Noob attending questions for the experienced

[goldsummer]

Some questions for more experienced people. Answer some of them or all, whatever input you have is appreciated:


1) When you get a random abnormal lab on asymptomatic patient (ex: ALT slightly high, WBC slightly high) do you always repeat it/work it up? Or just wait til follow up and address it then with routine labs? I see these and think im missing something and am gonna get sued unless i do a million dollar workup.

2) How do you notify patient about labs, Call them/letter/email? Do you only notify when its abnormal labs requiring a change (ex: Vit D low, take supplementation) or do you notify them about normal labs as well?

3) On my first day a patient new to me had a form about disability due to agoraphobia and needed a doc's signature. Said she had to have it that day. Is this a common thing to happen? Whats your approach to something like this? Can we lose our license over something like this if we just sign it willy-nilly, or refuse to sign it for any reason?

4) Whats your routine for handling incoming messages throughout the day? Address them at the end of the day, during the day, end of the week?

5) Do you chart review the day before? My schedule is super light now and so i have the time to really dig deep into new patient's chart and see whats goin on with their chemo, specialists, etc it takes awhile but i feel super prepared when i enter the room for the visit... but when i start seeing like 20 patients a day... is that possible? how do you adequately review everything?


Its crazy how different everything feels once you get to attending status... Im double checking even basic things cause im worried ill miss something. I guess this is normal?

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[deleted87716]

1) When you get a random abnormal lab on asymptomatic patient (ex: ALT slightly high, WBC slightly high) do you always repeat it/work it up? Or just wait til follow up and address it then with routine labs? I see these and think im missing something and am gonna get sued unless i do a million dollar workup.

How abnormal is it? An isolated ALT that's only a few points above the upper limit of normal doesn't have to be worked up, especially in somebody who's asymptomatic. Make note of it, sure, and plan to repeat it in a few months to follow. You're going to see "abnormal" lab values all the time. Use your own judgement. You're the doctor.

2) How do you notify patient about labs, Call them/letter/email? Do you only notify when its abnormal labs requiring a change (ex: Vit D low, take supplementation) or do you notify them about normal labs as well?

If they have an upcoming appointment, I'll go over their labs with them at that time. If the labs are drawn during or after an appointment, my nurse contacts them unless it's something super-serious, then I will. All patients who have signed up for our patient portal get a copy of their labs automatically as soon as I sign off on them.

3) On my first day a patient new to me had a form about disability due to agoraphobia and needed a doc's signature. Said she had to have it that day. Is this a common thing to happen? Whats your approach to something like this? Can we lose our license over something like this if we just sign it willy-nilly, or refuse to sign it for any reason?

I can't imagine any scenario where you could actually lose your license for signing a form, assuming you weren't doing something illegal or fraudulent. That being said, nobody should "disabled" due to agoraphobia, as it's a treatable condition. I'd have referred them to psych, as I don't treat "disabling" psychiatric conditions. Never allow a patient to bully you into doing anything that doesn't make sense.

4) Whats your routine for handling incoming messages throughout the day? Address them at the end of the day, during the day, end of the week?

I answer stuff as it comes in during the day. Procrastination is pointless. There's always more work to do.

5) Do you chart review the day before? My schedule is super light now and so i have the time to really dig deep into new patient's chart and see whats goin on with their chemo, specialists, etc it takes awhile but i feel super prepared when i enter the room for the visit... but when i start seeing like 20 patients a day... is that possible? how do you adequately review everything?

I glance over stuff before I go into the room, but if anything has come in before the visit, I'll have already looked at it.

Its crazy how different everything feels once you get to attending status... Im double checking even basic things cause im worried ill miss something. I guess this is normal?

Yep.

 

[VA Hopeful Dr]

My approach is pretty much identical to Blue Dog's.

The AAFP has great articles on mildly elevated transaminases. leukocytosis, pretty much all of the common abnormal lab findings you'll likely run across. Read those and you should be in good shape.

 

[Bacchus]

I pretty much do what these guys have already said. Re: LFTs - Get ready to see a lot of fatty liver with no will to change.

 

[sloh]

no will to change.

I know a seasoned physician when I see one.

 

[Bacchus]

I know a seasoned physician when I see one.

“You have a fatty liver which can lead to cirrhosis. You need to eat better, lose weight and (likely need to take this statin.)”

meh, no thx man.

 

[B1GM0N3Y86]

1. As stated previously, depends on elevation. If it worsens, starts to become 2-3x ULN, can consider elevated LFT algorithm from up2date or afp. Also, look over meds that can cause this as well.

2. Nursing does all my notifications to pt on labs if its done after visit. If done prior a visit, address at the visit. Anything that you see handled prior, have them notified on particular lab prior and address it prior.

3. Disability forms for psych conditions go to psych. Hard NO to any pt that comes in with this complaint. Refer to psych for eval/mgt of condition and or forms to fill out.

4. Handle tasks messages as they come in, I'm a bit OCD about having a clean inbox

5. I will read 1 or 2 min about pt prior to office visit that day. Sometimes longer if complicated complex pt, other times not too much if they are here for skin tag removal, injection, etc...

Very different as attending. I'm in 2nd year now, attendinghood def will put some hair on your chest. If you haven't already, attendinghood will teach you how to say No to patients, admin, manipulating colleagues, etc....

Stand up, keep reading a lot, and always place the patient first, even if its not what they ask for or want. Just just place the patient first. You'll always be able to sleep at night if you keep them in mind and practice by the motto "do no harm" (or do as little harm as possible in the circumstance). You do this, you'll survive the 3rd hardest time in our lives... (1st year med school, 1st year residency, 1st yr attendinghood)

 

[Sushirolls]

Forgot one:
(1st year med school, 1st year residency, 1st yr attendinghood, 1st year in own private practice)

 

[B1GM0N3Y86]

Forgot one:
(1st year med school, 1st year residency, 1st yr attendinghood, 1st year in own private practice)

1yr owning practice prob most difficult year ever. Lol

I'll avoid it for now...

 

[d2305]

Abnormal paps have a tendency to get lost to follow up.

 

[Candidate2017]

Did you not deal with these things daily in your residency clinic?

 

[deleted87716]

Did you not deal with these things daily in your residency clinic?

Residents typically have a lot less (read: little to no) control over how their clinic functions.

 

[FrustratedFamDoc]

I'll echo what BD said in post #2. Abnormal will be a multiple times a day occurrence if you're drawing labs on 25% of your patients for the day. How abnormal and what needs what depends on your judgement. Establish boundaries and expectations on day one. It will pay off in droves later on.

 

[Candidate2017]

Residents typically have a lot less (read: little to no) control over how their clinic functions.

Sure, residents have zero control over a clinic and things like disability paperwork policies. But I'm shocked how it's possible to get through a residency clinic in an outpatient specialty without figuring out how to notify about labs, how to chart review for clinic, how to handle incoming messages. Perhaps I'm just making an unfair comparison to psych, where a minimum of 12 straight months of carrying your own outpt panel is required.

 

[deleted87716]

Sure, residents have zero control over a clinic and things like disability paperwork policies. But I'm shocked how it's possible to get through a residency clinic in an outpatient specialty without figuring out how to notify about labs, how to chart review for clinic, how to handle incoming messages.

You learn it the way the residency clinic does it, which isn't necessarily the best way, or the way you'd want to do it in private practice.

 

[AMEHigh]

Sure, residents have zero control over a clinic and things like disability paperwork policies. But I'm shocked how it's possible to get through a residency clinic in an outpatient specialty without figuring out how to notify about labs, how to chart review for clinic, how to handle incoming messages. Perhaps I'm just making an unfair comparison to psych, where a minimum of 12 straight months of carrying your own outpt panel is required.

I think OP was just looking for advice as to how other people do it, not that they have never done it.

In FM you start carrying your own patient panel from the beginning of intern year. You don’t have as many sessions intern year in the outpatient clinic, they get increased pretty significantly in 2nd and 3rd year, but you do get that experience from day 1.

I’ve changed how I manage things like messages and lab notifications based on where I work and other factors. Never hurts to ask for advice how others do it especially if you’re just starting out and only have experience as a resident.

 

[goldsummer]

Thanks for the feedback guys. I have some more scenarios that I've come across and I'd like to see your input on:


1) Patient sees a specialist whose out-of-network. Their specialist plans to give an Rx for a medication (infusions q3months) but since out-of-network, wont be covered. The patient asks me if I will prescribe the medication, says the specialist will send me the details...

- For this one, I'm planning to say patient needs to get set up with a specialist within network to Rx the drug. At most, do a one time Rx to buy the patient 3 months until they establish with a specialist. My reasoning is: not familiar with the drug/sides, no experience in adjusting/modifying the drug when seeing patient for follow ups. How often do you come across this and whats your approach?



2) Patients you haven't yet seen asking for refills. I've had several times where a patient has an upcoming visit in 2 weeks or so and needs a refill on medication before I actually meet them.
- So far, I've generally filled the meds (fenofibrate, hydroxyzine, etc) I had one ask for opioid refill and did not do that one.



3) Chronic pain meds: whats your approach to this in general? Do you always do it, only select cases, always refer to pain management?

-My plan coming in was I'd provide short courses for acute cases only (something I was advised to do in residency). Nothing for chronic, long term use. So far I have not filled a single opioid, I refer to pain management when a patient is on chronic opioids for things like back pain. I worry about liability, and also I dont agree with using them for long-term use in most cases. But I still wonder, I being too conservative?


Thanks for being a resource to bounce ideas off of