Complete Clinical Picture

General Comments: You will spend a significant portion of your clinical training caring for hospitalized patients. This environment presents different demands and opportunities then other areas of the healthcare system. Within the hospital, each branch of medicine has its own structure and approach. Several elements, however, are common to all:

  1. Organization: Health care in teaching hospitals is very hierarchical. At the top of the pyramid
    is the attending physician, a staff doctor who has ultimate responsibility for the patient.
    Beneath them is the supervising resident, a physician in the advanced stages of their
    training. They supervise the interns, doctors in their first year out of medical school who are
    generally the worker bees of the service. Fourth year students (referred to as Sub or Acting
    Interns) may also be members of the team. This is their opportunity to work with an
    increased degree of autonomy in order to prepare them for their future role as doctors. Some
    teams have additional layers of residents or fellows (physicians participating in advanced
    post-residency training), depending on the complexity and volume of work to be done.
  2. Team Approach: Those at the higher levels function as managers while those in the trenches tend to focus on getting things done. However, this is also a system of graduated responsibility, allowing less experienced providers the chance to become increasingly involved in the decision making process over time.
  3. Role of the Student: The third year student occupies a variably placed position on the team. Clinical education is based on the concept that students learn through a process of observation and controlled participation in patient care. Their ability to function and contribute will depend on the scope of their general experience as well as specific knowledge in any one field. During the beginning of the year and/or early in a particular rotation, students will be less functional then towards the end. Furthermore, the very nature of some rotations (e.g. surgery) will pose obvious limits on the degree to which the student may actually participate. In addition, the student has a somewhat distinct position from the other team members in that their purpose is not merely to get work done. Nor, for obvious reasons, do they function with speed or efficiency, traits which frequently define the work of the other team members.

Why is it important that you understand this structure? The quality of your educational experience will be heavily influenced by your ability to identify, and then make the most of, your role within this system. You will receive educational input, to some degree, from all members of the team. Realize that their experience and abilities as teachers will vary widely. Some will be naturally gifted, most will be adequate and a few will be horrific. However, almost all value this exchange and want to do a good job. Be patient. Recognize that you’re functioning in a world of competing priorities. The primary focus of the team is to provide good care for the patient. Within this context, these physicians are also expected to supervise and train others, increase their own knowledge base, and provide for your educational needs. That’s quite a daunting task, particularly for someone who may have had little formal experience in either management or teaching. In order to get the most out of each rotation, try to make use of the following questions and behaviors:

  1. Ask the head of your team (both resident and attending physician) for a precise description of
    your responsibilities. How many patients will you follow? Will you be writing
    admission H&Ps, daily notes, presenting at attending or work rounds, etc? Who will be
    reviewing your work?
  2. What are your expectations for the rotation? What are the most important things that you
    want to learn or experience? Even if these are no different then the other students (e.g.
    observe operations on a surgical service, practice putting in I.V.s, etc.), keep a mental list for
    yourself that you can refer to periodically. If you have unusual expectations that you feel can
    be reasonably met within the scope of the rotation, discuss them with your supervising physicians.
  3. With whom will you be working? One or several of the interns or with the resident directly? Make sure that you know how to contact them and that they know how to find you. It helps
    to confirm even the most obvious details as non-communication of what others feel is
    implicitly understood information can become the substrate for conflict.
  4. Offer feedback to your teachers. Let them know what works and what does not. Similarly,
    solicit input on your own performance. Don’t leave this for the end of the rotation as by then
    you’ll have lost the opportunity to incorporate suggestions and experiment with new
    approaches.
  5. Determine the weekly schedule of events. Are there student conferences or other
    commitments that will make you unavailable to the team? When and where are work rounds,
    radiology rounds, attending rounds, etc.? If you’re on a surgical rotation, when will you be
    expected to be in the operating room?
  6. Identify when you are expected to be on call and what your exact responsibilities will be on
    those days. Will you be sleeping in the hospital? Who is responsible for informing you
    about new admissions? Should you see these patients with the rest of the team or interview
    them separately? If there are specific days that you need off, let your team members know at the start of the rotation.
  7. Realize that education is a two-way street. Students can and should contribute to the learning
    process. This is of particular value on fast paced rotations, when time constraints prevent
    other team members from being able to pursue this information on their own.
  8. Address conflicts or areas of dissatisfaction early in the rotation. Frequently, these are simply
    the result of miscommunication and can be easily remedied. More complex issues should be
    taken up either directly with the person(s) involved or, if you are uncomfortable with this
    approach, via the attending physician or course director. Don’t let problems fester!
  9. Take each rotation seriously and try to learn as much as possible while you’re there. A casual
    or cavalier attitude is rapidly transmitted to those with whom you work. Any lack of interest
    on your part will almost certainly lead to less enthusiasm and effort from your teachers. The
    resulting clinical experience is destined to be less fulfilling and interesting. Try to adopt the
    attitude that you are truly a practitioner in the field of medicine to which you’ve been
    assigned. The resulting experience will be more enjoyable, the teaching superior, and you may
    occasionally identify a previously undiscovered area of interest or aptitude.

Ultimately, you are responsible for your own education. As such, you really need to stop and consider the unique opportunities and challenges provided by the hospital environment. This is likely to be an experience which differs from any that you’ve encountered in your previous careers as students. The elements described above can either make or break a particular rotation. By becoming more aware of how and why things happen, you will hopefully be able to maximize the quantity and quality of each educational encounter.

Specific Suggestions for Making the Most of Inpatient Rotations

Pre-Rounding: Work rounds occur each morning and are the time when the team sees each patient, discusses their course, and decides on the diagnostic and therapeutic plan of the day. In order to be maximally efficient, it falls to the students and interns to gather relevant clinical data. This process is referred to as pre-rounding and should incorporate the following:

  1. Review the flow chart that is kept for each patient. This sheet is a record of their vital signs as well as fluids taken in or excreted (referred to as Is and Os, for Ins and Outs) over a twenty-four hour period.
  2. Be aware of major events that have occurred over the past day. Were any studies performed? Were there major changes in clinical status? Of course, access to this information is predicated on your having been actively involved in the patient’s care (i.e. you need to make it a priority to stay informed about the patient’s clinical activity). If things are happening that you are not made aware of, mention this to the interns and residents so that they can help you become an active participant in the patient care process.
  3. Tracking down events that occurred overnight can be challenging. These can range from
    evaluation of a fever to initiation of new medications. A few places to check:

    1. If your team was not on call, try to speak with the person who was responsible for caring for the patient overnight. Alternatively, it may be easier to check with your intern as they have, in all likelihood, obtained some sort of sign out from the covering person.
    2. Check the chart to see if any notes were written about specific overnight events (or by
      consulting physicians who may have stopped by late on the previous day). Also, take
      a look in the order section for things initiated over night. You may then be able to
      piece together what happened during your absence. If, for example, new antibiotics were
      given, then someone must have discovered a previously unrecognized infection.
    3. Speak with the nurse who was covering the patients overnight and/or the one who has taken over in the AM.
    4. Query the patient about any overnight events. You will need to perform a focused exam each morning, which is a prime opportunity to ask if anything has happened.
  4. Leave yourself plenty of time to pre-round. Early in the year, this can require up to 30 minutes per patient. You may need to arrive quite early, depending on your experience, as well as
    patient volume and complexity. However, providing yourself with a realistic time cushion will
    generate much less anxiety and allow you to be as complete and accurate as possible.

Record Keeping: It is important to develop a system for keeping tract of all your hospitalized patients. Whichever mechanism you choose should allow you to:

  1. Have instant access to each patient’s relevant past history, medications and baseline labs.
  2. Be aware of in-house medications and daily lab results.
  3. Maintain a list of things that need to be done for each patient.

Why is this necessary? You will frequently be required to recount specific information (when talking with consultants, arranging for studies, reviewing lab tests, etc.) at times when you don’t have access to the patient’s paper chart. It is therefore critical that you maintain a portable record keeping system. Furthermore, caring for patients can get quite complicated, particularly early in your careers when everything seems confusing. This tends to get worse with time as your responsibilities (and fatigue) grow. It’s quite easy to either mistake one patient for another or simply forget to follow through on a previously determined plan. As a wise resident once told me: “There are two types of house officers; those that write things down and those that forget!”.

The following system allows you to keep all relevant information on 5×8 index cards. This method has several advantages:

  1. It’s readily portable. The cards fit nicely into standard lab coat pockets and are available on most hospital floors.
  2. As opposed to clip-boards (which are frequently misplaced), these cards leave your hands free to perform tasks (e.g. physical examinations, compressions during CPR, etc.).
  3. It makes relevant data readily available and allows you to keep an organized list of things that need to be done.
  4. It’s easily standardized and understandable by others.
  5. This system can be learned and used by students and then carried over and applied during later careers as house officers and attending physicians.
Front of Card

Front of Card
Back of Card

Back of Card

A few things to remember:

  1. Over time you will develop a short-hand that allows you to make best use of the card space available. You can also adjust the format any way you wish.
  2. The information included on the back (PMH, PSH, HPI, PE, etc.) is in very brief form. It should only include the critical highlights. More detailed points can be found in the chart.
  3. If a patient is hospitalized for a very long period of time, additional cards can be stapled on top of the original.

Note Writing: The format for the complete H&P is discussed elsewhere. Daily notes should be organized so that they are brief, yet highlight important data and clearly express clinical impressions. This must, of course, be done within the context of your knowledge base. As with many of the other tasks in which students participate, notes serve two purposes: They are an actual descriptive document that chronicles the patient’s course. And, they are a learning tool that allows you to think about what’s going on and express organized thoughts. A few things to remember:

  1. The data presented should be factual. Old events that were described in earlier notes should not be repeated. The daily note is not meant to be a recapitulation of the H&P.
  2. The impression and plan generally reflects the thoughts of the entire team. That is, don’t use the note as a format for expressing ideas that differ wildly from everyone else. If you don’t understand, or even disagree with, the dominant view, talk to your team members and try to gain insight into their thought process. Independent reasoning is certainly encouraged. However, avoid using the note as a means of battling with (or inflaming) your colleagues. This is, unfortunately, a common problem for many “higher level” providers, leading to energy and time wasting “chart wars.”
  3. Don’t take hours (or more then 10 minutes, for that matter) to write a note. The length of the note will depend to a large extent on your experience, understanding of the case and the complexity of the patient’s illness. However, there is generally WAY TOO MUCH attention paid to this process. Many, many other endeavors are of greater value, to both the patient and yourself. Remember, compared with all of the other aspects of patient care, the note is a minor end unto itself. After all, those most interested in the note are you and your team members. Thus, the exquisite detail found in many of these masterpieces is for the benefit of physicians who are already well aware of the patient and their course! In the event that some point is unclear, the reader can always find you to discuss the matter further.
  4. Make sure that you get feedback from team members about your written work.
  5. Certain services have very particular styles, emphasizing aspects that are important to the care
    that they provide. General Surgery teams, for example, tend to highlight fluid status,
    wound care, and IV access issues, areas that are critical to their patient population.
    Furthermore, these notes are very brief. The surgeon’s time is spent elsewhere (e.g. the
    Operating Room) and by necessity they cannot spend exorbitant amounts of time charting.
    Realize that being succinct is not equivalent to being incomplete nor does it imply sub-optimal
    care. To my knowledge, no one has shown that the length of the note correlates with the
    quality of care delivered. In fact, it occasionally seems that more time and energy is put into
    notes then actual patient care!

The basic format is referred to as a SOAP note. This stands for the major categories included within the note: Subjective information, Objective data, Assessment, and Plan. A sample note for a patient receiving treatment for pneumonia is as follows:

Hospital Day # 3

  • S: Patient feeling less short of breath, with decreased cough and sputum
    production.
  • O: Maximum Temperature: 101.5 (yesterday 103)
  • Pulse: 80-90
  • BP: 110-120/70-80 RR: 20-24 Sat: 95% 2l O2 (yesterday 95% 4l O2)
  • I/O: 2.5 L IV, 1 L PO/ UO 2L, BM x 1 Wt 140 lbs (no change from yesterday)

    Day # 3 Ceftriaxone, 1g IV BID

    PE: No jvd
    Lungs: Crackles and dullness to percussion at R base with egophony; no
    change c/w yesterday
    C/V: s1 s2 no s3 s4 m
    Abd: soft, non-tender
    Ext: no edema
    Labs: Sputum and blood cx still negative; otherwise no new data

    Assessment/Plan:

    1. Pneumonia: RLL pneumonia. Responding to IV Ceftriaxone, with decreasing
      O2 requirement and fever curve. Also feeling better. No evidence of complications.

      Plan:

      1. IV abx x 1 addl day… then change to po Azithromax
      2. Hep. lock IV to assess if PO intake adequate
      3. Check sat off O2… d/c if under 92%
      4. Encourage ambulation
      5. consider discharge in approximately 2 days if continues to improve.

    That’s a pretty simple note. However, it clearly serves its purpose. More
    complicated patients with additional issues would require an assessment
    and plan that dealt with each problem specifically. Notice that I’ve chosen
    to highlight objective data so that improvement is clearly demonstrated
    (e.g. decreased O2 requirement, declining temperature curve) and number
    ranges are mentioned when discrete points in time might not be representative
    (e.g. for heart rate and blood pressure). This is based on common sense
    and is done at the discretion of the writer. In addition, I chose to mention
    the antibiotic given and duration of therapy to date. In this case, it’s
    an important issue and deserves mention. The patient may be receiving other
    medications, perhaps for the treatment of several chronic conditions (e.g.
    hypertension, glaucoma, etc.). As these elements were undoubtedly mentioned
    elsewhere and are not changing, I’ve omitted them from the SOAP note. If,
    however, there was ongoing medication adjustment, as might be the case if
    Insulin were being used to treat diabetes or extra doses of Lasix provided
    for heart failure, I would have made special mention of these meds as well.

    Presenting During Work Rounds: The formal, complete oral presentation
    is discussed elsewhere. Work rounds are, of course, for work. Regardless
    of the service, time constraints demand that presentations be succinct yet
    thorough. An average presentation should take no more then a few minutes.
    The following is a sample presentation for a patient on the General Surgery
    service:

    “Mr. Smith is post operative day #2 from his appendenctomy,
    day #3 of 7 of Ampicillin, Gentamycin and Flagyl.

    Events over the past 24 hours include:

    1. CXR performed as part of a fever evaluation; no pulmonary pathology
      identified
    2. Passing of flatus.
    3. Decreased abdominal pain.

    Patient appeared comfortable, without specific complaints
    Vital Signs:

    • T Max 102.5 yesterday, 100 over past 8 hours
    • Heart Rate 80s to 90s, Blood Pressure 120s-140s over 70s
    • Respiratory Rate in low 20s, Sat’ing at 95% on Room Air
    • Weight 150 pounds, down 1 pound from yesterday; still up 5 pounds
      from pre-op
    • Is and Os: 2L IV NS at rate of 100/hour. Additional 500 ccs IVF from
      antibiotics. Still NPO. Urine Output total 2 L, approximately 50 cc/h.

    Lungs: Clear
    Heart: regular rate and rhythm without murmurs
    Abdomen: hypoactive bowel sounds now present; slightly distended; wound
    without erythema or discharge; minimal pain at incision site

    Labs: This morning’s Chem 7 and CBC pending; Yetsterday BUN and Creat
    11 and .8, which are consistent with baseline; White count 16, down from
    20 the previous day. Intra-operative cultures still negative; blood and
    urine cultures from day of admission and yesterday negative.

    (Team may or may not take this opportunity to enter the patient’s room
    for group interview and exam)

    Assessment and Plan:

    1. G.I. (Gastrointestinal): Patient S/P appendectomy. Had prolonged ileus
      associated with significant peri-appendiceal inflammation. Now with
      apparent recovery of gut function as evidenced by flatus, bowel sounds.

      Plan:

      • Advance to sips of clear liquids this A.M… If tolerated, will
        allow full clears this afternoon and then hep. lock IV as appears
        to be euvolemic.
      • Encourage ambulation around floor
    2. I.D. (Infectious Disease): Recurrent post operative fever, presumably
      secondary to residual peri-appendiceal infection. Fever curve now trending
      down, white count decreasing, and improving clinically. Cultures from
      all other sources negative. Exam does not suggest infection elsewhere.

      Plan:

      • Continue current antibiotics for additional 24 hours. If remains
        well, change to oral ciprofloxin and flagyl to complete 7 day
        course.
      • Follow up on cultures.
      • Ambulation and incentive spirometry may help if atelectasis
        contributing.
    3. T/L/D (Tubes, Lines, and Drains): Patient has adequate IV access.
      Foley catheter still in palce.

      Plan:

      • D/C Foley
    4. Dispo (Disposition):

      Plan:

      • Expect patient may be ready for discharge in 2 days”

    A few things are worth highlighting:

    1. Every service has a different style. Some may see every patient as a
      group and discuss the assessment and plan after the exam. Others prefer
      to hear the entire presentation (including the A and P) prior to seeing
      the patient, with appropriate adjustments made after the visit. The only
      way to learn the particulars is to ask.
    2. Oral presentations do not precisely follow the SOAP format. In the above
      example I’ve opted to include an “events” section along with the Subjective
      comments. Patients presented for the first time will generally be done
      in a more inclusive fashion, covering enough background information so
      that the course to date as well as the assessment and plan are understandable
      to all team members.
    3. Accurate presentations require that the presenter be intimately aware
      of all the details related to a patient’s course. Pre-rounding and record
      keeping (see above) are thus vital. You’ll also find it necessary to read
      critical data from your portable record keeping system.
    4. You may find it helpful, particularly early in your careers, to take
      a few minutes before rounds to practice your presentations.
    5. The number of sub-categories mentioned in the assessment and plan will
      vary with the complexity of the patient’s illness. Patients with many
      issues will require detailed discussions. The major categories include:
      Neurological, Cardiac, Pulmonary, Gatrointestinal, Renal, Hematologic,
      Infectious Disease, Endocrine/Metabolic, Access (i.e. tubes, lines, and
      drains), and Disposition. If there are no issues related to a particular
      area, it is not mentioned in the discussion. At times, there will be clinical
      problems that bridge several areas. For example, pneumonia is both a Pulmonary
      and an ID issue. In such settings, the presenter uses their judgment and
      discusses the problem under a single heading in order to avoid redundancy.
      In very complex cases, these major headings can be exploded into sub-
      categories so that important issues are not missed. For example, a patient
      may have CHF, Hypertension and Atrial Fibrillation. These are all Cardiac
      issues, which may or may not be related. As each requires specific therapy,
      listing them separately allows for maximum clarity.
    6. It will take some time before you become comfortable presenting as this
      process requires rather advanced organizational skills. In addition, you
      are likely to feel quite exposed during this process. Try not to be intimidated
      or discouraged. Ask for feedback frequently.

    Closing Comments: I suspect that most of you will quickly recognize
    the awkward position that the student occupies on the team. You are expected
    to “follow” a patient, yet in reality may not have the requisite skills to
    adequately perform this task. It frequently seems as if the house officers
    are providing the real elements of care while you are participating in a redundant
    or meaningless charade in a parallel world. The tension created by this learner-as-participant
    system, while understandable, may become unnecessarily magnified. You can
    improve the nature of this experience by putting your efforts towards rapidly
    becoming an active, contributing member of the team.

    Adapted, with permission from University of California, San Diego School of Medicine By Charlie Goldberg, M.D.