General Medicine Floors Goals & Expectations

Overview of Inpatient Education on General Medicine Teaching Services

  1. A high yield, learner-centric experience with supervised autonomy
  2. Focus on development of the 6 ACGME competencies: medical knowledge, patient care, professionalism, interpersonal and communication skills, systems based practice, practice based learning and improvement
  3. Based on Experiential Learning (apprenticeship) and exposure to “Undifferentiated Disease”
  4. Emphasis on Critical Thinking in Clinical Reasoning, Self-directed Learning, Capitalizing on Teachable Moments, Deliberate Practice, Coaching, Role Modeling, Direct Observation and Reflection
  5. System based on clear role delineation, efficient time management and explicit goals and objectives
  6. Effectively follow and care for patients from the time of admission to discharge with careful attention to transitions of care during shift changes, at the time of admission (med rec) and at the time of discharge to outpatient care”

 

General Medicine Teaching Services – Intern Expectations

  1. Direct Patient Care

– Arrive on time in the morning, pick up the sign out from the NF, inform your upper year/attending about significant overnight events

– Perform a brief focused interview and physical exam on your patients each morning

– Check lab data, consult notes, procedures from prior day. Start your PN, pend them if not ready before rounds and finalize them in a timely manner during the day

– Follow up on results of tests/procedures ordered, consult notes, check on clinical status through the day

– Discuss with patient and family results of tests, procedures, etc. If new information obtained, place it in your PN or add a new note in Epic (ex: Downtime Event note)

– Let patient (and family) know of discharge plans early, ensure that proper pharmacy is recorded in Epic so prescriptions are appropriately sent, perform medication reconciliation and write discharge instructions (with input/supervision from your resident/attending)

– Always assess your patient at bedside if called by nursing staff about change in clinical status (including but not limited to significant change in mental status, VS abnormalities, fall, etc)

– Focus on safe transitions of care for your patients, work effectively in interprofessional teams to deliver high quality, cost-effective care to your patients, and use your experience on the general medicine floors to consistently grow, learn and improve

 

 

  1. Presentations: used as means to assess and expand clinical knowledge, develop clinical reasoning, implement illness scripts and enhance critical thinking

H&P

– Should include CC, HPI with relevant information (including ED VS and therapeutic course, as well as relevant information from previous admissions), home medications, PMH, PSH, FH, SH, ROS, VS, physical exam, lab and imaging data (all with a focus on what is pertinent to the case as well as, abnormal nonpertinent findings)

– Assessment and plan – focus on critical thinking and clinical reasoning

  1. Problem Representation:  including epidemiology and risk factors, temporal pattern of illness with semantic modifiers and key clinical findings
  2. Acute problems with reasoned differentials–using concordant and discordant features, in order from most likely to least likely, explain rationale and remember “can’t miss” diagnoses
  3. Use Illness Scripts (predisposing factors, pathophysiology, clinical manifestations) to determine which disease fits best with the presentation
  4. Develop a further investigative and management plan for each problem

 

Progress notes

– Focused subjective (prior day and o/n significant event, clinical presentation) and objective  (VS, focused PE)

– Summary of relevant lab and imaging data, including pending cultures and labs that require longer time to result (with trends and pertinent baseline values)

– Problem representation with ordered problem list including diagnosis, status and management (adapting to changes in clinical picture)

 

  1. Professionalism

– Be punctual

– Answer your pages in a timely manner

– Update the nursing staff on plans for their patients, as they can be very helpful in making things happen in a timely manner

 

 

  1. Relationship with upper year resident

– They are your support system and they know that!

– Review presentations, plans, EKGs, XRs, CT scans; run the list, ask for guidance for procedures, calling consults, updating sign out, placing orders, etc.

– Make a plan of action but run it by your resident/attending, especially at the beginning of the year.  It’s always easier to prevent an error than to correct it.

– Ask for feedback from your resident/attending

– Ask for help if you need it.  Better to ask than to guess.

 

 

  1. Wellbeing

Last but not least: remember to eat, drink water, use the bathroom and sleep.

– Be safe and aware of your surrounding when you go home to your car/subway. If you leave late in the night, ask for help from Temple Security Desk

Ask for help when behind with your tasks/notes. Our motto is:  “No intern left behind!!”

 

 

  1. Resources/ Point of Care Learning

– Pocket Medicine (orange book)

– uptodate.com

– Dynamed:  alternative to uptodate

– lifeinthefastlane.com:  ECG/rhythm library

– EKG Wave Maven (https://ecg.bidmc.harvard.edu/maven/mavenmain.asp) – A Harvad University managed website with a collection of EKGs which allows for self-assessment for both students and clinicians

– JAMA Rational Clinical Exam Series: evidence based use of the H/PE/testing to diagnose disease

– UCSD History and Physical Exam:  comprehensive guide to the H and P

– Annals of IM Update Series:  summary of landmark articles for that year in a given subspecialty

– Journal Watch:  email with most recently published articles in a given subspecialty

– ACP Journal Club:  summary of new evidence from 120 journals

– ACP Clinical Practice: guidelines

– Society to Improve Diagnosis in Medicine:  critical thinking in clinical reasoning/cognitive errors

 

General Medicine Teaching Services- Resident Expectations

Projected goals

– Improve clinical knowledge, both in areas of interest and across wide array of medical subspecialties

– Distill and sharpen leader and educator skills

– Share duties with the attending in overseeing and guiding patient care, medical student and intern education.

– At beginning of the rotation, remind attending to review goals and expectations, as well as learning objectives with entire team

– Focus on safe transitions of care for your patients, work effectively in interprofessional teams to deliver high quality, cost-effective care to your patients, and use your experience on the general medicine floors to consistently grow, learn and improve

 

Team manager and leader

– Learn all your patients well !!

– Identify which patients you need to see on pre-rounds (unstable, sick)

– Review daily labs, identify and review critical values with interns and students, use this at teachable moments (Ex. Electrolyte repletion, ABG interpretation, antibiotic choice, etc).

– Briefly review and revise intern and students presentations prior to rounds; allow them to present their impression and plan, ask them to reason through their plans, point out things the miss and help them tailor their clinical reasoning appropriately.

– Support your medical students/interns during rounds (look up the lab data, missing elements from the patient’s history, etc).

– Run the list with your interns at the end of attending rounds and choose tasks to be done by them and tasks to be done by you. Check on your interns during the day to assess completion of tasks/need for help/identify misses.

– Allow students to be integral part of the team, give them tasks both educational and helpful for patient care (with a focus on their patients)

– Teach on the fly: anything you do for your patient is a “teachable moment”; point it out to your interns (Ex: nurse asks you if she should change the Foley. Point to remember, if a patient comes with a UTI, always change the Foley). Think out loud.

– Remember your favorite resident during your internship and be that resident for your interns; they will appreciate it !

 

 

Educator

During attending rounds – share educator role with attending;

 

Rest of the day

– Assign students and yourself clinical questions to look up, articles to retrieve and review

– Use the cases on service to (look up and) discuss diagnostic criteria, treatment guidelines, complications of diseases. It may help to recapitulate teaching strategies discussed during RaTL. Every patient is an opportunity to review specific literature.

– Direct observation and feedback of interns and students – history taking, physical exam maneuvers, presentations during rounds, discussion with family members, patient counseling, discussion with nursing staff, anything you think it’s relevant.

– Review data with your team every day – blood smears, urine analysis, EKG, ABG, X-rays

– Discuss with consultant teams regarding patient care and education.

 

 

Resources/ Point of Care Learning

 

– Pocket Medicine (book)

– uptodate.com

– Dynamed:  alternative to uptodate

– lifeinthefastlane.com:  ECG/rhythm library

– EKG Wave Maven (https://ecg.bidmc.harvard.edu/maven/mavenmain.asp) – A Harvad University managed website with a collection of EKGs which allows for self-assessment for both students and clinicians

– JAMA Rational Clinical Exam Series: evidence based use of the H/PE/testing to diagnose disease

– UCSD History and Physical Exam:  comprehensive guide to the H and P

– Annals of IM Update Series:  summary of landmark articles for that year in a given subspecialty

– Journal Watch:  email with most recently published articles in a given subspecialty

– ACP Journal Club:  summary of new evidence from 120 journals

– ACP Clinical Practice: guidelines

– Society to Improve Diagnosis in Medicine:  critical thinking in clinical reasoning/cognitive errors

 

General Medicine Teaching Services- Attending Expectations

  1. Preparation

– Need to standardize uniform expectations and guidelines for the inpatient experience

– Review resident, intern and student expectations at the beginning of each block and implement into daily rounds

– The interns’ focus is on the ownership of the complete care of their patients

– The residents’ focus is on becoming a manager, educator and leader of the service

  1. Presentations

– Presentations should be focused with an emphasis on clinical reasoning

(SOAPS:  story, organization, argument, pertinence, speech)

– Incorporate Stanford 25 physical exam skills (with likelihood ratios)

– Presentations should contain a well thought out Problem Representation (brief epidemiology/demographics/risk factors, temporal pattern of disease with semantic qualifiers, key clinical findings)

– Focus on developing Illness Scripts (predisposing factors, pathophysiology, clinical manifestations)

 

  1. Rounds

– Use time management skills and preplanning to determine which patients to see together/bedside rounds vs. which patients to “run the list” (RTL) on

4D’s (Dire, Diagnostics, Discussion, Discharges) vs alternate daily (with focus on opportunity for students to deliver their presentations)

– Rounds must end no later than 11:30 (preferably 11:15).  Encourage and role model conference attendance

– Be prompt for daily (except post call day) multidisciplinary rounds at your specified location(s)

– Be explicit in your teaching and role modeling (“By going through your presentation this way, we are learning and using clinical reasoning skills.”  “I am going to role model for you how to deliver bad news.”)

– Give micro feedback (daily), and explicit mid rotation and end of rotation feedback

 

  1. Call Cycle

– Post Call:  5 overnight admissions and 3 evening admissions from night before (dismiss overnight intern after 5 overnight admissions)

– Short Call 1 and Short Call 2:  2 morning redistributions/3 daytime admissions until 4pm

– Pre Call: no new admissions (resident may have day off)

– On Call: 3 evening admissions (4p-7p), 5 overnight admissions (7p-5a)

 

Afternoon Rounds Teaching Toolkit:

  1. direct observation of new admission (portion) with feedback
  2. direct observation of focused patient encounter, patient counseling, transitions of care
  3. review new admission with more time for focus on clinical reasoning/problem representation/reviewing cognitive bias
  4. review case, article, EBM, PICO question pertaining to current patient
  5. medical student review of topic, resident mini EBM review pertaining to current patient
  6. reflect on patient care: learning points, errors, ways to improve
  7. review transition of care, close the loop

 

 

  1. Resources/ Point of Care Learning

– Pocket Medicine (book)

– uptodate.com

– Dynamed:  alternative to uptodate

– lifeinthefastlane.com:  ECG/rhythm library

– EKG Wave Maven (https://ecg.bidmc.harvard.edu/maven/mavenmain.asp) – A Harvad University managed website with a collection of EKGs which allows for self-assessment for both students and clinicians

– JAMA Rational Clinical Exam Series: evidence based use of the H/PE/testing to diagnose disease

– UCSD History and Physical Exam:  comprehensive guide to the H and P

– Annals of IM Update Series:  summary of landmark articles for that year in a given subspecialty

– Journal Watch:  email with most recently published articles in a given subspecialty

– ACP Journal Club:  summary of new evidence from 120 journals

– ACP Clinical Practice: guidelines

– Society to Improve Diagnosis in Medicine:  critical thinking in clinical reasoning/ cognitive errors