Queens Medical Center Inpatient Medicine MS 4 Subinternship

Queen’s Medical Center Inpatient Medicine MS 4 Sub-internship Orientation Academic Year 2014 -15 Revised Oct 2014 Masayuki Nogi (CMR)

al n r e Int ! o t me tation o c l We ine ro ic d e m Dr. Dennis Bolger (DME) Dr. Masa Nogi (chief) 2014 Block 2 students

uhmed. org/chiefblog Log-in Username: residents Password: residents

Core Competencies/Ultimate Goals Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health Medical Knowledge about established and evolving biomedical, clinical, and cognate (e. g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

Goals of this rotation 1. Function as an intern 2. Deliver patient care in high volume setting 3. Learn from patients and apply EBM knowledge to patient care 4. Obtain effective communication skills with multidisciplinary teams

Things you need to know as a medicine sub-I

Team structure Team member Attending UL UHS attending intern Sub. I Avg. 3 -5 pts intern Cap 8+1 MS 3 Cap 8+1 Max 18 pts MTC attendi ng Avg. 2 -4 pts • • Max 2 pts UHS: University Hospitalist Service MTC: Medical team care

Patient Acquisition Schedule Overnight Transfer New ICU downgrade Late ⑦⑧ 12 pm-6 pm ①② AED 　− − − ①②③④ 6 am-12 pm − Early ⑤⑥ 6 am-12 pm − Short ①②③④ 6 -10 am − ⑤⑥ 10 am-6 pm ①② Transfer Lw if E team capped Rounds will get busy on “Early call”

A day in the life: Sub-Interns 5 -6 am Arrive, get hand-over from night resident. 9: 30 -11: 30 UHS attending round. Start rounding on pts, sickest 12: 00 -13: 00 Noon conference (TH) st 1. Finish your notes. 13: 00 - Finish up work, prepare 7: 45 -8: 00 Radiology rounds (F) disposition for next day 7: 30 - 8: 15 Morning report (M, Tu, W, Th) 8: 15 -9: 00 Pre-rounding with the team. Contact MTC attendings & consults to update & discuss your A&P 3 -4 pm RUN THE LIST! 4 -5 pm Can leave hospital 8 pm Late team finishes

Rounds Pre-rounds- Team meets to discuss patients and plans. Call/text your upper in the AM to go over the plan Come prepared, have your own plan Upper will refine your plan as needed Attending rounds- You will present Upper level guides discussion of relevant information Attendings role: Double checks the Sub. I/upper plan Teaching topics (sometimes informal, sometimes more formal) Assigns learning issues

I-PASS Handover Electronic Hand-over in Carelink, should be updated daily! Verbal handover (Phone) Night team @ 6 pm (THIS IS NOT PAGER CALL) Your verbal and written I-PASS handover will be evaluated by either NF resident or CMR/faculty I QU Z What does I-PASS stand for?

The I-PASS Mnemonic I Illness Severity Stable, “watcher, ” unstable P Patient Summary statement; events leading up to admission; hospital course; ongoing assessment, plan A Action List To do list; timeline and ownership S Situation Awareness & Contingency Planning Know what’s going on; plan for what might happen S Synthesis by Receiver summarizes what was heard, asks questions; restates key action/to do items © 2013 I-PASS Study Group/Boston Children’s Hospital. All Rights Reserved. For Permissions contact ipass. study@childrens. harvard. edu

Conferences

SAS* Scholarly Activity Sessions Every Tues. 12: 30 -4: 30 pm Starting with Medicine Grand Round MS 4 s – Attend SAS unless it is specifically for residents (Town Hall, program business) Lunch is provided Check the chief blog Conference SAS for this months schedule!

Resident Morning Report Mon/Wed/Thurs Every 7: 30 am – 8: 15 am @ Iolani 5 Be an active participator! Good chance to practice “Clinical reasoning skills”. Check the chief blog category: QMC morning report for previous topics!

Student Morning Report Every Tues 7: 30 am – 8: 15 am @ Iolani 5 You will be assigned to present a student AM report Please discuss with UL and Chief Resident your Topic / MRN at least 2 -3 days prior 25 min duration: Present case S&R, CC, ID, HPI, PMHx, FHx, SHx, ROS, physical exam 10 min Teaching didactic Ask the CMR/upper level to help select a topic that is appropriate

Noon conference Thurs. 12: 00 pm– 1: 00 pm @ Every Iolani 5 What? New Case based learning modules for inpatient topics (hospitalist attending) Neurology lectures Cardiology lectures Infectious disease conference Pain & palliative care workshop Diabetes management Quality improvement report from R 3 (4 th week) * PIZZA for week 1 !

Radiology Rounds Every Friday 7: 45 -8: 00 am @ Radiology X-ray files room Time to ask and discuss interesting imaging findings.

Queen’s Grand round Every Friday 8 -9 am @Queens conference center auditorium MS-4 s encouraged to attend, but excused if urgent patient care matters. Check the chief blog Conference Queens Grand round for this months schedule!

Chief rounds For MS-3 & MS-4 Basically every Mon 1 -2 pm @iolani-5 Various didactics provided by CMR 1. 2. 3. 4. 5. How to get answers for your clinical questions Basics of antibiotics Basics of EKG reading Basics of ABG reading Basics of chest Xray reading Topics are decided per request

MS 4 / Sub. I Evaluation Assignments Morning Report (see schedule) End of Rotation evaluations Will be mailed to you by Julieta / Dr. Anegawa? Dr. Shiraishi? Interns/Residents/Attendings will fill in on-line. If you are unable to reach attending, have CMR contact attending

Miscellaneous

QMC map Queen Emma tower “ewa” (west) “diamond head” (east) east SAS GR DH ocean mountain 5 F 7 F ewa Pauahi- Goes up to 7 th flr. 1: ER 2: dialysis & CDU 3: cardiac noninvasive & cath lab 4 -7: tele/med/surg pts 1 F Code to enter: 4 -3 -5 -1 G: Clinic, coffee stand 1: radiology, lounge, cafeteria, hospitalist office 4: ICU (Med/Neuro/surgery) 5: neurology 6: cardiac ICU/ telemetry 7: oncology & *resident call room. 8 &9: med/surg pts 10: labor & delivery west Code to enter: 2 -4 -6 -8 -*

Where to eat 1 st floor Cafeteria Outside the cafeteria there are two lunch wagons Ground floor: Starbucks coffee kiosk 7 F Call room: refrigerator and microwave available “Ramen rounds”@Taisei ramen

Reminder about HIPAA: Health Insurance Portability and Accountability Act of 1996. first federal law aimed at protecting the privacy of health information. Be careful to protect Patient’s health information do not talk about patients in the elevators taking clinical pictures needs a consent do not take pictures or send information of patient’s information on personal phone or email Don’t lose/leave your papers in public areas

Absences Please Notify CMR ASAP – even the night before if you think you may be absent in the morning CMR will notify team / attending

Needlesticks/ occupational exposure QMC Blood/Body Fluid Exposure Policy 24 -hr confidential hotline: 6914004 Don’t wait! Based on the risk, the exposed person may need immediate care and follow-up Alternative = Call ER

Medicine sub-internship Tips for a successful rotation

Role of MS 4 The front line of the team, try to function like an intern Answer calls promptly, let your team know where you are You are the doctor to your patients (not the shadow, or spectator) Interview and examine all active pts, admit and d/c Write progress notes, H&Ps and discharge summaries Present pts on pre-rounds, attending rounds, conferences Update electronic hand-over Orders are “Pending Orders” and must be co-signed by UL Follow-up on any learning issues

Tips#1 Know your patient Know everything about the patient (more than the upper level) Read EVERY NOTE including PT/OT, dietary, nursing BE PROACTIVE, call… PCP, consultants office : med list, recent labs case manager : discharge planning Social history is KEY for discharging the patient safely PT/OT/SLP : progress in rehab Lab : pending labs, culture reports

Useful phone # Check the chief blog Training site QMC for useful phone numbers!

You will need a nice organizer (check list) Tips #2 Write down everything! Make sure to clarify orders with UL (or attending)

Ex) Organizer Traditional version

Carelink version Ex) organizer Family contact Med list 1) Make a new patient list 2) Copy “UHS organizer 2014” Consultant list Problem list The columns are easy to customize

Looking up clinical questions How do you identify learning issues? Your notes! During rounds! Ability to look up answers for your clinical question, will be a fundamental skill for your carrier. Try to go deeper than Up-To-Date! Dynamed original RCT article Review article (JAMA, NEJM, CCJM, Lancet, BMJ) Meta-analysis, systemic reviews Case reports Check the chief blog --> Clinical Questions for FAQs!

Clinical questions Reporter Interpreter, Manager Background questions Fore-ground questions • Textbook • Articles, trials • Expert opinions Ex) What are the risk factors for CAD? Ex) How can we utilize the TIMI risk score in deciding diagnostic tests?

Passive learner Active learner

No time to search for review articles ? ! Trouble with Care Link ? ! * Missed a morning report !? Username: residents / password :

Unofficial Guide Is this right for me? While you’re on the rotation, ask yourself: 1. 2. 3. 4. Do I get along with these people? Would I be able to hang out with them? Am I having a good time? Is this interesting to me? IF the answer to these questions are YES, then internal medicine is for you. Let as many people (DME, CMR, uppers, interns) know that you are interested in staying here and how you go about accomplishing your goal Talk to other JABSOM grads in the program

RIME model Reporter MS-3 / MS-4 accurately gather information through H&P, and can accurately report the information through presentations or write-ups Interpreter MS-4 / intern understand the clinical significance of the information obtained , and can generate a short differential diagnosis and prioritize problems Manager resident generate a reasonable diagnostic plan to deal with outstanding questions, and a therapeutic plan to solve problems. Educator CMR/ fellows risen to the level where they can identify knowledge gaps in others and effectively fill those gaps. Pangaro, L. (1999). A new vocabulary and other innovations for improving descriptive in-training evaluations. Academic medicine : journal of the Association of American Medical Colleges, 74(11), 1203– 1207.

Sample presentation at rounds Presentations: SPEAK UP! Start with a one-liner (48 M Hx of CAD, DM, HTN, HLD here with cc of SOB, admitted for ADHF) S: Briefly state: overnight events, active complaints, nursing concerns O: always state the vitals (quickly): Physical exam: pertinent findings, however always include heart, lung, abdomen for every patient

Example presentation (rounds) Assessment and plan (this is the most important part) In summary _____ Problem #1. (This is your assessment) SOB likely 2/2 ADHF Given increased weight, BNP > 1000, lower extrem edema, orthopnea. NYHA III, AHA stage C, forrester class warm/wet. Unclear precipitant at this moment, although we believe it’s from medication non-compliance, less likely 2/2 acute MI given no ECG changes, only mild Tn. I leak (0. 08), no chest pain. Improved from last night on admission, diuresed 2. 3 L total, breathing is improved. (this is your plan) Our plan for today… diagnostic plan is to obtain TTE today, TSH, trend Tn. I x 2, repeat ECG this am, daily weights, strict I/O’s, consult cardiology. Therapeutic plan is to continue lasix 40 mg IV BID target goal diuresis of 23 L per day. Educational plan is to consult dietitian and our Heart failure APRN to teach patient about low salt diet and emphasize on medication compliance.

You can make a change! With some careful observation, commitment and updated knowledge