how do you "know your patients?"

[jocg27]

I can understand and appreciate that one of the most important things for 3rd yr students to do is to know everything about their patients, every detail of their history, etc etc...Ideally, I'm told, they should know more about them than anyone on the team...etc etc

but I don't know... I find that I'm having a hard time doing this for some reason that I don't really understand. Even as I'm getting more comfortable with rotations in other ways, I don't really feel like I've figured out a particularly good way to organize myself yet. Patients all kind of blur together in my mind a little more than I'd like them too, and forget about keeping numbers - labs, i/o's etc straight. I forget past histories etc more than I'd like. All the stuff we should know, pretty much...

Has anyone figured out good ways to stay on top of these kinds of things? Am I just not paying close enough attention??!?!

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[mules05]

I can understand and appreciate that one of the most important things for 3rd yr students to do is to know everything about their patients, every detail of their history, etc etc...Ideally, I'm told, they should know more about them than anyone on the team...etc etc

but I don't know... I find that I'm having a hard time doing this for some reason that I don't really understand. Even as I'm getting more comfortable with rotations in other ways, I don't really feel like I've figured out a particularly good way to organize myself yet. Patients all kind of blur together in my mind a little more than I'd like them too, and forget about keeping numbers - labs, i/o's etc straight. I forget past histories etc more than I'd like. All the stuff we should know, pretty much...

Has anyone figured out good ways to stay on top of these kinds of things? Am I just not paying close enough attention??!?!

I carry index cards with info on my patients- pertinent history, lab values, stuff to do, etc. No one expects you to have lab values memorized, anyway.

 

[HamOnWholeWheat]

I feel your pain, as I had the same problem at first. Here's what you gotta do.

1) Make sure your initial interview is THOROUGH. Everything the patient tells you, do the full OPQRST if its at all relevant. This will take a while, but you have the time as an M3, as you shouldn't have more than a few patients.

2) Put it in chronological order and retell the story back to the patient, only focusing on the clinically important stuff. This will make it stick in your mind and the patient will correct you if you've mucked it up.

3) In the context of the story, memorize the relevant lab values (i.e. only the abnormals and pertinent normals) and explain them to yourself in the course of the story. It should all make sense and fit together once you've got the story straight. Example: Pt. was diagnosed with diabetes in 1995 and is poorly controlled (glucose = 500, urine = ketones, foot = missing), has Mono (heterophile = +), and has a gushing chest wound (bp = 90/50). When you attach them in your mind as details of the story, its easier to recall them on the spot.

So basically, be painfully thorough, put it in chronological order, tell the story back to them, and justify it to yourself with the labs. This works for me is because it forces me to not overlook things or make stupid mistakes.

BTW, for taking the history, I've found that just being thorough in addressing everything the patient says is better than following a checklist. I always screw up the checklist, or don't dig deep enough when I use it. If you just pick apart every single thing the patient says, it will all come out. Ex: I noticed I had a cough while watching the kids. Q: When was that? What was the cough like? What brought it on? Did you take something for it? How bout any other meds for anything else? Did the kids have the cough? For how long? Were they your kids? Do you all live together? Anyone else live there? Is it a house or apartment? Anyone smoke in the house? Do you have working smoke detectors? ... Doing it that way is more memorable to me than following the checklist.

Hope that helps,

HamOn

 

[AmoryBlaine]

1. You need a relatively amout of paper, chucking a copy of each days SOAP note into your pocket is not going to work.

2. You need to keep track of all pertinent daily in the same place. My system will be reproduced below, I just draw it out on a folded piece of paper.

3. Make check-boxes, they save your life.



Daily tracking system

9/7/07
24: here I add important stuff from the day before, I update this area on 9/6/07
S: brief discussion of pt complaints throughout the day i.e. "headache" or "pain controlled better"
O: vitals, lab stick figures
P: here is where I make my check boxes for 9/7/07. If we needed a CT, I make a check box and then call radiology. When the patient gets the CT I head down to the next day and fill in...
-------------------------------------------------------------------------
9/8/07
24: CT abdomen/pelvis
S:
O:
P:

I keep an updated Med list on the side of the page in the margin. Ditto for radiological studies. Ditto anything that is "long-term pending" i.e. a send-out lab test.

 

[Slitherin]

It helps organize all of the information, I put it on card stock and fold it so I dont need a clipboard. On the back I keep a current med list, and problem list. My current attending wants those two things primarily.

 

[PowderHound]

If you are able to write orders at your school (either in the computer or on paper), that is also really helpful for remebering a patient's complicated hospital course. I'm 10x more likely to remember "Oh, yeah, this patient has a urine culture pending and they got a renal ultrasound today" if I actually wrote the orders myself, called radiology, etc. I did medicine last rotation of 3rd year, and by then I was sort of the acting intern for my patients, and I found that the real intern appreciated me taking charge of the patient's I was assigned to...it was less work for her, and good for me because I remembered all the stuff I needed to about them, and learned to multi-task.

And I agree, check boxes rule!

 

[Kirksville]

I like your ideas of having these summary sheets in your pockets. I was planning on just filling out note cards on each patient, but this would obviously take far to long to make it worth the effort. Would some of you be willing to post an attachment of one of these sheets filled in so that I can see to what extent you are using them.

Much appreciated!

 

[Ypo.]

It helps organize all of the information, I put it on card stock and fold it so I dont need a clipboard. On the back I keep a current med list, and problem list. My current attending wants those two things primarily.

Wow, that is really nice and a lot less cumbersome than what I was using. What does MR, HD stand for? And what do you put for INFO?

 

[cbass1350]

I can understand and appreciate that one of the most important things for 3rd yr students to do is to know everything about their patients, every detail of their history, etc etc...Ideally, I'm told, they should know more about them than anyone on the team...etc etc

but I don't know... I find that I'm having a hard time doing this for some reason that I don't really understand. Even as I'm getting more comfortable with rotations in other ways, I don't really feel like I've figured out a particularly good way to organize myself yet. Patients all kind of blur together in my mind a little more than I'd like them too, and forget about keeping numbers - labs, i/o's etc straight. I forget past histories etc more than I'd like. All the stuff we should know, pretty much...

Has anyone figured out good ways to stay on top of these kinds of things? Am I just not paying close enough attention??!?!

It's not knowing 'everything' (obviously that's not possible). But knowing everything that is relevant top the chief complaint.

For example: If you have a 36 year old female with a possible acute appy, the relevant data include vitals, relevant history, physical exam, cbc/bmp/ua/hcg, and imaging (you can fit all that BS on one flash card). The fact that she is suffering from PTSD, has a left femoral rod, has an uncle with amyloidosis, likes cats, is allergic to french fries, is hyperreflexive on the left side, and has frequent headaches is irrelevant to the case.

 

[PeepshowJohnny]

Just make sure you don't "know them" in the Biblical sense.

 

[PeeWee137]

i go with the big, unlined index cards. then after i do their h+p i transfer the pertinent info onto the card with labs, meds, imaging etc. i also keep notes if consults were called and when, in case i get asked. i write everything by date, like 9/25: cardio called, increased toprol to 100mg, etc. that way it helps you remember to pay more attention to bp since you upped their meds. and dont forget their medical record # if you have an electronic system. everyone figures out a system that works for them though, it takes trial and error sometimes. i started out with pockets stuffed with h+p copies and notes, and it was ridiculous.

 

[Blade28]

All good tips.

I wish I had some of you as my med students. I've had a few outstanding ones...and LOTS of not-so-great ones.

 

[cbass1350]

Just make sure you don't "know them" in the Biblical sense.

 

[bjackrian]

The medfools site has some nifty organization sheets in their downloads section (http://www.medfools.com/downloads.php). They're helpful especially until you get a handle on what kind of information you need to write down and how you want to organize it. There are also pay options out there like Wassup Doc (you can google it, if you're interested). Anyway, I think that as a MS3, knowing what's happened with our patients and being able to be the source of information when the attending or resident asks for lab trends, old radiology results, medication changes, etc. is the best way to know the patient and contribute to the team and really makes you look good when it comes time for evaluations.

Of course, we should be working to develop diagnoses and plans too, but honestly, I don't think my A&P contributes much since (a) it's often wrong and (b) the intern/resident/attending will generally do their thing anyway. In other words, the A&P is good for my learning, but not really contributing to the team IMHO.

 

[Blade28]

Of course, we should be working to develop diagnoses and plans too, but honestly, I don't think my A&P contributes much since (a) it's often wrong and (b) the intern/resident/attending will generally do their thing anyway. In other words, the A&P is good for my learning, but not really contributing to the team IMHO.

This may be true, but this is really the most important part of the H&P, and the hardest to figure out (at least early on). Even early on in residency, many times you won't know the exact plan until your senior residents/fellows/attendings have discussed it.

The A/P format also depends on what service you're on.

*Medicine - usually in a problem-oriented format, where you address one issue at a time - e.g. hyponatremia, diabetes, HTN, etc.
*Surgery - either pre-op (what's left to be done before surgery?), post-op (what can we do today to get the patient one step closer to getting home?), or watchful waiting mode

Etc.

 

[Slitherin]

Wow, that is really nice and a lot less cumbersome than what I was using. What does MR, HD stand for? And what do you put for INFO?

HD=Hospital Day
MR=medical record #
Info=Where I obtained the history info, if not from the patient. Like Chart, relative, from patient with interpreter.

 

[bjackrian]

This may be true, but this is really the most important part of the H&P, and the hardest to figure out (at least early on). Even early on in residency, many times you won't know the exact plan until your senior residents/fellows/attendings have discussed it.

Definitely. I wasn't trying to say that I think the A/P is unimportant--I think it's very important, and it's actually the most fun part of my H&P to write. I just don't feel that as an M3 my A&P contributes much to the team. I do feel like I learn a lot from just about every one I write.

 

[Blade28]

Definitely. I wasn't trying to say that I think the A/P is unimportant--I think it's very important, and it's actually the most fun part of my H&P to write. I just don't feel that as an M3 my A&P contributes much to the team. I do feel like I learn a lot from just about every one I write.

You misunderstood me. I agreed that the A&P was important, and just pointed out that it's commonly difficult to complete as a med student and even as a junior resident.

I was agreeing with you. 🙂

 

[bjackrian]

You misunderstood me. I agreed that the A&P was important, and just pointed out that it's commonly difficult to complete as a med student and even as a junior resident.

I was agreeing with you. 🙂

Hehe--sorry. 😉

 

[nightowl]

bump

 

[Law2Doc]

This may be true, but this is really the most important part of the H&P, and the hardest to figure out (at least early on). Even early on in residency, many times you won't know the exact plan until your senior residents/fellows/attendings have discussed it.

Not sure why you bumped up this year old thread but as to Blade's above post, I agree. If you have an attending who reads your notes, it's safe to say that 90% of how you are going to be evaluated on these is in your A&P. Did you list out multiple ddx? Did you provide some discussion of why one is more likely than another? Did you address each system or problem? Do you have a plan as to what to do next? A&P and presenting are probably the key things you need to master in 3rd year, along with a smattering of physical exam and procedural stuff.

 

[jocg27]

I'm glad he bumped this thread actually...I am the OP, and wrote this ~1/4 into m3 year (after surgery and some of ob/gyn, both of which, in my experience, were kind of useless for learning this kind of practical day-to-day how to follow patients kind of stuff as an m3). And now I can say out of personal experience, for any new m3s just starting out who feel as I did above, it does get easier.

It's hard to give specific advice though, which is what I was looking for when I originally posted. There are some good thoughts on here, but the fact is, it's totally individual. Everyone needs to develop their own system; you may find it right away or you may not. The hospital's a pretty crazy place, and certainly not always logical, at least not to an outsider if you haven't spent much time there. So it's definitely hard to get a good sense of what's going on and how it all works. Try some of the H&P sheets and other stuff on this thread to stay organized. If you're having trouble with it you'll get the hang of it, but it will just be a matter of lots of trial and error. Medicine and peds are by far the two best times to work on these skills; you'll be surprised how much better you are at it afterwards than before.