Patient Care – 1.2: Comprehensively evaluate patients by a) obtaining accurate and pertinent medical histories, b) conducting appropriate and thorough physical examinations, c) gathering detailed ancillary information, d) synthesizing all relevant data to generate prioritized differential diagnoses, and e) formulating plans of care that reflect an understanding of the environment in which health care is delivered.
When I first started learning about how to take a medical history, I found it a bit overwhelming. I remember trying to learn different mnemonics, self-consciously practicing with other students, and repeatedly forgetting big chunks of the history. When learning how to do physical exams I again met a steep learning curve, at first struggling to just go through the motions without missing anything, let alone feel like I was gaining any useful information. I was grateful for my longitudinal preceptorship, where I had the opportunity to practice my history and physical. I started off with a lot of stumbling and disorganization, but I slowly started to figure out my flow. As can be seen in the evaluations by LP preceptor, I started to progress with my history and physical exam skills as time went on.
Evaluation from longitudinal preceptor in January 2018However, during my first 2 years, putting that information together and thinking about a differential was still very difficult for me. Although I was told my main job at this stage in my training was to work on just gathering the right information, I still wanted to be able to put together some sort of differential. Even for patients with a simple viral illness, whenever my LP preceptor asked me what I thought was going on with the patient, I felt like my mind would go blank and all I could think of was “I don’t know, I’m not a doctor”.
Third year brought new challenges with inpatient rotations and presenting on rounds. At first every morning felt like a scramble to try and effectively chart review, talk to, and examine the patient in time for rounds. I had to learn what information to actually present and would often overshare while still leaving out crucial details that I missed during pre-rounding. After a few weeks I started feeling much better about subjective and objective parts of my presentation; however, it took me much longer to improve on the assessment and plan portion. It was challenging for me to think beyond what I had seen in a resident’s note from the previous day or what the intern clued me in on.
Throughout third year, I continued to work on assessment and plan. Once I started feeling more comfortable obtaining the information in a timely manner, it became easier to spend time thinking about the next steps. By the time I started my mini-internship in pediatric hematology/oncology, I was able to start thinking more independently and feel confident in my decisions about what to do for my patients. My favorite part of my mini-internship was being able to take complete ownership of my patients and feeling confident that I had the skills needed for intern year. Since I was assigned as the primary resident for my patients, I was the one receiving pages and the primary communicating point for nurses, consults, and other care team members. I also pended all the orders for my patients to be signed by my senior. This allowed me to learn more about what needed to be in my assessment and plans, as performing these tasks forced me to be much more specific and detailed in my thinking. When talking to consults I needed to know the specific question for the consult and communicate the pertinent information about the patient. When choosing to order a medication, I had to think about why it was needed, doses for the specific indication, how long the treatment was needed, and possible side effects to look out for. I loved my increase in independence and responsibility and felt it really contributed to my learning and skill development. An excerpt from my letter of recommendation from an attending during this rotation really showed how much far I have improved throughout medical school.
Although I have come a long way during my time in medical school, there is still a lot I need to improve on in order to be a good doctor. During residency, I want to work on widening my differential and think of less obvious possible causes for a presentation rather than getting stuck on the first thing that jumps to my mind. I also want to improve on incorporating more evidence based medicine into my care and using literature to help guide my decision making. I will use PubMed to find up to date research and may enlist the help of a librarian for more specific searches such as those requiring MeSH terms to find the information I am looking for. I am grateful for all the experiences that have helped me develop the medical knowledge and skills that I have right now, and am excited to continue to learn and improve on them throughout my career.