Question For Hospitalists: Real-world vs. Training in Medicine

[Redpancreas]

I’m still in training, but sometimes I wonder what hospitalists working felt they were not prepared for coming out of training (if anything).

Part of me worries I’m going to be expected to write a million H&Ps if I have to do hospitalist years especially if I do nights. I’m worried because I’m at a place that doesn’t require more than 8 H&Ps per shift and I usually take my time listening to the patient’s stories, calling families for history, and writing A&Ps in prose etc. but I don’t know how sustainable that is.

Also, what are some pet peeves you see residents doing or things you roll your eyes at (not when you’re on the teaching service, but when you’re alone as a hospitalist and see a resident do)? What do you think residents (including past yourself) underestimate about your current job?

Thanks!

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[Redpancreas]

Bump…thought this was a good question and would give me some perspective at least. Maybe most of you are academic and don’t have this issue.

 

[NITRAS]

Resident notes are too long and have too much fluff. All I really care about is stuff that will effect my decisions, billing, and medico-legal.

 

[gutonc]

I'm not a hospitalist, but this advice should be universal.

Your notes should allow your coders/billers to do their job, and you and your colleagues to manage patients. That's it. You no longer have to write a paragraph in your A/P that explains to your attending that you understand the physiology of decompensated heart failure. You just have to justify the 73rd echo they've gotten this year, the cards consult, Foley and lasix gtt. That's it. Once you've tucked them in, literally nobody (except maybe SW) GAF about how they got there, and anybody that does care, can ask themselves.

Also, if you're not writing SAPO (or APSO, but I have my own issues with those) notes already, now is the time to start. If somebody has to scroll down even one line to figure out what you're doing for the patient, you've failed. Write better notes.

I've actually gotten rid of almost all of the note bloat with "Labs, imaging, meds and vitals reviewed". That's all you need. It's in the chart, it doesn't need to be in your note (most of the time).

 

[Redpancreas]

I'm not a hospitalist, but this advice should be universal.

Your notes should allow your coders/billers to do their job, and you and your colleagues to manage patients. That's it. You no longer have to write a paragraph in your A/P that explains to your attending that you understand the physiology of decompensated heart failure. You just have to justify the 73rd echo they've gotten this year, the cards consult, Foley and lasix gtt. That's it. Once you've tucked them in, literally nobody (except maybe SW) GAF about how they got there, and anybody that does care, can ask themselves.

Also, if you're not writing SAPO (or APSO, but I have my own issues with those) notes already, now is the time to start. If somebody has to scroll down even one line to figure out what you're doing for the patient, you've failed. Write better notes.

I've actually gotten rid of almost all of the note bloat with "Labs, imaging, meds and vitals reviewed". That's all you need. It's in the chart, it doesn't need to be in your note (most of the time).

This is what I was looking for. Guilty as charged.

 

[Redpancreas]

I'm not a hospitalist, but this advice should be universal.

Your notes should allow your coders/billers to do their job, and you and your colleagues to manage patients. That's it. You no longer have to write a paragraph in your A/P that explains to your attending that you understand the physiology of decompensated heart failure. You just have to justify the 73rd echo they've gotten this year, the cards consult, Foley and lasix gtt. That's it. Once you've tucked them in, literally nobody (except maybe SW) GAF about how they got there, and anybody that does care, can ask themselves.

Also, if you're not writing SAPO (or APSO, but I have my own issues with those) notes already, now is the time to start. If somebody has to scroll down even one line to figure out what you're doing for the patient, you've failed. Write better notes.

I've actually gotten rid of almost all of the note bloat with "Labs, imaging, meds and vitals reviewed". That's all you need. It's in the chart, it doesn't need to be in your note (most of the time).

I keep the labs in my note because I present off my note via my phone during rounds. Maybe others do the same.

I'll try to work on eliminating the fluff and limiting my ICD-10 queries. That said, I truly believe each patient's case is different. I've been looking over attendings addendums and what billing codes they check and notice they write a lot but then backspace a lot but only write 1-2 lines of information by the end of it. I think the lesson is that less is more, but what's there should be accurate and precise (in relation to labs and other team's observations).

 

[MedicineZ0Z]

Biggest difference is all the random nonsense fluff in resident notes. Academic attendings also feed that pattern.

 

[tantacles]

I agree with @gutonc but just keep in mind that each ship is different. I occasionally got criticized as a nocturnist because my notes often didn’t include functional status or living situation, two things that can definitely be addressed in the am by someone else who isn’t busy doing actual medical things.

However, is what the folks in my shop (ok, really just the chief) apparently felt was important.

 

[NewYorkDoctors]

Also don’t write on the ekg . Some do it out of habit . Some do it to circle a finding as if to say “look I paid attention !” I just find it unnecessary if you mention your findings in your note (briefly ) and may put a target on your back if something isn’t followed up by the day team down the line

 

[neoexile]

I would just write the management (maybe scores as well). You don't need to rewrite the entire pathophysiology in the note. Just write the management so that if someone needs to cover your patient during a rapid, they know what is going on.

 

[Siggy]

A/P that explains to your attending that you understand the physiology of decompensated heart failure. You just have to justify the 73rd echo they've gotten this year, the cards consult, Foley and lasix gtt.

1. Decompensated heart failure (acute on chronic systolic/diastolic heart failure)
-Admit to ICU
-BiPAP PRN
-Lasix
-Continue core measures
-Nitro infusion
-Check echo
-Trend troponins

2. HTN emergency
-Nitro infusion

3. Acute hypoxic respiratory failure
-Management per #1.

4. Cardiorenal syndrome
-Management per #1.

CCT exclusive of procedures: 45 minutes. (I have a longer Dragon auto text for crit care time actually).

 

[MedicineZ0Z]

1. Decompensated heart failure (acute on chronic systolic/diastolic heart failure)
-Admit to ICU
-BiPAP PRN
-Lasix
-Continue core measures
-Nitro infusion
-Check echo
-Trend troponins

2. HTN emergency
-Nitro infusion

3. Acute hypoxic respiratory failure
-Management per #1.

4. Cardiorenal syndrome
-Management per #1.

CCT exclusive of procedures: 45 minutes. (I have a longer Dragon auto text for crit care time actually).

Meanwhile the resident note will have detailed dosages, lab results and the last echo result all mixed into the A/P and hence it's impossible to actually know what's currently happening.
Like if I want the dose, I'll just look at the MAR. I'm not trusting the outdated dose anyways. And I'm looking at results if I want the echo/labs etc.

 

[DrMetal]

Attending notes are full of fluff and crap too. It's just auto-populated by epic.

 

[Siggy]

Meanwhile the resident note will have detailed dosages, lab results and the last echo result all mixed into the A/P and hence it's impossible to actually know what's currently happening.
Like if I want the dose, I'll just look at the MAR. I'm not trusting the outdated dose anyways. And I'm looking at results if I want the echo/labs etc.

...and that's why I generally don't put post op day (I'll put the date instead) and limit/avoid dosing. I don't want to have to double check to make sure that non one has changed anything (including pharmacy renal adjusting meds) unless it actually matters.

Maybe I'll throw a quick EF in for heart failure... but copying and pasting imaging findings? I refused to do that even as a resident. You want imaging results, go look at the CT scan read.

 

[Kaustikos]

Meanwhile the resident note will have detailed dosages, lab results and the last echo result all mixed into the A/P and hence it's impossible to actually know what's currently happening.
Like if I want the dose, I'll just look at the MAR. I'm not trusting the outdated dose anyways. And I'm looking at results if I want the echo/labs etc.

So,
The reason I absolutely HAVE to do dosing is because Attendings/Residents call asking what dose and frequency, oral vs iv. I get what everyone's saying, but real world medicine has doctors not looking **** up or remembering and bothering the consultants.
Also, it's not just residents that do this.

...and that's why I generally don't put post op day (I'll put the date instead) and limit/avoid dosing. I don't want to have to double check to make sure that non one has changed anything (including pharmacy renal adjusting meds) unless it actually matters.

Maybe I'll throw a quick EF in for heart failure... but copying and pasting imaging findings? I refused to do that even as a resident. You want imaging results, go look at the CT scan read.

I don't copy/paste. I only include the pertinent imaging findings. Like, if I'm looking for an intra-abdominal abscess and there isn't one...I'm not going to include the uterine fibroids.

 

[Kaustikos]

Attending notes are full of fluff and crap too. It's just auto-populated by epic.

I had to make my own template because good ****ing lord the auto-populated information is just horrendous. Therapeutic activity? No thank you.

 

[Redpancreas]

Meanwhile the resident note will have detailed dosages, lab results and the last echo result all mixed into the A/P and hence it's impossible to actually know what's currently happening.
Like if I want the dose, I'll just look at the MAR. I'm not trusting the outdated dose anyways. And I'm looking at results if I want the echo/labs etc.

I need to stop doing this. I'm a big believer in the "deal with it once" strategy.