Formulating a Plan

[Redpancreas]

Here's a helpful thread for those looking for surgery specifically.

http://forums.studentdoctor.net/threads/surgery-rounds-formulating-a-plan-when.1028451/
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I've had OB and Neuro. At both, my assessment/plan were never great. The advice I've received is use common sense. What were the patients complaints and pretend you're not a doctor and are just trying to help...from there, assess your plan for efficacy and eliminate things that may harm the patient and contraindications.

It should look like

#1 likely Diagnosis ---> What do we do?
#2 likely Diagnosis ---> What do we do?
#3 likely Diagnosis ---> What do we do?

That's what I do at this point, but it just seems like there's a lot more to it.
Is there some systematic format to do it in just like there's OPQRSTAA when there's pain as the chief complaint? I've heard of INVICTOE (infections, neoplasms, etc.) as a differential list.

Should I just start with differentials, rank them, and then learn the standard of care for each differential I give and then reassess to avoid redundancy and contraindications? The biggest issue I run into when I have an hour to see a patient is still TIME. It takes some time to just see what's going on and get to the bottom of their actual HPI, then it takes a great deal of time to communicate with the patient (who is often ill and hence hospitalized) and examine them without looking like an dingus for interrupting them a million times. After that, the rest of my time is spent looking for everything on the EMR that I'll anticipate the attending wants to know. After all that, I hardly have time to scrape together a common sense differential which oftentimes never gets presented anyways because the attending is in a hurry.

Even when the resident tells me what the differential is, it ends up being completely off and I realize I've just wasted 20 minutes on uptodate preparing for pimp questions that never come because by the time the attending gets to my patient, he doesn't care anymore and cuts to the assessment and plan.

Any advice?

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[BigRedBeta]

https://www.med.unc.edu/medclerk/education/grading/rime-framework

You're still very much in the Reporter mode of the RIME Framework. Hence the time you're spending "looking for everything on the EMR that I'll anticipate the attending wants to know" (emphasis mine) and the "20 minutes on uptodate preparing for pimp questions that never come".

You should be looking for ways that to become more efficient, especially as the year progresses. The easiest way is to simply stop asking so many questions about things that don't matter. For example, as a peds resident I watched dozens of third year students take historys and almost always they included questions about the birth history. Didn't matter if the kid was 2 weeks old or 18 years old, they were going to ask that question, with some going so far into it they were asking these moms why they had an abortion at 16 years old or trying to get them to remember something from nearly 2 decades ago. But how often does that portion of the history really matter? If the kids is over the age of 1 with no prior issues, truthfully NEVER. You need to be figuring out what you can safely drop from the standard template you googled as a cheat sheet in order to spend time on things that are more important.

And if you can't help yourself by asking those questions, or don't feel confident in skipping some, at least have the discipline to stay on task - don't waste time getting so deep into some answers that you don't make it to the questions that do matter.

You also need to move past this idea that if you can just learn the standards of care for each differential that you'll somehow become competent. It's a terribly inefficient way to learn and leaves you entirely unprepared for whatever sits down in front of you that you've never seen before. If you study the top 100 most common diagnoses, you're up a creek when diagnosis #103 walks in the door. And in the life of a third year med student, you're really going to have problems when you switch clerkships. Instead think of treatment plans as tools in your tool box and then figure out ways in which you can use them. That's far more adaptable and when you're presenting your plans, you'll be more likely to get at least one thing "right" and then you're attending or resident can amend it from there. For example, for respiratory complaints your "tools" might be albuterol q4, atrovent q6, incentive spirometry, +/- 3% hypertonic saline nebs, +/- steroids, High Flow Nasal Cannula as needed, and if you need more information or more direct intervention call pulm for a bronch. You can tailor this approach to the severity of your patient and it can work across multiple specialties. Even if a part is "wrong" then at least something is probably right. Even if you get completely rejected, it opens up the question of "why would you not do that in this case" and your understanding gets better. As you learn more about your interventions, then you further refine your tool box.

Decide what makes more sense in your brain so that you don't forget problems - either problem based lists or system based lists. Everyone has their preferred methods and part of being a med student is being adaptable but you have to start with what works for you first. I'm very much a systems based person so going through Resp/CV/FEN/GI/ID/Neuro/Endo/etc makes sense to me. If I was still in training and with someone who was very problem oriented, I'd still go through my systems but then take the extra step to switch to a problem based format when I presented.

Lastly, learn the phrase "I don't know the answer to that right now, but let me look it up and I'll get back to you with it" and repeat it over and over. AND THEN MAKE SURE YOU FOLLOW THROUGH. Seriously, there's no shame in not knowing the answer to something esoteric or deep in a patients history as a student. That's why you're the student and they're the teacher. The sooner you get over saying "I don't know" the better your life will be. And if you follow up, that tells me so much more about you as a person and future clinician then if you happen to be really good at "guess what the attending is thinking". Put it another way, I can teach you everything I know about disease X or how to manipulate a ventilator, I can't teach you personality traits or habits. Further, you'd be amazed at how often patients will ask you something you don't know and will appreciate you taking the time to look it up for them, even when you're an attending.