Clinic Day

As a first-year resident, I get approximately two half-days of clinic each week where I see my own patients on an outpatient basis. The actual amount of time in clinic depends on what rotation I'm on. I just started sports medicine, so my clinic time is all day on Friday. This is the first time I've had a full day of clinic, and it was a bit challenging. Every month, the administration adds to the number of patients we are expected to see in a half day. I started with just two patients in four hours and am now expected to see four to five patients in four hours. The idea is to allow the residents to get used to the electronic medical record and to give time to check out each patient to the faculty preceptors. And believe me, I need all the time I can get!

So, Friday I had my first full day with 4-5 patients in each half dayn (ended up seeing 9 patients total). Sounds pretty easy, right? And actually, I did manage to finish on time. But I still had to finish up my notes at the end of the day, so I was at the office till about 7:30 PM. I find it hard to actually write my note while I'm with the patient. The program loans us a laptop to use in clinic, so I take it into the exam room, but I feel bad if I'm trying to listen to the patient while searching around on the computer for where I'm supposed to enter information or orders. So generally, I talk to the patient and then leave the room to enter orders for labs, imaging or medications. Those have to be done before the patient leaves, so it's important to at least finish that much. I also try to fill in my assessment and plan before the patient leaves. This is like a "to do" list. I list the problems I'm addressing that day and what I did or am going to do about them. I'm getting better at it, but it's still really slow. Sometimes my patients have to wait while I figure out how to refill their medications or how to order a specific referral. They don't seem to mind too much, but I feel bad taking up their time.

Some patients are really straightforward - pregnant or post-partum patients, for example. For these patients, there is a checklist of things to do and standard labs to order. So they get in and out pretty quickly. Pediatric visits are also fast in general. The ones that take the longest are the patients with several major chronic conditions (diabetes, high blood pressure, heart disease, COPD, etc.) on 15 to 20 different medications. Of course, I can't expect to address all their problems every time, but when a patient is new to me, I want to know how they are doing with all their conditions, especially since these problems are all interrelated and any new complaint or symptom could be linked to poor management or progression of any or all of the chronic problems. It's really hard for me to sort through all that in a short time and focus on only one or two things. I guess I have to get more efficient, and I am sure I will learn as I go. Plus, as I get to know each patient, I will have a better grasp of what their underlying issues are and what things are most important to address. Right now, most of my patients are new - to me at least. Except for the pregnant patients, there aren't many that I have seen more than once.

Yesterday I did see one of my "regular" patients. I've seen her about four times already in the two short months I've been in residency. She has chronic abdominal pain, likely caused by adhesions from several prior abdominal surgeries. She's tried a number of different medications for pain, none of them completely effective. When I first saw her she had had a seizure, and after getting her history I felt that it was likely due to the large amounts of a specific pain medication she was taking at the time. She also had elevated liver function tests, probably related to some of the medications she was taking. So we had to stop that several of her medications and essentially start over in figuring out how to manage her pain. I am not comfortable giving a patient, especially a young person like this patient, narcotics for long-term pain control. Narcotics do have their role, but they also have high abuse and dependency potential. Anyway, I was trying to find a way to keep this patient from depending on increasing levels of percocet or lortab for her pain. Chronic pain can be very debilitating, and over time can lead to depression and worsening of the pain in a vicious cycle - pain leading to depression and depression making the pain even less tolerable.

Every time I have seen this particular patient, she looks depressed, fatigued and totally demoralized by being unable to enjoy her usual life activities because of pain, even though she denies feeling depressed. Yesterday when I walked in the room I could tell she was not doing well. Her face, posture and voice all looked depressed. However, after we talked about what was going on and I made some suggestions about steps we could take to improve her pain, her face brightened and she actually left smiling! Amazing! It felt so good to develop some trust and rapport with my patient! This is the way I imagine myself as a family doctor - seeing my patients regularly and becoming familiar with their lives, their medical conditions, what things they've tried, what's worked and what hasn't worked, what stressors in their lives make their conditions worse, how their major relationships are going. Being a doctor is an awesome privilige and joy.