A few weeks ago I featured an inspiring speech about a young college track athlete named Kyle trying to break the 4:00 minute mile. Having been stuck at 4:05 for some time, he insightfully observed,

“I don’t think there is one single thing I can do to cut off five seconds, but I do think there are ten things I can do that can each cut off half a second and together will total five seconds and get me under four minutes.”

I likened becoming a “successful intern” to breaking the four minute mile. So often do we try to become better but feel that we plateau. I observed how we (or at least I) often suffer from not sharing Kyle’s perspective:  I often focus on one thing at a time at the expense of others that require my attention. At the end of that post I promised to publish my own list of 10 small things I could work on to break the “successful intern barrier”.

Realizing that we have both inpatient and outpatient months, which require different skill sets, I feel that it would be better to split these lists into both outpatient and inpatient suggestions. After a few month of being on outpatient rotations, here is my list of eight things to master in order to break the successful intern barrier in the outpatient world:

1. Type your note while in the room . This takes some work, and some tact, but if you can master this it will help you get your work done so much faster. Personally I’m only able to get the history and a skeletonized version of the plan (I have to go back for the physical exam and other details), but it makes a world of a difference.
2. Use GAMeLevers to prepare .  GAMeLevers is a structured way to quickly prepare for an outpatient visit by reviewing the Goal, Active Issues, Medications, and Levers (tests, imaging, consults, therapy, time; see ‘Dr Reid’s Five Levers’ for more detail).
3. Redirect your patient to focus on the Goal of the visit . Anyone who has done outpatient work knows this is a problem. Your patient may be coming to the clinic for their rheumatoid arthritis, but they will want to tell you about the cold they have had or the restless leg symptoms they are experiencing. You may be tempted to try to address everything, but be sure to redirect and focus most of your attention on the goal of the visit, as that is the most important issue.
4. Think ahead to the next encounter .  Outpatient medicine is like a conversation, so think about what the next provider reading this note will want to know. We all get frustrated by those mini-novel notes we have to comb through for five minutes just to get the small bit of information we need for our visit. Limit what you write to that which will be most helpful and pertinent to the conversation.
5. Review the Levers at the end of the visit . We have all had that panic moment of sending off that complicated patient and forgetting to tell them about one of the medications we changed or that they need to get a certain test done. Running through the Levers I talked about earlier helps me make sure I do not forget to tell the patient anything crucial that we are changing (e.g. “Alright, so lab-wise we’re going to measure your A1C and your BMP, no imaging today, we’ve put in the consult for dermatology to look at that rash, we are changing your metformin dose and starting lisinopril, and we want you to come back in 5 weeks.”)
6. Pick something you saw in clinic to educate yourself about . For me, learning is always most optimal when I have something to apply it to. I do best learning about rheumatoid arthritis if I have just seen a patient with rheumatoid arthritis. So even if it is five minutes, I take time to learn about at least one of my patient’s conditions.
7. Get enough sleep . More of a general suggestion, but being tired sucks, and affects your performance, and will likely make it so you take longer on your notes.
8. Do something for yourself each morning .  I always find that I am more scatterbrained, more haphazard, and slower in general if I wake up late and have to rush to work. In contrast, there are no more efficient days than the ones when I get up early enough to read — even for five minutes — out of a good book, or make breakfast for myself. I leave with enough time to get to clinic, and my mind is calm and primed for action.

There are times when I have focused on one or two of these things. But, like Kyle, I recognize that breaking the successful intern barrier requires constant awareness of and effort at all of these things. Doing so has helped me to enjoy outpatient medicine while being as efficient as possible.

Image credit: St. Mary’s Hospital Thyroid Exam Room by Steven Depolo licensed under CC BY 2.0.

Justin Jones, MD (5 Posts)

Attending Physician Guest Author and Contributing Writer Emeritus

Intermountain Healthcare

Justin Jones is an outpatient primary care physician in Utah. He completed his residency in 2018 in Colorado and wrote for in-House during residency. He blogs at Residency Hacker.