Sunday, June 29, 2014

4 Tips for new medical residents

Since July is here and the academic calendar is starting over, it is time for new medical residents to be arriving to the hospital floors.  With this in mind, here are a few tips to help in the transition from student to physician.

1.  Utilize the non-physician clinicians and allied health professionals.

You will be interacting with a variety of people who have various roles in taking care of your patient.  Nurses, PAs, NPs, social workers, case managers, physical therapists, pharmacists and many others who may have years of training and experience in what they do.  They may be able to get your patients exactly what they (or you) need and can be especially instrumental in discharging the patient.  Know who you can rely on and feel free to ask many questions.  This includes calling the hospital pharmacy or asking the pharmacist on your team.

2.  Know your resources (for medications and diseases).

Many hospitals are likely to subscribe to any number of online resources for medication and disease state information on both mobile and desktop platforms.  Rather than just searching on Google or Wikipedia (where you can sometimes get to the right place, but in a roundabout way), knowing the strengths of each of the databases you have access to will make searching for answers much more efficient.  At North Shore LIJ, desktop computers will automatically be logged into Micromedex, Lexi-comp, and UpToDate.  Additionally, residents are able to use Lexi-comp on their mobile devices with their email address and the access code (found on the Lexi-comp desktop homepage - if you can't figure it out, let me know).

Some notable strengths of each of these resources are:

  • Dosing information is extensively referenced for both labeled and off-label uses
  • Adverse events are described and referenced in detail, usually including frequencies (make sure to click the "In-Depth Answers" tab for the detailed information)
  • Most robust mobile app for medications
  • More medication info than UpToDate (even though UpToDate takes you through to a Lexi-comp monograph)
  • A good amount of disease state information can be found here
  • Hyperlinked between sections so you can easily find what you’re looking for even if you don’t start in exactly the right place

3.  Double (or triple) check your prescriptions before giving them to the patient.

Here is a short list of things to make sure of when writing any prescription.  Follow these tips to cut down on phone calls from community pharmacies.
  • Check that the strength of the medication you're prescribing actually exists.  For example if you prescribe, "Methylprednisolone 50 mg, Take one tablet orally daily," this can't be filled because it only is available in 4, 8, 16, and 32 mg tablets (I encountered this one in a patient being discharged following a COPD exacerbation).  Lexi-comp mobile app is a quick reference for this.
  • Make sure your prescription has the necessary components that a pharmacist cannot legally add without speaking with you.  This includes at a minimum:
    • Patient name
    • Date (don't alter it if you make a mistake, write a new prescription)
    • Your signature and stamp (because it may not be preprinted on your prescription pad)
    • Drug name, strength, directions, and quantity
    • Write out the word for quantity of controlled substances.  If a numeric quantity looks like it's altered, the pharmacist is likely to call you.
  • Ensure legibility
  • Be careful with decimals.  Don't use trailing zeros but always use a zero before a decimal.

4.  Find out which pharmacy a patient uses to verify their home medications.

Patients will generally have a list of medications that they claim to take but a refill history from their community pharmacy may add some vital information.  A call to the pharmacy can be done by you, the team's pharmacist, pharmacy student, or medical student and can shed light on many issues.  Examples such as finding that a medication for a chronic condition has not been filled in the past six months or a patient taking both their ARB and their ACEI concurrently (when they were supposed to discontinue one) could otherwise go unnoticed and are all too common.  In fact, one study of more than 75,000 patients found that 22% of prescriptions written were never filled in the first place!

Do you have tips for new medical residents?  Leave them in the comments below.

Fischer MA, Stedman MR, Lii J, et al.  Primary medication non-adherence: analysis of 195,930 electronic prescriptions.  J Gen Intern Med  2010;25(4):284-90.

photo by kokopinto


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