Circulated handout below from one medicine attending for having a smooth month. Makes for a good email to team members at the beginning of the month. Please feel free to contribute your own wisdom and tips at the bottom.
Ward Expectations
Medical Students:
1) Preround with your intern and resident. Have your notes written before 8 AM. I don’t expect you to have the correct assessment and plan at this stage, but I do expect you to think on your own. Please read on the pathology you see in each patient. You will add a lot to the team’s care of the patients by gathering data, reading and spending time gathering history from the patient, nurses and the chart.
2) Please gather all the patient charts for each floor, so that we can write orders as we go.
3) Pertinent data to have on all your patients includes: knowing medical history, vital signs, a current medication list and all the labs, xrays and other imaging (Echo, Stress tests) on your patients up to that point in the morning. Maintain some sort of tracking system to follow trends (Hb, Na, etc.). Learn from ancillary services by going to see how the studies are done and talk to the radiologists reading the studies as often as you can.
4) A foundation in internal medicine will serve you will in any field you pursue, so make the most of this rotation. The best student doctors will make the best physicians; theyare on time, honest and care about their patients. They try their best to learn from and about all patient cases on the team, not just their own patients. This involves active time taking notes on all new admissions and being at hand to help at all stages of the patient’s admission, from writing Admission orders to the discharge orders, to calling to arrange outpatient care.
5) If one of the interns has an excessive amount of patients compared to the other, please offer whenever possible to help him/her make consults, track down studies, and write discharge orders.
6) Present one 5-10 minute report on a topic of your choice which is relevant to one of our patients.
Provide a concise handout on the relevant material.
Presentations:
1) Be thorough, but relevant. You are the filter. Your patient may have for two hours, but if he came in with chest pain, your presentation should sum up the characteristics of the chest pain in two minutes.
2) Post-call presentations should be in the following order: HPI, ROS, PMH, SocHx, FamHx, allergies, outpt meds, then the vitals, a full physical exam, and labs. In the assessment and plan - sum up the case quickly then address the big issue first. I would like a detailed problem list and plan, which should conclude with : DVT and GI prophylaxis, Contact with patients PCP (give me a name, and a telephone number if possible) and Disposition (Home, here for these further tests or treatments).
3) Daily presentations should follow a SOAP note format (Subjective, Objective, Assessment and Plan. The subjective should be one or two sentences which tells everyone what happened since we last met and talked about the patient. You may mention here what the specialists recommended and did. If the patient had chest pain o/n, say how it was handled by the on call team. This is especially important when a new physician or student is present, or on a busy service. It gives the other half of the team a chance to remember who your patients are so that they are capable of caring for them in your absence. Next should be the vitals – it is not okay to say vital signs are stable, report what they are. Next report the pertinent exam findings only. If they had lung crackles on admit, are they improving. It is not okay to say exam is essentially unchanged unless the patient had no physical exam findings on admit. Then report only the pertinent labs. Next report the labs, then the imaging or other studies. Then as above, the assessment and plan needs to address the main issue first and systematically address all other problems the patient has.
4) Be aware of how many patients we have on our team. If we have twenty patients to see, and you take 30 minutes to present a simple case of cellulitis, we may be compromising the care of the other 19 patients. Be thorough but be efficient. Direct the team to discuss and see the sickest patients first.
5) Present the plan you have discussed with your intern or resident. Ask them ahead of time if you are unclear of the plan. If you learn something about the patient’s care afterward, let them know before Staff rounds (AS soon as you learn it) so that they are not completely surprised when you divulge that their patient just coded and is being taken to the ICU, for example.
6) For high pass and honors grades, do more than is expected of you – know about the other patients on the team and participate in their care, track down all studies and be able to interpret them and plan diagnostic and treatment measures for your patients, actively participate in all relevant aspects of patient admission- orders, working with social workers, nurses, writing notes and discharge orders, scripts, etc. If you want to know how you are doing and how to do better, ask your resident or staff.
Days Off:
1) You will get four days off for the month to be arranged with your resident. It should really be a weekend . There may be times when you go two weeks without a day off, because of the call schedule.
Interns:
Similarly to above, the three basic ingredients to being a good intern and physician this year are showing up (with time to do your work), being honest and caring to do good by and for your patients. Regarding showing up, you should be the first person there on the team. You have the most grunt work in terms of collecting data, talking to nurses, patients and consultants, only to then round with both a resident and then your staff. This comes with the territory of the boot camp year of medicine. You will become more efficient as the year progresses. Ask a senior resident or me for pointers on how to be organized, efficient and for any other problems or areas you need assistance. I do not expect you to be perfect, but do seek help. You will not ever receive a poor report from me for asking for help, both with the aforementioned or with clinical knowledge. Residency is not about having an ego; it is about acquiring as much skill and knowledge to be a great physician. Next, if you do not have some data that I or your resident asks for, DO NOT under any circumstances make it up. I will be making decisions with the wrong information, which may be detrimental for our patients. Just say you don’t have it and someone will get it. Period. As for caring, that comes naturally for some, and may be an acquired taste for others. Often, you are tired and asked to do more than seems humanly possible. We have all been there and empathize. Be there for your co-interns. Try not to let petty personality conflicts come between your professional allegiance to one another and to the care of your patients.
Each of you brings his/or her own strengths and will be invaluable to the other. If one of the interns has an excessive amount of patients compared to the other, please offer, when you have the time, to help him/her make consults, track down studies, etc. This is especially true on clinic days. You should know about ALL the patients both your patients and the other intern’s patients as you will be cross-covering for them. That means we stick together for rounding. The intern not post-call (or the medical student) should be writing orders while we are rounding. Then pass the chart back to the primary intern to see if they have anything else to add/if they approve. Unless there is a big emergency or your staff excuses you, this is NOT time to break off and call consults.
Work Rounds:
1) Teach the medical students how to write orders. If it is not your patient that we are discussing, you should be the one helping the medical student write the orders. When you are finished give the chart to the other intern for review. This is how we double check to make certain things are not missed.
Rounds:
1) Fill in the gaps in the medical student presentations without being abrasive or condescending. You must discuss the plan with them to be on the same page.
2) Review Presentation tips above.
3) Please try to prepare at least one short 5-10 min talk during the month to help hone your ability at presentations and teaching. I can assign topics or you can pick them.
Work time: (After rounds):
1) You are expected to write a daily note on each patient. If a medical student has written a note, you cannot write agree with above. You must document a physician exam and a detailed assessment & plan. You don’t need to re-copy the labs. JHACO dictates that a physician must write a note every day.
2) Get your work done and get out. If you have clinic in the afternoon and don’t get everything done, check it out to the resident or the other intern. Do your best, though, to get as much done early so as not to perpetually rely on others for work which would be reasonable for you to complete.
On Call:
1) You are expected to write an admission history & physical on every patient. You will also write the admission orders unless it is crucial that we get things done ASAP. Write the orders first to get the ball rolling. You can always go back and add more orders if you think of additional things.
2) I expect you to take five to ten minutes and look up treatment information for each patient on UpToDate or some other source. You must develop habits that will serve you and your patients well in the future.
3) This is the time to teach the medical students. Take them with you and let them interview the patient. This is when you can teach them how to ask questions to elicit the answers you need. Teach them about EKG findings. Discuss the differential for shortness of breath or chest pain. Teach them in your own style, but avoid condescension. None of knows everything and being unreasonably tough will make timid students even more timid and no better in the end. You will learn more this way.
Days Off:
4 days a month, to be determined by your resident.
We are a team. We work as a team, and we leave as a team. If one intern is finished and the other has more to do, we all help out.
Residents
You are the leaders of the team and your staff should serve as a consultant. That being said, your staff’s name is on the chart, so should have all the information for making educated consulting opinions. See above, the three criterion for being a good intern or resident. Please preround and make decisions before staff rounds. Have the interns and students write orders. Teach. Please physically see all patients, particularly this early in the year. See the sickest patients first. Develop your own management style, but try to be considerate of your staff’s proclivities. You will have more time for decision making if your interns are gathering the data and you are having more time to think about it all. Do your best to delegate to facilitate this. Plan days off for the team. Know all the patients intimately on both sides of team. Know all the studies, labs and have a solid plan for their care, including good follow-up which won’t result in the patient “bouncing-back.” Use clinical evidence, coupled with standards of care, evidence-based related research and the patient’s particular limitations (uninsured, demented, homeless, etc.) to inform your decision. Please tell your staff, at any time of day or night if you want to run something by me. Also, I prefer to know –day or night—about a death or ICU transfer or if you want to send a patient home from the ER. Set the professional standard for fully integrating the team, i.e, sticking to rounds without breaking off, attending all morning reports and Grand Rounds. Try not to leave an intern struggling by himself post-call. That is not acceptable. You must trouble-shoot to help bring him/her up to speed. Read on all your patients and add your knowledge to that of the team.
Staff Duties:
1)Be on time for rounds and morning report when our team is presenting,
2)Keep rounds as efficient as possible.
3)Maintain a comfortable learning environment for all on the team.
4)Coordinate care with specialists.
5)Coordinate teaching and learning opportunities.
6)Serve as medical consultant for the residents and interns.
7)Provide feedback as often as appropriate and possible to strengthen all team members.
Further tips:
students should not feel like they have done their AM work until their note has been cosigned. Student notes should be done very early so a resident can review your note with you before rounds.
- There is no rule saying that you can't write a "skeleton note" the night before. That way, your AM note is more fill-in-the-blank, rather than an essay. That can allow you to spend less time being a secretary, and more time being a doctor.
-Start working on discharge paperwork as soon as a patient is admitted. Have expected prescriptions, clinic referrals, etc. ready in advance. Keep a typed draft of a discharge summary in your email for each of your patients, that you update daily. That way, dictating a good discharge summary will be a breeze.
- Whenever ordering a test (imaging, stress test, etc.), call down to the respective office and ask if it can be moved up on the schedule. The earlier you have the results, the earlier subsequent decisions/discharges can occur.
-Keep the census list as updated as humanly possible. Add patients fully to the list as soon as they are admitted.
- Place relevant/interesting articles you find in the chart for others to read/reference/learn. This is a teaching hospital, afterall
- for any patient you are sending to discharge clinic, place their name, diagnosis, and MR number in one of the boxes at the bottom of the list. This way you will know who to expect, and who to call if no-showed. Tell your patients to bring their all newly filled prescription bottles to the clinic, so you know they have them, and understand them. Also, tell your patients to bring their assigned bp, weight, or blood glucose diary to clinic.
- Always ask patients how they expect to get their medicines filled. If they are not going to be able to afford the meds, then they are no good to them. Think about cheaper alternatives, and consider starting those as inpatients to evaluate efficacy. Carry a copy of the latest (and often changing!) walmart formulary in your white coat.
- If there is an expensive medicine that they will need, recommend that patients ask the pharmacy they go to (chain stores especially) to "price match" and to "get the price the lowest they possibly can." Every pharmacy has an absolute lowest price they can charge for a medicine, often based on the amount of local competition that particular store has. Furthermore, nice pharmacy workers will even apply their employee discounts for patients. Tell patients to have the pharmacist page you if the price is too high, and mention these type of things to pharmacist. Pharmacists will often tell you where to get the drug cheaper, even. Outpatient clinics may have samlpes of certain meds, or discount coupons...just call and ask.
- Do not rely on the social workers. Call nursing homes, home health agencies, etc. yourself. You would be surprised how easy arranging certain things actually is. Putting a voice/face to your concerns helps you be a better patient advocate.
- spend at least 5 minutes each day to read something new about each one of your patients. This habit will enrich both your experience, and the assessment/plan section of your note.
- Call and update family members. Ask patients if there is anyone they would like you to talk to, and call them. Tell them about anticipated discharge planning/timelines. Also, notify family members immediately if a patient's health status suddenly changes, for example if they have been transferred to the ICU.