Hospital medicine new grad struggling to adjust

[wrangler]

I am a new grad PA who has been working in hospital medicine for 3 weeks. I did not do inpatient internal medicine rotation in school.  So far I work with an attending. S/he assign 3 - 6 patients to me. I see the patients come up with an assessment and plan and present. What is I struggling the most with is that all my patients have been in the hospital at least 2 days (not doing admissions yet) and have already had labs, imaging and diagnoses from providers who already saw the patients before me. Since all my rotations were outpatients or acute care. My mindset was that a patient will present to me with symptom, then I do and H&P and work up to come up with a differential but in hospital medicine the patients that I am seing for the first time are already being treated and I feel like I have to work backwards trying to figure why this lab was order why this medication... and I spend way too much time reading that chart. Can someone please share with me what your strategy is. For example if you are seing a patient for the first time who has been in the hospital for 10 days and you have to see them, get H&P, present them and write a progress note. Where do you start? Do you review all the previous progress reports, labs, imaging? Everyone I ask tellsbme that I will come up with my own system and that I need to give myself time, but I need to organize myself somewhat. I need even the simplest system to build on. I am feeling so lost right now.

[DizzyJ]

I start with the ED records and move forward in time.  No need to work backwards.  As you are going through the ED record you should be able to figure out what was ordered and why.  Then proceed to admitting H&P and what additional evaluation was put in process.  While you need to look at everything, to make sure something wasn't missed, you also need to figure out what you can weed out and not think twice about.  You have to look at every lab, image, and progress report.  On a patient that has only been there for a day or two, it takes me minutes to get up to speed.  However, with you being a new provider, it should take you longer.  Being it has only been 3 weeks, you are likely just fine.  3 months down the line, you should have noticed your speed picking up, but it may well take you 6-12 months before you are even feeling comfortable and then another year before you feel like a rock star.  

[greenmood]

On 1/28/2020 at 9:32 PM, wrangler said:

Can someone please share with me what your strategy is. For example if you are seing a patient for the first time who has been in the hospital for 10 days and you have to see them, get H&P, present them and write a progress note. Where do you start? Do you review all the previous progress reports, labs, imaging?

Short answer is that yes, you have to read everything in the chart. You do. My first day is usually a mess because I have to learn 5-7 patients who've been here for X number of days, and the hospital course is often extremely complicated. 

I start by reading what's in the hospital course so far. We keep a running document that each provider updates daily. Ideally, it has the reasons the patient presented and was admitted, along with key points in their hospital stay and remarkable diagnostic testing. I start a stub progress note and organize the patient's problem list. That gives me a really good review of their chronic medical conditions and current issues. Then I comb through their order list and make sure every medication correlates to something in their chart. I compare it to their home med list to make sure I know what they were on prior to admission. I look at their labs and lab trends throughout the hospital stay. I look at any micro results. I look at all of their imaging. I look at their most recent vitals and trends for the last several days. I check I&Os and weights.

TBH, it does not take very long for most patients, but I've been doing this for a while. When I first started, I routinely arrived two hours before rounds started so that I could do it effectively.

[newton9686]

It depends on how crazy the patient sounds. Things sound straight forward and I trust the person behind me, I might just read their note and go through the labs and images. I don’t trust the person behind me or the situation doesn’t smell right and then I’m working my way through everything. I also look at what the consultants are always saying. Also always look through the med list, mar and see how much fluids they have received and so they still need iv fluids.

[lov2xlr8]

Appreciate what others have said above. You'll find your system... Day one is always the worst but my general chart rounds in the AM starts out with reading the PA or Hospitalist note from the day before, this gives you an idea of what is going, as stated above very dependent on who was on before you; if note looks solid and straightforward I move on, if I have questions I might go back a day or 2 but given I usually have 10-12 Pts I don't have time to do a full chart biopsy (that can come later in the day after seeing the Pt, you're looking for the high yield big picture in the AM), then I look at consultant notes, next is most recent vitals followed by labs ordered for the AM (to make sure their ordered, usually not back yet) and then I order labs for the next AM (can always be changed later in the day), all the while I'm doing this I'm writing what my plan is for the day on my physical paper Handoff, to-do's etc... next is just reviewing the Handoff from the day prior to fill in the gaps that the provider the day before left, most of my colleagues are succinct some write novels, you'll learn what's important... then move to the next Pt... Like I said it can be nice to chart review and know everything about a Pt before rounds but then you might run out of time to do so on other Pts before rounds (also depends on how your hospital works, I round with my attendings), my chart rounding in the AM is for the big picture and to-do's for the day... after rounds is when you can chart biopsy and fill in the small details... Three weeks in, you'll be fine