If you want to know how your progress notes, your H-and-Ps, your discharge summaries, etc can impact your evaluations, your future job offers, your letters for fellowship, the likelihood you will be sued, and more importantly, your patients’ lives, then check this out. It’s short, but it’s not sweet:

Major changes are coming to the Membership area & other RookieDoc services.

I am making it even better, of course. And in a few more days, depending how long it takes, I’ll have a special surprise that you won’t want to miss.

But here’s the thing… I can use your help. In order to make sure that I cover all of the bases, I made an ultra-quick 2+ question survey. It basically just asks for the kind of thing you think absolutely MUST be taught/given/answered.

Here’s the link to those questions:

Oh… And if you’re not on the Priority Notification List, you might want to get on it. Some of the stuff coming out will be limited in quantity… You’ll want to know early. Judging by the response to RookieDoc stuff lately, I’m sure this stuff gonna go fast.

The images of CDs, books, and DVDs in this video correspond to downloadable products.

Ask Me About Internship or Residency

I may not get to every question directly, but may be able to post important answers here, in special RookieDoc reports (PDF), on the RookieDoc Squidoo lens, or in the Audio Tips series.

By the way, the RookieDoc membership is undergoing some upgrades and will open to new members soon. Stay tuned. In the meantime, though, get your question in. Go ahead, click the link above.

Well, three things… One. I am not a Wal-Mart guy. No offense to Wal-Mart Inc, but in my area the “customer service” there is quite pathetic. It is the type of place where those hilarious guys at Despair.com get inspiration. I have to consciously prepare myself to keep my mouth shut… suck it up… and move on.

Two. I am not a go-to-the-store-and-return something guy either. It’s just not me. I don’t like doing it. If I can get out of it, I will. (But if I’m wronged, I’m going full tilt – Better Business Bureau, letters to the home office, etc… just don’t make me return anything.)

Three. It’s the week after Christmas and the place is packed.

Anyway, I went.

There were no less than 40 people in line at the “customer service” desk (so naturally, I didn’t return anything . I briskly bobbed and weaved to get to the pharmacy pick-up line. I was number 16 in line. Ahead of me stood 15 uncomfortable-looking, elderly patients. Since 11 of the 15 folks did not have a smooth pick-up, I had plenty of time to stand there… to just watch and listen.

Here is some of what I saw and heard:

• The patients in line were elderly and uncomfortable standing so long.
• Most of the patients had even sicker-looking (in a chronic sense) family members sitting aisles away on empty shelves or in wheelchairs.
• While in line, these patients were cordial and patient, but as time went on, frustration and fatigue began to show.
• While they were waiting and becoming increasingly tired, several employees were walking out from the back talking about their break and why they need to take it now, “even though it’s busy”.
• Several patients were discussing “coming back out of retirement” just to be able to afford things for daily living.
• Several quoted the $4 prescriptions as the reason they were willing to withstand the “customer service” and the lines.
• Despite their interest in the $4 bargain, most (8) of them were unable to actually get the $4 drug… mostly because the way it was written.
• 11 out of 15 had issues with their scripts being filled at all – and not one of the 11 was given a solution that they could control… The staff blamed each issue on the doctor or the government – 8 on the doctor, 2 on the government (specifically Medicare Part D), and one on both.
• The second person in line (appearing to be in her late 70s) ended up being shouted at by the pharmacist, “Didn’t you read Medicare Part D?! Your doctor has to put the indication on your prescription! It’s not my fault! Go ask your doctor. We called, but your doctor is not getting back to us.”
• There was one employee who was visibly working her tail off to get the patients their meds before they even reached the counter. She walked out and asked each person in line their names and began trying to get their stuff 3, 4, and 5 people deep in line. No one thanked her. No one said, “Job well done”, at least in the 45 minutes I stood in line.

Here are some tips and pearls for interns and residents to take away from this experience:

• Small things on your part can make a humongous difference for your patients.
• Write the indication on your elderly patients’ scripts.
• Advise your patients to bring their discharge instructions with them to the pharmacy when they leave the hospital for the first time.
• If you are writing a narcotic, put your DEA number and spell out the number of pills to dispense.
• Try to avoid writing “Use as directed”… that doesn’t fly with some co-pays, Medicare D, and some discount programs.
• Choose the medications wisely… with cost being a huge piece to factor in.
• Ask your patients if they’ve ever had problems filling scripts before and what the nature of the problem was… too many to dispense, not covered by insurance, etc.
• Consider titrating doses before adding new classes, if possible.
• Keep an updated list of the discount meds available. And familiarize yourself with other discount programs (Target, Wal-Mart, Giant, etc).
• Get in the habit of writing the generic name anyway.
• If you get paged from a pharmacy outside of your hospital, it is probably regarding a patient you just discharged… Answer it promptly. That person who was just hospitalized is probably standing in Wal-Mart, or sitting off to the side waiting for a family member to fill their scripts.
• Write legibly.
• If there’s a discrepancy when looking at their meds and the meds you thought they were taking at home, ask the patient. Reconcile your scripts with their current meds.
• Be careful what you talk about in front of others. Sure, there’s nothing wrong with discussing where everyone wants to order from for lunch. But if you do that while a patient or their family is in earshot, you might really rub them the wrong way.
• Social workers and case managers know about these patients’ frustrations and potential problems… learn from them. Ask them for feedback. And appreciate what they do. (The insurance industry is like Wal-Mart on steroids.)
• When someone does something well, or goes a little further than they have to, tell them about it… thank them… let them know that it was appreciated.

Now, it is important to realize that when you actually do these things, you will not be praised. No one will thank you. No one will really notice. And that’s okay. It’s not about you. It’s about them, the patients.

And if you don’t think it’s about your patients, then quit health care right now… and go work at Wal-Mart. You’ll fit right in… probably best-suited for “customer service”.

And here are some tips for Wal-Mart and pharmacies, in general:

• Put some seats or benches for your elderly patrons. Be generous and be strategic. Put them in such a way that people can remain in line and remain seated if need be.
• Consider having a health professional (MD, DO, NP, PA, Pharm D, etc) that can write scripts for the edits and tweaks that someone else simply forgot… things like indication, quantity, etc.
• Consider having a looping video that explains procedures, policies, what’s needed, etc. so that people don’t have to wait in line to find out that they’re missing something.
• Keep track of all of the issues that prevent people from getting their scripts on the first trip up to the counter… use that list to get to the root causes… or at least publish it. If it is truly the doctors, then send the list to me, I’ll get it out there.
• Try to hire people that “own” problems, not the Me-Myself-and-I types that consistently shunt blame.
• Remind your workers that it might be viewed as a little inconsiderate to discuss their breaks while frustrated customers look on. Remind them to consider how they would feel.
• Tell your pharmacists that it is a very, very rare patient that ever “reads Medicare Part D”… In fact, I’ve never met one.

There’s my rant, but there are lessons in there, though. I learned a lot standing in line at Wal-Mart.

Anyway, here are a few tips I extracted from the Documentation Module of the RookieDoc Members area… Let me know what you think in the comments below or through email.

1. Know who reads your notes – you may be shocked at how many people rely on your documentation. If you know who these people are and what they are looking for, you will be light years ahead of others in your program.

2. Write legibly – If you work in a hospital or office that does not yet use electronic records, you better write legibly. It can have a huge impact on patient care, lawsuits, and your evaluations from attendings.

3. Use bulleted lists – Most people scan notes to the parts they think are important. If you list things like Past Medical History, recent tests and studies, Past Surgical History, recent hospitalizations, etc as bullets in a list, it will make it much easier for people that read the chart after you. You will stand out and your patients will be better for it.

4. Indent consistently – when making paragraphs or headings, do it in a consistent fashion. Avoid writing everything in one big blob of a paragraph.

5. Consistent order of things – from note-to-note, stay consistent.

6. Refer to other parts of the documentation – It’s okay to write, “See Dr. Smith’s review of the CT results in his note dated 12/13″ or “Exam is unchanged from 12/12″ or “See #2 above”. A good example of “see #2 above” may be if you have to refer to a problem more than once… like renal insufficiency in it’s own section, and then also again under diabetes.

7. Ask for specific feedback – ask attendings, risk management nurses, and upper level residents to look at your notes and give you feedback. And don’t accept answers like, “They’re good. Keep it up.” No. Ask specifically, “Well, what could I do better? What should I work on?”

I posted a blog post a couple of weeks ago, just after the American Board of Internal Medicine (ABIM) issued a press release warning about scam certification boards. In that post, I mentioned that I was working on an identity theft report for Rookie Docs – medical students, interns, residents, fellows, and new attendings.

Well, the report is done… all 40-some pages of it. And you can get it free. “Free” meaning no money, but not entirely free. It will “cost” you three short questions.

Now, I can sit back and write random post after random post, not having a clue if you find them interesting and helpful… OR, I can ask you what you want me to write about. So, that’s what I’m doing. That’s the catch…

You anonymously answer three short questions about your financial fears and concerns, and I give you a free 40-page ebook on protecting yourself and your patients from identity theft. Sound fair? Here’s what I want you to do:

1. Click on the ==> 3-question anonymous survey link <==
2. Answer each question honestly
3. Click “Done” after answering the third question
4. You will be redirected to the download page
5. Download and read (or skim) the report, or not…

Keep in mind, I am not a lawyer (thank God), I am not a financial planner, I do not know your particular circumstances, and my advice does not substitute for a qualified professional in these areas. You can take my tips or leave them. In general, it is solid advice, but it may or may not apply to you.

And, as always, I want your feedback. (And a quick thanks for all of you who gave such good reviews of the CXR Mistakes report in the Members Area… keep it coming)

Let’s say you are calling a consult. You are post-call and overnight your patient began to experience a change in mental status. Now, you want to call a neuro consult.

Guess what? You will notice that there’s a pattern. When most neurologists come by, they order the same type of stuff when it comes to a change in mental status. They’ll say let’s check a TSH, a B12, a folate, an RPR and a sed rate. Maybe if there’s no recent head CT they’ll suggest that or an MRI. This isn’t a knock on neurologists… it just is what it is.

Anyway, you can get some of that ball rolling by ordering some of those same tests that you know they’re going to order. And this does a couple of things for you…

• It saves you some of the time in having to track down the neuro recommendations later on in your post-call day. (It also saves you from signing out more stuff to your cross-cover resident or intern)
• It shows the neurologist that you’re thinking about things and not just calling a consult out of reflex or out of playing defensive medicine. (These guys have a role in your residency evaluations)
• It saves the patient from having multiple blood draws in the same day. (Which, by the way, will do wonders for your rapport with the patient – if you take 30 seconds to explain the plan for today and that you will be limiting their blood draws and giving consultants someting to work with.)
• You can potentially shorten the length of stay by half a day or even more.
• You can potentially identify something of huge clinical importance before the consultant even gets there… helping your patient with more rapid, more appropriate treatment, and making the consult more interesting to those on the neuro team.
• Also, it sort of forces the consultant into action. They have the data they were going to request, so now, they have to act on it.

Don’t order unnecessary tests, but you get my point. If you know that something is going to happen, start it happening. Why does it have to wait for them? It doesn’t. Be proactive.