Navigating through Clinic Sessions...

dr_almondjoy_do · Jun 8, 2007

wtf?

I don't have the slightest clue as to how I navigate through my clinic patients in time to get out of there in time for other things. I take care of them to my best ability, but somehow I have to do this in 15 minute intervals including precepting (something that was developed in prison I'm sure...)

Does anyone have advice on how to do this in a way that addresses the pertinent issues, leaves room to allow for follow up during future sessions for the non pertinent, and still allows me to survive precepting so that they don't make me address all the non critical bull crap in 15 mins?

Am I just screwed?

I also need a politically correct phrase for "I don't care what you had for dinner last night Dr. Attending, I have 3 charts in my box to see in 45 minutes, and you still have to grill me on Jones criteria in time for me to discharge this patient who just came for refills...."

I love my residency program, but apparently I am not getting the whole clinic atmosphere. It's counterintuitive for me to see patients and have all these obstacles in my way. And to have so see every case in 15 minutes can be impossible with new patients, the multiple comorbid, prenatal/preeclamptic, AGE baby.....

elizabeth5863 · Jun 8, 2007

dr_almondjoy_do said:
I also need a politically correct phrase for "I don't care what you had for dinner last night Dr. Attending, I have 3 charts in my box to see in 45 minutes, and you still have to grill me on Jones criteria in time for me to discharge this patient who just came for refills...."

It's tough to have to do a lot in just 15 minutes and still precept with the attending... but I still prefer that they teach instead of not at all. (Sometimes I get too busy to even have time to read, so every little bit of teaching in clinic helps me).

Also, if a pt has multiple, complex problems and you only have time to address the salient ones, then the pt could always make another appt to address other issues later.

deleted87716 · Jun 8, 2007

dr_almondjoy_do said:
Does anyone have advice on how to do this in a way that addresses the pertinent issues, leaves room to allow for follow up during future sessions for the non pertinent, and still allows me to survive precepting so that they don't make me address all the non critical bull crap in 15 mins?

Don't be too discouraged. Making efficient use of your time is something that you will improve upon with practice. At this stage of the game, you really should be more concerned about getting the medical stuff right; "moving the meat" is of secondary importance.

That being said, I never walk into a room "cold." Before I see the patient, I review their chart, note the reason for the visit, and formulate a rough "game plan" in my head. I'll then walk into the room, say "Hi" to the patient, make some (usually very) brief small talk, and get down to business. I always sit and make eye contact with the patient. Many times, you can elicit ROS answers while examining that body part to save time. I try not to speak in a hurried tone, even if I'm running behind. Listening is as important as talking. However, open-ended questions are used very carefully...most of my questions are fairly focused. I try to find out what the patient's agenda (if any) is right up front, so I can make sure I address that in addition to what it is that I think is important. If they have a long list, I tell them straight up, "All of these concerns are important to me, and I want to make sure that we give each one adequate attention. Our time today is limited, so we need to decide which of these concerns are most important for today and make another appointment to discuss the others." If they have a list, I'll read it quickly to make sure one of them isn't "chest pain" or something.

If precepting is slowing you down, you should probably talk about that with your attendings. Maybe something can be done to improve the efficiency of the process.

dr_almondjoy_do · Jun 8, 2007

Thank you.

I wish I could see the charts, but they get thrown into my bin literally 2 and 3 at a time, and some times, seconds before i see that patient. i look at the chart while in the room so that the patient can talk while I'm reading. That way, they feel that I'm paying attention due to the moments of eye contact while reading, and I can ask them about things that pop out at me while looking at the chart.

I guess my issue picking what needs to be seen. So let's say a patient has 6 problems, 3 of which are what I will address. What is a good time for people to come back? alot of times I don't know when I'm free for that patient since we are scheduled 1 month in advance, so the patient will know when they can see me when they go to registration to make the appt.

is it 1 week? 2?

the reason why i'm not asking my attendings is because when I do, they don't really give me advice. They assume I know more than I do, and when I ask things they think I'm joking or something. So frustrating!

I sound like an angry stepchild, but that is how I feel! lol

deleted87716 · Jun 8, 2007

dr_almondjoy_do said:
What is a good time for people to come back?

I don't think you'll find any hard and fast rules about followup intervals. IMO, it depends on the nature of the patient and their problems. For example, I typically see my diabetics every 3 months, but the rock-stable ones I'll see every 6 months. A routine, well-controlled asthmatic, hypertensive or hyperlipidemic has to see me twice/year.

I'll sometimes do short-term (e.g, 2 weeks, 1 month, etc.) follow-ups for titration of BP meds, insulin, etc. Pneumonia, COPD or asthma exacerbations, cellulitis, etc. are usually re-checked within 1 week.

Pretty much anyone I write prescriptions for has to see me annually if they expect to get their meds refilled. It's not only good medical practice, but it's also the prescribing law in my state.

dr_almondjoy_do · Jun 17, 2007

so, i decided to be the proactive resident that i have become and took all the advice given to me on this forum and my attendings. i followed an attending as she saw 3 patients in 45 mins and took note.

i am happy to say that in 3 hrs, i saw 7 patients, 3 of which were children with fevers, 1 RAD i sent to the ER, and the rest follow ups. all charts were precepted and compete by 12 noon!

what i learned:

i don't have to address every issue. the next visit can be a close follow up that will only tackle the issues that i left from the prior visit. this makes life easy and i already know what they are coming in for.

i don't have to complete each chart before seeing the next patient, or when the chart is being precepted. i can see a patient, write only pertinents in the chart, precept, then wrap it up with the plan and see another patient. i can clean up the chart when there s time (i.e. no patient waiting to be seen) and leave it to be signed by the attending in a nice pile.

when my census is low, there is a nice big pile of acute patients that can be seen by me and whoever is assigned to do it. this promotes teamwork and allows me to build my panel. there are patients that make a habit of coming in with no appointment. in my program they are seen by the NP or a resident assigned to either peds or adult acute. i can take these patients on and make follow up appts so that they can be seen and i am able to see more patients.

thanks for the advice KentW!

deleted87716 · Jun 17, 2007

Thanks for the update! I'm glad things are looking up.

Navigating through Clinic Sessions...

dr_almondjoy_do

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elizabeth5863

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deleted87716

dr_almondjoy_do

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deleted87716

dr_almondjoy_do

So Very Happy to Be Here!

deleted87716

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