*How to clinic with Paul Williams*

Mostly for internal medicine residents, but also for anyone else who is curious.

Others may do things differently or disagree, and that’s totally fine. (1/22)

Before you see the patient, look at the chart. I mean REALLY look. Focus on notes, but also on imaging and unusual labs. Why was it ordered, and does anything need done with it? (2/22)

Same goes for medications. Why are they taking it, who prescribed it, and is it still current? Keep your eyes peeled for antibiotics and analgesics, which can indicate interval events. (3/22)

Curiosity is key. If the patient is anemic, ask why. Same goes for thrombocytopenia. Does this 30-year old really have COPD? Question incongruities and take nothing for granted. (4/22)

Now the problem list. Is it accurate? Is the patient still anemic? Do they still have bacterial vaginosis? Revel in the joy of deleting resolved problems, wrong diagnoses, and old symptoms. (5/22)

There may still be a lot of problems to deal with. Accept that you cannot fix them all in one visit. One of the joys of primary care is that you have time to work on this stuff. (6/22)

AGENDA-SETTING is the absolute key to a successful outpatient visit. Choose two or three problems you’d like to address before you even go in the room. (7/22)

The patient will have their own agenda. Listen to it. Then, be explicit about the things you'd like to address, which of their concerns you'll address today, and what will be addressed at future visits. (8/22)

The social history is critical, and isn’t just substance use. Who does the patient live with, where do they live, and how do they get their medications? Can they afford their medications? Is there enough food? (9/22)

Ask your patients who smoke cigarettes about cessation at every visit. (10/22)

Language matters. Unless you’re talking about lungs or blood vessels, don’t say “non-compliant.” “Adherence” encompasses things like cost, ineffective physician instruction and adverse effects. (11/22)

Language matters. Do not say “alcoholic,” “drug user,” “addict,” or “substance abuse.” Instead, this is a “patient with alcohol use” or “substance use.” Similarly, this is not "a diabetic," it's a "patient with diabetes." Use patient-first language. (12/22)

Patient-first language emphasizes that this is a patient with a diagnosis, but is not defined by that diagnosis. If the patient becomes the problem, you’re both in trouble. (13/22)

Get to know your patients. This is the fun part. What do they do to relax? Do they have pets? How are their kids doing? What stressors are in their life right now? (14/22)

As Dr. Noel Bairey Mertz says: “Guidelines make good doctors great doctors.” Learn the important guidelines for common problems like HTN, diabetes, and dyslipidemia, and know the major studies that shaped them. (15/22)

Conversely, you’re allowed to use clinical judgement. But if you’re going to stray from a standard of care or widely used guideline, have a really good reason. Guidelines can help mitigate disparities. (16/22)

Get comfortable with the musculoskeletal exam and common diagnoses. “I think this knee pain is musculoskeletal,” while probably true, isn’t a diagnosis. Is this DJD, meniscal, or referred pain? This impacts appropriate treatment. (17/22)

Don’t forget to examine the patient. This happens more than you might believe. If you’re not sure how to do something (Dix-Hallpike, Thessaly, otoscopic exam, etc.), ask your preceptor to demonstrate it. (18/22)

Before you go tell your preceptor about the patient, ask the patient if there is anything else they want to discuss with you. There usually is. (19/22)

Health maintenance stuff (cancer screening, immunizations, screening labs, etc.) is pretty algorithmic. Just don’t forget to do it, or revisit if previously declined. This is a nice time for shared decision-making. (20/22)

Before the patient leaves, be explicit about the next steps in their care, including when they should return to clinic and how to contact you, if needed. Have them repeat this plan back to you, and be sure to follow through on your part. (21/22)

Rinse, lather, repeat. Don’t forget that being a patient's doctor is a privilege. Be grateful for the chance to take care of your patients, and they’ll bring you food and ask about your family and cry when you graduate. (22/22)

This was incredibly hard to do, and I could have gone on for 123 more tweets. I'm sure there are some glaring omissions. Looking forward to (am terrified of) feedback.

Ahhh!!! The quote is from Noel Bairey Merz, not “Mertz!” A million apologies, and a million curses for no edit option!