Rohit Marawar M.D. 🧠 Profile picture
Jun 27, 2022 21 tweets 9 min read Read on X
12 Principles for rounding and case presentations for medical students,

residents, and attendings who are forever residents at heart

#medtwitter
#neurotwitter
Whether you are presenting to the attending or calling in a consult,

it is your responsibility to convince
Where is this going?

Are you lost?

I am!
Isn't this better?

The Chief Complaint guides the rest of the presentation
Always start with the chief complaint OR reason for consultation.

This helps anchor the listener to a symptom/sign/scenario

and they can start developing differential for the case.
Don’t need to know if he is pleasant or not; don’t need to know race in most cases.

Might matter if the patient does not speak English. So you can say Indian with limited English communication coz now that has an impact on whether you are going to get reliable history.
This is even better!

In most cases, "Past Medical History" should be limited to "Past Medical History"
Your listener will thank you!
There are likely some exceptions in every specialty. For ex. in Neurology:
h/t @Dr_Oubre
@Dr_Oubre As you proceed to listen and present each aspect of the presentation, the number of differential diagnoses should narrow down.
@Dr_Oubre Most services will have a patient cap for residents. Collecting relevant data before rounds can be easily done and save a huge amount of time during rounds.

You can argue why to note the data when it is easily available in the EMR.

Try both. The suggested process is better
@Dr_Oubre Medications are beneficial toxins but toxins nonetheless.

The commonest consult in neurology is Altered mental status. Very common to have medications as the offender.
@Dr_Oubre Summary:
1. Presenter's job to convince listener
2. Start with chief complaint
3. Filter out the irrelevant (PMH)
4. Tell it chronologically
5. Keep positives and negatives together
6. Why is the patient presenting now?
@Dr_Oubre Summary:
7. Funnel approach to differential diagnoses
8. Keep relevant data handy
9. Compare and contrast imaging
10. It's all about the medications
11. Cheat but confirm
12. Supplementary information is everything

Anything you would like to add?
@Dr_Oubre This account exists to teach and share essential physician-specific knowledge that is untaught.

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1. Follow me @rohitmarawar for more of these
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More from @rohitmarawar

Jan 21, 2023
ChatGPT could be of enormous benefit to physicians.

However, there are serious ethical considerations.

A 🧵 with examples of AI-generated:

• Letter to insurance
• Personal statement
• Letter of recommendation
• Patient educational letter
• Review article

& much more Image created by Dall.E
Huge Disclaimer: I am not suggesting these should be used. But, as physicians, we will encounter or create such AI-generated content sooner or later. It is imperative we start thinking about it now.
1. Letter to insurance

I used this with minor changes, and the insurance approved the drug. I saved a few minutes typing it up

Win-Win

But, the reference was wrong. Since then, it has become common knowledge that ref can be wrong. They look real (authors, titles) but are not
Read 18 tweets
Jan 19, 2023
I asked #Medtwitter questions about a typical clinical scenario for outpatient E/M billing.

> 180 respondents.

Shockingly, 48% to 66% of respondents answered incorrectly. ImageImageImageImage
The one that most people got wrong was the scenario of refilling medications without changes.

Any medication-related action or discussion is Level 4 in the third column,
"Risk of complications and morbidity/mortality of patient management"
The results, unfortunately, prove that correct billing is still not taught well, and many physicians lack the basic skills.

Here's the original post
Read 4 tweets
Aug 12, 2022
2021 marked the first change in 20 years in how we billed for OUTPATIENT visits

7 major changes in the new OUTPATIENT BILLING guidelines follow.

A #tweetorial that literally makes you money 💵

#medtwitter #neurotwitter

1/
1. History & Exam does not count towards billing.

Only medical decision making (MDM) or time counts.

That does not mean no history or exam; medically appropriate history and exam is still needed,

But you don't have to obsess about 4 "qualifiers" for the chief complaint.
2. Billing by time is expanded.

Includes all activities for patient care.

Activities need to be done from midnight to midnight on the date of service.

Pro tip: Complete your note on date of service to add that time to the total time.

Can lead to a higher level of billing.
Read 9 tweets
Jul 6, 2022
You know what is more challenging than starting intern year?

The transition from junior resident to senior resident!

This was my personal experience and the experience of many residents I spoke to

How to win at this challenge: (in collaboration w/ @JayKinariwala @MihirKakara)
@JayKinariwala @MihirKakara 1. Be super-organized

• Review all patients the day before

• Keep track of new admissions and updates on old patients when you are off
@JayKinariwala @MihirKakara 2. Guide and set expectations

Provide realistic time that juniors will need to pre-round and complete daily tasks
Read 18 tweets
Jun 29, 2022
14 pieces of advice for a New Attending

OR

What I wish I knew when I first became an attending

#medtwitter
#neurotwitter
#academicphysicianlife

1/
1. Enjoy the independence

No more staffing with the attending.

A liberating feeling.

Enjoy it because the rest is on you.

2/
2. It’s a steep learning curve

I learnt more in my first 6 months as an attending than I did in my 6 years of training.

When the buck stops with you, you cannot stop learning.

3/
Read 18 tweets
Apr 29, 2022
Pathway to Green Card via J-1 Waiver Job

#medtwittter #neurotwitter #IMG

These are the steps in chronological order 👇🏼
Disclaimer: I am not an immigration lawyer. The information below is based on my experience and personal research. Do your own research
1. Visa for employment in a J1-waiver job : H1b

Sponsored by employer

3-year commitment to working in a “healthcare underserved area”

Pro tip: the physician contract should state that the employer will sponsor a green card and start the process during the 3-year employment
Read 18 tweets

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