1.What differences do you note between the two H&Ps? The biggest difference that I noted in the two H&Ps linked above is the flow of the HPI portion. Between the first and third H&P that I wrote I gained more medical knowledge and began to feel more confident in my knowledge. This allowed me to write in a way that is more enjoyable and easy to read, while still including most, if not all, of the pertinent information. Additionally, the chief complaints between both H&Ps markedly improved. This too was due to the knowledge that I gained over the course of the semester. In the beginning I was under the impression that in the chief complaint you were to write whatever the patient says in quotations. Therefore, I did just that and wrote “I have HF” as the chief complaint. When I got the feedback I was surprised to see that I got zero points for the chief complaint because I thought that I had done it exactly as I should have done. After discussing it further, I learned that even if a patient does say exactly that, it is important to elucidate the symptoms that they are experiencing and to write symptoms, and not a diagnosis in the chief complaint. This is something that I learned then and made sure to implement into the next H&P.
2. In what ways has your history-taking improved? Are you eliciting all the important information?
As I continued visiting the hospital and interacting with patients I progressively got more comfortable interacting with them and getting a history from them. From the beginning I never had a problem obtaining a focused history on the present illness, including a ROS. However, it became more difficult when it came to getting family, social and sexual history, as I felt that those were intrinsically more personal. As with most things in life, as I practiced with more patients I got more comfortable with the idea of asking these types of questions, as I had the knowledge that they are also important for treating a patient. Additionally, as I stated above, my medical knowledge between hospital visits one and three significantly increased and made it much easier for me to focus on what was important to discuss at that moment, regarding the ROS.
3. In what ways has writing an HPI improved?
While reviewing the rubrics for both H&Ps, I was happy to be reminded and to see that all aspects of the H&P improved between the two, including the chief complaint and HPI. As I mentioned above, the flow of the HPI greatly improved between the two. Also, when comparing the two rubrics, I noticed that for the second HPI I got more credit because I included more aspects of OLDCARTS. As a final note, another improvement that I notice between the two HPIs is that I began to be aware of correct medical terminology and how to phrase different details correctly. For example, in H&P 1 I wrote “dyspnea (on exertion).” When I wrote that I believed that was an acceptable way to express what I intended. However, after receiving feedback and discussing it further I learned that this terminology is confusing and I would need to either write dyspnea on exertion or dyspnea at rest, and skip any parentheses. In contrast, in H&P 3 I wrote “pain is confined to the lumbar spine.” Looking back I can say that this is not an especially academic or medical term, however I believe that if this HPI was written earlier in the semester I would have more likely written “lower back”, as opposed to “lumbar spine”. These phrases are equally as concise, with “lumbar spine” being more medically accurate. This improvement proves that over time, with gained knowledge, minor changes are made to the way you understand issues and write them out, ultimately forming a better H&P overall.
4. What is your self-assessment of your current skill in performing a physical exam? Which areas do you feel strongest about/weakest about?
As a student, learning in the classroom is comfortable for me. It is what I am used to and what I enjoy. Of course, my goal is to be a clinician and to be able to examine, treat and listen to patients empathetically. However, at this point in my training I still do not consider it to be completely within my comfort zone. Thus, conducting a physical exam on a patient was slightly more difficult for me than studying for and taking any clinical medicine test. Looking back since the beginning of the semester, I am very proud of my progress and can attest to the age old adage that practice does make perfect. Constantly practicing on patients has helped me to become a better clinician in training, which in turn has made me more comfortable doing it. In addition, I would say that I am most confident in conducting the physical exam of what we learned earlier in the semester (including vital signs, ears and hair and nails), only because I had more practice with those exams. I came home and practiced those exams on many family members and feel confident in my abilities to successfully perform those exams. On the other hand, the exams we learned later in the semester (such as abdomen, lungs, and cardiac) are a little harder for me, as they received less practice. Overall, I find the eye exam most challenging for me. Although we learned it earlier in the semester I find that visualizing the important structures of the posterior eye is not an innate skill that I have and it is something that will take some time until I am comfortable with. Lastly, I think that when I finally see some abnormal findings during an exam I will feel more comfortable with performing physical exams in general and know that I can differentiate between normal and abnormal findings when needed.
5. Of course we expect you to get stronger in all areas, but which of the specific areas will you target as needing particular focus in future patient visits when you start the clinical year?
I think that the most important thing for me to improve on with upcoming patients is to focus my thought process on developing a list of differential diagnoses from the first instant of hearing about the patient. This way of thinking is not natural to me, but is very important when treating patients. By making such a list it allows you to stay focused and make a diagnosis in the most timely fashion. Additionally, by making a list of differential diagnoses it will help guide the HPI and make it easier to know what information to include in the HPI, including pertinent negatives. This is because the HPI backs up the list of differentials and needs to include information that would rule in or rule out any of the differentials. As such, I am looking forward to the clinical correlations class this summer which I am hopeful will help make that skill slightly more routine for me. I also spend time listening to podcasts where medical students have to work up a patient and treat them, in order to help that way of thinking become a part of the way I think.
