MEDICAL CONSULT SERVICE ORIENTATION WELCOME UPDATED APRIL 2018

MEDICAL CONSULT SERVICE ORIENTATION WELCOME!!! UPDATED: APRIL 2018 MIREK OTREMBA, MD

OUTLINE Structure of the service § Schedule & Call Teaching & Feedback Clinics Misc. University Health Network

STRUCTURE OF THE SERVICE Hospitals covered § TWH – 2 residents max § UNIV AVENUE = TGH (+PMH, TRI), MSH – 2 -4 residents § �� – Discuss where elective students/residents will spend t Inpatient consultations § Services requesting consults § Surgery, Psychiatry, Gyne, OB (after 5/weekends) § �� - Discuss Common reasons for consultations Clinics § Pre-op clinics – 3 sites § OB clinic – OPG site – 700 University Health Network

YOUR SPACE There is a room designated for med consult residents/students • Room 431 at MSH (Dr. Otremba’s office) • Sign out entry key from Patricia in room 431 and return at end of rotation • Computer & phone available there • Water/Fridge/Microwave/etc. available there University Health Network INSERT TITLE HERE

REQUESTS FOR TRANSFER OF CARE & PESU AT TWH • At times, we will be asked to see patients on surgical services with the request for transfer to medicine • TWH: For medical issues in psychiatry patients in ED, psychiatry will call med consults first 8 -5, M-F and CTU team after hours and weekends/holidays • Med consults will see and decide: § A) Patient can remain under original service with our service following § B) Patient benefits from GIM admission/transfer: discuss with MC staff and then GIM on call resident/staff and pass on information University Health Network

SCHEDULE �� Review the on-call schedule HOME – call § 8 am-5 pm – designated resident at UNIV and TWH § RESIDENT RECEIVING CALLS ROTATES WEEKLY § 5 pm – 8 am § ONE ON-CALL RESIDENT COVERS ALL SITES § Weekends: 8 am – 8 am § ONE ON-CALL RESIDENT COVERS ALL SITES § Round only on sick patients (update signout list on FRIDAY with ‘TO SEE’) �� Review the clinic schedule § AM CLINICS – all UNIV AVE residents attend § Huddle in AM & decide if all stay in clinic or cover ward/consults § PM CLINICS/OB – one TWH resident attends University Health Network

OBSTETRICS - MSH Dr. Shital Gandhi § Pager 416 380 5557 Office 17 -4857 OB medicine covers consults Mon-Fri 8 AM 5 PM Weekend/Evening coverage § By med consults § OB hands over any acute issues § UNIV ave med consult staff reviews new consults/issues § Hand over to OB medicine next AM Wednesday OB clinic (1 -5 pm) § OPG – 3 rd floor - 700 University Ave § R 3 level clinic – attendance required! University Health Network

TEACHING ROUNDS SCHEDULE CANMEDS 2005 ROLES – MEDICAL EXPERT; SCHOLAR • Monday 8 AM – Harvey Rounds § TWH 8 th floor New East Wing – Cecilia Miller Conference Room • Tuesday 8 AM – Evidence based rounds (�� REVIEW RESIDENT ASSIGNMENTS ) § MSH PAU classroom • Wednesday 8 AM – Staff teaches rounds § MSH PAU classroom • Wednesday 12 noon – Grand Rounds • Thursday 8 AM – OB Medicine Rounds § 60 Murray St. 3 rd floor Seminar room 4 • Friday 8: 30 AM – Bedside Physical examination § Location rotates based on patient availability • Friday noon once/month - OB medicine rounds § OPG 3 rd floor classroom A – see monthly consult schedule for details University Health Network

FEEDBACK § Please seek out Feedback from staff on an on-going basis § UNIV AVE Staff with the UNIV AVE residents § TWH Staff with the TWH residents § Competency by design - Seek assessments during your rotation § 1 per week End of rotation evaluation at the end of the month with input from all staff University Health Network

SIGN OUT CANMEDS 2005 ROLES: COMMUNICATOR Sign out website § Accessible through the med consult website (under Useful Links) § consult. otremba. org Sign out login § Use your Cerner/Powerchart credentials § Secondary password: ‘consult’ Med consult website § consult. otremba. org § UN: consult PW: consult University Health Network

SIGN-OUT ETIQUETTE • For ON-CALL - please indicate only MUST-DOs for known patients with issue overnight/weekend needing follow-up • For new patients seen but NOT reviewed with staff add: NEW PATIENT - STAFF TO SEE • For patient seen in clinic and needs follow-up add patient and location as PRE-ADMIT and date of planned surgery • New consults to be seen following morning add patient to list as “NEW CONSULT – PLEASE SEE” • Patients signed off but possible re-consult in future change location to SIGNED-OFF University Health Network

COMPUTER ACCESS & DICTATION Computer access & training required § UHN – EPR (416 340 5091) § MSH – Power. Chart (416 586 4800 x 2100) Dictation § UHN (416 340 4800 x 6000) OR via email § MSH (416 586 4800 x 2649) University Health Network

SUGGEST ORDERS At MSH suggestions should be placed electronically: § Decide with the consulting service if you can order direct or as suggestions § Suggest Orders – Medical Consult order allows you to enter suggestions to be activated later by the primary team § Urgent/emergent orders should be placed directly so they are active without primary team needing to be contacted University Health Network

SUGGEST ORDERS/COMMUNICATION University Health Network

MSH SUGGEST ORDERS University Health Network INSERT TITLE HERE

COMPUTER CPOE – TGH/PMH/TWH • Leave your suggestions on paper orders • Most patient care orders still on paper only • Urgent orders to be placed directly into EPR University Health Network

HALF DAYS, LIEU DAYS, AWAY TIME CANMEDS 2005 ROLES – PHYSICIAN AS A MANAGER Half-day Coverage § Covered by another resident at the site or staff Academic sessions § Staff/resident colleague covers Lieu days § Arrange time with your colleagues/staff Doctor’s appointments & other away time § Arrange coverage with your colleagues University Health Network

�� REVIEW CONTACT INFORMATION Staff contact information Ensure accuracy of resident contact information Elective student/resident contact information Admin - Patricia Davison § 17 -3823 § Patricia. davison@Sinai. Health. System. ca Director - Mirek Otremba § 17 -3016 § Mirek. otremba@Sinai. Health. System. ca University Health Network

OPTIONAL INFORMATION Role of the consultant Problems in consultation medicine University Health Network

ROLE OF THE CONSULTANT – THE 10 COMMANDMENTS (1/4) 1. Determine your customer § Ask the requesting physician how you can best help them, if a specific question is not obvious § They may want co-management 2. Establish urgency § Emergent, urgent, elective University Health Network

ROLE OF THE CONSULTANT (2/4) 3. Look for yourself 4. Be as brief as appropriate § Need not repeat in full detail data that were already recorded 5. Be specific, thorough, and descend from thy ivory tower to help when requested § Do they need help order writing/entry University Health Network

ROLE OF THE CONSULTANT (3/4) 6. 7. § 8. § Provide contingency plans and discuss their execution Thou may negotiate joint title to thy neighbour’s turf Frank discussion defining which specialty is responsible for what aspects of patient care is needed Teach with tact and pragmatism Judgement on leaving references should be tailored to level of training and service University Health Network

ROLE OF THE CONSULTANT (4/4) 9. Talk is essential § There is no substitute for direct personal contact with primary physician 10. Follow-up daily § Daily written follow-up is desirable § When patient’s problems are not active, consultant should discuss signing-off with the requesting physician beforehand University Health Network

PROBLEMS IN CONSULTATION MEDICINE (1/3) Based on Detsky’s article in your book Reasons for requesting Consultation § Knee jerk/reflex reaction to a clinical entity § Threat of litigation after an adverse event occurred § Supervisor requests consultation even though residents do not feel it is indicated § Resident or medical student requests consultation without knowledge of the attending staff University Health Network

PROBLEMS IN CONSULTATION MEDICINE (2/3) Failure to Request consultation when help is needed Strategy during the consultation process § Too many consultations – the Double Whammy § Poor communication § Holding the patient hostage University Health Network

PROBLEMS IN CONSULTATION MEDICINE (3/3) Problems of Ego, Pride, and Embarrassment § Consultee is embarrassed because of criticism contained in consultant’s note § Consultant’s advice is not taken § Consultant is told to mind his/her own business § Request for help is viewed as a sign of weakness University Health Network