Wednesday, August 24, 2011

Doctor's Notes

Before going much further, I feel like I should apologize for not having written anything lately. The past seven and a quarter days I've been working with the hospitalist service and that includes the weekend. It's probably self-indulgence, but truthfully, our work as students doesn't end with a punch of the time clock. Anyway, thanks, as always, to any and all who've come by to see if there's anything new. I've got the next four days off and I'll try my best to make up for my laxity of late.

What's that? Oh, the hospitalist service refers to physicians who are employed by a hospital for the sole purpose of providing inpatient care. My current rotation entails spending a week to ten days working with one of them -- it's a bit like an apprenticeship -- and learning internal medicine under their tutelage. The two weeks prior were spent with family medicine residents seeing their assigned patients and it's to their service I'll report once again this coming Monday.

As healthcare delivery has changed over the years, it's pretty rare to see a family doctor or any kind of doctor, for that matter, admitting and then following their own patients in the hospital. There are still a few, mostly family practitioners in the hinterlands of upstate Maine or other remote locations, who do it the old-fashioned way, but they're a vanishing breed. For the most part, patients are evaluated in the ER and then transferred to the responsibility of a hospitalist who oversees their hospital stay.

And that's where my fellow students and I come in. We'll report to the Emergency Room, take a detailed history from the patient and/or their family members, complete a physical exam in the company of a resident or attending physician, and then become a member of their treatment team as long as they're inpatient. Sometimes the H & P (history and physical) has already been done when we arrive for rounds (morning report) and we just go on from there.

My first two weeks I spent learning how to write a clinical note. That may not sound like much, but really, it's huge. The clinical or chart or progress note -- they're all basically the same thing -- is how doctors talk to one another about a patient's condition, symptoms, and so forth. Even though I got the basic format down during my psychiatric rotation, writing a note for internal medicine takes practice and I practiced a lot. I didn't have nearly as many patients to follow as I did this past week, so I had time to write and rewrite my notes over and over to make sure I had something worth leaving in the chart.

This past week my task was slightly different. Having gotten accustomed to writing notes that were legible and covered all the clinical bases, now I had to figure out how to turn them out faster in order to keep up with my attending. But you can only write so fast before legibility gets tossed out the window and a student's note has to be readable in order for a supervisor to evaluate our thinking process. So, you learn the art of brevity, writing what is truly necessary, and generating a plan of treatment that specifically addresses a patient's symptoms that particular day. Pragmatics take precedence over literary perfection.

It's a matter of taking one step after another, one step at a time. That's really how a rotation like this one unfolds. To be of any value at all, you've got to be able to communicate about patients and since your note is a critical element in the process, you start there. It's not dramatic, no one's going to page you at the end of the day with an offer of a guest spot on Gray's Anatomy. But once in a while, an attending reads what you've got to say, decides you have a good idea, and adds the medication you suggested or obtains the consult you recommended. And right then, you got to do something good for someone. And that's really cool.

(Creative Commons image entitled "Doctor's Note" by keitamiyoshi via Flickr)
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