When it comes to clerkship/med school rotations and first year of residency, there is a lot to learn.
You are still pouring on the knowledge and didactic learning but now you also need to apply it clinically and learn how to work within a hospital or clinic.
An important skillset that you’ll have to master is rounding and writing notes as these will take up a lot of your time and cognitive capacity during the day.
We will assume that the patient has already been admitted and the initial admission note is already done (separate posts about these topics coming soon).
So we’ll go through day to day rounding and briefly, progress notes.
As a student you will be assigned patients, and as a resident, it will be similar as well but maybe more patients/complexity.
There are two ways to go about tackling your list. I prefer method 2, but at the beginning, you’ll probably stick with method 1.
Method 1- Floor By Floor
Just like it sounds, go floor by floor and get through the list.
This is nice because it feels like you’ve checked something of your list as you get done with each floor.
Most hospitals are organized to have certain services/types of patients on certain floors (surgical, medical etc). So this is nice too as it keeps you zoned into particular types of problems.
The downside here is that, regardless of the floor, you might be hit with a varying complexity of patients. You may go from a dressing change required to a syncopal episode overnight that needs to be worked up. That’s where method 2 comes in.
Method 2- Complexity- Eat That Frog
There is a method in the productivity space, I believe by Brian Tracy that states “eat that frog”. It is a metaphor for doing the hardest task of the day first.
This is what method 2 is all about. Organize your list with seeing the most complex, acute and active patients first. This can also include difficult families, admin tasks that need to get done etc. This group of patients will take up the most energy and thinking capacity so work on them first.
Then progress to your more “stable, waiting for rehab” patients.
The best part of this method is what I have described.
The poor part is that sometimes you will bounce from floor to floor depending on what service you are on or type of physician you are. Nurses or admin may ask you questions about patients you weren’t planning on seeing quite yet.
So sometimes I will just do a hybrid of the two. I’ll go floor by floor but on each floor, see the most complex people first.
Adapt, improvise, overcome.
Now that you know the order of patients you are going to see, start seeing them with a particular approach as well.
I like to review their chart before going in. This is faster if I am the one who admitted the patient as I know what is going on with them. If not, or if it is not fresh in my mind, I will quickly glance over the initial history and physical.
What brought this patient into hospital? How long have they been here? What were we thinking the problem was? What was our initial plan? (Again, go over the other post on how to admit a patient and do a good history and physical note).
Then I’ll browse through the most recent 2-3 progress notes. What have we done to investigate the problem and fix the problem? What have we found? How are they reacting to treatment?
Now that I have an idea of why they are here and what has been done so far, I focus on today.
Start with the basics. What are there vital signs like? What are this morning’s labs like? Did any investigations come back that need to be reviewed?
Now I am caught up on the objective measures. Then I find the nurse of the patient and ask if there were any overnight issues reported or if the nurse has had any problems with the patient or questions/concerns for me. Sometimes they’ll ask for agitation mediation, pain regimen adjustment etc.
This sounds drawn out, but it gives you a good picture of what is going on with a patient and avoids a barrage of phone calls later on.
Then after doing all of that and having a good idea of what our next steps will be, I walk into the patient’s room.
And of course, we’ll do another video on how to interview a patient properly.
But the long and short of it, I ask them how they are doing as a person. Then I ask them questions in the context of their presentation. Still having pain? Still having hematuria? Still having shortness of breath? Still coughing? And so on.
Whatever they presented with, how is that going now after our efforts to treat it? Are they progressing? Do we need to change things up?
I examine them physically in the context of their presentation. I also address any concerns the nurse may have had; patients refusing medications, agitation, a new rash etc.
Then I share with them any abnormal labs, or investigations that may have come back and what they mean.
Then I go over what our plan for the day is and moving forward.
Then I ask them, if they have any questions or concerns.
I walk out of the room, see if my management plan needs changing for the day- adjust medications, call for a consult, order physio, add PRN medications etc. And either change the plan (as a resident) or note it down to review with your senior (as a med student).
I usually do my note right away while my thoughts and plans are fresh in my mind as well as calling consults and orders.
However, administrative tasks like calling families, signing forms etc I’ll leave to later in the day as they (most of the time) require less cognitive load.
The above method can take a few minutes or a half hour or more depending on the complexity of the patient’s medical issues and also the psychosocial aspect and administrative work.
But following it to the tee every time assures that I don’t miss anything and that we have a clear game plan of why they are here and what we are doing for them.
It will get faster and more efficient with time.
Keeping patients in the hospital is very expensive but more importantly, can pose risks for them as well (DVTs, acquiring infection, falls etc) so we need to make sure (ideally at the time of admission) if they need to be in hospital or not.
And if they do, then we need to make sure we have a plan in place daily to make progress toward the next step.
I continue along the floors and see all my patients then either I’m done for the day, or meet and review with staff (resident level) or meet and review with your senior or team (med student).
This is a simple but important process that you’ll be doing for a long time, so you should learn it and adjust it to work best for you.
In the next set of posts, we’ll be going over how to do good notes, because that really makes the whole process easier and more efficient. There is nothing worse than having to figure out the patient’s entire presentation from scratch every day because the initial notes were poorly done.
More on that later.
Till next time.