What does this mean?

[Mossjoh]

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I'm on internal medicine right now. My attending told me today after I did an admission that my H&P's need to be a bit more detailed, however I'm doing resident work. (I'm a MS-3)
I think he just wanted me to be more detailed under my past medical history; instead of just putting "CHF" but "CHF-Diagnosed 2002, currently treated with...." ect.

I would assume that doing "resident work" is good right?

Mossjoh

 

[Samir Desai]

It sounds like you are not entirely sure where you have to be more detailed. Most attendings would like more than just a list of medical problems under the PMH (past medical history). Information about when the diagnosis was established, etiology of the CHF, severity, left ventricular ejection fraction, treatment, etc., are just some examples of what you might wish to include here. Since attendings have different preferences, it is best to ask the attending to clarify if you are not sure. You also need to know where else you need to be more detailed or if the PMH is the only place.

As far as the meaning of you are "doing resident work" - that can mean a lot of different things. Is he or she saying that your performance (except for the detail of your H & P) is at a resident level? Or could the attending possibly be saying that your H & P is similar to a resident, in which case it may not necessarily be a good thing. Remember that H & Ps of students are expected to be thorough and detailed but it is acceptable for H & Ps of residents to be more focused and less detailed. So if that's what the attending is referring to, that could be a negative.

I suggest that you talk this over with your attending to make sure you are on the same page. Whenever you receive feedback, make sure the attending gives you specific rather than general comments. It's also a good habit to summarize the feedback you receive from an attending at the end of the feedback session. That way, there is no confusion.

Best of luck,

Samir Desai, MD

 

[Seaglass]

What Dr. Desai said. I remember being told as a student (and telling students now) that residents don't make the best models for students since we go about our workl somewhat differently. Remember the H&P and daily notes are the place where you can show your attending what you know, so in the assessment and plan instead of just writing
1) Rule out MI

you should have

1) Chest pain- pt's symptoms and risk factors are concerning for cardiac chest pain. Relevant laboratory studies include . . .

You get the idea.

 

[Idiopathic]

To me, when coming from an attending, I interpret 'resident work' to be substandard and less-than-adequate, even though the work itself may be exemplary...remember, you cant do 'attending work' until you are an attending 😉

 

[doc05]

exactly. For IM, your admission H&P should be at least 2-3 pages. Do everything "by the book," include tons of details, and even if some information seems irrelevant or redundant, include it. A lot of this seems silly, but the point is to demonstrate that you've taken a thorough history, know everything about your patient, and are thinking about the differential diagnosis.

 

[Mossjoh]

As a 3rd year medical student, I took doing "resident work" at my level to be pretty darn good. I think that was how it was meant.

The 3rd year resident on our service has basically made me an intern, I'm seeing patients directly under his supervision without having to report to an intern. Anyhow, I'm half-way through medicine

Mossjoh

 

[Jaded Soul]

As a 3rd year medical student, I took doing "resident work" at my level to be pretty darn good. I think that was how it was meant.

The 3rd year resident on our service has basically made me an intern, I'm seeing patients directly under his supervision without having to report to an intern. Anyhow, I'm half-way through medicine

Mossjoh

You'd normally have to report to an intern first? That's not a good system. Students should be working directly under residents all the time.

 

[Seaglass]

You'd normally have to report to an intern first?

Maybe it's an east coast thing, but this is the standard where I'm from.

The intern has the primary responsibility for the patient (to make sure things get done and notes get written, esp. since MS notes cannot be used for billing purposes) but if the 3rd year MS is good the resident really has very little work to do. Once I was a fourth year I reported directly to the resident without any Intern involvement.

C

 

[Jaded Soul]

Maybe it's an east coast thing, but this is the standard where I'm from.

The intern has the primary responsibility for the patient (to make sure things get done and notes get written, esp. since MS notes cannot be used for billing purposes) but if the 3rd year MS is good the resident really has very little work to do. Once I was a fourth year I reported directly to the resident without any Intern involvement.

C

I guess there really is a difference in teaching philosophy. On every inpatient rotation I've done, if a student is following a patient, the intern doesn't see them at all. That goes for all the core clerkships in third year as well as electives in fourth year. As long as an intern or resident co-signs student notes or orders, they become legal documents.

 

[roja]

I guess there really is a difference in teaching philosophy. On every inpatient rotation I've done, if a student is following a patient, the intern doesn't see them at all. That goes for all the core clerkships in third year as well as electives in fourth year. As long as an intern or resident co-signs student notes or orders, they become legal documents.

ditto where I was.


And in our ED, MS4's write the notes and the attending signs it (as they are the ones that bill)

(and I am fairly certain that attending notes in floor charts have to have attending notes or its not billable....) or at least our attendings get in big doo-doo if they dont

 

[12R34Y]

Every inpatient service (medicine,psych,neuro...that's all i've done.) are followed by an intern. The ms3 reports directly to the intern and the intern must write a note every single day. The senior residents see briefly all of the patient, but are just administrative and oversee things. Kind of like an mini-attending. Attendings are only there for rounds and they're outta there.

later

 

[Seaglass]

Yes, my understanding of current medicare billing is that medical student activities (notes, procedures, etc.) are not billable, even if co-signed. This change happened during my fourth year. If you don't have a lot of medicare then I guess it probably doesn't really matter.

 

[14022]

I would be pleased with that remark. I would think it means that you can multitask, you have an adequate knowledge to provide a reasonable assessment and plan, and you appear comfortable in your role as student physician. I would agree that students should have as thorough of an h and p as possible. If you only check the prostate of people with urinary complaints, then it is harder to get a "feel" (pun intended) of what a normal prostate feels like. Perform a complete head to toe physical on every patient to get a sense of normal vs abnormal, solidify a regimen of performing the physical, and enhaning efficiency and technique. Histories should be detailed so you get a sense of associated symptoms with diseases that you may not know everything about. That is where a complete review of systems on every patient.

 

[Chisel]

I'd like to see the pt. population that will allow you to do a rectal exam on for the CC of Chest pain....maybe the pts I'm seeing are different than everyone else, but it just isn't going to happen. To rule out GI bleed, to assess BPH/Prostate Ca, et. al, then by all means do the rectal.

I agree that we should be as thorough as MS 3's as we can be, but I don't think that means doing portions of the PE that are not necessary. As far as history, I agree, be completely thorough...if you want to ask about the pt's fourth cousin once-removed PMhx then do it. But, we do have to learn to see these pts and assess them quickly...... learn to do so now.

If the attending asks me for a specific portion of the PE or History and I didn't do it, then I go back to the pt and do/ask it. That's where we learn.

Chisel
MS III
PCOM 2006

 

[AJM]

I'd like to see the pt. population that will allow you to do a rectal exam on for the CC of Chest pain....maybe the pts I'm seeing are different than everyone else, but it just isn't going to happen. To rule out GI bleed, to assess BPH/Prostate Ca, et. al, then by all means do the rectal.

It is absolutely necessary to do a rectal exam for any patient being admitted with chest pain. This is not just to scut out the med student/intern, but it is needed in order to give good medical care. If you are going to anticoagulate a patient (for an MI, PE, whatever), then you need to make sure they don't have an occult GI bleed first. I've only rarely had a patient with chest pain refuse a rectal - especially after it's explained to them why it's necessary.

 

[roja]

there are admissions that don't necessitate a rectal exam.... however, if there is ANY possibility of anticoagulation, then of course, its necessary. (or gi bleed, anemia, etc)


Do you really rectalize a pneumonia?

 

[AJM]

there are admissions that don't necessitate a rectal exam.... however, if there is ANY possibility of anticoagulation, then of course, its necessary. (or gi bleed, anemia, etc)


Do you really rectalize a pneumonia?

I don't believe I mentioned PNA as being a rectalizable admission...

I do agree that if you don't have a reason to rectalize a patient, then they shouldn't be rectalized on admission just for the sake of learning what a "normal" rectal exam is like. There are other venues to do lots of screening rectals to get good at the exam - like outpatient primary care clinics, or your general surgery rotation (almost all those patients need rectals). Patients being admitted to the hospital are usually traumatized enough by their symptoms and the stress of being admitted, that they should not be submitted to unnecessary invasion of their body cavities...

 

[14022]

At the VA, I did a rectal on every patient that consented. First of all, several of them had some degree of urinary difficulty, which warrants a prostate exam. As for others, I didnt tell them that I "needed" to do it, but I told them being a male over 50, theyre at increased risk for prostate cancer, which is true. I told them that one way to screen for prostate cancer is by digital rectal exam and if they would like to be screened, I would be willing to do it. Most agreed and the ones that did not, I respected their decision and never brought it up again.

Youre just dissing the rectal exam because of the stigma of the test itself. If someone comes in with nausea and diarrhea, you still do a good cardiovascular and respiratory and neuro exam, although most likely they just have simple gastroenteritis. You are probably not going to find any significant findings in many other body systems, but you do it anyways. Regardless of whether you absolutely need to do it or not, you should be practicing your clinical skills as much as possible as a third year. As long as they consent and your being honest with them, there is nothing wrong with doing things that are a bit uncomfortable. I imagine that you would have no problem drawing an arterial blood gas from a patient when there are more experienced people around you could potentially put the patient in more pain and discomfort than someone more experienced.

 

[AJM]

At the VA, I did a rectal on every patient that consented. First of all, several of them had some degree of urinary difficulty, which warrants a prostate exam. As for others, I didnt tell them that I "needed" to do it, but I told them being a male over 50, theyre at increased risk for prostate cancer, which is true. I told them that one way to screen for prostate cancer is by digital rectal exam and if they would like to be screened, I would be willing to do it. Most agreed and the ones that did not, I respected their decision and never brought it up again.

Youre just dissing the rectal exam because of the stigma of the test itself. If someone comes in with nausea and diarrhea, you still do a good cardiovascular and respiratory and neuro exam, although most likely they just have simple gastroenteritis. You are probably not going to find any significant findings in many other body systems, but you do it anyways. Regardless of whether you absolutely need to do it or not, you should be practicing your clinical skills as much as possible as a third year. As long as they consent and your being honest with them, there is nothing wrong with doing things that are a bit uncomfortable. I imagine that you would have no problem drawing an arterial blood gas from a patient when there are more experienced people around you could potentially put the patient in more pain and discomfort than someone more experienced.

I'm sorry I gave the impression of dissing the rectal exam - I am not dissing it by any means. It's an important part of the physical exam when it's called for. What I do take objection to is doing one only because of "educational purposes" with no intention of benefit to the patient. This is because as a med student, you have plenty of opportunity to do rectals on lots of different patients - so why add on those 1 or 2 unnecessary ones just for the "extra experience"? Patients consent to you doing it because you have a white coat, and they're scared to say no... just because they consent doesn't mean that the exam isn't going to be traumatic to them (yes, I know I'm generalizing, but this happens quite often).

The VA is a different type of place - pretty much all those patients will need rectals anyway because of the different diseases that they have. I do have one thing to say about your approach to the older male patient - telling them simply that a digital rectal exam will screen them for prostate CA is misleading the patient. First of all, to screen you need to do both a rectal exam and draw a PSA - the exam alone does not cut it. Second, it is not recommended to screen a patient who has a life expectancy of less than 10 years - which describes many of the vets being admitted to the hospital.

Again, I have no objections to doing a rectal exam when called for. And if you do a rectal, be prepared to explain to your resident/attending how it helped you in your management decisions.

 

[roja]

At the VA, I did a rectal on every patient that consented. First of all, several of them had some degree of urinary difficulty, which warrants a prostate exam. As for others, I didnt tell them that I "needed" to do it, but I told them being a male over 50, theyre at increased risk for prostate cancer, which is true. I told them that one way to screen for prostate cancer is by digital rectal exam and if they would like to be screened, I would be willing to do it. Most agreed and the ones that did not, I respected their decision and never brought it up again.

Youre just dissing the rectal exam because of the stigma of the test itself. If someone comes in with nausea and diarrhea, you still do a good cardiovascular and respiratory and neuro exam, although most likely they just have simple gastroenteritis. You are probably not going to find any significant findings in many other body systems, but you do it anyways. Regardless of whether you absolutely need to do it or not, you should be practicing your clinical skills as much as possible as a third year. As long as they consent and your being honest with them, there is nothing wrong with doing things that are a bit uncomfortable. I imagine that you would have no problem drawing an arterial blood gas from a patient when there are more experienced people around you could potentially put the patient in more pain and discomfort than someone more experienced.

I agree with AJM. There wasn't an appearance of 'dissing', just appropriate discussion of when its necessary or not. And depending on the situation, a rectal exam on someone with nausea and diarrhea is NOT warrented. While you mention education, it does not take a 100 rectal exams to figure out how to do it, nor to figure out what a positive heme-occult test is.

And part of your education is not to simply do exams simply because 'this is an educating institution'. Part of your education is figuring out when tests are appropriate adn when they are not (including rectal exams)

And thus asking yourself, should I perform a rectal exam- you should ask yourself: how will a positive exam help me? how will a negative? and if the awnser is NEITHER, then the test is not necessary. If you are appropriately screening a patient, fine. but if you are just doing it to 'practice your skills', you are doing your patient and yourself a disservice.

 

[Chisel]

My point has been stated here by other SDN'ers. I was trying to point out the issue of doing the rectal merely for "educational value".

As the last post stated, if it is going to help with diagnosis/treatment then it is warranted. If you're doing it to simply "get practice" and it is not warranted, even if it is consented to by the already distressed, nervous,overwhelmed,fearful pt, then you are flat out wrong.

Chisel

 

[Mossjoh]

I did a rectal yesterday, but I just tend to do them when I know its appropriate. For instance, this guy had a low hemoglobin and a history of gastritis/ulcers. I wanted to see if he was bleeding.

And guess what..the hemoccult was positive. Anyway, I think if it is warranted, you have to do it. However, see if the ER physician or someone else did one first, no sense in putting someone through that twice.

Mossjoh

 

[14022]

I guess I have been misled by my preceptors who have suggested that a patient treated at a teaching hospital should almost expect students to want to get practice seeing patients. Of course, if a patient objects to seeing a student or does not consent to a specific procedure, then obviously a student would not force this upon anyone. And of course, if a certain procedure (ie, rectal exam) has absolutely no place for a certain diagnostic work up, then it should not be done. But when a rectal exam has questionable utility (ie, it may or may not have any usefulness, depending on who you talk to) and the patient grants consent to the exam, then the student should perform the exam, regardless of whether it was done in the ER.

For many men, a rectal exam is not a traumatic experience as others have suggested. Men get a digital rectal exam every year. I have had a rectal exam before as a work-up for a bleeding hemorrhoid and I do not feel that it was traumatic experience.

 

[14022]

Let me pose a question. I am on gynecological surgery and several different residents and attendings have told me that prior to surgery it is a great idea to perform a pelvic exam on the anesthetized woman in order to get practice. Many have said it is not traumatic to the patient and you get a more technically adequate exam since the patient is not guarding. Sure enough, before every procedure the attending and resident (and I have worked with 6 attendings and 4 residents, both males and females) perform a quick pelvic exam.

Is this wrong? The attending does it for one last chance to feel for any previously undiagnosed masses or other abnormalities, but the resident and student do it primarily for educational purposes. The patient has consented to the surgery, but not for the pelvic exam. Does consent to surgery of the uterus, vagina, vulva, ovaries, etc. also imply consent to manual palpation of these structures during the surgery?

On second thought, I am going to post this as its own post, since I am very interested in other people's thoughts.