Difference in history taking--midlevels vs. junior doctors

[Nasrudin]

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I feel like for the first time in my career I have a significant sample size of working with midlevels and physicians to see a pattern. And what emerges to me is a clear difference in quality of history taking and differential generation.

With the exception of a few very experienced specialized midlevels the majority produce dull, unimaginative, frightenly impoverished history and physicals and their assessments are bleak and poor. They have a hard time conceptualizing why they're even calling a consult or what can be gained from the collaboration. Their clinical peripheral vision is non-existent.

It makes me realize what medical school was for. You can't gather a good history if you don't know what to ask and why. The histories that my 4th year medical students produce are so much more detailed, rich, diverse, interesting and useful. Given, there's a time and work load difference...but I think there's a thought process difference too. You can tell they have working differentials when they take a history.

What is your experience?

It's not the political debate that interests me, it's the quality of work difference. It could be I've seen a large number of new grad PA's and NP's. But still to see 4th year medical students operating with so much more sophistication is surprising. I'm surprised to see on the job training of midlevels as so limiting, that at 3-4 years in working in a single specialty that their basic general clinical skills are almost ******ed.

 

[Psai]

Writing those notes don't teach me anything. When people read my notes and tear them apart, asking why I didn't do this or why I didn't include this, that's when I learn. When I listen to specialists complain about getting consulted without a proper consult letter or read procedure reports that don't contain the information that they're looking for, I learn.
Any monkey can talk to a patient and write down what they say. I'm beginning to see that a lot of the information that I write in my notes is superfluous and unnecessary to addressing the chief complaint. I'm just starting to understand how to integrate the knowledge from the first two years and apply it to my history and physical. I used to just ask and go through the ROS to mark boxes but now I'm actively trying to narrow things down on my differential. It's still not very good but I feel like I'm improving

 

[giantswing]

I feel like mid levels/nurses think medicine and diagnosis is just straight, brute memorization which results in narrow minded, inflexible thinking that is incongruent with coming up with enough of a differential which guides a good history and PE.

 

[Priapism4tooLong]

Some of the 4th year students are good some are just miss-guided. Lol the other day a kid took a history and forgot to mention that the patient was jaundiced, then went to defend himself and was like oh yeah i didnt think you needed to say that cuz you can just see it. That's what annoys me the most, when they try to defend themselves when they've made a clear mistake. I make mistakes everyone does, but problems arise when you start defending yourself for wrong actions. I sat down and talked to him about it lol.

 

[DermViser]

Some of the 4th year students are good some are just miss-guided. Lol the other day a kid took a history and forgot to mention that the patient was jaundiced, then went to defend himself and was like oh yeah i didnt think you needed to say that cuz you can just see it. That's what annoys me the most, when they try to defend themselves when they've made a clear mistake. I make mistakes everyone does, but problems arise when you start defending yourself for wrong actions. I sat down and talked to him about it lol.

Can't believe that's a 4th year med student - I bet he's a book smart person too. And then they seriously wonder why they didn't get Honors at the end of the rotation. Everyone makes mistakes that's fine. But when you start defending yourself taking it as a personal affront instead of just taking responsibility, is when it becomes an issue.

 

[pathologyDO]

Can't believe that's a 4th year med student - I bet he's a book smart person too. And then they seriously wonder why they didn't get Honors at the end of the rotation. Everyone makes mistakes that's fine. But when you start defending yourself taking it as a personal affront instead of just taking responsibility, is when it becomes an issue.

Just out of curiosity, should this student have said "yeah you're right, I'm lazy and didn't write it down." What do you say? Simply, sorry next time I wont forget?

 

[giantswing]

Just out of curiosity, should this student have said "yeah you're right, I'm lazy and didn't write it down." What do you say? Simply, sorry next time I wont forget?

Yes. And most important, don't forget next time. It's ok to miss something once, just don't do it again.

 

[pathologyDO]

.

 

[maxxor]

They don't have to say they were lazy (obviously you are being hyperbolic, but still).

But yes, when you mess something up - you apologize for it and move on. Getting defensive or trying to make up a spur of the moment excuse or lie doesn't make you look good.

"I'm so sorry, I don't know how I missed that"
"I'm so sorry, I wrote that down but I forgot to mention it"
etc

Agree with above.

A wise resident told me, "you get one chance to make a mistake. Come late, forget to report a finding, whatever. Just apologize, move on, and don't do it again. "

 

[DermViser]

Just out of curiosity, should this student have said "yeah you're right, I'm lazy and didn't write it down." What do you say? Simply, sorry next time I wont forget?

Um, yeah. Like you would in any other profession when you are told and don't do it again, to show that you've learned.

 

[ACSurgeon]

Some

I feel like for the first time in my career I have a significant sample size of working with midlevels and physicians to see a pattern. And what emerges to me is a clear difference in quality of history taking and differential generation.

With the exception of a few very experienced specialized midlevels the majority produce dull, unimaginative, frightenly impoverished history and physicals and their assessments are bleak and poor. They have a hard time conceptualizing why they're even calling a consult or what can be gained from the collaboration. Their clinical peripheral vision is non-existent.

It makes me realize what medical school was for. You can't gather a good history if you don't know what to ask and why. The histories that my 4th year medical students produce are so much more detailed, rich, diverse, interesting and useful. Given, there's a time and work load difference...but I think there's a thought process difference too. You can tell they have working differentials when they take a history.

What is your experience?

It's not the political debate that interests me, it's the quality of work difference. It could be I've seen a large number of new grad PA's and NP's. But still to see 4th year medical students operating with so much more sophistication is surprising. I'm surprised to see on the job training of midlevels as so limiting, that at 3-4 years in working in a single specialty that their basic general clinical skills are almost ******ed.

Some experienced mid levels are impressive. As a whole, there is a significant knowledge gap and ability to think outside the box. Most things in a given specialty follows certain patterns, and they're usually very able to deal with the bread and butter stuff.

Finally, I'm usually much more impressed with PAs compared to NPs. Fund of knowledge and ability to think outside the box.

 

[Nasrudin]

Writing those notes don't teach me anything. When people read my notes and tear them apart, asking why I didn't do this or why I didn't include this, that's when I learn. When I listen to specialists complain about getting consulted without a proper consult letter or read procedure reports that don't contain the information that they're looking for, I learn.
Any monkey can talk to a patient and write down what they say. I'm beginning to see that a lot of the information that I write in my notes is superfluous and unnecessary to addressing the chief complaint. I'm just starting to understand how to integrate the knowledge from the first two years and apply it to my history and physical. I used to just ask go through the ROS to mark boxes but now I'm actively trying to narrow things down on my differential. It's still not very good but I feel like I'm improving

It's this process that they obvious lack from going through. I'm still learning the exact same process. But at a different stage. Attendings can be brief, but are generally decisively and powerfully so. Not for lack of understanding possibilities of things lurking...of things that can go wrong...or of things happening in the minds of their consulting teams.

I do disagree that any monkey can elicit a good history. That's like saying any cop or brand new detective can work a suspect. This stuff takes experience. You need to see a thousand cross examinations of patients' stories that completely contradict the one they gave you and to see how easily an attending can go after the key pieces of the puzzle for every complaint.

Did you know first trimester headaches can help differentiate necessary work up in perinatal headaches? Neither did I until this week. Now it's part of my history taking in a woman with headaches. And so on.

I also think you have to have imagination to take a good history. A blunt intellect, affect and an incurious mind is not someone anyone wants to talk to. That's a much different history. And it's one I've seen that characterized the PA/NP histories that I've encountered.

 

[Perrotfish]

nvm

 

[pathologyDO]

Um, yeah. Like you would in any other profession when you are told and don't do it again, to show that you've learned.

I take it you make pies to satisfy your attendings <3

 

[mimelim]

I feel like mid levels/nurses think medicine and diagnosis is just straight, brute memorization which results in narrow minded, inflexible thinking that is incongruent with coming up with enough of a differential which guides a good history and PE.

You just described a quarter of my medical school class.

 

[giantswing]

You just described a quarter of my medical school class.

Ha ha... Hopefully while in first and second year? It's an ever evolving process esp diring third and fourth year.

 

[hallowmann]

Ha ha... Hopefully while in first and second year? It's an ever evolving process esp diring third and fourth year.

I've seen a fair amount of mid-3rd years do this (I'm not really one to talk as a 2nd year who will likely spend a while doing that). That said, I think the learning curve is steep that year, but by 4th year, things look completely different. The 4th years seem to know exactly what they're asking and why.

 

[Psai]

I've seen a fair amount of mid-3rd years do this (I'm not really one to talk as a 2nd year who will likely spend a while doing that). That said, I think the learning curve is steep that year, but by 4th year, things look completely different. The 4th years seem to know exactly what they're asking and why.

it depends on the rotation
the things i learned on obgyn are totally different from the things i learned on medicine

 

[mimelim]

Ha ha... Hopefully while in first and second year? It's an ever evolving process esp diring third and fourth year.

I meant my graduating class. The same could be said for well over a quarter of the interns that showed up at our and the neighboring hospitals across all specialties.

 

[hallowmann]

Heh.

Maybe to a third year.

To a resident I'd say they still seem pretty clueless most of the time.

Haha, well obviously. And I'm sure to the attending a PGY1/2 resident seems pretty clueless. I was just saying that whereas 3rd years regularly aren't really sure why they are doing/asking something, a 4th year seems to have some reason. I was only comparing 3rd and 4th years in that quote.

 

[Psai]

Heh.

Maybe to a third year.

To a resident I'd say they still seem pretty clueless most of the time.

Well we can't help being clueless, we've only seen so many things. It's really hard to take book knowledge and use it in real life

 

[Nasrudin]

I think too much is made of our nascent cluelessness. Once you graduate medical school the next year after that has more to do with process. You will have assimilated more information that any generation of doctors before you. The stuff is still reasonably fresh. It's hard to convert it into usable forms but a powerful information infrastructure is in place. You have the basics of every specialty at your disposal. And you're part of the only profession standing that has that experience. No one else had to present to an OB attending every morning then take a shelf on it then the next week do the same thing all over on surgery. You're clinical competitors have considered that obsolete. Or not worth the time.

I'm saying that thing you've earned makes a huge f'n difference. I've seen it. I know this not because I'm awesome. But because I'm a clueless intern and if I think you're ******ed as a midlevel you really must be.

Sure, I'm not impressing the crap out of every attending or advanced resident I work with. But that's not the point of the thread. I consider myself an average intern. Below average in knowledge above average in process and working with people. And I still take a consult from a specialist midlevel and think holy crap is that person a *****.

I have never thought that about a 4th year medical student. Because I can see what they have in the rough. And I'm not that impressed with learning all this stuff I've had to, to survive. The only benefit is I've seen tons and tons of patients more than a fourth year by now. Which is something. But not anything impressive, to me, as this thing we have in common--medical school. I didn't always believe it made the difference.

Now I do. And I'm surprised by its extent. Which is why I was curious if others found the same thing.

 

[KnuxNole]

Histories aren't supposed to be interesting anyway or use overly imaginative things. Most histories are boring, the interesting ones usually contain drunk people, or sticking things in their vagina stories....

 

[Nasrudin]

Histories aren't supposed to be interesting anyway or use overly imaginative things. Most histories are boring, the interesting ones usually contain drunk people, or sticking things in their vagina stories....

You misunderstand my use of the words. But even so I disagree. The person who finds the patient interesting will take the better history.

 

[mimelim]

I would say that our NPs and PAs are functional equivalents to junior (pgy2-3) residents. They have little to no aspirations for more responsibility or to go up the food chain. They are happy with their status as above interns, equivalent to juniors and below chiefs and happy with their lifestyle and compensation.

The bigger problem is that not all specialties are the same. If you compare a PGY 3 IM resident at my hospital to me, I have literally been taking care of patients 50% more. Just because of how we are trained. A lot of it is irrelavnt stuff, but when comparing to midlevels, it is something to be aware of.

 

[Nasrudin]

I would say that our NPs and PAs are functional equivalents to junior (pgy2-3) residents. They have little to no aspirations for more responsibility or to go up the food chain. They are happy with their status as above interns, equivalent to juniors and below chiefs and happy with their lifestyle and compensation.

The bigger problem is that not all specialties are the same. If you compare a PGY 3 IM resident at my hospital to me, I have literally been taking care of patients 50% more. Just because of how we are trained. A lot of it is irrelavnt stuff, but when comparing to midlevels, it is something to be aware of.

This is why I asked the question. I'm not sure what I'm seeing is representative. But also I wonder what you're junior residents vs midlevels look like to other specialties. For example the midlevels on our ortho service may be the dumbest people I've ever talked to in a clinical capacity. But those junior residents have done a year of general surgery and were probably towards the top of their medical school class. That's an entirely different level of human performance. Sure, they may not be as useful to you yet as a midlevel who does nothing else but plug into your scheme and game plan.

But that's not really the question I'm asking is it?

 

[Nasrudin]

I'm just saying this whole lauding the glorious H&P's of fourth year med students is kind of over the top.

Honestly as @mimelim alluded to - I'd take our PA/NP's histories and assessments over a fourth year med students any day. And over a November intern.

That's not meant as a knock on fourth years or interns.

OK. I wonder if you're consultants feel the same way. idk. That's why I'm comparing notes. Also the H&P comparison is just meant to encapsulate clinical comprehension, broadly.

 

[DermViser]

I feel like mid levels/nurses think medicine and diagnosis is just straight, brute memorization which results in narrow minded, inflexible thinking that is incongruent with coming up with enough of a differential which guides a good history and PE.

You just described a quarter of my medical school class.

I meant my graduating class. The same could be said for well over a quarter of the interns that showed up at our and the neighboring hospitals across all specialties.

I wonder if that's the same 25% of your class that would have been happier doing the PA route (or even NP route).

I'm not actually surprised when you have a relatively very standardized basic science curriculum in the first 2 years in which everything is taught as Symptom/Sign A + B + C = This disease. Period. No ambivalence whatsoever. Esp. when there is pressure to teach only to Step 1.

The differential diagnosis process really isn't delved into much in the first 2 years so it can give a false picture on how medicine is like. You have a physical diagnosis course - but that can vary in quality across schools, and then you have MS-3 which has been watered down so much in terms of what med students can do and virtually not being able to fail any one that it essentially becomes the residency's problem.

 

[mimelim]

I wonder if that's the same 25% of your class that would have been happier doing the PA route (or even NP route).

Unequivocally, yes. And it is a tragedy. Not the end of the world for anyone, but it is very unfortunate that people feel the pressures of MD or bust, when there are far better careers out there for their interests.

 

[DermViser]

Unequivocally, yes. And it is a tragedy. Not the end of the world for anyone, but it is very unfortunate that people feel the pressures of MD or bust, when there are far better careers out there for their interests.

I think several things contribute to that:

1) the MD or bust mentality -- when there are other avenues that lead to relatively the same end point in certain ways (although there are differences - but for many those are things they would be perfectly fine with -- not having ultimate responsibility, not being on call, etc.)
2) Not thoroughly investigating other healthcare routes in which one would be just as happy with
3) Rose-colored glasses of the MD being a road to riches (esp. those who aren't in that bracket to begin with) or perceived prestige
4) Parental pressure
5) Doing healthcare extracurriculars that aren't realistic in terms of knowing what it's like to actually be a doctor -- i.e. volunteering at a cush private practice vs. volunteering in an inpatient academic medical center, since most of your education will be in an AMC and in inpatient settings.

I think SDN is fantastic when it comes to going thru the application, standardized testing, and CV building process. I think what is missing is the ability to give someone the ability to discern whether medicine is the right decision in the first place.

 

[DermViser]

Heh.

Maybe to a third year.

To a resident I'd say they still seem pretty clueless most of the time.

I wonder how much is the logistics vs. knowledge. I also attribute it to a lot of inefficiencies in the basic science curriculum, in which you learn what Krabbbe's Disease and Hurler's Syndrome is, but god forbid they would teach you how to treat something common - like a sprained ankle, or maybe go thru a differential diagnosis on a very common medical problem.

 

[maxxor]

OK. I wonder if you're consultants feel the same way. idk. That's why I'm comparing notes. Also the H&P comparison is just meant to encapsulate clinical comprehension, broadly.

Remember, you have a couple surgery residents in here. Surgery H&Ps/notes/etc are not going to be the "detailed, rich, diverse, interesting and useful" sort you are looking for as an IM/Psych trained person. Perspectives are going to be different.

On our medicine service, my notes are a couple pages long. On surgery, it's 1 page, handwritten. Also, surgeons LOVE midlevels for taking the floor BS / consults so they can focus on operating. The midlevel has a defined role that is different from the MD. People in non-procedural fields where their entire work is the cognitive process and the production of notes are going to notice the differences in midlevel vs MD/DO trainee notes.

 

[Nasrudin]

Remember, you have a couple surgery residents in here. Surgery H&Ps/notes/etc are not going to be the "detailed, rich, diverse, interesting and useful" sort you are looking for as an IM/Psych trained person. Perspectives are going to be different.

On our medicine service, my notes are a couple pages long. On surgery, it's 1 page, handwritten. Also, surgeons LOVE midlevels for taking the floor BS / consults so they can focus on operating. The midlevel has a defined role that is different from the MD. People in non-procedural fields where their entire work is the cognitive process and the production of notes are going to notice the differences in midlevel vs MD/DO trainee notes.

. This occurred to me too late. And I was already committed to the premise. So I had to keep going.

But yes. If your specialty is more doing than capturing and conveying information, then this premise fails. Badly.