Are We Healing People Yet?

So there you are, on the first day of third year about to start your clinical training. Two years of lectures behind you, thousands of facts disintegrating in your brain every day, and you are standing sheepishly in your new short white coat at the nurse’s station about to start your first real day of your new career without a clue as to what exactly is your job and what you should do first.

You’ve had the orientation, of course, where you are told what is expected of you but somehow it doesn’t exactly translate on a Monday morning at 6 AM surrounded by the bustling world of an academic medical center.

Relax. Here’s how a typical ward rotation works.

First thing: By “wards” we mean a rotation dealing with patients who have been admitted to the hospital and who reside there for the duration of their treatment. Some rotations are all “outpatient” (as opposed to wards which are “inpatient”) and you will be seeing patients in a clinic. Family medicine is a good example of an outpatient rotation. We will discuss these rotations in a later post. Just keep in mind that even on an inpatient rotation you may spend some time seeing outpatients in a clinic setting.

As you will find out, third year is divided into short blocks, typically two months long, during which you cover all of the major areas of medicine such as Surgery, Obstetrics and Gynecology (OB-Gyn), Internal Medicine (“Medicine”), Pediatrics, Surgical Subspecialties (such as Urology, Opthamology, and Otolaryngology), Psychiatry, and a few other things depending on the priorities of your school.

These two month blocks are typically further broken down into shorter sections. You might, for example, do one month of General Surgery and one month of Vascular Surgery in a two month surgery rotation. On a two month medicine rotation, as another example, you might do one month of General Internal Medicine, two weeks of Cardiology, and two weeks of Nephrology.

Suppose you start on General Medicine. Let’s flesh out a typical day. Bear in mind that every medical school is different and other’s may have had different experiences.

How early should you show up?

Get to the floor early enough to pre-round on the patients you are assigned to follow. This simply means that you must see the patients, examine them, and make a note of any changes in their condition before morning rounds. You must also follow up on pertinent labs or studies from the day before and be familiar with their treatment plan (including the all-important discharge plan) as well as any pending tests and their current medications. How early you show up depends on the number of patients you are following, your familiarity with them, and how efficiently you work.

Keep in mind that you will be waking most of the patients up to do your exam. (Usually a focused exam dealing only with the presenting complaint. You do not generally need to do a neuro exam for someone being treated for a small bowel obstruction.) While they expect to be disturbed during their stay, 4 AM is a little early to be turning on the lights and poking them in the belly. (Examining a patient in the dark is called “groping” and is a no-no.)

You will probably not be assigned more than two patients when you first get started, Still, as you will be completely unfamiliar with almost everything about the workings of the hospital I’d allow plenty of time. If you show up too early the worst that will happen is that you will be standing around with nothing to do before morning rounds. The converse to this is not having enough time and being asked embarrassing questions about your patients that you can’t answer.

Typically, you will be responsible to make a note in the patients chart before rounds summarizing what you have learned. This is the famous “SOAP” note of which you have probably heard. The SOAP note is easy to grasp but difficult, initially, for most medical students to execute. The usual problem is trying to cram too much into the note. It should be concise, not wordy, and should not recapitulate the admission History and Physical except to remind the reader about the patient. (Believe me, the admission H & P, especially on medicine, is where you can go crazy with detail.)

The parts of a SOAP note are as follows:

Subjective: Who the patient is, a brief summary of the reason for their hospitalization, and what they or the nurses told you about their hospital course overnight.

“Mr. Jones is a 63-year-old man admitted for congestive heart failure exacerbation. The patient reported difficulty breathing and a non-productive cough last night at around nine PM but these resolved after administration of IV lasix. Patient is currently without complaints.”

Objective: Subjective is just that, subjective. It does not cover things that you observed in your exam or were reported by the lab, radiology or other consultants. These things are all objective, that is, facts that do not depend on the patient’s interpretation.

Typically you record the last set vital signs making particular note of anything unusual like a fever overnight or a string of high or low blood pressure readings which were unusual for the patient.

Next you will record the results of your physical exam. Generally, every patient regardless of their complaint deserves at least a cardiovascular exam, a lung exam, and an abdominal exam. Listen to the heart in several locations, listen to the lungs, listen for bowel sounds and palpate the abdomen. You can record this succintly using any number of “boiler-plate” abbreviations such as “lungs CTAB” for “lungs clear to auscultation bilaterally.” Of course you need to note any new findings,

Although opinions vary, on my SOAP notes I like to record pertinent lab values. I know that the results are usually on a computer somewhere but it simplifies the job of the person reading your note. I also give brief summary of any new imaging results or the results of any other tests which were not available for the previous note.

assessment/Plan: This is the list of what is wrong with the patient and the ongoing plan to address these problems. Typically it is also preceded by a brief recapitulation of the patient as in the first line of the note. Is this necessary? Maybe not but since most people jump to the assessment and plan when they read a note, particularly a long one, the recapitulation is always helpful. People will read your notes. might as well make them useful and user friendly.

You might say “Mr. Smith is a 63-year-old man with a history of congestive heart failure, Diabetes, hypertension, and gout admitted on January 3rd for a CHF exacerbation.” Then you make a list, by problem, of the plan to address that problem and how things are either working or not working.

For example:

CHF: Patient diuresed of approximately three liters of fluid over last 24 hours on 60 mg IV lasix every eight hours. Chest xray shows continuing resoution of pulmonary edema. Last ejection fraction was 25 percent by transesophageal echo on January 1st.

Diabetes: Well controlled on sliding scale insulin.

Hypertension: Blood pressure well controlled on Hydralzine etc. etc. etc.

You get the point. Also, you might want to add in your note how the patient is doing towards meeting his discharge criteria. Use accepted abbreviations but try not to get too jiggy with them. Most people have to think a little before they realize that BRBPR stands for “Bright Red Blood Per Rectum.”

Why is a the SOAP note important? Several reasons. However, let’s not kid ourselves into thinking that your attending or your resident is going to rely on your assessment and plan for her treatment decisions. Ain’t going to happen. Sorry. What the note does is provide a framework for your over-worked resident to quickly add her own pertinent comments as an addendum to your note. Sometimes the addendum can be as simple as “Agree with medical student note.” At other times the resident will add her own assessment and plan. Either way it saves her a little bit of time.

For you, the medical student, the big advantage of the SOAP note is that if you copy them and carry them around you will be well-armed when the time comes to present your patient.

More on that in Part 2.