How do I get better at managing complex patients with multiple problems?

[Shark7500]

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I'm an MS-3 on my third rotation. I find myself quickly getting overwhelmed with patients who have multiple co-morbidities, multiple problems, etc. I don't think I have problem with collecting a good history. The issue is more with synthesizing the information I get and developing a differential, prioritizing my differential in order of likelihood, thinking about next steps, etc. How do I get better at this? I have medicine next and I really want to get at least a little bit better by then. Thank you!

EDIT: I'm looking for specific tips / books / resources etc. that will help me "think more clinically" if that makes sense. I feel like I have the knowledge (did well on Step 1), but I'm not able to put it all together.

 

[DrBowtie]

I'm an MS-3 on my third rotation. I find myself quickly getting overwhelmed with patients who have multiple co-morbidities, multiple problems, etc. I don't think I have problem with collecting a good history. The issue is more with synthesizing the information I get and developing a differential, prioritizing my differential in order of likelihood, thinking about next steps, etc. How do I get better at this? I have medicine next and I really want to get at least a little bit better by then. Thank you!

EDIT: I'm looking for specific tips / books / resources etc. that will help me "think more clinically" if that makes sense. I feel like I have the knowledge (did well on Step 1), but I'm not able to put it all together.

How are you organizing your A/P?
The CCM folks basically organize by organ system which helps stay on top of everything.

 

[Redpancreas]

Only on my first rotation but was told to organize the Assessment by Organ System. Postoperative patients usually have multiple comorbities. For heme, we usually transfuse, for GU we try to get them to pee.

The contraindications come when you re-read your post. I mean after all isn't this what we're always being trained to do with tests. I mean, thing of your S/O as a step question and see what's wrong if anything.


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[operaman]

Well for one you're just at the starting gate and you're talking about one of the more difficult tasks in all of medicine, but props to you for wanting to get better at it. ICU rotations are fantastic for this -- you will feel like an idiot every single day but you'll get better. The above advice to organize your A&P by systems is money. I actually found it helpful to organize by systems but still in a problem/diagnosis-based format, so under each system you would list problems and their respective plans. Big pain in the arse but definitely helped me get better.

Furthermore, constantly work to figure out what the endpoint for a given patient might be. What is keeping them in the hospital? We have lots of people who are sick as snot sitting at home; why is this person sitting in your ICU? What needs to happen to move things forward?

Are there signs or symptoms that do not yet have a clear cut diagnosis? If so, then start thinking about physical exams, labs, and imaging that might help you make an actual diagnosis. This is something a few of my favorite attendings always made us do - voice a specific diagnosis. It's easy to go down the rabbit hole of treating numbers; force yourself to identify an actual diagnosis. This is one of the reasons the problem-based approach is helpful; it forces you to commit. Many of your attendings and residents will have seen some issues so commonly that the diagnoses are just assumed, but since you're not there yet you should try to spell it out and ask for help if you are stuck.

Look at everything they are getting/not getting and re-evaluate it each day. Do they still need those antibiotics? Are they ready for extubation? Should you start or restart anticoagulation? Can the foley be removed? Any home meds that could be restarted? Can any iv meds be changed to oral?

Once you start thinking and organizing things in this or some other way that works for you, the management decisions will start to become clearer and you'll inevitably find yourself with questions which will help direct your reading as well as your questions to your upper levels. Just stick with it and give it time knowing that this is hard. Remember that critical care medicine is a rather long fellowship!