Progress (Notes)

During this rotation part of my position as a PA-S at the clinic required me to complete progress notes for all the patients that I saw. After about the first week of the rotation I was instructed to see patients on my own. I would greet the patient and then subsequently follow the clinical approach my preceptor taught. Then my preceptor would come see the patient with me and after his history and physical we would formulate an assessment and plan.

Progress notes were written and stored on a computer software, and my preceptor structured the software so that there were many templates that would be used for filling out the progress note. For example, if the patient presented with and was diagnosed with GERD, I would type in “esophageal reflux” in the template search bar and then click the arrow to populate the note. That template would automatically fill out the chief complaint, history of present illness (HPI), physical exam, assessment, and treatment. This was useful but I also thought it was sometimes too generic or not detailed enough for the patient’s specific presentation. Typically I would use the template and then go back and edit the HPI so that it included details the patient said during the interview.

Oftentimes the treatment would be appropriate for the patient, but sometimes the doctor would change it to tailor it to the patient’s particular needs. This was good, but I did not really learn how to know what to change the medication to or how to adjust the medication dosage. This is something I still need to practice.

This clinic has only been in the area for about two years and the number of patients seen each day is not overwhelming, which is great for my pace at this time in my clinical experience. On the days where I would see patient after patient, I would not be able to complete the progress note until after the rush of patients. By that time I would maybe have three or four patient encounters to complete. Usually during the patient visit I wouldn’t type the HPI while talking to the patient so during the lull times I finished up notes.

I found it to be a little repetitive and a lot of work, though I recognized the importance of a good note. Sometimes when I read older progress notes from previous patient encounters it would be difficult for me to get the full picture when the HPI basically only consisted of the template’s description. The whole point of the note is to communicate to other health care providers a comprehensive picture of the patient’s condition. If many details are too vague or left out, it makes it very difficult for the provider to fully understand the reasoning behind previous visits assessments and plans, and also it is annoying for the patient to have to explain themselves visit after visit.

I remember one day after work I went home and I told a friend that I realized being a PA is a lot of work. Of course I knew this going in, but oftentimes in class I only thought about making the diagnosis and coming up with the management plan that the documentation portion of a PA’s duties went over my head. In my first rotation I never wrote the notes, so when I got to primary care, my tasks were such a contrast to emergency medicine. I would not say that I really enjoy writing notes but I know how important it is to a patient’s medical care, and I would not skimp out on work just because I felt like it was a lot to do.

 

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Primary Lessons

It’s been hard to figure out what to write about throughout this whole rotation. I feel it was easy to reflect upon all the different things I experienced and learned from working in the emergency department because it was my first rotation and I saw something different every day. Here at the family medicine private clinic, I find it harder to pinpoint things I have gained from working in this setting.

Many patient visits are very routine. Patients come in for physicals or for routine blood draws, or to review recent imaging or blood test reports. These encounters are all fine, but when I am speaking with patients I don’t really feel like I’m accomplishing much. It’s strange. I know that as a primary care provider, I am the first line medical contact for the patient. There’s a relationship that is supposed to form between the patient and his or her primary care provider. As a primary care provider, I am supposed to treat the patient in a way that shows I care about them, their well-being, and I am there to support them medically. But I don’t feel this trust relationship is reciprocated, as in the patient is not invested in me as a trusted figure in their life. I feel like they come just to see if they have any illnesses and/or to get medications. And yet, I still want to make sure they monitor their chronic illness and they complete all preventive medicine measures to ensure they’re healthy and to catch diseases early.

Even though sometimes I feel like what I’m doing is not making that big of a difference, I feel strongly that no matter what, it is important to do your job well. If not, there were be repercussions. A few days ago, I saw a patient who came for a vaccination and also mentioned that her last menstrual period was more than 2 months ago. After a confirmed negative pregnancy test, I looked at her problem list in her file and did not see anything unusual that would correlate with her menstrual period, though she did mention she felt fatigue often. The patient also said she was not taking any medications currently. I thought the best course of action would be to call it amenorrhea and do a workup for it. But after I presented the patient to my preceptor and after further conversation with the patient she mentioned she ran out of her thyroid medication. This changed the picture entirely. The visit ended up being much different than how the patient, and I, had expected it to go, but in the end everyone was on the same page. Whoever saw this patient in the past did not indicate in the patient’s file she had some sort of thyroid dysfunction and did not educate the patient about her medication. Because these things were not done, neither the next provider (me) nor the patient was able to follow through properly to take care of the patient’s health.

Thankfully the patient’s condition is not extremely serious and she is able to get back on track with treatment and my preceptor was experienced enough to get the whole picture and properly advise the patient. For me, I learned the hard way to not overlook anything in the patient’s chart from previous visits and to always check lab values. It’s hard to do especially when you’re rushed to see patients, but a quick glance at values is much better than not pulling them up at all. My preceptor semi-scolded me for not fully investigating the presentation and lab values and documents, and therefore not realizing the patient had a thyroid problem. The feeling of failure was not pleasant, and from then on I was again determined to always strive to do my best work, all the time.

Practice

At the current clinic my preceptor has this clinical approach:

5 Fingers

  • Chief Complaint
    • This is documented in the patient’s own words. It reflects the reason why the patient came to the clinic.
  • Problem List
    • This shows the past medical history of the patient. By going through this, the practitioner has a better idea of what is already going on with the patient and this will allow you to have a better idea for diagnoses when they present with symptoms.
  • Medications
    • It is important to review what medications the patient is currently taking, what have they stopped taking, and if it matches up with the medical history.
  • CDSS
    • This stands for Clinical Decision Support System. There are some guidelines recommended by the government in order to practice good preventive medicine. These ones are in the top portion of the CDSS tab. The bottom portion encompasses additional preventative medicine the clinic would like to include in the patient’s care.
  • HPI
    • After you have gone through the first four “fingers” you can evaluate what the patient presents with in a comprehensive way.

Physical Exam

  • No matter what the patient presents with, it is imperative to always do at least a brief physical exam of all systems. There may be incidental findings which would be missed if only a focused physical exam is done. These findings may be serious. Patients will only respect you more for being thorough.

“See something, do something”

  • This means if you see something, even if the patient doesn’t complain of it, you should implement some sort of treatment for it. Patients may not be aware of the problem, but if you find it, you should act upon it.

The traditional approach we learned in school is termed SOAP, which stands for subjective, objective, assessment, and plan. Basically it’s what the patient presents with, what you find, the diagnosis, and treatment plan. When taking the history (as I’ve written about before), it usually starts with the present illness, then past medical history and medication, surgical history, allergies, family history, and social history.

The approach that my preceptor has adapted is actually very similar to the overall SOAP format but within the “subjective” portion, the five fingers approach is a little different. Because my preceptor reviews the patient’s problem list first, this gives an idea of what he’s working with. If you have a blank slate, it’s hard to know where to start, but if you already have a landscape it allows you to more accurately map out a direction where to go. For example, if a patient comes in complaining of a cough, instead of going through all differential diagnoses for causes of a cough, you could look at the patient’s medical history. Perhaps this patient has a history of hypertension and is taking an ACEI which can have a dry cough as a side effect. After you review the medical history and medications and address any preventive medicine measures, you go through the history of present illness and ask appropriate questions to lead you to a diagnosis. Of course, this is not to say that you don’t explore other differential diagnoses when the patient already has a medical history.

I think it’s important to always do a brief physical exam even when it doesn’t seem warranted. Incidental findings could be the only way a patient finds out early about a cancerous growth or a concerning condition. In my personal experience, I once saw a doctor for a sick visit and she happened to palpate an enlarged thyroid. From there I had an ultrasound and learned I had a thyroid nodule. Though it’s not cancerous, I’m grateful the doctor was thorough and brought this medical problem to my attention. To contrast, I went to a different doctor for a physical exam and to get a medical form filled out for school. He barely even looked at me, checked off everything on the form as normal, only listened to lung and heart sounds, and signed and stamped his name on the form. This was after I knew I had an enlarged thyroid, so I knew he missed findings during the visit.

At my rotation I’ve been told that a lot of the patients come to the doctor but they don’t want to hang around—they just want to get in, get a prescription, and get out. One of the people I’ve been working with told me to work fast because the patients don’t want to stay a long time. I have mixed feelings about this because I understand people have lives, but also this doesn’t allow the practitioner to do a good job. If you don’t allow your practitioner to do his or her job, what is the point of visiting? And to be quite honest, I only had one patient where she was actually in a rush to leave. All the others never mentioned to me that they didn’t have time to talk to me because they were short on time. Though this isn’t to say that we should take all day to talk to one patient. In my opinion, being thorough never hurt a patient, and patients will recognize your genuine care for their well being.

In the past three weeks in a family medicine clinic, I’ve been able to practice more medicine and interact with patients in a way that allows for more patient interaction based on the principle that as health care providers we are to care for the entire person so that they will live healthy lives. I stand behind this and it’s nice that I get to build this foundation as part of my clinical experience.

New Rotation, New Challenges

Rotation 2 for me is primary care in a private clinic in the “Chinatown” of Brooklyn and the first week and a half at my new rotation site has been rocky. Going in, I knew primary care was going to be different from emergency medicine but I didn’t realize how different.

There have been a couple obstacles that I’ve had to figure out how to handle, one being my preceptor not being at the clinic to teach me sometimes. For example, my preceptor did not show up the first two days I went to the clinic. Because he didn’t show up, it was hard to know what I was even supposed to do. There’s another guy at the clinic that sees patients but he’s not my preceptor and his approach to seeing patients is different to what I was used to in the ED and is also different to my preceptor’s, which I found out on the third day of the rotation. So after two days of learning how this person saw patients and documented patient visits, I had to mentally switch processes under the tutelage of my preceptor. My assigned hours start at 10 a.m. but sometimes my preceptor doesn’t show up until the afternoon, so there have been days where in the middle of the day I switch methods to match the person I’m working for.

Another issue has been a language barrier. On some days I’m thankful I wrote down I could converse in Chinese when we signed up for rotations back in February, but on many days, especially at this clinic, I wonder why I did that to myself. Many of the patients, especially if they’re seeing the other person at the clinic, speak a different dialect of Chinese that I cannot understand, so oftentimes I stand to the side lost in translation. This makes it very difficult to follow the conversation and visit for obvious reasons, and it also makes it very difficult to write the progress note for the patient visit. There have been days where many patients in a row speak the foreign dialect and then when I’m trying to catch up on notes I have to stop every sentence to double check with the person who actually spoke to the patient.

Many times I have had a hard time interviewing patients because they seem to not trust me. Just yesterday, I was reviewing a blood test report with a patient and also going over his past medical history and everything I told him was medically sound but he didn’t seem to buy what I was telling him. When the other person came into the exam room and repeated everything I told the patient, he readily received the information. After the person explained everything, the patient told him he liked chatting with him. The person I work with told me many times Chinese people don’t trust me because I look young and when I smile I look like a kid. I kind of took offense to this initially (internally, of course) though I admit I look young. But in my opinion, it’s not something I can change, and I never had that problem at the ED in my past rotation. So now I’ve become more conscious of how I carry myself and also how I present the medical information to patients.

Clinically the greatest challenge has been learning how to turn medical information into practical and applicable knowledge for the patient. For example, when I see that an ultrasound report shows ovarian cysts, I understand what that means. But patients don’t care so much about the pathologythey want to know is it dangerous, is there any medication for it, does it require surgery, etc. In the classroom we didn’t really learn how to explain findings to patients and how to navigate treatment/management plans, and my preceptor assumes I already know how to practice on my own, so in my mind I’m going “Help! I don’t know what to do!” while I plaster on my professional face and try to say something that makes sense and is helpful.

In the ED we focused on very acute illnesses but in primary care we focus a lot on chronic illnesses and preventing diseases. Therefore communicating with the patient is paramount for patient compliance and cooperation, which leads to their wellbeing.

Thankfully my preceptor enjoys teaching, and by observing I’ve gotten some ideas of how to talk to patients. I still have a lot to learn—not just to solidify my medical knowledge, but also to become skilled at asking the right questions, motivational interviewing, and formulating the best plan of action for the patient.