Internal Medicine Clerkship

INTERNAL MEDICINE CLERKSHIP

2009

Table of Contents

I. Fundamentals (overall objectives) …………………………………………………… 3

II. Clerkship Basic Framework ……………………………………………………….... 4

III. Daily Clinical Responsibilities …… ………………………………………..……... 5

1. Seeing your patient ……..…………………………………………………. 5

2. Daily Data Collection ……………………..………………………………… 5

3. Daily Patient Notes (SOAP notes) …………………………………………. 6

4. Daily Oral Presentations …………………………………………………… 6

5. Daily Patient Work …………………………………………………………. 7

6. Clerkship typical weekday daily schedule .……………………………….. 7

IV. Taking Call ……...…………………………………………………………………. 8

1. Responsibilities ……………………………………………………………… 8

2. History and Physicals (How to)……………...... ……………… 9

3. Typical schedule for a call day …………………………………………….. 11 V. Curriculum ………………………………………………………………………….. 12

1. Afternoon Report …………………………………………….…………….. 12

2. Grand Rounds ……………………………………………….…………….. 12

3. Clerkship School …………………………………………..………………… 12

4. EKG Lecture ……………………………………………………………….. 12

5. Shelf Review……………………..………………………………………….. 13

VI. Assessment and Testing …………………………………………………………… 13

1. Observation Worksheets …………………………………………………… 13

2. History and Physical Evaluation ………………………………………….. 13

3. Student Presentations on an IM topic……………………………………… 13

4. Mid-Block Feedback ………………………………………………………… 13

5. Practical Exam …..………………………………………………………. 14

6. Shelf Exam …………………………………………………………………… 14

7. Ward Evaluations ……………………………………………………………. 15

8. Professionalism ………………………………………………………………. 15

VII. Grading ..…………………………………………………………………………….. 16

1.Honors ………………………………………………………………………. 16

2. High Pass ……………………………………………………………………. 16

3. Pass ………………………………………………………………………….. 16

5. Borderline Grade …………………………………………………………… 17

6. Condition Grade …………………………………………………………….. 17

7. Failure ……………………………………………………………………….. 17

8. Grade Breakdown ……………………………………………………….. 17

VII. Books ……………………………………………………………………………… 18

VIII. Food and Bags …………………………………………………………………. 18

IX. Dress Code ………………………………………………………………………….. 19

X. Hygiene ……………………………………………………………………………….. 19

******XI. Days Off …………………………………………………………………………….. 19

******XII. Absences …………………………………………………………………………… 19

XIII. End of the Clerkship Checklist ..………………………………………………… 20

XIV. Potential Student Pitfalls ………………………………………………………… 21

INTERNAL MEDICINE

CLERKSHIP 2014

I. Fundamentals (overall objectives).

To be an outstanding student and future physician, you must be able to

1. Take an accurate history and perform a thorough physical exam. Understand the importance of making clinical decisions based upon accurate and complete information.

1. Organize your notes, patient information, and data. You must be able to access them readily on rounds. You should track your patient’s data so that you notice trends and can intervene as necessary.

1. Communicate your findings effectively through daily progress notes and oral presentations.

1. Interpret patient data to devise an appropriate diagnosis and treatment plan. Use logic, clinical judgment, and evidence-based medicine. You must be able to devise a plan to treat the patient’s acute issues and work-up the differential in a manner that does not include unnecessary tests and procedures.

1. Behave in a professional manner at all times. In particular, interact in a respectful manner with your colleagues, nurses, and hospital support staff. Be on time. Communicate with your team. Be honest. Take pride in your work and the ideals you represent as members of this profession.

1. Accept constructive criticism, acknowledge errors, flaws in reasoning, and take the appropriate action to remedy the problems. Understand that this is how doctors in training become better doctors.

1. Demonstrate the ability to read and learn on your own. You must be able to apply this newly learned information to the clinical context of your patient.

1. Be an active and integral member of a team.

1. Keep your patient as a priority and always respect his or her autonomy.

1. Leave some time for yourself. Because of the heavy workload, it is even more important to care for yourself. Understand that life outside the hospital affects your clinical performance and vice versa.

II. Clerkship Basic Framework (The nuts and bolts)

1. The entire rotation is an inpatient rotation. In other words, all patients seen will be hospitalized patients or patients being evaluated for hospitalization. Students will spend their time at either Tulane University Hospital or the Medical Center of Louisiana-New Orleans (University Hospital) or both. The Veterans Hospital service is contained within the Tulane University Hospital until the new VA hospital is built. Students will spend 6 weeks on a general internal medicine hospitalist service and 2 weeks on a subspecialty consulting service, either cardiology, hematology/oncology, gastroenterology, infectious disease, or nephrology.

*** For General Internal Medicine Hospitalist Teams***

1. Each hospitalist ward team is comprised of interns, residents, and an attending.

1. Students are expected to see patients everyday and present their patients on rounds. Students should go over patients with their resident before attending rounds. At Tulane, MCLNO, or the VA, students should present their patients to their residents during resident rounds. Resident rounds typically take place at 8:00 AM.

1. Students will take call with their team. At Tulane, MCLNO, and the VA, call is usually every fourth night. Students do not take overnight call and should be dismissed by 10:00 PM.

1. Students should attend Grand Rounds and Afternoon Report with their ward teams, unless the time conflicts with mandatory curriculum obligations.

***For Subspecialty Teams***

1. Subspecialty teams will be comprised of an attending and a fellow. There may be residents and interns also on the team, but this may be variable depending on the subspecialty service and availability of residents and interns. Please contact your fellow when beginning your rotation on a subspecialty service.

1. Subspecialty services receive new consults everyday. You do not officially “take call” with the subspecialty services. Rounding times will be dependent on the service and the fellow.

1. You are expected to attend Grand Rounds with your team. You are NOT expected to attend afternoon report while on a subspecialty service.

1. Students are expected to observe their colleagues performing H&Ps and complete worksheets based upon their observations. Students will need to complete 2 worksheets on the history of present illness (HPI), 2 worksheets on the 2nd paragraph of the HPI and Past Medical History, 2 worksheets on the physical exam, and 2 worksheets on the assessment and plan. Please turn these into Alyssa in the Student Programs Office. See “worksheets” for more details.

***For All Teams***

1. Students are to help their team with ward work during the day unless they have mandatory curriculum obligations (Clerkship School, EKG lecture, Shelf Review,) or their resident or fellow dismisses them.

1. Students will turn in copies of their History and Physical Exams to their attendings for evaluation. Two perfect scores on two separate H&Ps are required for passing the clerkship. Please give H&Ps only to attendings on the general internal medicine services. Do NOT give H&Ps to attendings on subspecialty services. Please turn these into Alyssa in the Student Programs Office. See “History and Physicals” for more details.

1. Students will choose two topics during the eight weeks and teach their team about them in a 10-15 minute presentation. Attendings will grade the students’ performance. The gradesheet and a single page summary of the presentation should be turned-in to Alyssa in the Student Programs Office. See “Student Presentation on an IM topic” for more details. This may be done on either the general internal medicine services or subspecialty services.

1. Students will need to keep track of the types of patients seen throughout the clerkship. All encounters must be entered into E-value. This is extremely important because it is necessary for the accreditation of the medical school.

1. After three to four weeks on the rotation, each student will need to complete a self-assessment of his or her performance on the wards.

1. After completing the self-assessment, each student will obtain feedback from his or her attending and meet with Dr. Miller to discuss.

1. A practical exam, including EKGs, and clinical problem solving will be administered at the end of the block.

1. The majority of the clerkship grade will be comprised of the ward evaluations by attending, fellows, and residents.

1. A shelf exam, written by the NBME (National Board of Medical Examiners), will be administered on the last day of the clerkship (Friday) at 8:30 AM. It will be electronic. Location is scheduled to be in room 5001 in the Med School building (1430 Tulane Ave).

III. Daily Clinical Responsibilities.

1. See your patient and perform a physical exam everyday. Ideally, you should be seeing at least two patients a day, but no more than four. Ask how they’re doing. Ask about his or her night. Ask relevant questions regarding his or her reason for being in the hospital (i.e. Is your chest pain better? Did you have a bowel movement? Are you still vomiting?). Make sure you note any changes in condition from the previous day, better or worse. Perform a focused physical exam. You are expected to focus your exam only after you have completed a total physical exam at the time of admission.

1. Collect relevant data from the chart, computer, and nurses. Get the vitals, accuchecks, ins and outs, daily weight (if applicable), etc. from the chart. Read the nurse’s notes in the chart. Read any consultant’s notes from the prior day. If your patient has a cardiac monitor on, do not forget to check the overnight telemetry readings! This will be in the chart as well as the telemetry room. Talk to your resident for specific locations at each hospital. Get the labs from the computer system as well as the results of any important radiologic studies or procedures. This may require you to go to radiology to get the preliminary read or have a Radiologist read the study for you right at that moment. Find the patient’s nurse and obtain any relevant information to the patient’s night and current condition. Sometimes, there is very important information that gets passed between the nurses that does not make it into the chart.

1. Daily patient notes. You must write a daily note on each of your patients. The note should be titled: T-3 Internal Medicine Progress Note. All notes MUST BE PROPERLY DATED AND TIMED!!!. Simply put the date and time in the left margin at the beginning of your note. This note must be co-signedby your intern, resident, or fellow. Each note should contain the following:

Subjective: What happened to the patient overnight? How does the patient say he or she is doing this morning relative to their clinical problem? Are there any new complaints?

Objective: Always put the vital signs next, followed by the physical exam, and then labs and studies. Current medications and dosages should be listed along the left marginof paper notes for easy reference. Electronic notes will have the medications listed in

the body the note.

Assessment: This should be what you are thinking about the patient’s condition. This should be the synthesis of important information to arrive at a conclusion as to the patient’s main diagnoses and main problems. Pertinent questions to guide you might be, what is the patient’s clinical trajectory? Is the patient getting better or worse? Are you closer to a diagnosis (if previously unknown)? Is your diagnosis incorrect? Are there new findings that need to be addressed?

Plan: This is what you are going to do. It should be organized into a problem list. The first problem should always be the most serious or the reason why the patient is admitted to the hospital. The plan for each problem might include further tests and studies you wish to order, adjustments in medications, or other changes in management (i.e. will consult surgery for acute appendicitis).

***NEVER should a student note say, “will discuss with team.”***

***Student notes should be completed before attending rounds.***

1. Daily oral presentation on rounds. Anytime you see a patient and write a patient note, you should present this same patient on rounds. This does not mean reading off of your SOAP note. The information presented should be organized similar to the SOAP note (i.e. first the subjective, then objective, then assessment and plan). You do not need to state when you are transitioning from subjective to objective or to the assessment and plan. It will be obvious to all listeners. The best presentations are done without notes and done in a fluid manner. You should be able to look your teammates in the eye while you present. It should not be loaded with extraneous information, but include all the relevant information (this is the hardest part to learn, so don’t sweat it if you include some unnecessary stuff early on in the clerkship). Always attempt to discuss your patient with intern or resident during pre-rounds. This will help you jettison the extra information and focus on the important stuff.

***Interns, residents, or fellows should not repeatedly interrupt your presentations. Expect them to augment your presentations at the end, especially early in the year. If this becomes a problem, let Dr. Miller know***

1. Daily patient work. This is the stuff that needs to get done to advance the care of the patient. This is variable, but common tasks include ordering labs and studies, calling consultants, following up on labs or tests that were not completed by attending rounds, and completing paperwork for discharge, nursing home placement, etc. Sometimes this stuff gets labeled as scutwork. Yeah, it may be some of the less glamorous stuff, but it has to get done. You are expected to help in these tasks, but these assignments should not be overbearing. Remember, these seemingly menial tasks are essential to getting the proper care for your patient. I promise you that the more you invest in your entire team, the more you will get out of the clerkship.

6. Typical Weekday Daily Schedule for Hospitalist Teams

Tulane, VA, and University – Monday through Thursday

6:30 AM – 8:00 AM / Pre-rounds – see your patient, collect patient data, write note.
8:00 AM – 10:00 AM / Resident rounds – present patients to resident, make clinical decisions, complete morning ward work.
10:00 AM – 12:30 PM / Attending rounds – present patients to attending, make additional clinical decisions.
12:30 PM – 3:00 PM / Ward work – finish orders, finish discharges, track down studies and follow-up labs, etc.
3:00 PM – 4:00 PM / Afternoon Report – meet at designated report room
4:00 PM – 4:30 PM / Checkout – tie up loose ends and check out to on-call team.

***If your residents are not having Resident Rounds, please let Dr. Miller know. Your attendings expect that you have properly rounded with your resident before presenting to them****

***Please note that weekend days do not include Afternoon Report. Resident rounds may be shortened and attending rounds may take place at a different time. You will need to adjust your pre-rounds accordingly***

IV. Taking Call

1. On-call responsibilities. If you are assigned to the VA, Tulane, or University Hospital, you will be on-call every 4th night. You are expected to arrive on your call day at 8:00 AM and stay until 10:00 PM, unless your resident sends you home sooner. You should see a minimum of one new patient each call and perform a complete history and physical. You should dedicate a large amount of effort into getting your history and physical in order. Once each student on a team has completed one H & P, you are strongly encouraged to see additional patients and perform additional H & P’s. You are expected to examine, discuss, and take part in the care of other patients the team admits that you have not written an H & P. You are expected to share your interesting findings and patients with your fellow students. Teach them about your patients. On the post-call day, you are expected to stay on the wards helping your team until your team goes home or your resident dismisses you. It there are mandatory curricular activities that day such as Tuesday School, EKG lecture, or Harvey, you are required to leave the wards to attend these activities. Students should remain in professional attire. NO SCRUBS or Sneakers.

***Occasionally, you may have a call night and not receive a patient. Unfortunately, a significant number of patients are admitted after 10:00 PM. You are expected to then assume the care of one of the new patients the next day after rounds***

1. History and Physicals – these should be comprehensive when written, but only the relevant information should be presented on attending rounds. In other words, you may have to leave out some information that you have collected because the information is not important to the patient’s case.

H & P organization:

Chief Complaint:Do not forget this!!!!

1st Paragraph: Characterization of the chief complaint (FAR COLDER). Once you have gotten all the information necessary to properly characterize the chief complaint, you need to develop a differential of five possible diagnoses. You don’t have to write these down, but you may want to put them in the margins just to keep you honest in the beginning.

2nd Paragraph: Ask the patient questions relevant to your five potential diagnoses that were not covered by FAR COLDER. The answers to these questions should make up the second paragraph.

Review of Systems: This should be comprehensive from head to toe, but only include pertinent positives or negatives in your oral presentation.

Past Medical History: List any diagnosis they have been given or any diagnoses for which they have been treated. Try to list the year of diagnosis, if possible. This gives insight into complications that we might expect with a long, chronic disease history versus a relatively new diagnosis.

Past Surgical History: List any surgical procedures. If recent, try to get month and year of the surgery. Otherwise, the year will suffice.

Family History: Make sure you probe deeply if you are considering an unusual disease (especially autoimmune) or an early presentation of a common disease, such as heart disease or cancer. Deaths of family members at a young age from medical illnesses are usually very relevant so make sure you don’t miss them.

Social History: Include occupational history, living situation (i.e. alone? With wife and kids? Homeless?). Include habits such as tobacco use, alcohol use, and recreational drug use. Include a detailed sexual history here.

Allergies: Make sure you note the reaction associated with the allergy… hives? Angioedema? Bronchospasm (Asthma)? etc.

Medications: List all medications. Make sure you include dosages and frequency. Make sure you reconcile the medication list with the past medical and past surgical history. Each medication should correlate to a diagnosis or procedure already listed. Otherwise, it should be purely preventative (Aspirin, vitamin, etc). If there are orphan medications, meds without clear indications, you need to question your patient about these. If you do not get a satisfying answer, you should consult old medical records.