What differences do you note between your H&Ps?
Coming from a background in both EMS and medical office scribe work, I had previous experience with medical documentation before PA school. However, my knowledge was much more fundamental than the knowledge I had to develop to develop a thorough H&P. While I found that the documentation skills I developed in my previous roles were transferable to the skills needed to write a strong HPI as a PA student, it took some time for me to understand how to integrate the other aspects of the H&P alongside my HPI in a complementary way. The biggest difference I see in my H&Ps is due to reducing redundant information throughout the document and including information only in the area it best belongs. To name one of many examples, I learned that since a general survey is found later in an H&P, it does not need to be included in an HPI. As a result, I think my most recent H&P is more succinct and logically written than my first.
In what ways has your history-taking improved? Are you eliciting all the important information?
I think I have most improved in my ability and understanding of which ROS symptoms are important to ask the patient in order to direct my developing differentials. Secondary to that, I think I have a better understanding of which pertinent positives and negatives are important to highlight in my HPI. I think both of these skills are secondary to my developing medical education. Also, although it can’t be seen on paper, I recall notably increased comfort taking a patient’s past medical history between my first and last H&Ps. It felt easier to recall which questions to ask after I had forgotten a few during my first patient encounter. Overall, I feel that I am eliciting nearly all important information, but I know that as my medical knowledge and patient-interviewing skills continues to expand, I will strengthen this skill further.
In what ways has writing an HPI improved?
Although the difference between my rubric scores was small, I recall a significant difference in my comfort and efficiency writing my first and last HPIs. Over the course of PD, I learned how to approach HPI writing from the more critical lens of an advanced provider rather than that of an EMT. As an EMT, I was not expected to have a knowledge of what information may be pertinent for a differential diagnosis. As a PA student, that information is of utmost important. I felt much more comfortable with my selection of what was pertinent to include in the HPI in order to guide my initial differential. Overall, I have a better understanding of the true purpose of an HPI from the lens of an advanced practitioner expected to make a diagnosis rather than from the lens as an EMT or scribe who would not.
What is your self-assessment of your current skill in performing a physical exam? Which areas do you feel strongest about/weakest about?
Similarly to my experience with documentation, I do have experience performing physical exams from my work as an EMT, but transferring those skills to succeed as a PA student required an expansion of what I previously knew. I believe my strengths to be that I know how to communicate and prepare the patient for the ways in which I will be assessing them, and I know how and when to ensure their comfort throughout the exam. I feel most confident with vital signs and lung auscultation since I frequently did them as an EMT. Also, although examining these body systems was new to me, I feel comfortable with the ears, nose, and throat exams as well, maybe from observing so many of them from my time working in an urgent care office. I feel weakest with the fundoscopic exam as well as cardiac auscultation.
Which of the specific areas will you target as needing particular focus in future patient visits when you start the clinical year?
I think my biggest weakest at this time is taking a patient’s past medical history. I’ve taken a lot of past medical histories, but they were not required to be as in depth as they are for a true H&P. Sometimes I find muscle memory taking over, and I resort to asking the patient the more reductive PMH questions that I am used to from my past roles. I think I need to focus on emphasizing to myself which areas of the PMH are new to me and practice ensuring that I integrate them into the series of questions that I am used to asking. I think this will come easily with time and practice. Similarly, I think I need to get better at memorizing all body systems that need to be included in ROS. I don’t think I have the ability to recall all of them in a systematic way, but I think that too will come with time and repetition.
