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Medicine Wards


ALBERT EINSTEIN COLLEGE OF MEDICINE

MONTEFIORE MEDICAL CENTER

INTERNAL MEDICINE RESIDENCY PROGRAM

ROTATION: IN-PATIENT WARDS

 I. GOALS AND OBJECTIVES:

1. Goals          

The in-patient medical service experience is intended to expose the learner to a wide array of basic and complicated medical diseases. Under supervision, the house officer is expected to develop the ability to diagnose and manage these diseases, understand the underlying pathophysiology and develop the ability to interact effectively with patients and interdisciplinary team members. It is expected that over the course of 3 years of Internal Medicine training, the house officer will be become familiar with specific disease entities encountered in internal medicine practice. We expect that this familiarity will be augmented by specific subspecialty in-patient and out-patient rotations and electives. During any given rotation on the in-patient service, it is expected that residents will be exposed to some, but not all disease entities.

Residents will work in teams consisting of one attending, one PGY-2 or 3 resident, one or two interns, one sub-intern and one or two third year medical students.  The responsible attending directly supervises all patient care. 

The patients in the inpatient service are very ethnically and socioeconomically diverse and provide a great variety of acute and chronic conditions. 

2) Level based rotation objectives and expectaions:

PGY1:

-          Patient Care: Prioritize daily tasks; recognize the relative significance of a given patients list of medical conditions; begin to recognize the acuity levels of illness; inquire about the indications, contraindications and risks of common procedures; work with all providers to provide patient-focused care

-          Medical Knowledge:  Use literature and reference sources to increase knowledge base; demonstrate basic knowledge in the areas of underlying pathophysiology and the clinical aspects of basic disease states; apply knowledge in the treatment of patients 

-          Professionalism:  Establish trust with patients and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients and staff; work to fulfill the needs of patients; accept assignments graciously; attend conferences

-   Interpersonal and Communication Skills: Write understandable and timely notes; communicate verbally and nonverbally in a productive manner; work effectively as a member of the health care team.

-    Practice Based Learning and Improvement:  Recognize limitation of knowledge; use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed.

-  Systems Based Practice:  Advocate for patients; learn about the health care system/structure and begin to develop mechanisms to utilize ancillary services to benefit patients.

PGY-1 Expectations:

- Admission notes - complete history, physical examination, initial diagnostic assessment, and therapeutic and discharge plans
- Enter appropriate orders - therapy, tests, records, consents, procedures and consults
- Participate in daily rounds to examine and assess patients
- Write meaningful progress notes daily
- Participate in discussions with patients and families
- Complete of appropriate forms pertinent for patient are
- Daily sign-out with update of appropriate information for every patient

  PGY2/3:

-      Patient Care: Prioritize daily tasks and supervise the junior house staff appropriately; recognize the relative significance of a given patients list of medical conditions; recognize the acuity levels of illness;  recite the indications, contraindications and risks of common and uncommon procedures; work with all providers to provide patient-focused care

-          Medical Knowledge:  Use literature and reference sources to increase knowledge base and share knowledge with junior house staff; demonstrate sophisticated knowledge in the areas of underlying pathophysiology and the clinical aspects of simple and complicated disease states; apply knowledge in the treatment of patients 

-          Professionalism:  Establish trust with patients and staff; exhibit honesty, reliability and responsibility in patient care; demonstrate respect for patients, staff and junior house staff under your supervision; work with team to fulfill the needs of patients; lead health care team in patient care; understand limitations and ask supervisors for help when indicated; accept assignments graciously; attend conferences

-          Interpersonal and Communication Skills: Write understandable notes; develop ability to listen to patients and staff and communicate verbally and nonverbally in a productive manner; work effectively as a member of the health care team

-          Practice Based Learning and Improvement:  Recognize limitation of knowledge and use references and literature to improve practice patterns; accept feedback and change behavior; ask for help when needed; learn from the outcomes of patients care and alter practice patterns to improve outcomes in the future

-          Systems Based Practice:  Advocate for patients; develop an understanding about the health care system/structure and develop mechanisms to utilize ancillary services to benefit patients

PGY-2 Expectations:

-          Admission notes - summarizing pertinent positive and negative findings, diagnoses and plans.

-          Review of PGY 1 and/or subintern notes and plans 

-          Periodic reassessment notes for complicated patients and/or problems

-          Conduct daily work rounds with PGY1s and students.

-          Attend daily attending rounds.

-          Primary clinical teaching of PGY1, subinterns and medical students.

-          Respond to requests by nurses, supervisors, administrators, staff, etc. concerning patient care, care problems and/or difficulties 

PGY-3 Expectations:

On in-patient medicine services or subspecialty electives, the PGY 3’s responsibilities and privileges shall be the same as the PGY 2’s.

- respond to all cardiac arrest codes (CAC) and direct all cardiac resuscitation
- assign all admissions to team members
- respond to inquiries regarding teaching service patients
- respond to questions and aid the junior medical house staff as needed.

 

 

     II.  ROUNDS AND CONFERENCES

1)      Resident Morning Seminar:

a)      Participants:  PGY2/3

b)      Objectives: clinical reasoning, case review

c)      Time: M-F 7:00AM-7:45AM

2)      Team Walk/Work Rounds:

a)      Participants:  PGY1/2/3, MS III, IV

b)      Objectives: direct patient care and review of past nights events, development of plan for the day

c)      Time: M-F 7:45AM-8:30AM

                            Sat/Sun: variable based on attending and census

3)      Intern/Resident (IR/RR)Morning Report:

a)      Participants:  PGY1; PGY 2/3

b)      Objectives: case based clinical reasoning

c)      Time:  2-3 times weekly, 12:00 noon – 1:00 pm

4)      Autopsy Conference:

a)      Participants:  PGY 1/2/3, Medical Students

b)      Objective: case-based review of pathologic specimens

c)      Time: third Monday of month, Weiler Campus, 12:00 noon– :00 pm

5)      Attending Rounds:

a)      Participants: all team members (day and night team)

b)      Objective: presentation and review of overnight cases, direct patient management, direct bedside and interactive learning

c)      Time: M-F 8:30AM-10:30AM

                Sat/Sun: variable

6)      Interdisciplinary (IDT) Rounds:

a)      Participants:  PGY2/3, nurses, social workers, case managers

b)      Objective: coordination of patient care, facilitating systems based practice

c)      Time: M-F 10:30- 1:00AM

7)      Core Curriculum Conference

a)      Participants:  PGY1-3, MS III, IV

b)      Objective: cover core topics in Internal Medicine to increase medical knowledge, optimize patient management

c)      Time: 2-3 times weekly  12:00PM-1:00PM

8)      Chief of Service (COS) Rounds:

a)      Participants:  PGY1-3, MS III, IV, chief medical resident

b)      Objective: case based learning, clinical-reasoning

            c)   Time: weekly 12:00 noon – 1:00pm (days vary per campus)     

 

9)      Clinical Reasoning Seminar (CRS):

a)      Participants:  PGY1-3, MS III, IV, service leader

b)      Objective: case based clinical reasoning

c)      Time:  Friday, Moses Campus,  12:00PM-1:30PM

10)  Journal Club:

a)      Participants:  PGY2/3, service leader, chief resident

b)      Objective: review of current literature and development of critical evaluation skills

c)      Time: 12:00 noon – 1 pm every other week at Weiler Campus

12)  Medical Grand Rounds:

a.       Participants:  PGY1/2/3, MS III, IV, attending staff, nurses, others

b.      Objective: update and review of current and emerging IM topics

c.       Time: weekly, Thurdays (time varies per campus) 

13)  M&M:

a.       Participants:  PGY1/2/3, medical students

b.      Objective:  review outcomes of cases with potential adverse outcomes, identify systems and other  issues for quality improvement

c.       Time: Mondays (first, second, fourth), Weiler campus,  12:00 noon- 1:00PM


III. METHODS OF TEACHING COMPETENCIES AND OF COMPETENCY ASSESSMENT

 

                                            VENUES                                           ASSESSMENT

           

Patient Care                        Wards, IR, RR, morning seminar,            Attending, peer                                                                                                  

                                            CRS                                                        evaluations

                                           

Med Knowledge                Morning seminar, attg rds,                        Attending, peer                                                                                                 

                                           COS, CRS                                               evaluations

 

Professionalism                  Wards, attg rds,                                         Attending evaluation

                                            IDT rounds                                                Staff evaluation

 

Interpersonal skills             Walk rds, attg rds                                      Attending, peer                                                                                                  

                                                                                                            evaluations

 

PBL+I                                 Journal Club, M&M                                Attending, chief eval

                         

 

Systems Based Practice      IDT rounds, wards,                                   Attending, staff, peer 

                                                                                                            evaluations



______________________________________________________________________________________________________



The Oral Case Presentation: Guidelines for the 5-minute Presentation

Adapted from “Paccione ‘91”

 

1.    Chief complaint

a.    The first sentence should include (1) age, sex and race (if pertinent to the case), (2) the chief complaint – one problem or two at the most if closely related, (3) duration of the chief complaint

                                          i.    e.g. “Mr. Jones is a 49 year old male with the chief complaint of cough & bloody sputum of 3 weeks duration

2.    HPI

a.    Orientation sentence:  the HPI should not launch off on a discussion of the chief complaint “in a vacuum”. Orient the listener first by mentioning the patient’s previous state of health and/or active disease background

                                          i.    It is important to describe what “usual state of health” means in the first sentence or two i.e. if it is excellent or “fully functional”, state that; if not, try to convey in a few words the patient’s functional status (eg (1) bedbound/non-verbal, (2) dyspnea upon walking two blocks (3) has presented to the ED 10 times this year …crucial for both diagnostic and prognostic considerations.

1.    DO NOT PROVIDE A LAUNDRY LIST OF MULTIPLE MEDICAL PROBLEMS IN THE ORIENTATION SENTENCE…would give 1-2 medical problems if you feel that they are highly relevant to the case, especially in terms of affecting one’s pre-test probability of diseases on your differential

 

b.    Maintain sensible chronology:  then continue the story with the first real change in health status related to the chief complaint.  This may mean starting your account of the HPI 10 years ago if the chief complaint is an acute exacerbation of a chronic disease like COPD or CAD.  Don’t make it tough on the listener by force him/her to reassess the details of the presenting complaint when the prior history of the chronic disease later unfolds.  You may want the listeners to be interpreting the presenting problem and forming hypotheses as you speak, and this is very difficult to do well when one has no sense of the “substrate” underlying the acute problem.  Thus if a chronic disease is closely related to the chief complaint (e.g. prolonged chest pain on a background of angina) succinctly summarize the pertinent past history (e.g. angina) before describing the details of the presenting problem (e.g. yesterday’s pain).  Your prior statement of the chief complaint should provide adequate context with which to listen intelligently to a HPI that starts at “the beginning”.  (However, for chronic diseases that only have an indirect pathophysiologic association with the chief complaint, e.g. diabetes and an episode of chest pain, you need only mention the diabetes in the “orientation sentence” before elaborating on the presenting pain.)

                                          i.    In describing the prior history relevant to the chief complaint:

1.    NEVER REDUCE THE HISTORY TO A THOUGHTLESS LIST OF TEST RESULTS.  Emphasize the evolution of symptoms chronologically, and periodically punctuate this important clinical data with PE and lab findings that carry diagnostic or prognostic significance.  When reporting test results, always first provide the clinical context (i.e. symptoms and/or functional state) which called for the tests.

2.    If a diagnosis is not clearly established by the data available to you, don’t write or state it as if it was.  Use quotation marks or qualifiers like “presumptive”.

3.    When discussing a past admission mention the clinical reason for the admission, important findings on admission, significant later test results, diagnosis made, therapy, response to therapy, and discharge meds.

4.    With multiple admissions (i.e. more than 3 or 4) for the same problem, summarize the general themes or trends for a few of the admissions with more detail reserved for the most recent admission(s) or those that provide particularly helpful clues to present dilemmas.

5.    Don’t forget to describe briefly the activity and health of the patient in between admissions and use clinical and test data from the outpatient setting – these data are often much more important than past in-hospital data in establishing the most recent “baseline state” and there for the present goals of therapy.

6.    Remember to note compliance with and response to past therapy in the HPI.  To repeat: mention not only the drugs the patient was prescribed, but whether she took them and how she responded (by appropriate history, physical, or lab measures.)

7.    Use present physical and lab abnormalities as a guide in selecting which past PE or lab data to include in your presentation, but of course don’t mention the present PE or lab data until later. 

c.    Reflect differential diagnosis:  When considering symptoms whose etiology is unknown the purpose of the oral presentation is to elucidate the patient’s problem in such a way that the diagnostic possibilities become clear to the informed listener.  This means a concise description of the characteristics of the symptom(s), preserving temporal relationships.  It also means including in the HPI whatever is relevant to the present illness but elicited in the interview during the PMH, FH, or ROS.  Finally, it’s crucial to mention pertinent positives and negatives that are relevant to the differential diagnosis of the patient’s problem…repeat, very important.

                                          i.    In this context “differential diagnosis” does not only apply to solving the unknown disease but rather to addressing the clinical question at hand:  e.g. if it’s a “known recurrence of asthma or CHF, the diagnostic challenge involves not “what is the disease diagnosis?” but rather “what precipitated the recurrence?”  your presentation should reflect your thinking about that question.

 

DO NOT DISCUSS THE ER COURSE AT THE END OF THE HPI, but only at the end of the entire History, and there only sometimes (see below).  THE HPI ENDS WHEN THE PATIENT COMES TO THE HOSPITAL.

 

3.    PMH

a.    Only present active problems or illnesses, i.e. those that cause symptoms, receive therapy, or have a propensity to recur.  Omit inactive ones (like a bout of hepatitis in 1966 in a patient admitted for lung disease). 

b.    Be brief.  Be pertinent. Present only those aspects that impact on management or round out the picture of the patient’s baseline state.

c.    No need to restate if mentioned in the orientation sentence

4.    SH, FH, ROS:

a.    Social history: Is very important for appropriate patient management and should be succinctly (10-20 seconds) presented at attending rounds and possibly elaborated thereafter.  Remember any aspect of the SH relevant to diagnosis should have been mentioned in the HPI.

b.    FH:  should be succinctly summarized in about 10 seconds.  Again, if relevant to diagnosis, pertinent aspects should have been mentioned in the HPI…repetition unnecessary

                                          i.    Family histories of elderly patients can be completely omitted

c.    ROS:  should generally be omitted from the oral presentation.  While very important for a complete write-up and patient data base, it generally is edited out of the oral case presentation with the following rationale: ROS refers to active present symptoms; if the symptoms are relevant to the chief complaint or any active illness they should have already been mentioned, perhaps as pertinent (+)’s or (-)’s in the HPI.  If not and truly “minor”, they shouldn’t take valuable time in the oral presentation.

5.    ER Course:

a.    At the end of the history (which includes the HPI, PMH, SH, etc), one must decide where to present the ER course.

b.    Guidelines: In order to keep one’s thinking during the presentation open, active, and critical.

                                          i.    Present the ER course BEFORE the physical exam if the ER therapy so changed the exam that your physical exam cannot be interpreted intelligently without first knowing the exam and therapy in the ER

1.    Patient arrived with tachypnea, tachycardia, hypoxia and crackles ½ way up the lung fields.  Then, after lasix, when you saw the patient, the vital signs had improved and crackles were minimal.

                                         ii.    If however the changes were “simple”, e.g. a different temperature or BP, go right into your PE, noting these differences when appropriate.

                                        iii.    If there were hardly any changes in the PE attributable to the ER intervention there is no need to mention prematurely the ER course at all.  It might then might mentioned at the very end of the presentation or during the ensuing discussion, as other options about the case

1.    For example, what, if any, antibiotics that were given can be saved for the assessment/plan section (if at all), as they would not have changed the patient’s presentation significantly over the course of a short period of time.

6.    Physical examination:

a.    The PE should be introduced with a general description of the patient as he appeared when you examined him.  Vital signs are next.

b.    The description of the rest of the PE is selective, depending on the problem. For each area, think of what PE signs would be relevant for those diseases in the differential diagnosis and edit with the rule for pertinence as master…both positives and negatives.

7.    Labs/diagnostic studies:

a.    Present data that is either pertinent to your differential diagnosis or that if significantly abnormal (and thus warrants its own assessment and plan)

b.    If you present an abnormal lab, remember to follow that up with a detailed description of the history of that particular lab (is this “at baseline”, is this improving or worsening (specific details should be given as to the exact dates in which we last have labs to compare)

                                          i.    As with historical and exam data, absolute values matter much less than how things have changed over time and the slope of those curves – be as specific as possible

8.    Summary sentence:

a.    Wrap it up with a summary sentence which briefly recapitulates the chief complaint and highlights the few most important pieces of clinical data from the history, PE, and/or lab.

9.    Impression & Plan:

a.    Organize your impression in a problem based manner and not system based

b.    Take each problem in turn and address the relevant clinical questions: i.e. diagnosis, and/or management, and/or prognosis…For the diagnostic dilemmas it is often best to list right away the pertinent differential diagnosis in descending order of likelihood:

                                          i.    SOB: Ddx includes (1) CHF, (2) bronchospasm – induced by atenolol, (3) pulmonary embolus, (4) pneumonia

c.    Then continue your discussion of this problem by “making the case” for your differential on the basis of the information you have, and concluding with your diagnostic plan for that problem.

d.    It’s crucial to be able to identify the relevant clinical questions first. With exacerbations of a known chronic disease, the clinical focus may seem to be on management, not diagnosis…but always ask yourself “why? What precipitated the recurrence?” and address that differential diagnosis as well.

 

_________________________________________________________________________________________



Goals and Expectations of Resident Rounds

July 2016


Effective resident rounds (also known as work rounds or walk rounds) are essential to team-functioning, clinical decision-making, medical management and promoting workflow efficiency and positive patient outcomes.  This is your moment to lead your team, synthesize data, teach your interns and students and make independent sound clinical decisions. The function and objectives of resident rounds will evolve as you and your interns’ progress through the year.

Beginning of the Year with New Interns: (July – October)

1.      Watch over and help the new interns: You are their role model and coach. Exchange pager/cell phone numbers on day 1 and reassure them that you were just in their shoes! Be open, present, and approachable.

2.      Although formal topic teaching is important to resident rounds, the first/beginning months should focus on making sure that interns are able to appropriately gather data during pre-rounds, and are able to identify the most concerning/important items either from history, physical exam or laboratory data. Stress that patients should be seen before resident rounds.

  1. Organization is key!  Use this time to teach interns how to appropriately organize their day and their to-do lists. A little time spent here will make a dramatic difference in the workflow of your team.
  2. Require thorough, systematic presentations so that YOU don’t miss anything. Set the expectation for targeted SOAP format.  In the beginning, there is an overwhelming amount of information and it’s easy to overlook thing that can dramatically change patient outcomes. (Interns may not always know that an ANC of 400 is bad, but if you hear that the WBC count is 1, you would have a whole different perspective on that patient’s fever and choice of antibiotics). Ask them about missing data and explain why you are asking the question. This is an excellent way to do targeted teaching.
  3. The expectation is that all residents should see EVERY PATIENT every day, but this does not mean that you have to see then all during resident rounds. In the afternoon the resident has ample time to visit and examine the patients not seen during rounds. 
  4. Please see the sickest patients prior to attending rounds.
  5. Go into patients’ rooms to examine patient, point out pertinent physical exam findings and role model good bedside manner.

 

Middle of the Year Expectations (Nov – March)

1.      At this point during the year, as interns have become more comfortable with work flow and organization, this is when you can take your teaching and group dynamic to the next level

2.      Encourage your interns to not only provide you with information but also generate their independent plans.  Promote their understanding of the basis for medical actions taken with the team patients.

3.      Prepare for Resident Rounds! There are endless teaching points from our patients. This is your opportunity to really develop your leadership style and specific teaching techniques and empower the learners on your team. Teaching can be as simple as asking the intern or student to verbalize their thought process on a given problem so that the rest of the team can listen and learn from a more senior resident thought process. Some others examples of content area preparation include:

a.       Physical exam techniques at bedside, and their sensitivity/specificity

b.      EBM original articles

c.       Most recent  guidelines regarding management

d.      Management pearls

e.       Review of radiology and guided teaching

4.      Give and Get Feedback:  reinforcing and corrective.

  1. Foster Learning: Assign interns and especially MS3s clinical questions/topics based on the patients they are caring for. This will engage them and encourage them to speak up on rounds.
  2. Role Model Patient Communication:  If you know the plan for that day, discuss it with the patient - work up, tests for the day, discharge planning, etc.
  3. Remember that resident rounds are walk rounds. You should see at least some of the patients during the morning.

 

End of the Year Expectations (April - June)

  1. Consider having the interns practice leading resident rounds to prepare them for their role the next year and give them feedback around it.  

At the end of work rounds your team should have a plan for every patient. This is the resident’s chance to make critical independent decisions. Even for difficult management issues, the goal of rounding on the patients initially is so that resident has a plan on every patient prior to attending rounds.

 

 

CARDIOLOGY-Acute Coronary Syndrome
    Aspirin
        CAPRIE TRIAL
        ISIS TRIAL
    Betal Blockers
    GP IIB/IIIA Inhibitors
    Anticoagulation
    Plavix
        MIRACL TRIAL
        PROVE-IT TRIAL
        WOSCOPS TRIAL
    Thrombolysis & PCI
 CARDIOLOGY- Arrythmia
CARDIOLOGY-Heart Failure
    Acute Heart Failure
    Aldosterone
        CHARM TRIAL #1
        CHARM TRIAL #2
        VAL-HEFT TRIAL
    Beta Blockers
        CIBIS II TRIAL
        COPERNICUS TRIAL
        MERIT TRIAL
    Digoxin
    AICD 
    Biventricular Pacing
CARDIOLOGY- Hypertensive Emergency and Encephalopathy
CARDIOLOGY- Peripheral Arterial Disease
CARDIOLOGY- Preventative Cardiology
CARDIOLOGY- Syncope

ENDOCRINOLOGY-Diabetes
    Diabetes
        ACCORD TRIAL
        UKPDS33
        UKPDS 80
    DKA
ENDOCRINOLOGY-Parathyroid Disorders
    Primary Hyperparathyroidism
ENDOCRINOLOGY-Thyroid Disorders
    Hyperthyroidism
        GRAVES' DISEASE
    Hypothyroidism
    Thyroid Nodule

GASTROENTEROLOGY-General
    Acute Gastroenteritis
    IBD/IBS
    Colon Cancer Screening
GASTROENTEROLOGY-Hepatology
    LFT/Hepatitis
        HEPATORENAL SYNDROME
        HEPATORENAL SYNDROME
    Albumin and Diuretics
        ALBUMIN FOR LVP
        CIRRHOSIS
        CIRRHOSIS II
        CIRRHOSIS & DIURETICS
    Spontaneous Bacterial Peritonitis
    Variceal Bleeding
    Hepatic Encephalopathy
 
HEMATOLOGY-General
    Sickle Cell Disease
    Thrombocytopenia
         ADAMTS-13
    Anemia
Hematology-VTE
    Prophylaxis
    Treatment

INFECTIOUS DISEASE-General
    C. Diff
    Endocarditis
    Double Coverage Pseudomonas
    Meningitis
INFECTIOUS DISEASE-HIV
    HIV Associated Diarrhea
    PCP
    Bacterial Pneumonia
    Misc.

PULMONARY-Asthma
    Bronchodilators
    Role of PEFR Monitoring
PULMONARY-COPD
    Antibiotics
    Bronchodilators
    Steroids
    Supplemental 02
    Misc.
PULMONARY-PE

RENAL-General
    Acute Renal Failure
    Microalbumin
    RTA 
    Misc.
        ADPKD REVIEW
RENAL-Anemia of Chronic Disease
RENAL-Contrast Induced Nephropathy
RENAL-Hemodialysis

RHEUMTOLOGY-General
    Rheumatoid Arthritis
    Septic Arthritis
    SLE
ĉ
Chief Resident,
Jun 23, 2016, 1:19 PM
ĉ
Chief Resident,
Sep 21, 2016, 5:08 AM
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