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The Q-Wave: SOAP – Subjective, Objective, Assessment, and Plan

John Bielinski, MS PA-C By April 15, 2021No Comments
The Q-Wave: SOAP – Subjective, Objective, Assessment, and Plan

You know, I’m a fan of thinking, thought processes. That’s been a big part of my lecturing over the last ten years. Not how to read an EKG, but what are your thought processes before you get the EKG? I did a lot of lecturing on medical errors, why we make cognitive errors, and I realized we often think, but we rarely think about how we think. Do we think about our own biases? Do we think about the way we process content? Annie Duke, a Texas Hold’em world champion, did a talk that I heard. She talked about our thought process when we make decisions because if we think with due diligence, we have an optimal chance of a good outcome. We can get lucky, but often, our thinking determines our decisions.

Now, when it comes to medicine, we’re taught in optimal thought processes. If you think about a SOAP note, that’s an optimal thought process, and it can be used outside of medicine. Recently, I did a presentation on thought processes. When we have a high-stake decision, how do we think? I came up with a system, and a lot of it aligned with a SOAP note.


S is Subjective

What do you think? What are your emotions telling you? What are your potential biases? With this situation, I try to think about what could be going on within me that might be causing conflict, which in turn may be blinding me from seeing the big picture.

O is Objective

Then I ask, what are things I know?” and I put that into a few different categories. What are the things I know for sure 100%? What are some things that I think I know, but I may be mistaken? Within that is, what are the things I don’t know? And that falls into two categories. What are the things I don’t know I don’t know, which if I don’t know I don’t know it, how could I possibly know it? Well, colleagues, I want to suggest to you that it’s impossible that we know all the details of anything. We have to appreciate the fact that we’re ignorant, and we’re even ignorant to our ignorance. So, when you make a thought process, and you’re thinking, you’ve got to realize there are variables: one, I don’t even understand, and two, there are things that I know I don’t know. Therefore, under objective, I put things into four categories:

What are things that I know with a very high degree of confidence?
What are things that I believe in but have high confidence that I may be wrong?
What are things that I don’t know I don’t know? -Clearly, I can’t know that. I know that sounds a little silly, but that needs me to keep my cognition open, so maybe I can look around and think, “Could I innovate thinking?”
Things I know, I don’t know.

A is Assessment

Now, the Assessment is where we look at our options. Our assessment is our differential diagnosis. This is where we look at possible choices, and we weigh them two ways, probability, what’s the likelihood, and then what’s the magnitude. Suppose someone comes in with chest pain. Ok, it hurts when they eat food and when they lay down flat, it’s burning. The person is young, with no cardiac risk factors. Well, the likelihood of GERD is high, 80%. What’s the magnitude if it’s GERD? If it’s GERD, it’s no big deal. No one dies of GERD, not really, not like a heart attack, right? So, the magnitude is low on the impact on the patient’s life. What are the chances it’s unstable angina? Cardiac ischemia? Low, 2% or 3%. What’s the magnitude? Well, the magnitude is really high. With assessment, we often think about probability and magnitude.

P is Plan

And then, Plan, we make a decision. And we don’t just make a decision, but we also decide how we will follow up on this decision? How are we going to assess our accuracy? How are we going to be able to adjust if we’re wrong? Colleagues, a SOAP note is way more than a medical tool. It’s a thinking process, and it’s excellent. Subjective, Objective, Assessment, Plan.

Using processes keeps me out of trouble

Now, what I’ve found in medicine is using processes to think keeps me out of trouble. In the book, The Checklist Manifesto, they talk about this because we are flawed in our thinking. Let’s imagine we’re going to see a patient, and we’re having a busy day. We didn’t eat lunch, we didn’t sleep well last night, we just got yelled at by hospitals who didn’t want to admit our patient, and we go in to see the next patient a little frazzled. Our cognition, albeit we go through our medical training to keep it really sharp, it’s flawed. It’s flawed because we’re flawed. That’s where systems come in. Systems come in to keep you out of trouble. I can tell you, systems, for me, have saved lives.

I’ll never forget working as a hospitalist. I had a simple chest pain admission; a 72-year-old guy with chest pain. Everything about it seemed very simple. I read the ER note, chest pain, normal cardiac workup. We need to admit this guy, probably heparinize him, but everything about this seemed like a straightforward admission for cardiac ischemia. But I had a system. It was a handwritten note, and I remember exactly where I would write what interventions they did in the ER. I got into the habit of writing down what they did in the emergency room. Did they give aspirin? Did they give a beta-blocker? You know, I always documented it. And as I’m reading through the nurse’s note, I realized his blood pressure was low, and they had to give him a liter of fluid for blood pressure control. I look at his note, and his pressures were in the 90s. I think that’s weird, but maybe he lives low; perhaps he lives hypotensive. So, I went into the room and asked, “How’s your blood pressure, normally?” And he says, “Well, it’s 120/80.”, “What? How do you know?”, “Well, I check it all the time.” So, here I say, “That’s weird. Why would someone have chest pain and hypotension? That doesn’t make sense.” If he had cardiac ischemia and became hypotensive from it, well, that’s cardiogenic shock, but he would look super sick. He looked pretty good. He didn’t look that sick. I thought about it, and then I looked at the chest x-ray, and I think that doesn’t look right. That chest x-ray looks big. The mediastinum seems big, and I decide I’m going to scan him. It’s the middle of the night, but I’m going to scan him. And where I worked, it was a fiasco to get a CAT scan with contrast at night. But something didn’t feel right, and quite frankly, I felt foolish. I felt like, “Boy, John, you’re blowing this out of proportion. You’re making a big deal out of nothing.” Not an hour later, I get the phone call that it was type one dissection and he needed to go right to the OR, or he was going to die. Honestly, I don’t know if I’m good or if my systems saved me.

I was recently working at an ER, and there were some really complicated patients. I’m working in a great ER, really strong docs, and a great team, but I know that some docs are more friendly and more collegial with advanced practitioners than others; that’s just human nature. I get it, ok, because if you were taking care of super sick people, and you have a thought process, you have a way to assess a patient, look at their triage note, look at the nurses note, look at their old records, then do a subjective assessment of the patient, get the information and object. You have a system, and you’re good at it, but then you have to work with advanced practitioners who violate your system; they break your system. That can be very confusing. That could be how people die, and you miss things. That’s what happens at sign-out in emergency medicine. When you sign a patient out, your thought process is different. You’re accepting data from another person; you didn’t apply your pattern. You didn’t follow your system. So, some of the patients I had to talk to the one doc about you could feel a little conflict, and I know it wasn’t personal. It was because I was violating her system of how she takes care of patients. I don’t blame her for one second because the stakes are so high. It’s not personal. It’s about the patient, and I realized that there are many people that I work with that are conducive to this system, and that probably should be a big part of medical school; how do you work with advanced practitioners to optimize thought process?

Don’t get burned by process

Ok, how to not get burned by thought processes? You know, some of the best docs I’ve ever worked with in emergency medicine, I would give them my assessment, and they would take my whole assessment as subjective. “Ok, I hear what John’s saying. I got it. Now I’m going to go in and start over. I got John’s stuff, and John helped me be efficient, but now I’m going to see this patient and think of them from an objective perspective.”

I know in my life that it’s really important that we have thought processes. How do you think? That’s my question for you. How do you think? There are a lot of books on thought processes, there are a lot of books on how we think, and I’m a huge fan of that. Daniel Kahneman, who won the Nobel prize, wrote this book, Thinking Fast and Slow. It’s all about the systems that drive the way we think. If you think about it, if you think really well, you have a really good thought process. You do your due diligence, and you have a good outcome from your decision. That’s how it’s supposed to work. If you think really hard, have a good thought process, and have a bad outcome, you have bad luck, which happens because of many factors. If you don’t think very well and you have a good outcome, you got lucky. And if you don’t think very well and have a bad outcome, you got what you deserved. Our life is defined, in huge degree, by our thought process and luck. Clearly, we can’t control luck, but we can control our thought process.

And in medicine, how are you thinking, and do you have processes in place? I recently realized that at the place I’m working, I often overlook vital signs. I would casually look at them. Well, I realized that’s unacceptable. So, I started putting them right into my objective note. The first thing I do now is dictate my vital signs. And that makes me acknowledge them in a very objective way. I also realize I’m juggling a bunch of super sick people, and out of nowhere, guess who is going to pop in and say, “Hey, is this guy in coagulation? Is he on anti-platelets coagulation?” And then I’m scrambling. So, I had to come up with a system. I would know, hey, these are high yield questions, and they are often asked. So, within my system, I had to make sure that these are ready to go.

Any good provider has systems in place. And ladies and gentlemen, in life, if you’re habitually missing something, if you’re habitually swinging the bat and missing the ball on something important, you need to incorporate it into your system. Incorporate into a system something that you do habitually, so it takes it off your cognitive plate. Like when I travel to lecture, I know right where my adapter goes for my computer and right where my laser pointer goes. I know exactly what pocket they go in. So, as soon as I’m done, I unplug my computer, and I put them in those two pockets. I don’t have to think or worry about them because I have a system. I know it can harm me at my next lecture if I don’t have them. So, I have a system in place. I take vitamins in the morning, and frequently I’d buy vitamins and forget them. Why would you buy something potentially good for yourself and forget? But I get hung up in the morning; my cognition is off. So, you know what I did? I put them right on my Keurig, and I love my coffee in the morning. This system made it easy for me to be good and not forget.

Discipline x Strategy = Willpower

So, listen, this is important, guys. This came from a book called Atomic Habits. You know, I used to think discipline was willpower, but it’s not. Discipline is not willpower. Discipline is willpower times strategy. Let’s say you want to go to the gym and workout; if you go to the gym and workout, you’re disciplined, and you’re like, I have willpower. That’s not true. If your willpower is a little lacking to go to the gym, you need a better strategy. Maybe you need to go to train with somebody. Perhaps you need to join a fitness class. Maybe you need a coach or a fitness trainer that requires you to sign up and pay money to go; that’ll probably give you the strategy to optimize your outcomes.

Pause and look at the big picture

So, colleagues, my hope with what I teach is to have you pause and look at the big picture. First and foremost, SOAP: Subjective, Objective, Assessment, and Plan. And under Assessment, think about likelihood and magnitude. For me, it’s been very helpful. I now have a thought process that I use for my high-stakes decisions. And according to Harvard business review, there’s a heck of a return on investment for high-end thinking.

Welcome to this month’s Q wave. My name is John Bielinski. If you like what’s going on here, challenging the status quo, thinking. We also do the same thing with medicine. We challenge the status quo with how you approach urgent care, emergency medicine, advanced emergency medicine, as well as EKG interpretation. There are a lot of courses that give you data and facts. One of the things we do is try to teach you a thought process. We don’t just teach you, “Hey, here’s a few coronary syndromes.” We teach you how to think about chest pain. We teach you how to document chest pain and the risk factors. We teach you how to keep yourself out of trouble. Consider coming to one of our live conferences, or we have video programs online, Category 1 CME Programs. And in 2022, we are working on an urgent care symposium in Orlando that will be all-inclusive. We hope you consider joining us. Good luck. God bless.

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