How can I get up to speed on patients quickly and develop a plan?

GunnerBMS

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Aug 26, 2014
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Every morning at 4 am, I look at my surgery team's patient list and pick a few to follow. I dread patients who have been in the hospital for a 5 or more days, because when I read in their documentation since admission what has been done, I feel very overwhelmed. Reading every progress note and trying to figure out what has been done for the patient and what problems they have since admission is very difficult for me. I can barely keep up with understanding the history of one patient.

My seniors all tell me I need to be an expert on my patients. Yet, reading about one patient is hard for me. Also, no one calls me about what has been done for the patient throughout the day since I am the student, so I never know what is going on with the patient. All I depend on is reading the charts and progress notes. I am confident at examining the patient and developing my own assessments and plans at this stage, but how can I do them if I don't know everything that has been done for the patient so far? It takes me 2 hours to go through a patient's chart and develop a plan.

Can someone please help me? I am afraid I will drown on my Sub-i and and eventually intern year if I can't handle understanding multiple patients' hospital courses. I am struggling a lot.
 
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Syncrohnize

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Every morning at 4 am, I look at my surgery team's patient list and pick a few to follow. I dread patients who have been in the hospital for a 5 or more days, because when I read in their documentation since admission what has been done, I feel very overwhelmed. Reading every progress note and trying to figure out what has been done for the patient and what problems they have since admission is very difficult for me. I can barely keep up with understanding the history of one patient.

My seniors all tell me I need to be an expert on my patients. Yet, reading about one patient is hard for me. Also, no one calls me about what has been done for the patient throughout the day since I am the student, so I never know what is going on with the patient. All I depend on is reading the charts and progress notes. I am confident at examining the patient and developing my own assessments and plans at this stage, but how can I do them if I don't know everything that has been done for the patient so far? It takes me 2 hours to go through a patient's chart and develop a plan.

Can someone please help me? I am afraid I will drown on my Sub-i and and eventually intern year if I can't handle understanding multiple patients' hospital courses. I am struggling a lot.
I can definitely relate to this. First of all, do your best to project confidence because engaging in too much outward self doubt will make you a target. I don't know if you are being criticized or doing a good job on your rotation, but if you are getting called out, chances are it's due to your soft rather than hard skills even if you're being told the former. Second, before seeing each patient, quickly use UpToDate if you don't know the management for something cold.
That should help with knowledge.

Also, find the most thorough resident's notes and try to read the plan and see what system the interns follow. Treat that as your beginner's template for presenting the plan. For example, on my vascular rotation, they always wanted to know what we were going to do regarding anticoagulation and which sort of labs needed ordering as well PT/OT/Dispo status. A lot of the time, your upper levels will give you feedback about the organization/format of your plan+presentation. By emulating their style, you avoid this and hopefully feedback will focus more on your suggestions for the plan.
 
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Ismet

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Couple clarifying questions: when you started this rotation, did you start out by picking a few patients or did you start by picking 1 patient? If you pick up a patient on day 3 of their hospitalization, do you also follow them on day 4+? (you should)

I'm not in a surgical field, but now as a senior responsible for medical students, this is what I told our students last month:
For the first week, they each follow 1 patient. They should read all the notes and ask their intern or senior if they need any clarification on the plan or what's going on. For the 2nd week, they'll follow 2. And onward until the 4th week, if there are enough patients, each student should be following 3-4. They present the patients on rounds. They write notes on the patients and write discharge summaries and get feedback on their notes.

The BEST thing a student can do in my mind is ask questions. Not sure about what's going on with the patient? Ask the intern or senior. If you have to present the patient on rounds and you're not sure of the plan, ask the intern/senior if you can run through the assessment/plan quickly with them before rounds. It's the end of the day and you have no idea what happened with your patient? Ask!!! I once had a month of students who appeared like they couldn't care less about the rotation because they never asked us about anything regarding the patients. Then they present the wrong thing on rounds and we have to correct that, it all could have been prevented if they just discussed the plan with their residents beforehand. Most residents won't bite, and even if they do, that's their issue and not yours. You're there to learn, and part of their job is to teach you.

Also, try picking up new patients and following the progression of their stay and the decisions are made. Unless we're really short on patients or there's interesting pathology/workup, I usually don't assign students to patients who have been there forever. If you have the choice between someone who came in yesterday or someone who's been there 5 days, go for the new one and learn the workup from the beginning, following them every day until discharge.
 
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Jabbed

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Especially for post-op patients, the most important question that you need to ask yourself every day is: why are they still here?

It's great that you know the EBL of the surgery that occurred 5 days ago and their entire post-operative course, but for most presentations and management decisions you really need to key in on what needs to happen in the next 24-48 hours in order to get the patient on his or her way to home/rehab/placement. Is their pain controlled? Are they ambulatory? Are they advancing their diet? Do they have an AKI? Do they have any post-op complications that require further intervention? Do we need imaging to further clarify these complications? Are there social considerations for placement?

Most students can and will nail H&Ps but flounder with the basic "what do we do next?" in a practical sense. If you can't find anything that's keeping the patient in the hospital, say it in your presentation. Even if you're wrong, the feedback that you'll get will be infinitely more useful as it will directly identify your gap in knowledge/clinical acumen (i.e., "Well MedStudent, as much as I would like to send Ms. Smith home, we can't because she still has active xyz complication and requires abc intervention")
 

Syncrohnize

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Especially for post-op patients, the most important question that you need to ask yourself every day is: why are they still here?

It's great that you know the EBL of the surgery that occurred 5 days ago and their entire post-operative course, but for most presentations and management decisions you really need to key in on what needs to happen in the next 24-48 hours in order to get the patient on his or her way to home/rehab/placement. Is their pain controlled? Are they ambulatory? Are they advancing their diet? Do they have an AKI? Do they have any post-op complications that require further intervention? Do we need imaging to further clarify these complications? Are there social considerations for placement?

Most students can and will nail H&Ps but flounder with the basic "what do we do next?" in a practical sense. If you can't find anything that's keeping the patient in the hospital, say it in your presentation. Even if you're wrong, the feedback that you'll get will be infinitely more useful as it will directly identify your gap in knowledge/clinical acumen (i.e., "Well MedStudent, as much as I would like to send Ms. Smith home, we can't because she still has active xyz complication and requires abc intervention")
Not to be understated. If you ask this, you'll magically find the plan on surgery.
 
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Especially for post-op patients, the most important question that you need to ask yourself every day is: why are they still here?

It's great that you know the EBL of the surgery that occurred 5 days ago and their entire post-operative course, but for most presentations and management decisions you really need to key in on what needs to happen in the next 24-48 hours in order to get the patient on his or her way to home/rehab/placement. Is their pain controlled? Are they ambulatory? Are they advancing their diet? Do they have an AKI? Do they have any post-op complications that require further intervention? Do we need imaging to further clarify these complications? Are there social considerations for placement?

Most students can and will nail H&Ps but flounder with the basic "what do we do next?" in a practical sense. If you can't find anything that's keeping the patient in the hospital, say it in your presentation. Even if you're wrong, the feedback that you'll get will be infinitely more useful as it will directly identify your gap in knowledge/clinical acumen (i.e., "Well MedStudent, as much as I would like to send Ms. Smith home, we can't because she still has active xyz complication and requires abc intervention")
This, absolutely.


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operaman

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Agree 110% with asking why they've are still in the hospital. Works magic on surgery but also very important on all rotations. It's still a question I ask when I'm getting signout before taking call on patients I don't know.

OP your overall struggle is exactly what you should be having. It will continue and should continue on through your residency. It will get easier with time, especially as a resident when you start getting all the pages and following everyone every day for a long time. You'll start to see patterns and you'll know where to quickly look for information. As you progress, you will develop an instinct for where each person is on their overall trajectory and what needs to happen to move them along.
 

HooliganSnail

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Every morning at 4 am, I look at my surgery team's patient list and pick a few to follow. I dread patients who have been in the hospital for a 5 or more days, because when I read in their documentation since admission what has been done, I feel very overwhelmed. Reading every progress note and trying to figure out what has been done for the patient and what problems they have since admission is very difficult for me. I can barely keep up with understanding the history of one patient.

My seniors all tell me I need to be an expert on my patients. Yet, reading about one patient is hard for me. Also, no one calls me about what has been done for the patient throughout the day since I am the student, so I never know what is going on with the patient. All I depend on is reading the charts and progress notes. I am confident at examining the patient and developing my own assessments and plans at this stage, but how can I do them if I don't know everything that has been done for the patient so far? It takes me 2 hours to go through a patient's chart and develop a plan.

Can someone please help me? I am afraid I will drown on my Sub-i and and eventually intern year if I can't handle understanding multiple patients' hospital courses. I am struggling a lot.

This is a typical anxiety thing for students this time of year. The problem that you are having is that you don't yet have enough experience to understand what matters with every patient. This means that in order to be prepared to round, you are forced to write down every minute detail, even though 94% is irrelevent, because you don't know what questions will be asked.

It is an anxious time. It will pass.
 

scpod

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One other idea... Get used to working with the nurses. Humble yourself. A good nurse knows who is following the patient and the generalized plan. If they are going back for a repeat CT because of persistent leukocytosis, fever and increased pain, chances are that they will know. They have to discuss the history and plan with their replacement at every shift change. Thye might not remeber it all, but they usually keep the details written down somewhere. In the real world I use them every day. I might not get a reply to my text from the nephrologist in a timely manner, but the nurse will know that s/he has already rounded and plans another day of dialysis prior to discharge.
 
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