Crowdsourced tips for clinic success- 2016


More Clinic tips!

Welcome to those who moseyed over after lecture today. As promised, more and more tips on success in clinic. Enjoy and have fun in clinic this year!

Prep Before Clinic  Very common advice from your fellow residents.  Spending 30 minutes the day before is huge to keep your clinic session moving.   

Karla Williams: Review your clinic schedule including the patient’s history, last clinic note and the reason for their visit before the start of clinic.

Prep your clinic notes. This gives you the opportunity to make tentative plans of care for chronic and health maintenance issues in advance. It also helps me to create my goals for the visit and not miss key issues/interventions. You can always in error the note if the patient is a no show.

Lauren Shea: I start by going through the most recent note and any d/c summaries to construct a past medical history. I type this up by hand when I write my notes, so I can use if for next time (rather than the pre-populated list).

I review the reminders beforehand to make sure there is nothing I’m missing.

Last, I make three lists: “Labs”, “Discuss” (smoking, pain, etc). and “Orders” (immunizations, eye clinic, etc) for every visit beforehand. With all this, I tend to miss less!

Rachel Labovitz: Before going into the room I search the chart and know the things I must get answered in that visit (is it a wellness/ACRF and know what goes along with those, any screening tests that need to be ordered etc)

Jake Lancaster: I’d say that preparing beforehand is key. I usually spend 30 minutes to an hour before clinic clearing out my reminders and reviewing each patient as well as taking notes about what their main issues are and what screening items they need. I then can spend the time in clinic addressing their primary concerns as well as the main things I feel we need to cover. Most of the time they have new issues that tend to distract us from the main issues that I want to address. I usually try to refocus the conversation and bring them back soon to further address their other issues.

Katie Chitwood: pre-round on your clinic patients- I print off the plan from the last note and also make notes about labs/imaging/subspeciality clinic visits since they were last seen in clinic so that I can focus on these highlights and address specific points during the visit without staring at the computer and scrolling through results while talking to patients. It also helps to highlight health maintenance that may be due soon so that you aren’t scrambling at the end of the visit to discuss this.


Preventative Health  Automate as much of this as you can. Checklists/templates or the EMR generated Heath Maintenance tools are all recommended.

Ginnie Prater: I made my own template in CPRS in which I list indications for specific screening (ex: screen 40-70 year-olds who are overweight for diabetes). When previewing clinics I jot down what is missing so I can devote more time to listening to the patient and quickly make preventive care recommendations at the end of the visit.

Susan Karam: Spend some time making checklists for health maintenance, immunizations, DM etc. It is a little work up front but will save you time in the end

Andrew Land: It is a time investment upfront but the Health Maintenance section in the chart actually is really useful and is customizable

Chitwood: Have a health maintenance list that you can insert at the bottom of your note that you can refer to in order to see what is due for the patient. The impact populated HM list is less user friendly and some things can get lost in translation. (Ed. We can’t always agree…  My take, the IMPACT HM tab is helpful, but requires several visits and attention to get right. Residents don’t always have that luxury, it is harder to see the benefit)

Shea: For health maintenance, I use the “Worksheet” in CPRS to review HIV, HCV, Hgb A1c and lipids, and calculate their 10-year ASCVD risk in advance if appropriate. I use “Health Summary” under the “Reports” tab to review Immunizations and make sure all these are up to date. Then I just scan the “Onc-Watch” note for the last colonoscopy and recommended follow-up.


Negotiating the Agenda  You just can’t do it all, and patients generally understand this. Bring them back! 

 Land: For patients with too many concerns, the earlier in the visit you set up the understanding you aren’t going to be able to discuss everything the better they accept i

Louis Cummings: If chest pain is mentioned as problem #9, when your hand is on the doorknob to escape, it is probably not unstable angina

It is ok to tell pt ‘that is enough new problems for today, I’d suggest a followup appt for you other concerns, so we will have time to address everything thoroughly’

Karam: Bring people back frequently. You don’t have to address every condition at each visit. Better to focus on a few and be thorough than to try to do too much and not do any of it well. Explain this to patients at beginning of visit and let them give input on what issues are important to them to include in the visit.

Erin Contratto: The biggest tip I have for residents starting out in clinic is that not every problem has to be addressed at each visit.  Except emergent ones (new chest pain, sob, abd pain).

Rachel Labovitz: They might do a ROS and complain of 50 things, if that is the case I ask, what of these things are new? I’ll try to tackle some of the new things that are bothering them, but not all.

In residency I feel so often that you have to address every item at every visit because 1) you think they all might be connected and will give you some amazing diagnosis 2) you think every problem needs to be addressed at every visit BUT these people walked in here today and for the most part they are going to walk/wheelchair right back out and come back the next visit to further discuss these issues. I would say that I could reasonably tackle 5 problems/diagnoses a session if there are some uncontrolled issues. Sometimes less than that depending on the issue. Now that I have return visits for people that I know and have stabilized it is obviously more than 5, but starting out I think 5 might be a maximum to try to tackle


Efficiency  How the heck will I see 5 patients (or 10-20) in a session?  Read on…

Williams: I tend to type key details of the HPI while in the room, a tentative plan of care while awaiting checkout, and place all orders (Rx, labs, and consults) either while awaiting checkout or after.

Land: May be worthwhile to arrange for someone to cover your pager while in clinic, nothing disrupts the flow like having to go deal with an inpatient issue for 20 minutes while still seeing patients

Putting orders in while in the room with the patient will help save time and helps to avoid forgetting to order things later on

Oubre: Gaining home access is the biggest game changer (although that’s a huge issue at the VA right now). It allows you to look up your patients prior to clinic and have all the data at hand and a plan in mind. Additionally, it allows you to look up results, write letters, clear reminders etc at home or when you get a second of free time at the hospital.

Read the Clinic portion of the VA survival guide prior to clinic. THEN 3-4 months into clinic read it again.

Shea: Telederm and E-consults are wonderful resources at the VA.

One thing I have had to start doing is calling in person about every CT or MRI I need ordered. Otherwise, several months can go by and my patient is never scheduled for his or her test. This is easiest to do when the patient is with you in the office, but sometimes I have to do it after clinic due to time constraints

Labovitz: “Hi, how are you today (fine, fine), anything “new” going on since our last visit?” If that doesn’t get much response I ask “ Is there anything you are concerned about today?”

Then, for those who the answers might be yes I always ask “ Any chest pain, palpitations, dyspnea, cough, nausea, vomiting, diarrhea, fevers, chills, or sweats?” [It is funny because it basically all comes out of my mouth at once now that I have asked it so many times, but these are the things I do not want to miss on a patient and the things that can REALLY slow me down if it is an “oh by the way” comment at the end of a visit.

Jake Lancaster: I also used to write very elaborate subjective/HPI components of the note which I came to realize were not so helpful. Most of the time when I review patients or other providers notes I do not read this section at all. It allows me to spend less time documenting “fluff” and record a more accurate plan.

Most of all, I try to do everything the same day during the same clinic slot. That way I don’t have to come back on a different day to complete it. Doing so made it feel like my life was consumed by clinic and finishing the same day gives me a sense of completion.

Cummings: For work in patients it is important for the patient’s expectations to be  lowered consistently from initial contact: the Dr. is seeing you for this problem only, you have been worked into a busy schedule, so please stick to the complaint and do not try to get routine refills and other problems addressed ‘while you are here’. And it is OK for the Dr to remind the pt of the deal when he or she strays “ I’m happy to see you if you are sick, but you cannot expect me to do a lot of routine stuff while scheduled pts are waiting.”

Chitwood: Don’t be afraid to send impact messages to sub specialists regarding mutual patients. It is a lot easier to get a question directly answered and most are very happy to communicate with you. It is also a lot quicker and more convenient than waiting for the patient to see them or trying to reach them through the phone sometimes


On Follow up AFTER clinic   So you had a great session, things went smoothly and your patients and attending seem to like you.  Great work. But time marches on and all those orders will lead to results, suggestions, and new possibilities. How to keep up with all of that?  These guys have some ideas..

Prater: View alerts: I took some of the non-mandatory ones off. I organize them by last name and by priority and process the HIGH priority ones first, in between patients if possible. I take some time after my last clinic of the week to go back and process alerts, make phone calls and write results notification letters.

What I wish I knew as an intern:  1) How consults work at the VA…I would take some time to read the material available and understand it.

Prater: 2) The value of the RN care managers… They are there to help make sure things don’t fall through the cracks with your patients.

Williams: I usually finish my notes after clinic. Labs are usually back around this time and available for review. I have found it very important to review labs the same day or at least within 24hours. I have called patient’s the day of their office visit due unexpected labs and needed them either to report urgently for further evaluation or following instructions for an intervention before having repeat labs. I usually send a letter (via the IM IV nursing pool) to the patient explaining their testing results that same day that I view the labs.

Check your message box daily if possible or at least every other day. You will receive messages from partnering practitioners regarding care of your patients, nursing and patients.

If you have any questions concerning scheduling patients or referrals while you are out of clinic, send the message to the IM IV Nursing pool. They are excellent about responding.

Karam: The first time you see a patient confirm with them that you have a good contact number as the ones in the chart may not be correct. This is especially important if you have important results that need to be communicated.

Learn how to write letters to send to patients with results. They are much quicker than calling and patients appreciate getting their results.

If you put in a referral or order imaging for a patient outside of a clinic visit (either your personal patient or through the pool) send a message to the nursing pool and let them know so they can get things scheduled

Oubre: For follow up I now have a running email to myself which has names and things to follow up for my clinic patients so that they don’t get lost in the mix. I used to rely on the view alerts but those don’t always go come back to me.

Building a relationship  This is the good stuff, but sometimes the details can overwhelm it.  Here are some tips to keep your humanity about you, and to find the good stuff in clinic life.

Tyler Fuqua: One piece of advice that I received that was really helpful was this: “the more visceral reaction you have towards a patient, the sooner you need to bring them back.”  Often times you get new, very complex and challenging patients and the best way to become comfortable with them is to see them back frequently until you know their history, quirks, etc. Hope this helps. 

The pool  IM4 residents, check this section.

Karam: Use your nurses! They are great resources and can answer lots of questions and help facilitate follow-ups, imaging and paperwork. I wasted a lot of time especially as an intern trying to handle paperwork/referrals/etc. that they do every day and could get done very quickly

Keep an eye on the pool. If everyone does a few messages throughout the morning/afternoon when you have a few free minutes it prevents it from building up at the end of clinic

Chitwood: Try to tackle pool messages between patients if you have time. This is easier for interns at the beginning of the year. That way, everyone in clinic is not stuck with the whole pool at the end of the day.

Write notes only when pool messages have been completed. It helps to jot some information down either in the chart or your pre-round sheets, but be mindful that the pool is everyone’s responsibility. I usually have to do my notes at home or outside dedicated clinic time.

Learning outpatient medicine  Medical knowledge?  We’ve got it…

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This or that… Asthma vs COPD

So how can you tell if your adult patient has asthma or COPD.  Sometimes you can’t, and sometimes it might be both.  But here are some clues.

helpful conceptualization from Medscape

Clinical course: The hallmark of asthma is intermittent episodes of obstruction or bronchospasm. These patients, particularly at onset, often have asymptomatic periods.  COPD, on the other hand, is slowly progressive and NOT reversible. Patients clearly have exacerbations, but are rarely completely symptom free.

Age at onset: Asthma patients tend to be younger. They may be able to identify specific triggers: allergens (pets), irritants (tobacco smoke), exercise, temperature. COPD is due to long-standing exposures, so patients are older, and almost always have a smoking history.

PFTs: Asthma and COPD both have an obstructive pattern on PFTs. Think low FEV1/FVC ratio, larger lung volumes. The difference is that the obstruction seen in asthmatics is REVERSIBLE with bronchodilators. The bronchodilator administration is necessary for the diagnosis of asthma. Specific criteria are that FEV1 increases more than 12% over baseline or Peak Flow increases > 20% over baseline with bronchodilator. Normal PFTs essentially rule out COPD, but PFTs can be normal in an asymptomatic asthmatic.

Wondering what else is in the differential?  Check out this post from 2013.

Itchy Skin

Inspired by last Friday’s AMR case, I thought I’d write an overview of the causes of pruritus, particularly the causes that DON”T go along with a rash (because I hate rashes? Nah).  You can organize these causes in a few ways, but I like to think of them based on the big categories of: dermatologic, systemic disease, neurologic, and psychogenic.

Only takes a few of these guys to set off some serious itching


Most dermatologic etiologies are going to have an associated rash, but it may be subtle. Here are a few where you make have to look closely:

  • Xerosis: The most common cause of generalized pruritus, just plain old dry skin. Common in winter, often can tell skin is try just by feeling it.
  • Scabies: Regular scabies, not the Norwegian kind discussed in AMR, may not have much of a rash associated. Sometimes you can see a burrow, but rarely. I learned that the itching is a delayed hypersensitivity reaction, and may not appear for weeks after infestation.
  • Atopic Dermatitis: Think of this in a patient with other allergic phenomena (rhinitis, conjunctivitis), sx at an early age, and a family history of allergic disease. Patients also have allokinesis, when an innocuous stimuli, like temperature changes or clothing, induces itching.
  • Contact dermatitis: there are two kinds of contact dermatitis. Irritant contact dermatitis (like that caused by poison ivy) occurs when an irritant directly damages the skin.  There is often a rash in this instant.  Allergic contact dermatitis occurs when the irritant induces an allergic response. The rash here may be diffuse and obvious, or may be more subtle. Ask about anything that comes in contact with skin, including soaps, lotions, and laundry detergent.

Systemic Disease

  • Cholestasis: The first thing we think of, but pretty rare. Most commonly starts in the palms and soles before becoming more generalized. Disorders that cause cholestasis include: Primary biliary cirrhosis, cholestasis of pregnancy, viral hepatitis, and anything that causes obstructive jaundice.
  • Renal disease: We think about this in uremia, but it is actually common even in dialyzed patients. Worse at night or after a dialysis session,
  • Malignancy/hematologic disorders: More often with hematologic malignancies than with solid tumors. Think of: Hodgkin’s disease, Polycythemia vera (worse in water), Carcinoid (thank you, histamine), and cutaneous T cell lymphoma. Patients without a diagnosis for their pruritus may be at increased risk for malignancy.
  • Thyrotoxicosis: cause you can’t have a list without thyroid on it. Actually, a fairly common sx of Graves disease.  hypothyroidism can cause xerosis, which itches
  • Connective Tissue Disease: Common with dermatomyositis and scleroderma in particular.

Brachioradial pruritus


Small fiber neuropathy may be associated with pruritus, so anything that causes neuropathy could lead to itching, including diabetes.  These are typically localized to the affected area, however.

  • Post herpetic neuralgia: Up to 50% of patients with post herpetic neuralgia experience this as itching rather than pain.
  • Notalgia Paresthetica: Itching on the upper back, perhaps due to trapped nerve fibers in the T2-T6 nerve roots. Unilateral, near the medial or upper border of the scapula.
  • Brachioradial pruritis: Itching of the proximal dorsolateral forearm, but may extend up to the upper arm or even trunk. Feels better with ice application. Similar to notalgia paresthetica, this may be related to nerve root entrapment in C5-C8, but also may have something to do with sun exposure.
  • MS: Compared to the rest on this list, MS is more likely to cause generalized pruritus. Typically a relapsing, remitting type course that mirrors the rest of the disease.


  • Psychogenic excoriation: Skin is normal, but affected individuals pick and scratch at it. Lesions are all within reach of the patient, and may be precipitated by psychologic stressors.
  • Delusional parasitosis: Patients experience a firm, fixed belief that they are infested by parasites, despite a lack of evidence of infestation.  This may be secondary to another psychiatric disorder, or may be the primary disorder itself.
  • No matter the underlying etiology, pruritus may get worse under emotional stress.

For many, the itching itself causes emotional stress. It impacts sleep, work, relationships. Relief can really improve your patient’s quality of life, plus you may uncover a systemic disease earlier.

If you are itching after reading this post, that is probably psychogenic itching. Good luck!