I was surfing the internet this past week and happened upon an article written for first year residents as they enter into clinical practice. The idea resonated with me and I considered: what does a first year PA or NP need to learn for a smooth transition into clinical practice? This is totally new territory for the graduate; some suggestions or pointers just may be advantageous for you. It is never a coincidence that something like this article pops up in your newsfeed. I would encourage you to avail yourself of three minutes of your reading time to digest the pointers in this article to create a pleasant landscape in which to start your medical practice.
- Dress Appropriately – We are graduate professionals; therefore, we should dress in a manner that reflects sensitivity to our patients and pride in our accomplishment. You are not required to wear a suit and a tie, nor are you expected to wear a dress. But it is acceptable and expected by both employers and patients that you wear clean, unwrinkled business casual clothing, with or without your lab coat, with its proper designation.
- Don’t Be Lazy – Take the time to examine your patient. I retired two years ago. I have since been shocked and dismayed that I have been seen in urgent care and in clinics, and that the provider did not perform a basic medical examination. Telemedicine certainly has its place in the practice of medicine, but not to the exclusion of the utilization of our five senses in order to diagnose your patient. We need eyes on, the ability to smell breath, the ability to touch, palpate and percuss, and to test strength on each side. If you are in surgery, emergency medicine, urgent care or internal medicine, you may need to supercharge your skills with one of my old favorites: “Copes’ Diagnosis of the Acute Abdomen.” Not all diagnosis requires invasive scans.
- Listen to your patient – You were taught that up to 70 percent of your diagnosis can be made by taking a complete history. In today’s rushed medical consultations, we find little time to ‘discover’ through simple interrogation. This has taken the fun and pleasure out of medicine. Avail yourself of the time to take a good history.
- Medication Reconciliation – Our offices are designed for an MA to review medications, but woe be it unto you if you choose not to review them also. As I read the medication, I am consumed with new insight and interest in the patient that sits before me. I begin to see diseases that were hidden and suddenly appear with a treatment plan. This review also gives me the opportunity to look for side effects and drug interactions. A new clinician cannot afford to miss this.
- Oral Hygiene – You may enjoy garlic or other strong spices in your meals, but does your patient have the same taste in food additives? When we perform an EENT exam, we are literally inches from our patient’s face and this can make the exam unpleasant. Carry breath mints for a better patient experience.
- SOS – Learn early when to ask for help and when you may need to refer. If you work with other clinicians, avail yourself of their knowledge and experience. Always seek to discover a differential diagnosis.
- Cultivate thoroughness – It may take two additional minutes, but isn’t that worth finding your patient’s illness and prescribing correctly? This is the manner in which you avoid a subpoena, a deposition and two weeks in a courtroom. Protect your NPI number with an unrushed diagnosis and treatment plan.
- Discovery – Did you observe something significant or did your patient offer a compelling question or concern? Documentation is the active approach. Document what you have seen, heard, smelled and touched. Documentation is the key to good practice as well as the key to litigation prevention.
- Education – Learn from everyone you work with as well as from your patients. Education is not limited to CME’s or CEU’s. Learning can be obtained in other places rather than a classroom, conference or webcast.
- Experience – Our personal experience and that of others is key to broadening your understanding of health-related problems.
- Street drugs and alcohol – Yesterday I was taking a history of a person in a shelter who had not received medical care for many years. I saw two long vertical scars on either side of his lower leg. I inquired as to what the circumstance was for this surgery. Thirty years ago, he suffered from a drug overdose and fell asleep in a position that compromised his circulation to his lower leg for almost a day. He was taken to a hospital, diagnosed with a compartment syndrome and required fasciotomies to relieve the pressures in his leg. I had just discovered a drug history. Do not fail to ask about street drugs, ETOH, Herbal supplements, OTC medications and any history of allergic reaction. This can open a whole new world of understanding and inquiry.
- Peace of mind – Confirm and get a copy of your malpractice policy, your job description, your contract, your health insurance and all other benefits you were offered. Promises are forgotten, but a printed copy that is signed by both parties is a contract. Consider if you should purchase a personal liability insurance policy. You must plan today to protect your finances, home and family security and it is foolishness not to consider this as you begin your career. Are you aware of gaps in your employment insurance that can otherwise be covered by owning a personal policy with your name on the title page? Place these papers in a file and put them on your calendar to be reviewed by you in eleven months. Review your policies and make sure they are up to date at this time and that they will be in force the following year. I have seen PAs join a practice and, a year or two later, become involved in a litigation, only to discover that their employer did not secure insurance after your first year or there was a change in practice ownership and you happened to fall through the cracks. This becomes a personal nightmare and can be avoided. Trust no one, document, confirm and revisit annually.
In conclusion – when I was an 18-year-old soldier newly arrived in Vietnam, I encountered a sight that made an indelible mark on my life. As we walked from our plane in clean pressed fatigues, we encountered a group of battle-hardened grunts that made an impression on all of us. Their clothes were disheveled, their eyes were tired, and their faces were weathered by the sights and sounds of war. They were returning home, forever changed by their experiences in the past year in hostile combat. “To know the road ahead, ask those coming back.” I offer this to you on your road ahead.
By: Robert M. Blumm, PA, DFAAPA, PA-C Emeritus
CM&F Clinical Advisor
