I entered into my clinical rotations feeling accomplished for having studied and completed my first USMLE exam. I felt that I had finally synthesized a great deal of the information that I had been studying over the first two years of medical school. I felt that I was ready to implement this knowledge as I cared for patients on my various services moving forward. This proved to be true, but only in part. I quickly experienced how seemingly different taking care of a patient actually was when compared to the practice questions I had used to prepare for exams. I didn’t have a select number of options to choose from when formulating my plans and rarely did a patient have only one problem that needed to be addressed. This was, frankly, a daunting experience and certainly an awakening for me. I had to take a step back. I’ve come to realize that the assessment and plan is as much an exercise in medical knowledge as it is one in bookkeeping and presentation skills.
Before any plan can be proposed, an appropriate assessment needs to be put forth. I found myself often trying to multitask both of these components and getting lost in the weeds. It may seem like a trivial realization, but for me the methodical approach of first constructing a list of problems before moving forward has been invaluable to me. From there, I can much more confidently suggest plans that I feel more completely address the patient’s needs.
As part of my fourth year schedule, I spent time in the ICU. This part of the hospital is where a robust assessment and appropriate plan is truly paramount.The first step to creating a strong assessment and plan is to thoroughly review all relevant information in the EMR. Reading a patient’s chart, reviewing vitals, labs, imaging and relevant provider notes, followed with reading well structured resources like UpToDate, have given me a roadmap to continue to improve in my understanding of medicine with the relatively limited time that I have now compared to previously. One particular advantage to this style is that I feel like I am able to retain more and at a quicker pace simply by remembering my patients and our time spent together. It makes it much easier to retain information when that information is directly applicable to someone in your care. This method of initial data acquisition has allowed me to rapidly improve in my ability to differentiate important information in the chart from potential red herrings. I am then able to go speak with the patients already having a general construct of what I believe the problems are and what I would like the plan to be for that day. After speaking with the patient, my assessment and/or plan might change but I now have the information necessary to start the care for my patient on that particular day. Over time, my ability to efficiently review and construct an assessment and plan has dramatically improved but I know that there is more improvement to be made with more practice.
I hope to continue to improve on efficiency during my time in residency. This will certainly be a step up from my experience in medical school, where I will be responsible for not only more patients but also have more responsibilities as a whole. It will require me to continue to practice my ability to gather information in a time sensitive fashion and improve on my ability to acknowledge what limits my patient from being discharged. I believe I can more effectively map out what my goals are for each individual day if I talk with senior residents and my attending about what our global goals are for that patient’s stay. I need to continue to educate myself on the various pathologies I will be treating and consult resources like UpToDate or relevant literature when I reach the limit of my understanding. I believe that with consistent practice, feedback from my team and a strong ability to consult the literature, I will continue to see improvements in my ability to effectively construct an assessment and plan for all of my patients.
General Medicine Evaluations
Neurology Evaluations
CVICU Evaluations
