1. Brian Crownover, MD, FAAFP Nellis FMR
Teaching structure and efficiency to residents and students performing inpatient duties
Brian Crownover, MD, FAAFP
Nellis FMR

2. Objectives
Describe the Captain’s Wheel paradigm to structure inpatient work organization
Diagnose and correct errors in note “synchronicity”
Teach a formal structure for comprehensive construction of assessments and mgt plans emphasizing clinical reasoning

3. Video
Play video of learner presenting a patient

4. Group Discussion
Identify areas for improvement in the video of a resident patient presentation

5. Group Discussion
Discuss solutions utilized by attendees for identified problems

6. Captain’s Wheel

7. Patient Ownership
Heart of the wheel and connected to all other parts
Admitting physician must consider self as "captain" of this episode of care
Not placeholder for PCP simply generating subspecialty referrals or X-cover mindset

8. Captains know all relevant patient details
Patient Ownership
Captains know all relevant patient details
Background info, labs, imaging results
Desire primary accountability for patient and their care
Judicious use of consults

9. Outpatient status (pre and post admit)
Continuity of Care
Inpatient status
Handoffs between day and night team
i.e. SBAR, APES, etc…
Outpatient status (pre and post admit)
Records from outpatient physician
Accurate outpatient medication list
Leads to…

10. Plan for discharge on admission
Anticipate discharge needs while admitting
Requires learner to define discharge criteria
Post hospitalization requires baton pass back to PCP
Think pre-curb and post-curb

11. Plan for discharge on admission
Some items require longer lead times, such as evaluation for SNF transfer of setting up home oxygen
Work with multi-discipline mindset: utilize Discharge Planner

12. Never be afraid to ask when don’t understand
Clinical Curiosity
Never be afraid to ask when don’t understand
Don’t be satisfied to not know a term or medicine dose
Scratch that itch and look it up!

13. Never fail to question incongruity
Clinical Curiosity
Never fail to question incongruity
If clinical history or data point conflicts with working diagnosis, attempt to chase item to closure
Doubt the data or prove veracity
Back up, cast net wider for possible ddx

14. Synchronicity

15. Failure to ensure implies sloppy care
Synchronicity
Horizontal
Problem list matches the medication list
Vertical
All abnormal data collected in the S/O: assessed in the A/P:
Failure to ensure implies sloppy care

16. Poorly constructed medical notes are a widespread problem
Structure in A/P:
Poorly constructed medical notes are a widespread problem
Few learners clearly convey reasoning that reveals their clinical thought process and justifies managment
USMLE 2010 Clinical Skills Exam
No requirement to discuss clinical reasoning

17. Commit to a diagnosis and state WHY
Structure in A/P:
Commit to a diagnosis and state WHY
5 Microskills model readily applicable to inpatient setting
Allows faculty to readily sculpt learner’s revealed paradigms
Provide formative feedback

18. Structure in A/P: Confirmed Diagnosis New or established
Controlled or uncontrolled
Treatment goal
Evaluation/surveillance
Management
Disposition

19. Structure in A/P: Hypertension:
Established uncontrolled by home blood pressure (BP) log; systolic BP in 150s
Treatment goal: SBP 130s
Chemistry panel/lipids/urinalysis in one week
Increase lisinopril to 20 mg qpm #60/5
Consult nurse education for DASH diet and RTC one month with BP log

20. Unconfirmed Diagnosis
Structure in A/P:
Unconfirmed Diagnosis
Suspect ____________ dx
Given ______________ rationale
Confirm by __________ evaluation
Manage with ________ treatment
Doubt ______________ dx
Due to ______________ rationale
Rule out by __________ evaluation

21. Structure in A/P:
Suspect allergic photodermatitis given location in sun-exposed areas and onset after use of new sunscreen lotion. Confirm by stopping lotion. Treat: PABA-free sunscreen
Doubt lupus given no prior hx and absence of other lupus type complaints
Doubt prescription medications d/t no hx use. RTC if sx persist after lotion change

22. GLOBALLY (make sure abnormal data in S/O are addressed in A/P)
Confirmed Diagnosis
Symptom-Based Diagnosis
GLOBALLY (make sure abnormal data in S/O are addressed in A/P)
SYNCHRONICITY
-new or established
-Suspect (diagnosis)
-stable or uncontrolled
-due to….(rationale)
-treatment goal
-confirm with …(evaluation)
-evaluation/surveillance
--(including related comorbidities)
-treat symptoms with …(management)
-management
-Doubt (diagnosis)
-disposition
-given…(rationale)
-rule out with…(evaluation)
-Disposition

23. Take Home Points
Use the Captain’s Wheel to structure inpatient work organization
Diagnose and correct errors in note “synchronicity”
Teach a formal structure for comprehensive construction of assessments and mgt plans emphasizing documentation of clinical reasoning