How to be faster in 3rd year?

[TheNightingale]

I'm in my 2nd half of 3rd year and have recently become concerned that I'm too slow in my clinical duties. For example, right now it takes me about 30 minutes for a full H&P interview. I then usually need another 15-20 minutes to organize my thoughts and think about my assessment and plan before giving an oral presentation. It then takes me about an hour to write a full H&P note.

Recently I gave an absolutely atrocious HPI in my oral presentation because I ended up having no time to organize my thoughts after seeing a patient (and the patient happened to be a highly anxious, likely hypochondriac with circumstantial thinking and poor chronologic recall). It then took me an hour to write the patient up and I just left the hospital feeling really disappointed in myself.

I know I'm going to have to get faster because as an intern, I'll have 10x the work and 1/2 the time. But I didn't know if how I'm feeling now is common for a 3rd year. I should admit that am a bit of a perfectionist; I know people who are evaluating me are going to look at my notes and I want them to be decent. And I like to try to explain my thinking in my notes because I feel that's my job as a medical student. But perhaps I need to do less of this? In terms of oral presentations, I really have no idea how to be better/faster. Right now, I take a skeleton template of an H&P into patient rooms with me, write bullets as the patient tells me the story, and then afterwards I rewrite the subjective info I've gotten onto a fresh template to make things more organized (to help organize my thoughts, and as a reference if I get lost during presentations). I then quickly look whatever I might need to up to help me jot down bullets for my assessment and plan. I usually don't have time to "practice" my presentation before giving it.

Does anyone have any thoughts on what I'm doing wrong or tips on how to be faster at prepping for organized oral presentations and note-writing?

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[Celestia]

I think you are probably on the right track. Making the jump to being an intern, the biggest time saver I can see for you is not having to rewrite your H&P. So when you go in there with your skeleton, try to do your best to make it a finished product when you come out.

Depending on the complexity of the patient, 30 min for a new patient H&P is not bad.

Clearly the time to think will get less as you learn more and know how to manage a particular problem. That being said, 15 -20 min is not bad for an M3.

But taking an additional hour to write your H&P will kill you as an intern.

In terms of oral presentations, make a promise to yourself that you will always take the 1-5min to organize the HPI before presenting. Even if it means staying an extra minute in the room.

It occurs to me to ask you - what tasks are you performing during that hour you write the H&P? Can you break it down to find out how to make the process more efficient?

 

[mimelim]

I'm in my 2nd half of 3rd year and have recently become concerned that I'm too slow in my clinical duties. For example, right now it takes me about 30 minutes for a full H&P interview. I then usually need another 15-20 minutes to organize my thoughts and think about my assessment and plan before giving an oral presentation. It then takes me about an hour to write a full H&P note.

Recently I gave an absolutely atrocious HPI in my oral presentation because I ended up having no time to organize my thoughts after seeing a patient (and the patient happened to be a highly anxious, likely hypochondriac with circumstantial thinking and poor chronologic recall). It then took me an hour to write the patient up and I just left the hospital feeling really disappointed in myself.

I know I'm going to have to get faster because as an intern, I'll have 10x the work and 1/2 the time. But I didn't know if how I'm feeling now is common for a 3rd year. I should admit that am a bit of a perfectionist; I know people who are evaluating me are going to look at my notes and I want them to be decent. And I like to try to explain my thinking in my notes because I feel that's my job as a medical student. But perhaps I need to do less of this? In terms of oral presentations, I really have no idea how to be better/faster. Right now, I take a skeleton template of an H&P into patient rooms with me, write bullets as the patient tells me the story, and then afterwards I rewrite the subjective info I've gotten onto a fresh template to make things more organized (to help organize my thoughts, and as a reference if I get lost during presentations). I then quickly look whatever I might need to up to help me jot down bullets for my assessment and plan. I usually don't have time to "practice" my presentation before giving it.

Does anyone have any thoughts on what I'm doing wrong or tips on how to be faster at prepping for organized oral presentations and note-writing?

Practice, practice, practice. Everyone starts slow. The key is to not shy away from doing them just because you aren't good at them. I'm not sure what you mean by "explain my thinking". The best way to learn is to simply read other's notes and emulate. Always keep in the back of your mind that many physicians write terrible notes and that just because someone else does it doesn't mean that YOU should do it. But, having someone to template off of is a strong starting point.

 

[alpinism]

With time you'll learn that half the H&P questions you're asking now are useless and won't change management.

Start practicing doing a more focused H&P.

 

[URHere]

With time you'll learn that half the H&P questions you're asking now are useless and won't change management.

This. With time you should be able to go through your differential/assessment while you're in the room with your patient. Listen to them, think about your top 2-3 diagnoses and ask targeted questions relevant to those things. Of course don't leave out things like PMHx or SocHx, but always think about why you're asking the questions that you are. Then when you leave the room, you can jump straight to "sounds most consistent with X, would treat with Y. Also consider A, B, and C."

 

[DrBowtie]

Spend more time on chart review before seeing the patient. It's easier to rattle off their PMHx, Allergies, PSHx, Meds, etc to them and have them confirm or add than have them recall from scratch.

Cut your ROS and Physical down to problem focused. Don't waste tons of time discussing stable problems in your A&P.

 

[J ROD]

I have a built in list I run once I hear the complaint. It may be good for you to get a book like Step 2 CS and go through their workups so you know what to ask when you see those kinds of patients.

Also, it is hard to explain but you can get most of your physical findings in a few minutes. Also, I start working on some of the physical while asking questions still. Saves time.

And you get better as you go. You just have to get your routine. Especially on the ROS. I used to get bogged down there.

And remember you are conducting the interview. Don't let the patient run it. Cut them off and redirect them back to what brought them in. If they have several complaints, say we can cover maybe 2 or 3 of these today and you will have to come back for the rest. What can I do to help you the most today right now? You all know those pan symptom patients. lol

 

[Celestia]

Question - do you all think 30 min is reasonable amount of time to do H&P for an M3?

I sort of feel that amount of time is not that bad.

 

[J ROD]

Are you talking about writing the note. I think the Plan could take that long.

Hell, I do basically a whole H&P in the ED right now in under in 10 min. A more focused Physical but still many components.

 

[Celestia]

I'm just trying to think about being an m3- and to me the 30 min with the patient didn't sound so bad - as long as the note is pretty much done when they walk out. That's as much as a working internist will get to evaluate a new outpatient.

I think it also depends on how complex the patient is. somehow I envisioned the OP on some medicine ward working up patients with 30 meds and complex histories, then doing their formal ddx mgmt plan in their write up over the hour but maybe I am wrong.

 

[cbrons]

The key is to buy a book like this and carry it around with you

Under a given chief complaint, look it up and ask all the relevant questions.

Then incorporate the answers to those questions into your presentation.

Also do not routinely report everything about their family history, social history, etc. Do not go through each step of the exam, just say the parts that were abnormal or at the very most the parts that were normal that are relevant (i.e. abdominal pain -> say no rebound, rigidity, or guarding). Most attendings don't pay attention during M3 presentations because there isn't anything of relevance being said.

 

[cbrons]

Question - do you all think 30 min is reasonable amount of time to do H&P for an M3?

I sort of feel that amount of time is not that bad.

To do everything including writing the note? Or just the examination part?

If your actual history-taking and exam takes 30 minutes that is pretty long IMO. Why would you need that amount of time for most patients? I guess ones that are ultra complex, sure. But in that case, you can save a lot of time by just reviewing their chart and then going over with them only the stuff that is new and maybe quickly confirming the old stuff.

Although there is one girl I know of who would literally spend 2 hours in a patient's room taking a history and doing the exam, and then when she presented she didn't have any information that was relevant, just info about various family or social issues.

 

[Psai]

To do everything including writing the note? Or just the examination part?

If your actual history-taking and exam takes 30 minutes that is pretty long IMO. Why would you need that amount of time for most patients? I guess ones that are ultra complex, sure. But in that case, you can save a lot of time by just reviewing their chart and then going over with them only the stuff that is new and maybe quickly confirming the old stuff.

Although there is one girl I know of who would literally spend 2 hours in a patient's room taking a history and doing the exam, and then when she presented she didn't have any information that was relevant, just info about various family or social issues.

Oh god...

Op, it's just something that takes practice and you're at the right spot for your level. The best thing is to be organized. I used to carry around one of those template sheets from medfools until I was very comfortable with the history and physical. Just write down the important details and you'll be better at presenting. A lot of people seem to read their lengthy notes which is incredibly boring and a waste of time. When you present from memory, you filter out a lot of extraneous stuff and if something is relevant, you'll be asked about it.

If someone has chest pain you should think ok well the chest has the heart, lungs, esophagus, muscle, ribs, skin, what are the things that I'm most worried about like mi, dissection, tension pneumo, pe, etc. and you tailor your h&p based on that. You'll ask about previous cardiac history, risk factors, recent travel, malignancy, surgery to change the order of what you think is most likely. So you'll have a template to present because you are already organized and not trying to organize afterwards. This helps you be more focused as well.

When you present, just be like the chief complaint is chest pain of 1 day duration. Hpi was 55 year old female with relevant past history, who presents with relevant history. Relevant rest of history including social and family. Pertinent positives and negatives on ros only. Vitals, pertinent exam findings. My assessment is likely atypical chest pain but also on the differential are these things because reasons. My plan is basic labs, trops, pa and lateral xray, ekg, whatever. I would like to give these meds for the chest pain. Short and sweet so they get all the relevant info but don't get so bored that they start tuning you out

 

[J ROD]

it is an acquired skill

 

[Doctor4Life1769]

Adderall.

Kidding...

 

[Doctor4Life1769]

I'm in my 2nd half of 3rd year and have recently become concerned that I'm too slow in my clinical duties. For example, right now it takes me about 30 minutes for a full H&P interview. I then usually need another 15-20 minutes to organize my thoughts and think about my assessment and plan before giving an oral presentation. It then takes me about an hour to write a full H&P note.

Recently I gave an absolutely atrocious HPI in my oral presentation because I ended up having no time to organize my thoughts after seeing a patient (and the patient happened to be a highly anxious, likely hypochondriac with circumstantial thinking and poor chronologic recall). It then took me an hour to write the patient up and I just left the hospital feeling really disappointed in myself.

I know I'm going to have to get faster because as an intern, I'll have 10x the work and 1/2 the time. But I didn't know if how I'm feeling now is common for a 3rd year. I should admit that am a bit of a perfectionist; I know people who are evaluating me are going to look at my notes and I want them to be decent. And I like to try to explain my thinking in my notes because I feel that's my job as a medical student. But perhaps I need to do less of this? In terms of oral presentations, I really have no idea how to be better/faster. Right now, I take a skeleton template of an H&P into patient rooms with me, write bullets as the patient tells me the story, and then afterwards I rewrite the subjective info I've gotten onto a fresh template to make things more organized (to help organize my thoughts, and as a reference if I get lost during presentations). I then quickly look whatever I might need to up to help me jot down bullets for my assessment and plan. I usually don't have time to "practice" my presentation before giving it.

Does anyone have any thoughts on what I'm doing wrong or tips on how to be faster at prepping for organized oral presentations and note-writing?

You're a third year.
Of course it's common. You have 1.5 more years of being a Med student and even the first several months of intern year to get at where you need to be. Don't sweat it, nail down the fundamentals and work with your intern/resident. With time you will be fine.

 

[alpinism]

To do everything including writing the note? Or just the examination part?

If your actual history-taking and exam takes 30 minutes that is pretty long IMO. Why would you need that amount of time for most patients? I guess ones that are ultra complex, sure. But in that case, you can save a lot of time by just reviewing their chart and then going over with them only the stuff that is new and maybe quickly confirming the old stuff.

Although there is one girl I know of who would literally spend 2 hours in a patient's room taking a history and doing the exam, and then when she presented she didn't have any information that was relevant, just info about various family or social issues.

Agreed.

Even on the wards you should't be spending more than 20min MAX with a new patient. 15 min is usually more than enough time.

That being said, as an M3 no one is expecting you to be that fast. That's why you're doing rotations, to practice and get faster.

2 hours is ridiculous.

 

[2021Doctor]

The key is to buy a book like this and carry it around with you

Under a given chief complaint, look it up and ask all the relevant questions.

Then incorporate the answers to those questions into your presentation.

Also do not routinely report everything about their family history, social history, etc. Do not go through each step of the exam, just say the parts that were abnormal or at the very most the parts that were normal that are relevant (i.e. abdominal pain -> say no rebound, rigidity, or guarding). Most attendings don't pay attention during M3 presentations because there isn't anything of relevance being said.

I think that this is the best advice on the thread.
Every one of Dr. Paul Chan's books is a gem imo.

 

[takeurmeds02]

I'm so glad I scribed...I'm basically paid to write H&Ps

 

[TheNightingale]

Thank you EVERYONE for the tips. Reading them over, it seems like a few of the biggest things I could do to help myself are to 1) Not have to rewrite anything, 2) Do a thorough chart review for basic stuff like meds, social hx, etc and just confirm with pts, 3) Ignore irrelevant PMH, etc (sometimes I don't always realize something is irrelevant), and 4) Try to have a running ddx in my head as I conduct the H&P. I'll admit the last one is tough for me right now because it just seems to take a lot of the ol' brainpower and I might not always think of everything that should be on the differential.

It occurs to me to ask you - what tasks are you performing during that hour you write the H&P? Can you break it down to find out how to make the process more efficient?

I'm not sure what you mean by "explain my thinking". The best way to learn is to simply read other's notes and emulate.

I'm just trying to think about being an m3- and to me the 30 min with the patient didn't sound so bad - as long as the note is pretty much done when they walk out. That's as much as a working internist will get to evaluate a new outpatient.

I think it also depends on how complex the patient is. somehow I envisioned the OP on some medicine ward working up patients with 30 meds and complex histories, then doing their formal ddx mgmt plan in their write up over the hour but maybe I am wrong.

To clarify some of the points asked about above, when I write my note, I usually have to transfer everything I have jotted down on paper from my interview into eRecord. I use templates (that I made myself) to try to make my life easier which allows me to basically not have to write out everything, but I make modifications to my standard ROS, physical exam section, and prepopulated labs as needed. Where I spend the majority of my time is writing my HPI, and writing my assessment and plan. I try to make my HPI a clear story of what happened to paint the picture for what I'm going to say in my assessment and plan. Sometimes this is easy, and sometimes it takes me a bit of time to make sense of how best to organize the patient's story. It's possible I'm just obsessing too much over including every detail so I think I'll try to be more concise here.

After the HPI I review the chart to make sure I've included all the relevant labs and imaging, etc. Then I do my assessment and plan and this is where things can take awhile for me. I was told that this is the MOST important part of how my thinking as a med student is evaluated so I always feel a little nervous when I do this because I want to be thorough. But maybe I should focus more on being fast? When I write my assessment I usually say, "this is my top diagnosis and these are other things on the differential. These top dx'es are most likely because xyz. These other dx'es are less likely because xyz." I used to justify my plan alot more in the beginning (like saying "plavix and ASA for dual-antiplatelet therapy post-PCI" and "recommend EEG to r/o seizure activity" instead of just "recommend EEG"). I don't really know if attendings/residents like this justification or if I can leave it out.

And to clarify on length of time with the patient, I can pretty much always be out of the room in 30 minutes, even if the patient was super complex. At my teaching hospital, there are a lot of complicated patients but I try to redirect them as best I can when our interview gets derailed and I try my best to ask a focused ROS. If am able to use a computer WHILE conducting the interview then I can fill out my note template partially which lets me write my note faster later.

What REALLY screws me up, is if a resident comes into the room partway through my exam. I defer to them, obviously, but then I'm often trapped in the room while they repeat much of what I just did. This happened on Friday and I ended up spending over an hour in a pt room because the resident spent over an hour in there, only he was writing his note while doing his interview. I accept that there really is no solution for this so I just accept that it's going to look like I was a super slow med student whenever this happens.

 

[Celestia]

In terms of what is relevant and irrelevant- having a reference in your pocket - digital or paper - is key. Key for relevant PMH, ROS, SHx, meds, and especially for A/P. If it is in your pocket, you can refer to it when the resident comes in. You can also refer to it before your chart review and before your H&P.

If appropriate, you can always excuse yourself to a computer outside the room when the resident is doing the H&P.

 

[Psai]

I use an app called diagnosaurus, it's really helpful to be thorough in your differential