Intern needs adice re complex patient management

This is for interns/resdients/docs with experience in outpatient primary care clinics!

I really need your advice on 2 things - scanning a chart and managing a complex patient.

What are your strategies for quickly scanning a chart and organizing the info that you need for the 15 to 30 minute slot - reports from specialists, preventive care, patients CC so that when you go in you are sure everyting gets covered?

I also need your advice on what phrases I can use with patients to let them know 1. how much time we have together and 2. what we can expect to cover this visit and what we will reschedule. Please provide specific examples as I will use them until I am comfortable with my own. I think I am too nice and end up chatting too much, especially with the complex patients who often are all too willing to do so as they are elderly and/or unemployed.

You can PM me or email! Please help as my next clinic is soon! I felt horribly frustrated, incompetent and rushed at my first clinic this week

Having been in practice for a year, and having had two years of mostly outpatient experience before that as a resident, I can tell you that this skill takes a LONG time to master. You should have a faculty advisor during your outpatient clinics who can help you with this.

If the charts are printed, there should be a summary page - maybe an inside folded over portion of the cardboard folder - where key diagnoses, immunizations, and health maintenance stuff is summarized. There should also be a page with updated med lists. If you’re working in an EMR, this should be on a summary page as well. Notice I said should be. In my experience the well-updated chart was the exception…

As for the patient encounter: My opening question is usually some variation on, “What brings you to the clinic TODAY?” Note the emphasis. That can help you start to set the agenda. You may get a looooong list in response to this question. As you hear the list, decide what concerns YOU the most or what YOU as the doctor feel must be addressed. Keep those thoughts in your head, and then ask your patient, “Can you give me the top two [could be one, three or any other number you’re comfortable with] things from there? That way I will be sure to spend time on those, and if we are able to, we will get to some others as well.” And then, if neither of their top two is your main concern (you would be surprised how often chest pain is an oh-by-the-way), you can say, "I want to be sure we talk about your heel pain and your trouble sleeping. You did mention one other thing that especially concerns me, and I’d like to start with that… " and then do the chest pain or whatever thing you heard that was alarming.

You can say, “Each of these things deserves a good conversation so I would like you to come back to see me in a month, so that we can talk about your toenail fungus. You can then let me know how the medicine to help you sleep is working, and whether these exercises for your heel pain are doing any good.” First of all, this is good medicine: you should follow up when you’re treating something. Secondly, it assures the patient that you aren’t just blowing them off - you’ve set the agenda for next time.

As you are contemplating and triaging the patient’s list of concerns, remember that there will be things on there that require at least a brief acknowledgement because you do not want to send the patient home still worried about something, or feeling that s/he wasn’t heard. A lot of times I can say something like, “You’re worried about that spot on your leg. I can tell you that those sorts of things usually aren’t a big worry, and they don’t change fast at all, so we can set aside time in a few weeks to really look at it carefully and decide if it needs a biopsy.”

You MUST address, at the time of the visit: chest pain, rectal bleeding in a person over 40, unexplained weight loss, very high blood pressure, depression. I’m sure there are a bunch of other things but these were the first that occurred to me. They’re the “oh, shit” symptoms – when I hear them, I think, “there goes my afternoon…” at least potentially.

But even then, once you are good at this, you will be more comfortable triaging these symptoms and deciding whether they require the full-court press or a brief drive-by to make sure nothing bad is happening.

And you really do have to address the reason for which the patient made the appointment, even if it turns out to be a minor concern. If you handle the entire diabetes follow-up appointment (and he’s got hypertension, hyperlipidemia and a BMI of 42) but don’t set aside the time to address the patient’s concern about erectile dysfunction, the rest of what you have to say to him is not going to be heard.

It is July 8 of your intern year!!! The whole point of your outpatient experience is to help you get a sense of how to do this and develop your own style for handling these situations. So telling you what I say and how I handle it won’t be very helpful, I bet. Doing it yourself, over and over and over and over and over and over… that’s what makes it work for you. Good luck!

(Oh, and enjoy those conversations with your patients even if you are running behind. Those are the rewards for those tough days.)


Thanks for your very helpful comments!!