A/p??

[marie337]

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So, I'm weeks away from being a fourth year, and my assessment and plans suck. I get great feedback on my histories and PEs, but unless I have 10 minutes to sit down and think of a differential and assessment I really struggle with this part. I'm on outpt IM right now, and with 2 weeks left I really want to work on this part. Any suggestions? With this particular attending, I don't really get time to formulate much. He just heads in and expects a presentation as soon as I'm done with the physical (understandable...he doesn't have all day).

 

[vtucci]

What pocket guides are you using? Any? I would suggest either Pocket Medicine or Ferri's Guide to Caring for the medical patient. They give you the workup and A/P for many dx. Part of the A/P is also being able to come up with a good ddx. Maybe it would be good to get a pocket ddx guide as well.

 

[Blade28]

Also remember that each specialty has a different system and format for their A/Ps. Internal Medicine is known for their long, numbered "problem list" with a separate plan for each (e.g. hyponatremia, hyperkalemia, diabetes, etc.).

 

[futuredo32]

It's unfortunate that your attending can't rearrange his schedule just a tad and give you a few minutes to collect your thoughts before just coming into the exam room by seeing 2 patients to every 1 patient that you see or something. You're a student and it's been my experience that it's ok to take longer than an attending to complete the h&p as well as the a/p.
Maybe you could try memorizing the A/P for the most common h&p's that you've been seeing in his office?

 

[marie337]

This particular attending gives me plenty of time in the room. But, then when I come out and am finishing up my note and trying to come up with a plan I don't feel I have time to organize my thoughts. But, I think that's my own issue to deal with. I think I generally do okay. I just got flustered this afternoon when my first two patients were for dizziness and then fatigue. He laughed when he sent me in, and just said good luck. They ended up both being pretty complex and even he wasn't confident about what was going on. But, I need to work on giving a confident a/p. I think there is a good reason why I'm not going into IM!

 

[smq123]

So, I'm weeks away from being a fourth year, and my assessment and plans suck. I get great feedback on my histories and PEs, but unless I have 10 minutes to sit down and think of a differential and assessment I really struggle with this part. I'm on outpt IM right now, and with 2 weeks left I really want to work on this part. Any suggestions? With this particular attending, I don't really get time to formulate much. He just heads in and expects a presentation as soon as I'm done with the physical (understandable...he doesn't have all day).

I agree. I think that this has been the hardest part of outpatient. Inpatient medicine is much easier because you almost always have 20 minutes to collect your thoughts after the H&P and come up with a differential. And inpatient medicine "treatment plans" usually consists of a WIDE variety of lab tests...and the list of tests that you are supposed to order never seems to change! (CBC, Chem 7, LFTs, CXR, , ESR, CRP, TFTs, RPR. It's like the IM mantra.)

I'm at the same place that you are, and what I've been told over and over again is that they just want to see that you're thinking and that you're becoming more confident in your own opinions. It's okay to be wrong - but just try to think.

Does your attending actually ask you for a really long, drawn out differential? My attendings never did - they wanted 2, at the most. Once I didn't feel the need to have a 10 item differential, I felt a lot less pressured, and could kind of think of an assessment more easily then.

It's unfortunate that your attending can't rearrange his schedule just a tad and give you a few minutes to collect your thoughts before just coming into the exam room by seeing 2 patients to every 1 patient that you see or something. You're a student and it's been my experience that it's ok to take longer than an attending to complete the h&p as well as the a/p.

I know - but this really is something that, as fourth years, we should be getting ready to do. It would be nice if the attendings gave us 5 minutes to collect our thoughts, but....oh well.

Maybe you could try memorizing the A/P for the most common h&p's that you've been seeing in his office?

I tried that on family med. It didn't work out so well. The attendings seemed to approach each patient so differently....plus, the preferred A/P will depend on which attending you're with that particular day.

 

[vtucci]

Okay- things I have done to organize my thoughts:

1. Write out the headings in advance (i.e., CC, HPI, ROS, PMH, PSH, Allergies, Meds, FH, SH). I would also try numbering things in the HPI if multiple c/o and with PMH and PSH. It is neater and helps you think and spot potential landmines.
2. If you can look at the patient record in advance to your clinic day, so much the better (it might give you tip offs if the patient has long standing aniscoria etc so you don't freak out on exam)
3. I also try to write out the first sentence of my presentation, i.e., 45 y.o. white male with a PMH c/b___________ presents to our clinic complaining of X. PQRST for pain. I also repeat the beginning part of this sentence in my A&P, it gives me another second to think what I am going to say (i.e., 45 y.o. white male c/o: 1. 2. 3.
4. Personally, I include A&P together as this is the way I naturally think. Deal with one problem have a plan and go on.

 

[AmoryBlaine]

1. My personal philosophy (and experience) in medical school was this.

M3 is for H&P
M4 is for A
Residence is for P

Not that there isn't alot of overlap, I just noticed when I was an M4 Sub-i that assesments came very naturally and that it was something I found myself guiding alot of younger students in. Plans are much harder because they are so often attending dependant or according to hospital protocol. You could have a perfectly reasonable plan and your attending could disagree with every step. If you're ever on a service where attendings change weekly you will see this in exquisitely painful detail.


2. Differentials don't have to be vast even in IM settings. My format is usually 1 to 3 common things + 1 to 2 "less likely" + 1 "much less likely."

Dizziness: BPPV vs. other benign vertigo vs. less likely Menierres vs. labyrinthitis vs. much less like structural lesion.
Fatigue: Depression vs. Sleep apnea vs. less likely Hypothyroidism vs. much less likely badness such as cancer, rheumatic illness.

If you throw two or three likely things in there but show the doc that you know about scarier stuff you're usually golden.

 

[futuredo32]

I know - but this really is something that, as fourth years, we should be getting ready to do. It would be nice if the attendings gave us 5 minutes to collect our thoughts, but....oh well.

We should be getting ready to do it, but we aren't expected to be at the level of an attending. Even the residents take more time on patients than attendings do.

I tried that on family med. It didn't work out so well. The attendings seemed to approach each patient so differently....plus, the preferred A/P will depend on which attending you're with that particular day.

I'm not sure what you mean, unless you're talking about what specific way to write out the A/P. A patient with xyz symptoms has xyz diagnosis with an xyz plan, regardless of the attending.

This particular attending gives me plenty of time in the room. But, then when I come out and am finishing up my note and trying to come up with a plan I don't feel I have time to organize my thoughts. But, I think that's my own issue to deal with. I think I generally do okay. I just got flustered this afternoon when my first two patients were for dizziness and then fatigue. He laughed when he sent me in, and just said good luck. They ended up both being pretty complex and even he wasn't confident about what was going on. But, I need to work on giving a confident a/p. I think there is a good reason why I'm not going into IM!

I thought that the attending was walking into the exam room before you were finished. One of my first rotations was a FP rotation, but it was on a mobile medical unit for the indigent population. The mobile clinic not only saw and treated patients at no charge, but also provided diagnositcs, prescriptions, and arranged for surgeries all at no charge. Needless to say, we saw patients with very complicated histories that, in many private practices, would have been seeing several specialists. For many of these patients, I would sit in the room with the patient and write out the A/P so that I could present it to the attending who was doing nothing but waiting for me to come out of the exam room. Maybe you could try getting at least a little bit of the A/P thought out in the exam room before you leave? I haven't really tried doing that in a private office, but the patients on the mobile clinic didn't seem to mind.

I think you are probably doing better than you think you are doing. 🙂

 

[marie337]

Maybe you could try getting at least a little bit of the A/P thought out in the exam room before you leave? I haven't really tried doing that in a private office, but the patients on the mobile clinic didn't seem to mind.

I think this is exactly what I need to work on. He did actually come into the room once yesterday, before I was done. Otherwise, as soon as I step out of the room he's ready to go. At that point I'm usually still trying to get my exam entered into the EMR and not focusing on the a/p, yet. I just feel awkward sitting in the room working on this part.

I think I'm doing okay, but I need to work being more systematic with my thought process. I tend to get flustered when I'm not organized and this causes too much unnecessary stress!

 

[smq123]

I'm not sure what you mean, unless you're talking about what specific way to write out the A/P. A patient with xyz symptoms has xyz diagnosis with an xyz plan, regardless of the attending.

THIS is what I mean....

Plans are much harder because they are so often attending dependant or according to hospital protocol. You could have a perfectly reasonable plan and your attending could disagree with every step. If you're ever on a service where attendings change weekly you will see this in exquisitely painful detail.

I totally agree. This is the worst part about being at one site for a long time, with patients that hang around the hospital for weeks. Inevitably, you will change attendings, and the next attending that you get will make suggestions that will undo the work that you did with the previous attending.

For many of these patients, I would sit in the room with the patient and write out the A/P so that I could present it to the attending who was doing nothing but waiting for me to come out of the exam room. Maybe you could try getting at least a little bit of the A/P thought out in the exam room before you leave? I haven't really tried doing that in a private office, but the patients on the mobile clinic didn't seem to mind.

I also tried doing that on family med (which was mostly in the office - not in a mobile clinic). The attending would usually come in and interrupt me, wondering what was taking so long to get out of the room. In a private office, room turnover can be important, because you don't want to keep patients waiting. 🙁

So far, I've just let myself be wrong. It's kind of freeing, actually. I come up with a quick assessment, based on what I've seen. And then I just say that that's what I think it is. It's never been a problem that I've been wrong several times so far....but taking forever to come up with a diagnosis list, or not confidently standing behind my opinion has been.

 

[DrDre311]

So far, I've just let myself be wrong. It's kind of freeing, actually. I come up with a quick assessment, based on what I've seen. And then I just say that that's what I think it is. It's never been a problem that I've been wrong several times so far....but taking forever to come up with a diagnosis list, or not confidently standing behind my opinion has been.

Yes...people prefer someone who is confidently wrong to someone who may be right but is not confident in his/her skills.

Bill Clinton actually said that about why Bush was reelected in '04: something along the lines of "voters are more comfortable with someone who is strong and wrong to someone who is weak and right."

 

[Blade28]

Yes...people prefer someone who is confidently wrong to someone who may be right but is not confident in his/her skills.

👍

"Sometimes wrong, never in doubt."

 

[LadyGrey]

I'm not sure what you mean, unless you're talking about what specific way to write out the A/P. A patient with xyz symptoms has xyz diagnosis with an xyz plan, regardless of the attending.

In a perfect world, maybe. (Or on board exams). In family I worked with three different docs and someone with the same URI symptoms and same underlying illnesses would reliably get antibiotics or not based on who was working that day. So "xyz symptoms = viral URI = suck it up" with one doctor, but with another, "xyz = eh, could be something bacterial = here's a Z-pack."

A/P is going to vary a lot less with some symptoms than others, obviously -- a 60 y/o smoker with crushing substernal chest pain coming to the ED is going to get the same A/P no matter who is on. But with subtler and less acute things, it can be very different.

(Also, I think attendings don't always verbalize to us what is going into their A/P -- their years of experience, intuition, intimate knowledge of the patient's history, etc., all shape what they do, so things that all look like xyz to us may look like abc to them).

 

[futuredo32]

In a perfect world, maybe. (Or on board exams). In family I worked with three different docs and someone with the same URI symptoms and same underlying illnesses would reliably get antibiotics or not based on who was working that day. So "xyz symptoms = viral URI = suck it up" with one doctor, but with another, "xyz = eh, could be something bacterial = here's a Z-pack."

A/P is going to vary a lot less with some symptoms than others, obviously -- a 60 y/o smoker with crushing substernal chest pain coming to the ED is going to get the same A/P no matter who is on. But with subtler and less acute things, it can be very different.

(Also, I think attendings don't always verbalize to us what is going into their A/P -- their years of experience, intuition, intimate knowledge of the patient's history, etc., all shape what they do, so things that all look like xyz to us may look like abc to them).

i
I was thinking more of the definitive diagnosis, like the smoker you mentioned.
What I was trying to say about the patient with an URI, for example, is that your A would be
1.Viral URI

2.Bacterial URI

And your plan would then be antibiotics or not, depending on the attending.

It's been my experience (so far) that even if your attending always prescribes antibiotics, they don't seem to roll their eyes if I suggest not prescribing antibiotics for what seems more likely to be a viral infection. Your P may not be the attending's P, but it's still a reasonable P.(After a few patients with Dr.X, it's easy to tell if Dr.X is contributing to the problem of antibiotic resistance or not and then I can adjust my P accordingly).
There's often a few As for a given set of symptoms. I've gotten good feedback from my attendings (so far) for having reasonable As to go with reasonable Ps.

 

[Terpskins99]

Quickie way to work-up a SOAP note A/P

A: VITAMIN C your differentials:
Vascular
Infection
Toxin/Drug
Allergy
Metabolic
Inflammatory/Idiopathic
Neoplasm
Connective Tissue disease

P: 3 step management: Diagnostics, Therapeutics, Complementary
Diagnostics = cultures, labs
Therapeutics = drug regimen, other treatment
Complementary = prognosis, consults, ancillary needs (physical tx, social service)

 

[Acherona]

So, I'm weeks away from being a fourth year, and my assessment and plans suck. I get great feedback on my histories and PEs, but unless I have 10 minutes to sit down and think of a differential and assessment I really struggle with this part. I'm on outpt IM right now, and with 2 weeks left I really want to work on this part. Any suggestions? With this particular attending, I don't really get time to formulate much. He just heads in and expects a presentation as soon as I'm done with the physical (understandable...he doesn't have all day).

Well you should be thinking about your impression/plan before you even enter the room. What information do you need on H&P to rule out or rule in a diagnosis or help you decide if the patient needs a particular investigation or treatment? You are probably doing this already if you are getting great feedback and not just using the shotgun approach.

 

[Vader]

Well you should be thinking about your impression/plan before you even enter the room. What information do you need on H&P to rule out or rule in a diagnosis or help you decide if the patient needs a particular investigation or treatment? You are probably doing this already if you are getting great feedback and not just using the shotgun approach.

Yes, this is the key to becoming efficient. I didn't realize this until late M3 year. Studying for Step 2 CS actually helps for this since you have severe time constraints in this case and must quickly formulate an assessment and plan.

But actually the ability to quickly formulate a differential and make a plan is a skill you will build over time and something you will need during residency, especially during internship when you are first call for your patients (i.e. "Doctor, the patient's heart rate is in the 150's"). You have to be able to quickly think about what are the really bad diseases are and what you would do to rule them out.

In this clinic setting, try to think about 1) the most likely 1-3 diseases, in order of likelihood based on the evidence, 2) one or two less likely diseases, and 3) one or two diseases that you don't want to miss (i.e. MI, cancer).

Study the differentials for common complaints:
chest pain, shortness of breath, fatigue, knee pain, back pain, abdominal pain, etc. Have a differential in mind based on the chief complaint and ask questions that will help you to rule-in or rule-out your ideas. Then make the physical exam even more focused to rule-in or out your ideas.

If there are multiple complaints (as there usually are in clinic), prioritize the complaints and limit them to a 1-3 for a single visit. Then quickly think about very short differentials for each and the questions you will ask and things to do on exam that will help you rule-in/out.

Honestly, this really comes with experience. During 4th year try to come up with an assessment and plan for each patient you see and present this confidently to your residents/attendings. As others have mentioned, your superiors do not expect you to get the correct answer every time, but they DO expect that you will present your A/P in a confident way.

 

[Blade28]

What a lot of med students often don't realize is that the entire H&P presentation is supposed to help "lead" the listeners towards a differential...then slowly narrow it down.

If you're presenting a patient with chest pain, you want to cover the pertinent positives and negatives during the history (radiating pain/diaphoresis/SOB - MI? pleuritic pain/fever/coughing - PNA? occurs with food/burning - GERD?). The listeners are making their own differential in their head as they listen to you, and from the positives and negatives that you report, they can begin to narrow down the differential along with you.

So when you get to the end of the H&P and it's time for the A/P, it's time to vocalize your thoughts - show the listeners what differential you initially started off with and how you were able to narrow it down based on the findings of your interview and physical exam. You don't come up with a differential AFTER the H&P, you have one in mind BEFORE you start and you work with that.

 

[marie337]

Well, things are already going much better this week. I think that just taking some time over the weekend to refocus really helped my confidence. I've had a lot of good feedback over the last two days, so I think it was just a confidence issue. This particular attending tends to intimidate me because he's just so freaking smart. But, he's a great teacher! I've been trying to gather my thoughts before leaving the room, which seems a little awkward but ends up being more efficient in the end. The scary thing is....I'm actually starting to like IM 😱!

 

[futuredo32]

Well, things are already going much better this week. I think that just taking some time over the weekend to refocus really helped my confidence. I've had a lot of good feedback over the last two days, so I think it was just a confidence issue. This particular attending tends to intimidate me because he's just so freaking smart. But, he's a great teacher! I've been trying to gather my thoughts before leaving the room, which seems a little awkward but ends up being more efficient in the end. The scary thing is....I'm actually starting to like IM 😱!

Liking a rotation makes the four weeks on that rotation a lot better. There are worse things to like other than IM.🙂
I took the practice Comlex PE at MSU yesterday and being forced to do it under such restricted time limits really just helped a lot. All throughout the exam, I was focused on the A/P. Though I think the Comlex PE is not the best use of 1,000, I do think that it will help me, maybe others to really do a better H&P/A/P on all of my rotations.
Glad to hear that your confidence is better.

 

[waldenwoods]

For me, coming up with the assessment and then planning what to do for the patient was a gradual process I got better at as the year progressed. Still have plenty of room for improvement in both thinking broadly about differential diagnoses as well as becoming more efficient.

I want to offer a difference in opinion to the one above, where year 3 is for learning the H&P, year 4 is for the assessment, and residency is for the plan. I have had two different attendings this past year pimp me on which is the most important thing for a third-year medical student to focus on in the H&P/progress note. And the answer was the assessment. One of them followed up with the explanation that you learn how to take a history in the first year, learn physical exam skills in second year, should spend third year learning how to present a good assessment, and fourth year is for getting a better understanding of the plan. This is not to say that one opinion is more right than the other one. Just for incoming third years, there are differences in opinion out there that you'll encounter.