July 24, 2009

MED K – ORIENTATION CHEAT SHEET

Welcome to Med K, a unique medicine service that is rich with teaching and caring experiences. This can be a very fulfilling rotation and you will have opportunities to grow as well as greatly impact the health of patients under your care. Below are important responsibilities we stress on this service.

Responsibility / Expectations / Explanation
Morning Rounds / Pre-round M-F then Attending Rounds at bedside and always ending at 10am at which time the Resident goes to AM Report.
Rounds must be efficient and structured to be completed in a timely fashion. / We believe that there is value in the team rounding together in terms of continuity of care and teaching.
Interdisciplinary Rounds / The Attending and Resident will round with Social Work Case Manager and Charge Nurse M-F at 11:15am. / This is an essential part of the day and aims to coordinate the care team to deliver service in an efficient fashion.
X-Ray Rounds / M, W, F at 1:15pm. / Invaluable for care and learning.
Attending Rounds / Two to three times per week. Med G and Med K will combine these didactic sessions. / Required for teaching aims of the service.
White Boards / Collectively ‘owned’ by Medical, Nursing, Social Work, Ancillary Services (PT, OT etc), the boards in patient rooms are used to communicate important data (procedures, plans) to patients and their families. They should be kept up to date and accurate by all. / Patients often complain they are out of the loop. The white boards are popular and helpful in keeping patients up to date on plans. Use them.
Rounds Report / At the end of each day the Rounds Report should be updated to reflect anticipated plans and on-going and future needs for the patient. / Social work uses the data in the report to work on plans while the team rounds in the morning.
Discharge Planning / Begin formulation of discharge plans at the time of admission. Where the patient will go to after release, medications coverage, central lines, PT/OT, O2, IV therapy, dialysis, all must be anticipated and planned for early. / The goal is not to discharge patients from the hospital earlier than medically necessary but to reduce avoidable delays in discharge.
Satisfaction Surveys / Encourage patients to complete these surveys, particularly the many patients who may have had a good experience. / A fraction of patients complete the survey and often these are those who have something to complain about. As the survey is used to gauge quality of service, encouragement of broader use will reflect our service.

MEDICINE K WARD SERVICE ORIENTATION

EXPECTATIONS and RESPONSIBILITIES for HOUSESTAFF and STUDENTS

Welcome to Med K. This is a busy service and you will learn a lot in the short time you are part of our team. The Division of Infectious Diseases faculty members are very committed to ensuring that you have a first rate experience, both fun and educational. We also hope that at the end you will realize why all of us love our work so much. There are certain expectations that we want you to meet and that you should expect of us. Please read the following to better understand what it is we expect of you and what we will aim to provide to advance your training. If you have any questions please ask your attending.

For All Team Members:

1. TAKE CARE OF YOUR PATIENTS: Most of you want to do well on this rotation. To receive a great evaluation you should behave like the physician you aim to become and take responsibility for your patient. The patient is ‘yours’ and that means they are your responsibility. You need to know everything about them.

-Take a complete history and review all old records on your admissions: If the patient was transferred from another hospital, institution or referred from an outside physician, call that person/institution the day or night of admission and get a copy of the record faxed to the ward. If the patient is not a good historian then call family members. Call the microbiology laboratory at the outside hospital or the state TB laboratory if the patient had any cultures sent there and call again until the culture is final. (Important: Be sensitive to the fact that if a patient is HIV+, their family members may not be aware of the diagnosis.)

-Perform a complete physical exam on each patient: It is not appropriate for housestaff or students to take short-cuts such as “no focal findings” on neurology exam or “clear” on lung exam. Most physical findings need to be evaluated and described via inspection, palpation/percussion and auscultation. We expect you to do this. In particular, you need to learn what is appropriate in terms of a physical exam for particular findings or complaints. For instance, someone who is clearly dizzy and exhibiting symptoms of orthostatic hypotension, should have orthostatics performed. Someone with a brain mass needs a detailed neurologic exam. If a woman has abdominal pain, she needs a pelvic exam. If you need to open up your old Physical Diagnosis textbook, do so.

-Physical exam instruments: Get ophthalmoscopes/otoscopes, reflex hammers, flash lights and tongue depressors. We will be assuming that you have such items.

-Review the EKG on your admission so you know what it looks like.

-Review the laboratory results: Look back at old microbiology results in patients with recurrent or chronic infections.

-Visit radiology and ask the radiologist on call to go over the CXR, MRI, etc of your patients. Simply reading ARTAS reports is not optimal. All films, and abnormal radiographs in particular, must be inspected by you with a radiologist, if not at the admission then at X-ray rounds.

-Aim to make a diagnosis the day of admission. Writing orders for sputum gram stain is not sufficient. It needs to be done! Pretend the patient is a relative, would you like them to sit around waiting for the diagnosis?

-Learn from patients and their families. Take the time to listen to their stories, their lives and learn how they cope.

-Take responsibility for your patients. You should know every test result and every event that happens to your patient as well as each medication they are taking. There will be little tolerance for not knowing results of cultures or serological tests or the medication list.

-Progress Notes: With WebCis there is a great temptation to cut and paste from prior notes to the next. This renders these important sources of information useless. This will not be acceptable on Med K. Make certain that the information in the progress note is up to date and informative, reflecting the events and discussions of the day. Up date problems lists, medications, procedures and assessments every day.

-Discharges:Start discharge planning on admission. Consider where the patient will go to next and anticipated needs such as oxygen, IV antibiotics, ability to afford medications, PT, OT, dialysis etc. If a PICC or central line is needed, order sooner rather than later. All patients must have a clear understanding of their diagnoses, discharge medications, and follow-up, including a way to get their prescriptions filled. This MUST BE DOCUMENTED will not happen unless the person taking care of them ensures it. The medication instructions for patients must be written in lay terms. The intern must meet with the patient to go over their medications and follow up appointments. Only a licensed clinician should do this. Discharge summaries must be dictated the day of discharge. All HIV+ patients can receive a post-hospitalization appointment in the ID Clinic. Call Lynda Bell at 6-7199 to arrange.

-Think ‘big picture’. If a patient keeps getting admitted for an illness, either you have the wrong diagnosis or something is happening to the patient that is making them sick, either environmental or social.

2. ROUNDS AND TEAM LEARNING. There are ample opportunities for independent and group learning during your rotation.

-Independent learning: You are expected to read about the diseases your patient may have, their diagnosis and management. For the resident and medical students, you should be a source of information to the interns and team as a whole. You need to pull articles (not just UpToDate) and share what you read with your busy interns and team-mates.

Rounds:

-Morning Work Rounds – The morning work rounds are critical to the dual missions of patient care and medical education. All team members should arrive on time and prepared to discuss the details of the care of patients for whom you are caring. Rounds will start at a time that will allow for each patient to be seen and discussed prior to 10 am when the resident must be at Morning Report. Rounds will be efficient and focused.

Pre-rounding before Morning Work Rounds is essential and will avoid surprises during work rounds.

On rounds, the intern or student must be prepared to formally present on new and established patients. The resident and attending will provide teaching at the bedside and assess presentations for organization, accuracy and style. This is a chance for students and interns to shine! Always pay attention to patient comfort and privacy (draw curtains, close doors, turn back on TVs, etc). Proper infection control techniques must be followed.

-Social Work Rounds – Every day, typically at 11:15 am, the attending and resident should meet with the ward social workers and clinical care coordinators to discuss discharge planning, coordination of inpatient services and referrals and outpatient access to care. It is unacceptable to send a patient home on new medications that he or she cannot afford. This meeting is crucial to maintaining a reasonable ward census and coordinating essential services for our patients. If you cannot make these rounds, out of courtesy, let the social worker know. See the Social Work Survival Guide below for helpful contact numbers and advice.

-Attending Teaching Rounds – At least two times a week, the attending will ask that the team convene for formal sit-down teaching rounds. This should be a protected time dedicated to learning. Ask questions, bring papers to discuss. When paged out of rounds, please inform the caller that you are in attending rounds and will call them back. All efforts will be made to combine Med G and Med K teaching rounds.

-Radiology Rounds – As part of the teaching experience we will round with a radiologist three times a week (every Monday, Wednesday and Friday at 1:15 pm). Attendance is mandatory and we are certain you will find this to be a very useful and enlightening experience. Bring a list of films you want to review.

-Wednesday Morning ID Rounds – The Med K team is expected to attend the Med K conference every Wednesday morning at 8:30 am in the 5th floor Orthopedics Conference Room. Unknown cases from the ward and consult services will be presented. Students who volunteer to present cases are typically praised for their initiative.

-Morning Report – Residents must go to morning report except on Wednesdays when the ID conference occurs. We mean it.

3. GENERAL TIPS

-Dress appropriately for working hard and follow the hospital dress code.

-Be nice to ancillary personnel such as the nurses, aides, pharmacists, social workers and secretaries. They work hard and appreciate your acknowledgement of their role in the health team and they’ll make your life easier. Remember, they too are your teachers.

-Ask for help if you need it.

-Never lie! It is much better to say ‘I don’t know.’

-Think prevention: flu, pneumovax, mammogram, PAPs, rectal, STD’s.

-We understand that the socialization process of becoming a physician can be painful but thousands have gone through the process before and survived. Look in mirror every day and say “I am a good person, a smart person and I would not be here if that were not true.” Trust the many hours of education and hard work that got you to where you are today.

-If you are not having a good learning experience, tell the attending as soon as possible what can be done to improve your rotation.

-If you have specific rotation requirements, i.e. observed complete physical exam, please tell the attending on the first day of the rotation.

-Don’t get in arguments with other physicians, students, or staff about your patient’s care. If you think your patient needs something done and another health care worker refuses to do it then call your resident or attending to facilitate.

-Don’t get the disease yourself and think about communicable diseases

Never sit on the bed and always be on the look out for loose needles

Never do a procedure using sharps if you are tired or don’t know what you are doing.

If you stick yourself call your attending and resident immediately.

4. ATTENDING RESPONSIBILITIES TO HOUSESTAFF AND STUDENTS

-Attending lectures.

-Bedside teaching.

-Accessibility to you for additional questions.

-Feedback on performance, areas for improvement, presentations and write-ups early in the rotation.

-For students, physical diagnosis rounds at least once a week.

-Formal meeting with attending half way through rotation to give assessment.

For Medical Students

DON’T BE PASSIVE, FIND LEARNING OPPORTUNITIES. Each patient provides a learning opportunity. There are no boring patients. The 63 year-old woman with a community acquired pneumonia and the 56 year-old man admitted to rule-out MI can both provide a wealth of learning for you. Learn why she was prescribed a quinolone and how the HCTZ he is taking works.

As a first and second year student you are a dependent learner where you are told to memorize 10 facts, given a study guide on the 10 facts and then told the 10 facts that will be on the exam and then given the exam with 10 facts. As a third and fourth year student you need to realize quickly that what you learn is dependent on you taking the initiative to begin the life long process of learning medicine.

-Students should not have to be told to jump in during rounds. If they hear of someone with a murmur of mitral regurgitation on working rounds, they need to take out their stethoscopes and listen with the rest of the team or come back later with the resident or attending.

-Volunteer to do every procedure on every patient whether your own or not (i.e. starting IVs, central lines, chest, spinal and abdominal taps, putting in Foley catheters, etc). If you don’t do them you won’t learn them and will have a painful internship. This is your best opportunity to learn these procedures.

-Help your intern and volunteer to stay over on your night on call to learn the cross-cover routine procedures such as a fever workup, mental status change, chest pain, acute SOB, and falling out of bed. You should be able to think of the differential and carry out the work up for these clinical scenarios in your sleep.

-Don’t wait to be told to work up a patient, keep asking your resident if there is a patient for you to see, even if it is not your on call day.

-READ, READ, READ: We have a tendency here to gain "knowledge" by asking people superior (e.g. the resident asks the attending, the student asks the resident) and stopping there - instead of looking things up - both in texts AND in journals. It's OK to ask as a starting place (or even better AFTER looking it up). You should challenge your superiors - make them back up their statements, rather than using them as the "gold standard". You should read and learn about every problem. Do PUBMED searches on your patient’s diagnoses.

-WRITE UPS SHOULD BE THOROUGH: Patients come in with chief complaints and problems, not a list neatly divided up into cardiovascular, pulmonary, endo, etc. Therefore H&P’s should be problem focused. We want to see a detailed problem list where each problem is listed down to every laboratory and physical exam finding and that the distillation of how these inter-relate or do not is included in the discussion with a differential diagnosis for the top 1-3 complaints/findings. The difference between high pass and honors is that there is some evidence of independent learning which does not involve simply textbooks or Up-to-Date. Remember, honors is a grade bestowed for superior work. To get this grade you need to be extraordinary. On the Medicine Wards you need to order your discussion focusing on the different problems the patient has such as chest pain, diarrhea, headache, fever, etc and then list a differential diagnosis for each problem along with pertinent positives and negatives in history, physical exam and laboratory data and the pathogenesis of your final idea as to diagnosis. Don’t regurgitate a textbook instead relate the discussion to your patient (See example below).

Ask your resident for help with your write up.

Write ups should be given to the attending within twenty-four hours of admission.

PRESENTATIONS: There is an art to presenting information and it is perhaps one of the most important tasks a physician does other than diagnosing a patient’s illness. If you don’t convey the information accurately then the person assuming care may misunderstand you with disastrous consequences.