Anyone works at an Internal Medicine clinic?

Riburn3, BSN, MSN, APRN, NP · Aug 4, 2015

I work for an IM practice. When I was new I was given several months of orientation in our practices main clinic, and I know solo run a satellite branch for the practice.

I almost never look up my patients the day before I see them. Typically, right before I go into the patient room (if I have time), I will review their chart and recent visits to get a better picture. If not I will do this while in the exam room with the patient where we also have computers to chart on. Either way it only takes a minute or two to get a rundown. In many cases you will start to remember your patients so it gets quicker and quicker. I never ever have to finish charting after hours.

Patient load does vary, but 20 is a very standard. You will have patients come in for very simple things that take 10 minutes, and others that take more of your time. It's important to recognize the simple things and be efficient. It's also important to focus on the issues that brought them in in the first place. If you let them, these chronic IM patients will tell you everything is wrong with them, so stay on target.

I would imagine if you give it time, you will get the flow well and establish a good rhythm.

Jules A, MSN · Aug 4, 2015

Are these students or NPs or both that you spoke with? The good news is they said nice things about the clinic. Personally I have a fairly high burn-out threshold and would certainly see it coming and make other arrangements so the possibility of burning out isn't really something I would be too worried about but of course you might be different. Having health benefits and PTO if you don't have access to benefits elsewhere is a huge consideration.

Although I'm not working in an IM practice in general the NPs I know who aren't able to finish their work within business hours on a regular basis are usually the ones who are trying to be Florence Nightingale and aren't focusing on the problems at hand. Their patients love them because a visit for eye discharge also includes a 30 minute marital therapy session but that isn't what they are being paid to do. I totally understand our patients in general might need additional services but that isn't up to you to single handedly solve during this visit. I keep a list of other providers who specialize in the misc. stuff you will be asked about.

For providers who are competent and set reasonable boundaries staying late should be rare, imo.

CocoaLoverFNP · Aug 4, 2015

I work for an IM practice. When I was new I was given several months of orientation in our practices main clinic, and I know solo run a satellite branch for the practice.
I almost never look up my patients the day before I see them. Typically, right before I go into the patient room (if I have time), I will review their chart and recent visits to get a better picture. If not I will do this while in the exam room with the patient where we also have computers to chart on. Either way it only takes a minute or two to get a rundown. In many cases you will start to remember your patients so it gets quicker and quicker. I never ever have to finish charting after hours.
Patient load does vary, but 20 is a very standard. You will have patients come in for very simple things that take 10 minutes, and others that take more of your time. It's important to recognize the simple things and be efficient. It's also important to focus on the issues that brought them in in the first place. If you let them, these chronic IM patients will tell you everything is wrong with them, so stay on target.
I would imagine if you give it time, you will get the flow well and establish a good rhythm.

Thank you for this great info, Riburn!

I will only have 1 month of clinic orientation but I am hoping this would be sufficient. I did my last rotation at an IM practice but that doesn't mean I know everything. But at least, reading your post made me feel better about things. Yes, you are right about just giving it time to get the flow of things and establish a good rhythm. I usually believe that I could thrive and be successful at anything. However, this is new to me so I'm very nervous. Will keep you posted!

Thanks again!

CocoaLoverFNP · Aug 4, 2015

Are these students or NPs or both that you spoke with? The good news is they said nice things about the clinic. Personally I have a fairly high burn-out threshold and would certainly see it coming and make other arrangements so the possibility of burning out isn't really something I would be too worried about but of course you might be different. Having health benefits and PTO if you don't have access to benefits elsewhere is a huge consideration.
Although I'm not working in an IM practice in general the NPs I know who aren't able to finish their work within business hours on a regular basis are usually the ones who are trying to be Florence Nightingale and aren't focusing on the problems at hand. Their patients love them because a visit for eye discharge also includes a 30 minute marital therapy session but that isn't what they are being paid to do. I totally understand our patients in general might need additional services but that isn't up to you to single handedly solve during this visit. I keep a list of other providers who specialize in the misc. stuff you will be asked about.
For providers who are competent and set reasonable boundaries staying late should be rare, imo.

Thank you for the reassurance, Jules!

Yes, i was pertaining to two students who had their clinic rotation there for several months and two NPs that had been working there for 1 year. They are not the same people.

Like you, i also have a high threshold for burn out. I also try to reorganize things or talk to the supervisor first if something is not working out. However, being an NP is a totally different job so we shall see how it will affect me in a few months.

Yes, knowing that they said nice things about the practice/MD really makes me feel better. I will remember your advice about being competent and setting boundaries. Even though i love to talk to patients about their personal lives, you are right about being focused or knowing what their clinic visit is for so I can manage my time well. I don't know how these NPs practice and why they are charting late. However, I am guessing it's the same reasons you provided. Or they just have OCD, lol. Like Riburn said, it would take time to find my good rhythm as well.

Full benefits is really great! We shall see though. I'm sure they will be ok with me going down to part-time in 6 months, if I think I am getting burnt out.

Thanks again, Jules!

PG2018 · Aug 4, 2015

I agree with Jules. When I was an internt I worked with a very good PMHNP. But she took forever with every patient and would stay in her office a few hours after clinic closed doing her charting, etc. I can't fathom that. Any health teaching I do is done quickly unless it is a matter of focus on the reason they're present. I just had a 15 minute med ck appointment that took like 2 minutes. I had a 30 minute eval earlier that turned into a 45 minute holy train wreck. It doesn't really matter how you schedule people as long as you know how to move through them quickly. .

Regarding history, if the patient is new to me, I look at their very first chart with us. (Thank you EHR.) I look for complaints, meds, and speed read the rest. I'll then go back over the most recent notes and look for trend. If they're particularly interesting or concerning I'll even look at some of the therapists's note. I realize you won't have therapists's notes. Nonetheless, you don't have to prepare their case like nursing students and know every mole and wrinkle on their body.

Patients want their needs met, yet the vast majority of them want them met quickly. Some of the stuff in IM can be complicated, but if it's overly complicated it's probably already been farmed out to subspecs. I know we all want to tell them to walk daily, eat plenty of broccoli, and drink a glass of water, but they're there for their refills (American patients want their dang pills!). You'll realize the ones that are codependent and need you to coddle them. You can get bogged down with this, but you're fortunate in a way. Patients come to my office so I have to make them leave. I'd rather bounce from exam room to exam room so I can get in and out on my timetable. I see that a lof of this can seem uncaring. It's not. Most of my patients really like me because I do a few things.

1. I shake their hand when they come in, and although there's no telling where a psych patient's hand has been I shake it anyway. (It also tests their social function.)

2. I look at them when I talk. A lot of providers don't do this anymore because they're glued to their tablet. Granted, I'm typing rapid fire, but I look at them. I've done HPIs as an entire word for word quotation before. A soft touch keyboard helps.

3. Ask them questions. If you hit a lot of different points of their life they'll often feel well assessed like you're thorough. To them, if you look at them, talk to them, and you're thorough you must care. That makes them happy. That makes them give good surveys. And that keeps them coming back. They also seem more amenable to shorter visits.

CocoaLoverFNP · Aug 4, 2015

I agree with Jules. When I was an internt I worked with a very good PMHNP. But she took forever with every patient and would stay in her office a few hours after clinic closed doing her charting, etc. I can't fathom that. Any health teaching I do is done quickly unless it is a matter of focus on the reason they're present. I just had a 15 minute med ck appointment that took like 2 minutes. I had a 30 minute eval earlier that turned into a 45 minute holy train wreck. It doesn't really matter how you schedule people as long as you know how to move through them quickly. .
Regarding history, if the patient is new to me, I look at their very first chart with us. (Thank you EHR.) I look for complaints, meds, and speed read the rest. I'll then go back over the most recent notes and look for trend. If they're particularly interesting or concerning I'll even look at some of the therapists's note. I realize you won't have therapists's notes. Nonetheless, you don't have to prepare their case like nursing students and know every mole and wrinkle on their body.
Patients want their needs met, yet the vast majority of them want them met quickly. Some of the stuff in IM can be complicated, but if it's overly complicated it's probably already been farmed out to subspecs. I know we all want to tell them to walk daily, eat plenty of broccoli, and drink a glass of water, but they're there for their refills (American patients want their dang pills!). You'll realize the ones that are codependent and need you to coddle them. You can get bogged down with this, but you're fortunate in a way. Patients come to my office so I have to make them leave. I'd rather bounce from exam room to exam room so I can get in and out on my timetable. I see that a lof of this can seem uncaring. It's not. Most of my patients really like me because I do a few things.
1. I shake their hand when they come in, and although there's no telling where a psych patient's hand has been I shake it anyway. (It also tests their social function.)
2. I look at them when I talk. A lot of providers don't do this anymore because they're glued to their tablet. Granted, I'm typing rapid fire, but I look at them. I've done HPIs as an entire word for word quotation before. A soft touch keyboard helps.
3. Ask them questions. If you hit a lot of different points of their life they'll often feel well assessed like you're thorough. To them, if you look at them, talk to them, and you're thorough you must care. That makes them happy. That makes them give good surveys. And that keeps them coming back. They also seem more amenable to shorter visits.

I really love these suggestions too! Thanks, Psychguy!

The little things, like shaking hands, making eye contact, etc., really matter. You are right, the patients would feel more satisfied with the appropriate gestures. We don't really have to sit there forever and talk about broccoli and exercise (to the point that some may repeat themselves over and over, in every visit). Most patients know this and there is no need to remind them during their refill visit. I have to focus on what's important and get things done in a timely manner. But remember to smile, pay attention, and act like they are the only patient in the world (but without taking too much time!)

Thanks everyone! Great responses ;-) I feel great.

allnurses Guide · Aug 6, 2015

I used to work in an IM practice that was crazy busy and gave us 15 min for each appt., be it for a sore throat or a full physical with pelvic. I often ended up finishing my charting at home cause there was no time to get it all done. I learned very quickly that I didn't have to address every issue the patient has in 1 visit. Also, I templated the notes for most common conditions, so I could do my notes very quickly, making changes as needed. That saved a lot of time.

CocoaLoverFNP · Aug 6, 2015

I used to work in an IM practice that was crazy busy and gave us 15 min for each appt., be it for a sore throat or a full physical with pelvic. I often ended up finishing my charting at home cause there was no time to get it all done. I learned very quickly that I didn't have to address every issue the patient has in 1 visit. Also, I templated the notes for most common conditions, so I could do my notes very quickly, making changes as needed. That saved a lot of time.

Thank you, BC grad! I hope they wouldn't schedule our patients that way. But if so, the doctor/owner is really nice that I could see how she will attebtively listen to my concerns about her practice in the future. If not, we would just stick it out for a year then go.

I will remember your tips too. I already have my templates saved and ready to go ;-)

indophillygirl · Feb 19, 2016

Can you give me a sample template you made

phosphorus · Mar 28, 2016

Expect to be slow when you're new. You'll get progressively better at your job and time per visit (if it's well organized) though I'd give it 1-2 yr. After a few months you'll get a groove. Utilize MAs and ancillary staff to the max. They often don't practice at the height of their practice and appreciate it like we do when people believe in them, train them to take on meaningful tasks, etc.