Standardized patients...

[DermViser]

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Of course it helps for the patients with relevant complaints. But if your patient has knee pain, what's on your differential that makes you listen to their heart? Most primary care docs I've worked with listen to the heart and lungs regardless of what the patient is complaining about, but why?

Probably for reimbursement purposes i.e. having at least 8 ROS.

 

[pathologyDO]

Of course it helps for the patients with relevant complaints. But if your patient has knee pain, what's on your differential that makes you listen to their heart? Most primary care docs I've worked with listen to the heart and lungs regardless of what the patient is complaining about, but why?

Lets see.. knee pain. Could it be an inflammatory condition? If I took the time I could list enough differentials that cause both joint and heart pathology to make heart auscultation worth it. The PE, even the heart/lung auscultation, helps guide your diagnosis and can tip you off on early pathology, maybe even save someones life with a completely unrelated condition to their chief complaint.

 

[Ismet]

Probably for reimbursement purposes i.e. having at least 8 ROS.

Oh true. So dumb, but true.

 

[DermViser]

Oh true. So dumb, but true.

Yup. Pretty much if you don't have a certain number of Physical exam things checked off, or certain number of ROS checked off on an initial visit the third party doesn't have to reimburse you the full amount. I believe this is more for Medicare, but private insurance follows Medicare on many things: http://www.todayshospitalist.com/index.php?b=articles_read&cnt=463

 

[Ismet]

Lets see.. knee pain. Could it be an inflammatory condition? If I took the time I could list enough differentials that cause both joint and heart pathology to make heart auscultation worth it. The PE, even the heart/lung auscultation, helps guide your diagnosis and can tip you off on early pathology, maybe even save someones life with a completely unrelated condition to their chief complaint.

You could come up with a million things on your differential for any one complaint. That's why there's biostatistics and recommended vs non-recommended screening tests for things. Auscultation takes such little time to do and is harmless, so it's easy just to do it, but if the patient is asymptomatic from a cardio/pulmonary standpoint, what are you expecting to find? A murmur? If there are no symptoms it's likely not going to change your management.

 

[Ismet]

Yup. Pretty much if you don't have a certain number of Physical exam things checked off, or certain number of ROS checked off on an initial visit the third party doesn't have to reimburse you the full amount. I believe this is more for Medicare, but private insurance follows Medicare on many things: http://www.todayshospitalist.com/index.php?b=articles_read&cnt=463

Yeah learned that in my first outpatient rotation when my note apparently didn't have enough boxes checked. Also learned that "obesity" is not a visit that will get reimbursed, so a patient coming in to discuss weight gets billed as something else.

 

[alpinism]

Our school only gives us 10 minutes for H&P... You kids complaining about getting 15 minutes are spoiled.. (Pro Tip: Step 2 CS stations are also 15 minutes long)

Yeah but step 2 is a focused H&P, not complete.

If you're doing it correctly, a complete H&P from head to toe covering every organ system is hard to do in less than 15min.

 

[alpinism]

Probably for reimbursement purposes i.e. having at least 8 ROS.

Yep that too.

 

[TooMuchResearch]

I think so as well. Once you've done one at the bedside, with your upper level guiding you, then going back to the sim lab to do it would be much more helpful so you're almost replaying in your head what you did at the bedside in your head when you're doing it again in the sim lab. Of course some parts of it can't be reproduced.

Like the patient desperately trying to jab their carotid at your needle. And there is no one around to hold the head. Very difficult to simulate.

 

[qw098]

Question guys: I had a standardized patient today.. I took his pulses and as feedback he tells me:

"You said you could feel my pulses but I doubt you could because I couldn't feel them when you were pressing" WTFFFF??????? Him feeling his pulses when I press or not is irrelevant.. no? Also, for the first time ever I was able to feel a popliteal pulse..

 

[MrChance2]

Question guys: I had a standardized patient today.. I took his pulses and as feedback he tells me:

"You said you could feel my pulses but I doubt you could because I couldn't feel them when you were pressing" WTFFFF??????? Him feeling his pulses when I press or not is irrelevant.. no? Also, for the first time ever I was able to feel a popliteal pulse..

Standardized pts can be weird sometimes. I had one that I started asking her psych questions because I was sure she was pretending to have depression. Like every answer she gave to my basic HPI questions seemed painfully awful for her to say and I think her actual symptoms was like DM or HTN or something simple. She said no for all the psych stuff, I guess she wasn't pretending...

One in small groups was supposed to say stuff to be a difficult patient to the doctor. The student doctor handled it well then afterwards during the review when they are supposed to "break character" she was still unnecessarily mean and rude, right after she left the attending watching the session said "hmmm, I thought she was faking but I guess she was actually a bitch" Good times...

Also, according to this thread is seems like every medical school is pretty similar, I thought a lot of the quasi clinical testing format was somewhat specific to my school, interesting...

 

[Mad Jack]

No time limit for us, when I volunteer at our free clinic, takes me about 20 minutes.

You're already doing full H&Ps 4 months into your first year for actual people that require medical care? Crazy.

 

[Mad Jack]

I'm pretty sure we get 20 minutes for a standardized patient H&P. When doing our exams, we get 40 minutes to do two full physicals, along with ortho tests and whatever else need to go into the particular focused exams.

 

[EMDO2018]

You're already doing full H&Ps 4 months into your first year for actual people that require medical care? Crazy.

FREE CLINIC. You know what type of care poor people get? Med students who don't know ****.

 

[MedWonk]

To all MS1 & MS2 out there...

How many minutes your school gives you to do an H&P on a patient? I think 15 minutes is too low to do an H&P, take notes etc... They gave us 20 minutes at the beginning to take a history and now they add physical to it and drop the time to 15 minutes... I am getting slaughtered on them... I think it's impossible to do that in 15 minutes...

Our first "mini-OSCEs" are coming up, and we have to do 3 histories, each one with a 12 minute time limit. Basically, 7 cardinals, ROS, PMHx, family hx, and social hx.

FREE CLINIC. You know what type of care poor people get? Med students who don't know ****.

You guys don't have attendings or senior residents that you present to and see the patient themselves to make sure you didn't miss anything?

 

[Frazier]

For our "final" for MS1/MS2 H&P course, we have a standardized patient, camera rolling, and faculty sitting in a corner with a checklist.

The faculty member checks off the checklist if we do an item correctly, incorrectly, or not at all.

There are 140 items on the checklist by which we are graded.

The SP also offers feedback/score.

We have 45 minutes. Need over a 90% score to pass.

I don't care who it is -- no one is getting though that list (at full credit) in 15-20 minutes. Even if you did manage to perform every item, you would likely lose points due to rushing or interrupting the patient.

 

[Postictal Raiden]

We get 25mins for a full H&E OSCE. Then 9 mins afterward to do the SOAP.

The 25 mins is plenty, it can actually be done in 20 or less if you are really good, but 9 mins for doing the SOAP is not enough.

 

[Ismet]

Question guys: I had a standardized patient today.. I took his pulses and as feedback he tells me:

"You said you could feel my pulses but I doubt you could because I couldn't feel them when you were pressing" WTFFFF??????? Him feeling his pulses when I press or not is irrelevant.. no? Also, for the first time ever I was able to feel a popliteal pulse..

I had an SP tell me that I only checked one patellar reflex when I was 100% positive that I elicited both. Why the heck would I only check one?? I told him I was pretty sure I checked both and he was adamant that I didn't, so I just let it go. It's only one point of many, so whatever.

Also on one of our OSCEs, the instructions on the door specifically said to explain what you were doing and why (there was a doc in the room as well). So I did a full cardiac exam, explaining in detail what I was checking and why. when it was time for feedback, the SP just told me that it was awkward how I was telling him "what I was doing to him" as I was doing it. The doc in the room gave him a look like "wtf" and told me I did a great job. Most SPs my school employs are really great actors, I just don't think they get the educational part of it sometimes.

 

[DermViser]

Question guys: I had a standardized patient today.. I took his pulses and as feedback he tells me:

"You said you could feel my pulses but I doubt you could because I couldn't feel them when you were pressing" WTFFFF??????? Him feeling his pulses when I press or not is irrelevant.. no? Also, for the first time ever I was able to feel a popliteal pulse..

Yeah, there's a reason the attendings don't give a **** sometimes what the standardized patient thinks. That can be a good or bad thing.

 

[DermViser]

I had an SP tell me that I only checked one patellar reflex when I was 100% positive that I elicited both. Why the heck would I only check one?? I told him I was pretty sure I checked both and he was adamant that I didn't, so I just let it go. It's only one point of many, so whatever.

Also on one of our OSCEs, the instructions on the door specifically said to explain what you were doing and why (there was a doc in the room as well). So I did a full cardiac exam, explaining in detail what I was checking and why. when it was time for feedback, the SP just told me that it was awkward how I was telling him "what I was doing to him" as I was doing it. The doc in the room gave him a look like "wtf" and told me I did a great job. Most SPs my school employs are really great actors, I just don't think they get the educational part of it sometimes.

They do it bc it pays good money. Some might do it for a temporary power trip, but most do it as it pays very well. Attendings have discretion on which feedback is crap and which are good, and the encounters recorded so you can watch them later. Good that your attending said that to you.

 

[DermViser]

FREE CLINIC. You know what type of care poor people get? Med students who don't know ****.

Seriously, you have a chip on both shoulders on everything, it's getting quite tiresome. You're making Ark look good at this point.

 

[qw098]

FREE CLINIC. You know what type of care poor people get? Med students who don't know ****.

I'm confused bud... as an M1 you can volunteer at a free clinic? Where at? I'd like to try it out a couple of times as "practice"

 

[Ismet]

I'm confused bud... as an M1 you can volunteer at a free clinic? Where at? I'd like to try it out a couple of times as "practice"

We do it here as well. There's always a physician there, it's never just med students running the show.

 

[EMDO2018]

I'm confused bud... as an M1 you can volunteer at a free clinic? Where at? I'd like to try it out a couple of times as "practice"

Are you pre med? Yeah I don't know how they let M1s do H&Ps yet, we haven't had our first OSCE exam yet. Whats even crazier, they let M2s make sort of a "diagnosis" then the attending checks and if he like the M2s plan, then just signs off on it lol.

 

[sinombre]

Whats even crazier, they let M2s make sort of a "diagnosis" then the attending checks and if he like the M2s plan, then just signs off on it lol.

That's not crazy at all. You should definitely learn how to start organizing ddx in your head during second year.

 

[DermViser]

That's not crazy at all. You should definitely learn how to start organizing ddx in your head during second year.

Doesn't have as much shock value though. Much easier to say poor people only get medical care from medical students as he said (wrongly) before.

 

[Roxas]

We get 25mins for a full H&E OSCE. Then 9 mins afterward to do the SOAP.

The 25 mins is plenty, it can actually be done in 20 or less if you are really good, but 9 mins for doing the SOAP is not enough.

That sucks man, that's definitely not enough time (while you're learning at least). You're going to be a rock star at efficiency!

 

[qw098]

Are you pre med? Yeah I don't know how they let M1s do H&Ps yet, we haven't had our first OSCE exam yet. Whats even crazier, they let M2s make sort of a "diagnosis" then the attending checks and if he like the M2s plan, then just signs off on it lol.

M2 - added my status just now... that's pretty cool i've never heard of such a thing (prob they offer it at my school but im unaware of it)

Would you mind giving me more information of such a clinic? How it works, etcc..? Just for "poor" people? I'll ask admin here if they have something like that already in place and if not I'll try to organize one. Seems very very beneficial.. good way to practice

 

[Southplains]

M2 - added my status just now... that's pretty cool i've never heard of such a thing (prob they offer it at my school but im unaware of it)

Would you mind giving me more information of such a clinic? How it works, etcc..? Just for "poor" people? I'll ask admin here if they have something like that already in place and if not I'll try to organize one. Seems very very beneficial.. good way to practice

Ours consists of a couple FM attendings, some residents, elected MS2 officers plus 2-3 Ms2 volunteers and 2 MS1 volunteers. Volunteers have to sign up. Always some M3s and M4s too and I think they can just come. Clinic is open once a week and serves mostly homeless population, free of charge. Meals are provided as well.

 

[lisi326]

M2 - added my status just now... that's pretty cool i've never heard of such a thing (prob they offer it at my school but im unaware of it)

Would you mind giving me more information of such a clinic? How it works, etcc..? Just for "poor" people? I'll ask admin here if they have something like that already in place and if not I'll try to organize one. Seems very very beneficial.. good way to practice

having been on the board for my school's free clinic (which is on the small side compared to many med schools), it takes A LOT of time and effort and $$$ to run a free clinic. you need considerable support from many people in a med school to make it happen, as well as a large source of funding.... and somewhere to run it. consider it not small undertaking.

that being said, we do a weekly saturday clinic for uninsured people only. a preclin (usually M1) is paired with a M3/M4/MSTP in grad years and they go see the patient together with the preclin doing as much as they're comfortable doing. 1 attending/fellow volunteers per session - you staff the pt with him/her then go see the patient together again. our clinic is able to do a number of labs and give vaccines, place PPDs, give IM ceftriaxone etc in the clinic, and the pts can be given vouchers for meds if they can't afford any rx's they're given.

 

[Rirruto]

Don't forget to bust out that ruler to measure extent of diaphragmatic excursion. Especially on a patient with knee pain or something totally unrelated.

 

[Flamen04]

Yeah but step 2 is a focused H&P, not complete.

If you're doing it correctly, a complete H&P from head to toe covering every organ system is hard to do in less than 15min.

That's how real life is bud. If you're going to take more than an hour to work up every patient you see, you are going to run into problems..

 

[seminoma]

MS2 here. We have an OSCE with 5 patients. We are given a list of 10 possible patient complaints ahead of time (general stuff like infection, headache, abdominal pain, etc) and have 25 minutes per patient to do an h&p and formulate a differential.

 

[seminoma]

We get 25mins for a full H&E OSCE. Then 9 mins afterward to do the SOAP.

The 25 mins is plenty, it can actually be done in 20 or less if you are really good, but 9 mins for doing the SOAP is not enough.

25 minutes is not enough to do a full h&p... Maybe your school didn't teach you what a full h&p actually involves?

 

[Instatewaiter]

Sometimes I wonder if practicing physicians do half the things we do. Like, in the CMH we have to ask things like if they have functioning smoke alarms in their home and if they wear a helmet when riding a bike. In the physical, we have to do things like percussing for the upper/lower borders of the liver. I've never had the doctor do this to me... Is this just the kind of thing you do when it's relevant? We have to do it all when we're being graded, but I don't see myself ever spontaneously asking a patient if their smoke alarms are activated.

You add stuff if it's needed. If you can't feel the liver edge below the costal margin, you can be pretty confident the liver isnt enlarged. An then who cares if it's 9cm or 10 cm...

 

[Postictal Raiden]

25 minutes is not enough to do a full h&p... Maybe your school didn't teach you what a full h&p actually involves?

Our full H&P entails the following:

Subjective: CC, HPI, Allergies (food, contact, environment, meds), meds (dosage, route and frequency), past medical history (hospitalizations, immunizations, chronic illnesses, etc), past surgical history (surgeries, dates, outcomes), family history (parents, maternal and paternal grandparents, siblings), social history (occupation, diet, exercise, sexual, tobacco use, alcohol use, and elicit drug use), and the ROS (2 items from the following, general, head, eyes, ears, nose, throat, neck, cv, resp, gi, gu, psych, neuro, msk, and skin).

Objective: This includes the physical exam findings. Start off with taking the vitals. Then, move on to examine the main systems in the body from head to toe.

It's a lot to do in a limited period of time, especially if you also have to factor in time taken to address the humanism aspect of the interview (building a rapport, show sympathy, etc.). However, if you practice constantly, it can be done. The problem I'm having tho, is having to document all that in 9 minutes. I try to take notes as I'm going through the history taking, but it's hard to do so while maintaining eye contact and practice reflective listening.

 

[seminoma]

Our full H&P entails the following:

Subjective: CC, HPI, Allergies (food, contact, environment, meds), meds (dosage, route and frequency), past medical history (hospitalizations, immunizations, chronic illnesses, etc), past surgical history (surgeries, dates, outcomes), family history (parents, maternal and paternal grandparents, siblings), social history (occupation, diet, exercise, sexual, tobacco use, alcohol use, and elicit drug use), and the ROS (2 items from the following, general, head, eyes, ears, nose, throat, neck, cv, resp, gi, gu, psych, neuro, msk, and skin).

Objective: This includes the physical exam findings. Start off with taking the vitals. Then, move on to examine the main systems in the body from head to toe.

It's a lot to do in a limited period of time, especially if you also have to factor in time taken to address the humanism aspect of the interview (building a rapport, show sympathy, etc.). However, if you practice constantly, it can be done. The problem I'm having tho, is having to document all that in 9 minutes. I try to take notes as I'm going through the history taking, but it's hard to do so while maintaining eye contact and practice reflective listening.

And your full physical includes full neuro exam, muscle strength, etc? Sure, practicing and being efficient is important but when it comes to a full h&p in 20 minutes the real issue is getting the patient to move quickly enough..

 

[Postictal Raiden]

And your full physical includes full neuro exam, muscle strength, etc? Sure, practicing and being efficient is important but when it comes to a full h&p in 20 minutes the real issue is getting the patient to move quickly enough..

Yup. We do that too. Our neuro component of physical consists of: Testing full motor strength in upper and lower extremities, check for deep tendon reflexes in upper and lower extremities bilaterally, check if the patient is aware and oriented, check for presence of sensation in U&L extremities B/L, and check for patient's balance by having them walk on their heels and toes. The MSK component consists of: Checking the full ROM of U&L extremities, symmetries, leg lengths, and TART changes.

Yes, it's a lot to do in 25mins, and that's why I keep losing points for running out of time. However, bunch of kids in my class have been constantly scoring perfect.

 

[KnuxNole]

It is difficult as a first year, since your differential is VERY bare bones or non existent. The main thing is to learn HOW to ask questions, and what are basic questions for a chief complaint. It takes time for this, and by 2nd year, it'll make a little more sense.

 

[KnuxNole]

Our school only gives us 10 minutes for H&P... You kids complaining about getting 15 minutes are spoiled.. (Pro Tip: Step 2 CS stations are also 15 minutes long)

Keep in mind that's after people went through their rotations. For the average med student(and above average), who has never done a history or physical exam in their life before this, it is all new information. I knew that I was overwhelmed at first, with remembering all the symptom descriptors, keeping the skeleton together, and remembering all the different PE techniques. It got easier with time though, and practicing with classmates! As you know, a 1st year is NEVER expected to be ready for the real world so quickly. I would never look at one like that, ever, haha.

 

[KnuxNole]

Of course it helps for the patients with relevant complaints. But if your patient has knee pain, what's on your differential that makes you listen to their heart? Most primary care docs I've worked with listen to the heart and lungs regardless of what the patient is complaining about, but why?

I'd probably get yelled at if I didn't document a heart and lung exam, even if they are coming in for depression medication refills. I always do a 4 system PE at the bare minimum. Especially for Medicare, there needs to be a documented physical exam, or it gets rejected. For hospital admits, a minimum 10 point ROS too(which is fine, that is easy to do).

I always listen to the heart and lung first, regardless. It's quick, easy, and doesn't have any detriments to my encounter. I usually tell the patient "Let me take a quick listen to you, make sure you sound good, then I'll move on to X, Y and Z.". Honestly, the patient is coming to the doctor to be examined, so they aren't surprised or shocked.

 

[Ismet]

I'd probably get yelled at if I didn't document a heart and lung exam, even if they are coming in for depression medication refills. I always do a 4 system PE at the bare minimum. Especially for Medicare, there needs to be a documented physical exam, or it gets rejected. For hospital admits, a minimum 10 point ROS too(which is fine, that is easy to do).

I always listen to the heart and lung first, regardless. It's quick, easy, and doesn't have any detriments to my encounter. I usually tell the patient "Let me take a quick listen to you, make sure you sound good, then I'll move on to X, Y and Z.". Honestly, the patient is coming to the doctor to be examined, so they aren't surprised or shocked.

Yeah I'm not saying not to do it, as I do it on all patients too. And I get that a part of it is for billing. I just think it's silly to do sometimes. Especially when the patient broke his wrist and the ED resident listens to 1 breath sound and 1 heartbeat in 1 location. And gotta feel those legs-over the winter boots mind you-to make sure there's no edema. I mean, if you're going to do it and document that you did it, then do it right.

 

[KnuxNole]

True. I never only listen to one breath sound or one beat though, haha. I do the four heart sounds, both sides of the lung, listen to bowel sounds and press on the belly as the big 3. In the ED, I wouldn't ONLY examine the wrist. Yes, that's the big part of why they are here, but I would do those three above systems and focus on the wrist afterwards. It doesn't take much time, and there is nothing detrimental about spending a few moments listening and palpating the abdomen, at least nothing I can even think of....