The SOAP Note of Quiet Desperation

Being the med student on Internal Medicine makes me understand how most aspiring novelists must feel.  NOTHING I WRITE WILL EVER BE READ.

Sure, I can understand flipping past the “MS-III” note and glossing over the H&P.  Med student notes are dumb.  I accept that.

But dude, if I spend two hours with a patient, going through their drug list and a Pill Identification Book to par down the “every drug prescription every doctor has ever foisted upon them” list from the EMR into a “what they actually take” 4-item list:  please, please, read my drug list.

The EMR drug list some of them insist on using doesn’t tell them that the patient stopped taking warfarin 3 months ago.  Or that when the hospital changed the hypertension meds two months ago, the patient got confused and just kept taking the old ones.  Or that they’re taking tylenol instead of aspirin because “it’s the same main ingredient, right?”

I feel like I’m trying to sell my residents something.  I have these revised drug lists for my patients, but no one wants them.  And I’m all, “I swear, this has information you can use!” and the residents are all, “Ah, no thanks – I’m good with the one on the EMR.”

(Yeah, okay, I’m sure they’re right about not needing my drug list.  It’s just a sad reminder of how little I matter.)
(… Stupid robot EMR.)

Vignettes from Internal Medicine

Two days ago.

Me:  “And on abdominal examination, the patient had significant right lower quadrant pain on light palpation.”
Resident:  “OK.  Let’s figure out how to correct the main diagnosis”

Yesterday:

Me:  “… Today the patient has significant right lower quadrant, left lower quadrant, and left upper quadrant pain on light palpation.  And new-onset involuntary guarding.”
Resident:  “OK, good presentation.  Thanks.  Let’s figure out how to correct the main diagnosis and the mysterious transfusion-dependent anemia.

Me: …

So today I gave up on the idea that my presentation would ever mean anything in terms of this patient’s care, and pulled the “Oh, hey, I’m not sure if this is involuntary guarding or not – can you examine the patient and tell me?” card.

And of course then the patient got a DRE and abdominal CT.

At this rate, I’m going to start turning my patient presentations into interpretive showtunes to see if my voice is in a special frequency only I can hear.

(If this hypothesis turns out to be wrong, watch out.  “Patient Presentation: The Musical!”, coming to a ward near you.)

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4 thoughts on “The SOAP Note of Quiet Desperation

  1. As a somewhat experienced senior resident, I’ll let you in on a secret – sometimes we ignore what medical students say because we just can’t process all of the information that’s being thrown at us on morning rounds. Listening to 20 to 30 patient presentations is overwhelming, and sometimes we miss details because it’s just too much information. If there’s something you’re really concerned about, it can be useful at times to go back to the senior resident after rounds and discuss it.

  2. It’s ok. I remember my first patient on IM was admitted for atrial flutter, but when I talked to her she kept going on and on about her acute abdominal pain, which was NOWHERE in the resident’s admission note. She ended up getting transferred to the ICU for some other reason, but while she was there, someone took note of her abdominal pain, and she ended up with a laparotomy for suspected mesenteric ischemia. Anyway, just because the resident ignores you, doesn’t mean you’re wrong. You will never go wrong by taking a complete history. Like SD said, if you’re really concerned about something, try to discuss it with the resident after rounds.

  3. I couldn’t agree with you more – but I also agree with the above comments as to why this happens to us lowly med students. In reality, residents are extremely busy, and we can’t even fathom having to deal with all that they have to take care of. So, it’s ok, we’ll all be there one day and understand.

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