I don't know if I'm cut out for this, need advice.

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zeppelinpage4

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I'm 3 weeks into my pediatrics floor month and really lagging behind the other interns. Multiple senior residents have pulled me aside and told my I'm not keeping up with my patient load as well as the other interns and they're concerned I'll be in trouble when I carry 9-10 patients instead of the easy 5-7 that I am carrying now.

My main issue is that I have difficulty remembering all the details of my patient's care and just can't seem to keep track of all of it as well as the other interns. I'll have one patient need their post-albuterol treatment check at a specific time later in the day, another needing follow up from a specialist, a third with social works issues where I need to coordinate meeting with case management and the medical team, and orders and tasks for so many others, sprinkled in with rounds and meetings.

I tried the medical scut sheets and wrote everything down which has helped, but by trying to write everything down I've become really slow and don't finish my notes till hours after my shift has ended, or I have to fumble through a bunch of papers during rounds. Everyone has told me to write less, but when I write less I forget things...but when i write more, I get disorganized and slow and then miss things as well. And this is only with 5 patients which should be easy for mot residents and interns.

I'm worried I just don't have the brain power for this, I barely got through medical school and struggled then as well. Has anyone struggled with keeping organized and being efficient, but still trying to remember what needs to be done and staying on top of all the tasks? Any advice on how I might try to improve? If it wasn't for the debt, I might do my fellow residents and future patients a favor and just leave as I'm clearly not good at this...or even average.

Thanks to anyone who replies.

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The resiliency that got you this far just has to go a little further. El diablo sabe más por tiempo que por diablo. Give yourself more time.


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If it is any consolation, the first month sucks for everyone regardless of what they tell you. i know I went through multiple systems before I came across the one I use. But to start, I would carry notecards in my pocket which was my daily to do list. If I had notes on a patient lists like "CBC, BMP, CRP" which would tell me to put in morning labs, I wouldn't write it on my to do list as I would go through that stuff later and it didn't matter when it got done. I would put stuff like "check on 404 at 1300 for albuterol" or "307 parents" if someone wanted to ask some questions. I would revisit the list tons and not miss stuff. Maybe trying a centralized to do list so you don't miss the big stuff.
 
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A to-do list is key. It comes in many forms and you will eventually settle on a method that works for you.

As an intern I would print out a rounding sheet from the EMR for each patient that was pre-populated with vitals, labs, I&Os, meds etc. for the last 24 hours. I would fold each paper over to give myself blank space to write. In that space I would write my to-do list for that specific patient along with overnight events, concerns from nursing, etc. Each item had a box that I would check when the item was completed.

This is not a matter of brain power. This is a matter of coming up with a system that works for you that you will perfect as you gain experience. You need to get in the habit of checking your to-do list regularly throughout the day or you will forget to do things. This is true for everyone. Don't be afraid to write things down during rounds. It will get easier.
 
1) It's the first month. Give it a hot second.

2) It's great that your seniors are letting you know, but they also need to be offering suggestions based on what they're seeing you struggle with. If they're not, then you need to ask for that piece.

3) You have to prioritize, in a way that makes sense for you, but also in a way that gets the important things done first. In general for most people, after rounds, that sequence of tasks should be new orders, discharges and transfers, calling new consults, following up with old consults, families, new admissions and then notes that you haven't finished.

4) Anything you can do to get faster at notes is a huge step forward. For most people who struggle with time management, the first thing they can/should do is let go of ideals of perfection. Yes you want to be complete, but let's face it, plans change. In the PICU, what I set out for my plan at 9am may be complete crap by 945am. Put the initial plan in, and if it changes a whole bunch later in the day, throw in an interim progress note later. As a resident, I tried to have 75% to 90% of my notes done before morning rounds started, but I could only do that if I kept things simple.

If your EMR has templates, ask your seniors to share the templates they have with you. EPIC has a lot of smart phrases already built in, and you can make your own. I have a standard asthma template that says things like "space albuterol as tolerated" and "decrease IVF as PO intake increases" which are technically accurate at any point in the hospital stay. You need something more than a 30,000 foot view of your patient, but you don't need to be Google Street View either.

5) Until you're consistently faster, don't get sucked into the socializing team room in the afternoons. Don't worry about teaching the medical students, and don't let families monopolize your time. Ask nurses to get you out of rooms if you're not back out in xx number of minutes.

6)Fewer papers the better, or at least they need to be organized well. The EMR signout is a good place to start as it'll format it for you. Some of my co-residents and co-fellows did note cards, but I would always fumble through them trying to find the right one, and they would always get out of order which I didn't like (although one of my co-fellows but them on a ring so they were at least in numerical order by bedspace, which probably would have helped me).

7) Not everyone is destined for inpatient medicine, and you may find yourself doing much better in clinic. That's great, but you got to get through this three year period.

8) If you're constantly staying late to finish your work, it's probably a sign you need to get in earlier. Nurses don't know to bother you when the night shift is still in the hospital. You can get yourself organized for the day, and set yourself up for success.
 
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I'm 3 weeks into my pediatrics floor month and really lagging behind the other interns. Multiple senior residents have pulled me aside and told my I'm not keeping up with my patient load as well as the other interns and they're concerned I'll be in trouble when I carry 9-10 patients instead of the easy 5-7 that I am carrying now.

My main issue is that I have difficulty remembering all the details of my patient's care and just can't seem to keep track of all of it as well as the other interns. I'll have one patient need their post-albuterol treatment check at a specific time later in the day, another needing follow up from a specialist, a third with social works issues where I need to coordinate meeting with case management and the medical team, and orders and tasks for so many others, sprinkled in with rounds and meetings.

I tried the medical scut sheets and wrote everything down which has helped, but by trying to write everything down I've become really slow and don't finish my notes till hours after my shift has ended, or I have to fumble through a bunch of papers during rounds. Everyone has told me to write less, but when I write less I forget things...but when i write more, I get disorganized and slow and then miss things as well. And this is only with 5 patients which should be easy for mot residents and interns.

I'm worried I just don't have the brain power for this, I barely got through medical school and struggled then as well. Has anyone struggled with keeping organized and being efficient, but still trying to remember what needs to be done and staying on top of all the tasks? Any advice on how I might try to improve? If it wasn't for the debt, I might do my fellow residents and future patients a favor and just leave as I'm clearly not good at this...or even average.

Thanks to anyone who replies.
All good advice above. Additionally, there are tons of other people at the hospital and you need to learn to ask for their help in completing tasks. Example above, Albuterol check. The RT and nurse have to do it too. Ask them to page you when they do, then you can do it together (and get a reminder). Second example, usually the specialist will tell you who to follow up when and a number to call. You could call the clinic and make the first available appointment, that should take less than 5 minutes (unless you have to hold, but that's why phones are portable). Third, why don't you ask the case manager to help you organize the meeting. It's kind of their job. Most orders should be completed on rounds. I don't know what meetings you are talking about, but prioritize them. I doubt every meeting is essential.

Lastly, most places have some sort of signout sheet or whatever. Write a "To do" list on the signout sheet and check off boxes when task is complete and draw a new box when a new task comes up.

Honestly, a lot of this sounds like you are in a new place, in a new system and still getting your feet wet. You'll learn who to delegate tasks to, who can help and how to utilize the system to your advantage. It takes time though...
 
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Here's a couple things that have helped me:

1) At the beginning, I got to the hospital by 4:30 AM. First, I read the previous night's comments from residents, any changes on my patients, and what my plans for my patients are by just chart review.
2) I carry A LOT of paper. I take a white piece of paper and divide into foul halves. One for each patient for that day. I don't put every detail on it, but the most important ones and the date on it. So, if I admit a patient for DKA; typical range of sugar's, amount of insulin, amount of fluids received, electrolyte changes, allergies, weight, age etc. And then put a box next to the things for the "To Do" section after I check on that patient. Again, only important details that will enable me to present about the patient. For Day 2 for that patient, I add another paper and staple the most recent on top, so it's easier to access during rounds and keeps it organized.
3) When I do my rounds, I start a note on the patient outside his or her room. I don't complete it, but I put in any changes in the note on Epic immediately. And subsequently scribble that change in my note for my patient I carry. I write-down what I think needs to be done for that change or maybe pend that order for my patient before I see the residents. Add more insulin? Require more mag? You get the point.
4) This process typically takes me until 6:30 AM by which point my R3 arrives. I check in with him or her and update any changes on my patients and what I want to do for them.
5) I spend the remaining working on my notes for my patients or maybe putting orders in. If I don't complete my notes, it's ok. I will come back to them later. I typically "pend" them until I finish writing them later.
6) I organize my hand notes based on what room we start rounding, so I don't lose track/look organized and confident.
7) Most residents carry a portable computer with them, so they can update orders as they go. If you don't have this capability, write down those orders so you don't forget so you can put them in later.
8) After rounds, I go through my notes again. Are these kids I need to follow-up on? If so, when? Here, I prioritize the sickest patients first.

For in-patient, I really think organization is key to success. I have faith you will pull through and do great! I remember an intern my M3 that was in the same boat as you and she turned out fine! Some people just need time to get used to the pace. And for others, it just comes naturally.
 
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Heres my system that is getting me through 8-10 patients/day, will likely only work with EPIC specifically:

pre-rounding:
1. get checkout, write down overnight events on list/handoff
2. log on to computer go to notes section and copy forward my note
3. erase what I have in subject and type in overnight events that were just signed out to me
4. read new notes in chart very quickly, paying specific attention to consult notes (mainly the new recs) and nursing event notes. Write down pertinent info in subjective. Time mark notes.
5. go to MAR prns section, as quickly skim through day. Put any PRNs given and why in your subjective.
6. scroll down to vitals sections of your note and open vitals table. Review vitals, if any abnormalities go to vitals graph to get trend. Type what would say in rounds on note.
7. Go to I/O section of note and I/O section of epic. Type what would say on rounds.
8. skip over the physical exam section, this you will simply have to remember to change later
9. go to results review section of note and open results review in epic. Review labs and place what is important in your note. Dot phrases are key here so you don't have to do a lot of copy pasting. I usually type what I would want to say about important results here so on rounds I don't stumble. Time mark results review
10. Go to assessment and plan which I do by problem list. Make any needed changes for the day with a *** and bold them. If your plan is right you won't have to change it later.
11.print out notes
12. by subjective write down specific problems you want to ask the patient about. For example if they have nausea on their problem list write down and ask how their nausea is.
13. talk to patient and ask only about those specific problems and any other info you need to know and do a quick physical exam. Inform them that you will update with plan after rounds.
14. on the note you printed up date the subjective section and assessment and plan with any necessary changes

rounding:
I basically read off my note. Only thing I actually have to draw from my memory is my physical exam findings, but this is usually pretty easy for me. On my handoff I have each patient folded in half where I will write my to-do list immediately after we discuss the plan for the day so its fresh in my memory. Orders should be put in by one of your co-interns.

Post-rounds:
typical priority list is discharges, call consults, make sure orders are in right, admissions, rest of stuff on to do list, make changes to notes (which are already almost done)
Any events that happen during the day I will write down next to my to-do list.

Check-out:
This is fairly straight forward. Give brief summary of the patient. Look over to where I wrote my to do list and any events on the folded part of my handoff and basically read off that which covers any of the days update. I then follow this with any to-dos for the night and my if-then scenarios

And then I leave. I like this system because I have a tough time remembering things off the top of my head, and this helps me be thorough and at the same time get my notes almost done which saves a ton of time.
 
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