performed in a meticulous and careful fashion. All patients should be discussed between the surgical intern and the cross-covering intern to cover all potential problems. A sign-out list containing all the patients, patient locations, and the responsible attendings should be given personally to the cross-cover intern. Any investigations performed at night (e.g., lab studies, chest x-ray, electrocardiogram [ECG]) should be checked that night by the covering intern. No test order should go unchecked. Abnormal lab values should be reviewed and discussed with the senior resident or the attending staff, especially on preoperative patients. Starting antibiotics should be a decision left to the senior resident or attending staff. If consultants are asked to see patients, their recommendations mustbe discussed with your senior resident or attending priorto initiating any new plans. Independent thought is good; independent action is bad.
5. Document all procedures performed on patients—including arterial lines, chest tubes, and central lines—with a short procedure note in the chart. Every patient contact should be documented in the patient record.If you see a patient in the middle of the night, write a short note to describe your assessment and plan. Remember, if there is no documentation, then nobody responded to the patient’s complaint or needs. Obtain appropriate supervision for procedures. There are always more senior residents available if your chief is not. Protect yourself; practice universal precautions! Wash your hands before and after examining a patient. Wear gloves. All wounds should be inspected every day by the surgical intern as part of the clinical examination. Please re-dress them; the nursing staff is not always immediately available to do so. There should never be any surprises in the morning.
Your senior resident is responsible for the service and should be kept aware of any problems, regardless of the time of day. If the senior resident is not available, the attending staff should be contacted directly. There are always senior residents in the hospital who are available to be used as resources for emergencies. Always be aware of who is in-house (i.e., consult resident, ICU resident, trauma chief). A surgery resident’s days are long. They start early and they fi nish late. Always remember the three A’s to being a successful resident: Affable, Available, and Able. Be prepared to maintain a flexible daily schedule depending on the workload of the service and the requirement for additional manpower.
A cirurgiã e inventora Catherine Mohr nos guia pela história da cirurgia (e seu passado pré-anestesia e pré-antissepsia), e depois demonstra algumas das mais novas ferramentas para cirurgias realizadas através de pequenas incisões, usando ágeis mãos robóticas.
O prontuário médico é o conjunto de documentos padronizados e ordenados, onde devem ser registrados todos os cuidados profissionais prestados aos pacientes e que atesta o atendimento médico a uma pessoa numa instituição de assistência médica ou num consultório médico. É também o documento repositório do segredo médico do paciente. O preenchimento do prontuário médico é obrigação e responsabilidade intransferíveis do médico, fazendo-se exceção aos hospitais de ensino, onde alunos de medicina o fazem sob supervisão, correção e responsabilidade de médicos, sejam professores de medicina ou do staff do hospital de ensino. É prática antiética e ilegal, portanto condenável, delegar seu preenchimento a outrem que não médico habilitado perante o Conselho de Medicina. O prontuário médico corretamente preenchido é, e efetivamente tem sido, a principal peça de defesa do médico nos casos de denúncias por mal atendimento com indícios de imperícia, imprudência ou negligência, ou seja, na presunção da existência de erro médico. Este é o primeiro documento que a polícia, a Justiça e o próprio Conselho solicitam aos hospitais/médicos denunciados para apreciação dos fatos da denúncia.
Na década de 1960, Lawrence Weed publicou um artigo (Weed LL. Medical records that guide and teach. N Engl J Med; 1968) que descreve um modelo de prontuário que é atualmente adotado em diversos centros médicos de todo o mundo. O modelo de Weed se destaca pela objetividade, organização, maior facilidade de acesso às informações para tomada de decisões e pela descrição sistemática das evidencias e das razões que apoiam as conclusões e os planos diagnósticos e terapêuticos durante o acompanhamento do paciente. O termo originalmente utilizado por Weed para o seu modelo de prontuário foi Prontuário Médico Orientado por Problemas (Problem-Oriented Medical Record).
No Brasil este modelo ficou conhecido como Prontuário Orientado por Problemas e Evidências (POPE) para destacar uma das características básicas deste modelo que é a ênfase nas evidências clínicas e científicas. No POPE as notas de evolução são orientadas pelos problemas ativos do paciente e segue o contexto descrito como SOAP. Cada letra da sigla SOAP se refere a um dos quatro aspectos fundamentais das notas de evolução diária, ou seja os dados subjetivos (S), os dados objetivos (O), a avaliação (A) e o planejamento (P).
COMO DEVE SER PREENCHIDO O PRONTUÁRIO NO SISTEMA S.O.A.P.?
No momento da realização das anotações o médico deverá identificar o paciente pelo nome e sobrenome, juntamente com a idade, a Clínica ao qual esta internado e o horário. Os itens de evolução médica são assim transcritos:
1. Os dados subjetivos (S) compreendem as queixas dos pacientes e outras informações fornecidas pelos pacientes, parentes ou acompanhantes.
2. Os dados objetivos (O) incluem os achados de exame físico e os achados de exames complementares.
3. A avaliação (A) se refere às conclusões sobre a situação do paciente, os pensamentos relativos ao diagnóstico e a resposta ao tratamento, tomando por base os achados subjetivos e objetivos.
4. Os planos (P) inclui os exames a serem solicitados visando o diagnóstico, as razões para inclusão, modificação de doses ou retirada de itens da terapêutica e as informações prestadas aos pacientes e familiares visando orientação e educação.
ASPECTOS ÉTICOS E LEGAIS
A “medicina de defesa” reforça a importância do prontuário e de seu preenchimento completo. O documento, para ser admitido em juízo como elemento de prova, necessita de ter sua autenticidade reconhecida, estar datado e assinado. A ausência desses elementos demonstra má qualidade da assistência prestada ao paciente. Rasuras comprometem o valor legal. Em casos de retificações, aconselha-se a escrever entre parênteses indicações como sem efeito, digo ou expressões análogas e, a seguir, escrever a correção.
Segundo o artigo 299 do Código Penal, a anotação incorreta, incompleta, falseada ou inexistente no prontuário quanto aos fatos relacionados com o paciente pode caracterizar falsidade ideológica: “Omitir, em documento público ou particular, declaração que dele devia constar ou nele inserir ou fazer inserir declaração falsa ou diversa da que devia ser escrita, com o fim de prejudicar direito, criar obrigação ou alterar a verdade sobre fato juridicamente relevante. Pena – reclusão de 1 (um) a 5 (cinco) anos, e multa, se o documento é público, e reclusão de 1 (um) ano a 3 (três) anos, e multa, se o documento é particular”. Se o agente for funcionário público e cometer o crime, prevalecendo-se do cargo, aumenta-se a pena de sexta parte.
Desta forma deverão constar em cada folha de evolução clínica do paciente as seguintes informações:
1. Identificação: Nome, idade e sexo; 2. Dias de Internação; 3. Diagnósticos (Sindrômico, Anatômico e Etiológico); 4. Terapêutica Básica; e 5.Data e hora de atendimento;
Os autores de todos os registros no prontuário deverão ser identificados através do nome completo e assinatura do profissional assistente com seu número de inscrição no respectivo conselho de classe. Recomenda-se SEMPRE USAR CARIMBO. Em caso de não-profissionais assistentes, como alunos em treinamento, é necessário que sua assinatura conste ao lado da do titular atendente.
A caligrafia faz parte da ética profissional do médico. As anotações precisam ser legíveis. “É vedado ao médico receitar ou atestar de forma secreta ou ilegível, assim como assinar em branco papeletas de receituários, laudos, atestados ou quaisquer outros documentos médicos” (artigo 39 do Código de Ética Médica). Nos prontuários em suporte de papel, é obrigatória a legibilidade da letra do profissional que atendeu o paciente (Resolução CFM n.º 1.638/02).
Life as a Surgeon
Surgical careers begin long before one is known as a surgeon. Medicine in general, and surgery in particular, is competitive from the start. As the competition begins, in college or earlier, students are confronted with choices of doing what interests them and what they may truly enjoy vs doing what is required to get to the next step. It is easy to get caught up in the routine of what is required and to lose track of why one wanted to become a doctor, much less a surgeon, in the first place. The professions of medicine and surgery are vocations that require extensive knowledge and skill. They also require a high level of discretion and trustworthiness. The social contract between the medical profession and the public holds professionals to very high standards of competence and moral responsibility. Tom Krizek goes on to explain that a profession is a declaration of a way of life ‘‘in which expert knowledge is used not primarily for personal gain, but for the benefit of those who need that knowledge.’’
For physicians, part of professionalism requires that when confronted with a choice between what is good for the physician and what is good for the patient, they choose the latter. This occurs and is expected sometimes to the detriment of personal good and that of physicians’ families. Tom Krizek even goes so far as to question whether surgery is an ‘‘impairing profession.’’ This forces one to consider the anticipated lifestyle. In sorting this out, it is neither an ethical breach nor a sign of weakness to allocate high priority to families and to personal well-being. When trying to explain why surgery may be an impairing profession, Krizek expands with a cynical description of the selection process. Medical schools seek applicants with high intelligence; responsible behavior; a studious, hard-working nature; a logical and scientific approach to life and academics; and concern for living creatures. He goes further to explain that in addition to these characteristics, medical schools also look for intensity and drive, but are often unable to make distinctions among those who are too intense, have too much drive, or are too ingratiating.
There are many ethical challenges confronting medical students. As they start, medical students often have altruistic intentions, and at the same time are concerned with financial security. The cost of medical education is significant. This can encourage graduates to choose specialty training according to what will provide them the most expedient means of repaying their debt. This can have a significant, and deleterious, impact on the health care system in that the majority of medical graduates choose to pursue specialty training, leaving a gap in the availability of primary care providers. As medical students move into their clinical training, they begin interacting with patients. One concern during this time is how medical students should respond and carry on once they believe that a mistake on their part has resulted in the injury or death of another human being. In addition, the demands of studying for tests, giving presentations, writing notes, and seeing patients can be overwhelming. The humanistic and altruistic values that medical students have when they enter medical school can be lost as they take on so much responsibility. They can start to see patient interactions as obstacles that get in the way of their other work requirements. During their clinical years, medical students decide what field they will ultimately pursue. For students to make an informed decision about a career in surgery, they need to know what surgeons do, why they do it, and how surgery differs from other branches of medicine. It is important for them to be aware of what the life of a surgeon entails and whether it is possible for them to balance a surgical career with a rewarding family life.
Beginning residents are confronted with a seemingly unbearable workload, and they experience exhaustion to the point where the patient may seem like ‘‘the enemy.’’ At the same time, they must learn how to establish strong trusting relationships with patients. For the first time, they face the challenge of accepting morbidity and death that may have resulted directly from their own actions. It is important that residents learn ways to communicate their experience to friends and family, who may not understand the details of a surgeon’s work but can provide valuable support. The mid-level resident confronts the ethical management of ascending levels of responsibility and risks, along with increasing emphasis on technical knowledge and skills. It is at this level that the surgical education process is challenged to deal with the resident who does not display the ability to gain the skills required to complete training as a surgeon. Residents at this level also must deal with the increasing level of responsibility to the more junior residents and medical students who are dependent on them as teacher, organizer, and role model. All of this increasing responsibility comes at a time when the resident must read extensively, maintain a family life, and begin to put long-range plans into practice in preparation for the last rotation into the chosen final career path. The senior surgical resident should have acquired the basics of surgical technique and patient management, accepting nearly independent responsibility for patient care. The resident at this level must efficiently and fairly coordinate the functioning team, engage in teaching activities, and work closely with all complements of the staff. As far as ethics education is concerned, residents at this stage should be able to teach leadership, teamwork, and decision-making. They should be prepared to take on the value judgments that guide the financial and political aspects of the medical and surgical practice.
The Complete Surgeon
The trained surgeon must be aware of the need to differentiate between the business incentives of medical care and doing what is right for a sick individual. As financial and professional pressures become more intense, the challenge increases to appropriately prioritize and balance the demands of patient care, family, education, teaching, and research. For example, how does the surgeon deal with the choice between attending a child’s graduation or operating on an old patient who requests him rather than an extremely well-trained associate who is on call? How many times do surgeons make poor choices with respect to the balance of family vs work commitments? Someone else can
competently care for patients, but only parents can be uniquely present in the lives of their children. Time flies, and surgeons must often remind themselves that their lives and the lives of their family members are not just a dress rehearsal.
Knowing When to Quit
A 65-year-old surgeon who maintains a full operating and office schedule, is active in community and medical organizations, and has trained most of her surgical colleagues is considering where to go next with her career. Recently, her hospital acquired the equipment to allow robotic dissection in the area where she does her most complicated procedures. She has just signed up to learn this new technology, but is beginning to reflect on the advisability of doing this. How long should she continue at this pace, and how does she know when to slow down and eventually quit operating and taking the responsibility of caring for patients? Murray Brennan summarizes the dilemma of the senior surgeon well. The senior surgeon is old enough and experienced enough to do what he does well. He yearns for the less complicated days where he works and is rewarded for his endeavors. He becomes frustrated by restrictive legislation, the tyranny of compliance, and the loss of autonomy. Now regulated, restricted, and burdened with compliance, with every medical decision questioned by an algorithm or guideline, he watches his autonomy of care be ever eroded. Frustrated at not being able to provide the care, the education, and the role model for his juniors, he abandons the challenge.
Finishing with Grace
Each surgeon should continuously map a career pathway that integrates personal and professional goals with the outcome of maintaining value, balance, and personal satisfaction throughout his or her professional career. He or she should cultivate habits of personal renewal, emotional self-awareness, and connection with colleagues and support systems, and must find genuine meaning in work to combat the many challenges. Surgeons also need to set an example of good health for their patients. Maintaining these values and healthy habits is the work of a lifetime. Rothenberger describes the master surgeon as a person who not only knows when rules apply, recognizes patterns, and has the experience to know what to do, but also knows when rules do not apply, when they must be altered to fit the specifics of an individual case, and when inaction is the best course of action. Every occasion is used to learn more, to gain perspective and nuance. In surgery, this is the rare individual who puts it all together, combining the cognitive abilities, the technical skills, and the individualized decision-making needed to tailor care to a specific patient’s illness, needs, and preferences despite incomplete and conflicting data. The master surgeon has an intuitive grasp of clinical situations and recognizes potential difficulties before they become major problems. He prioritizes and focuses on real problems. He possesses insight and finds creative ways to manage unusual and complex situations. He is realistic, self-critical, and humble. He understands his limitations and is willing to seek help without hesitation. He adjusts his plans to fit the specifics of the situation. He worries about his decisions, but is emotionally stable.
The outcome of patients who are scheduled for gastrointestinal surgery is influenced by various factors, the most important being the age and comorbidities of the patient, the complexity of the surgical procedure and the management of postoperative recovery. To improve patient outcome, close cooperation between surgeons and anaesthesiologists (joint risk assessment) is critical. This cooperation has become increasingly important because more and more patients are being referred to surgery at an advanced age and with multiple comorbidities and because surgical procedures and multimodal treatment modalities are becoming more and more complex. The aim of this review is to provide clinicians with practical recommendations for day-to-day decision-making from a joint surgical and anaesthesiological point of view. The discussion centres on gastrointestinal surgery specifically.