Objectives — Management Skills

Explanation: Your patient management skill level refers to the level of responsibility that you take without being told what level of responsibility to take. You will be placed in situations where the resident or attending will sit back and see what level of responsibility you take because they don't want to make you nervous by pushing you too hard. There are four levels of clinical care. They are:

Observer - You should fall into this role during the first day or two of the rotation, and only occasionally after that. You are not just watching, but you are looking for things such as in what order does the doctor do the history and physical and does he/she make the patient feel comfortable. Think for yourself about the pertinent questions and try to predict what the resident/attending is going to do. Understanding how the exam is tailored to the child's developmental stage is key. As an observer you should try to figure out why aspects of the exam are developmentally appropriate. You should be spending 15-20% of your time as a skilled observer.

Reporter - This is the skill of a third year medical student. As a reporter, you gather information by asking the different members of the team what they did for the patient and why they did it. You also read the chart, ask the nurses what happened during the night, etc. with the goal of gathering all relevant information about your patient. Then you write up what you've learned in the form of a SOAP note. By week four you should be able to compile a SOAP note with all of the pertinent information for a patient. In order to be a good reporter, you have to get to the hospital early in order to pre-round, gather information, and consolidate it into a note. During your first week I expect that you will all be learning how to be a reporter, but by the fourth week, you should be very good at it.

"Editorial Writer" - If you are reading with depth and you have a good knowledge base, then by your third or fourth week you should be able to offer your own ideas about the patient's disease. The point is not to be inflammatory but rather to begin to think independently. For example, on rounds you might see an anemic patient with a low MCV. A student at the "editorial writer" stage would say that the low MCV might be a result of iron deficiency in the patient. You must read with focus and be able to predict the complications of the disease and therapy in order to achieve this stage of management. By the fourth and fifth week of the clerkship, it should be obvious in your presentation that you are anticipating the possibilities. For example, you should be able to say for a patient with asthma, "If he starts breathing to fast, I'll do A, and if he starts breathing too slow, I'll do B." As an editorial writer you should strive to not only understand what has happened to the patient, but you must also anticipate what might happen. I hope that you all will be able to do this at least once during the clerkship.

Independent Worker - Based on the patient's history and/or chief complaint, you can predict what four or five problems the patient might have and be able to do a focused physical exam to differentiate between the given problems. For example, if you have a patient with neutropenia who suddenly spikes a fever, you would be able to go into the room thinking about the opportunistic infections that the patient is susceptible to so that you can do a focused physical examination. This is the level of an expert clinician. I don't expect that you will reach this level, but you should continually strive for it.