OUTLINE FOR DESCRIPTION OF ROTATION

 

 

ROTATION:              Teaching Service

 

PRECEPTOR:                        Dr. Ferstenfeld and Family Practice Faculty

 

DURATION:              Two Months (PG-I, PG-II, & PG-III)

 

Responsible Faculty:  Dr. Mazzone

 

 

1.         GOALS/OBJECTIVES:

            ---        Become competent with diagnosis, treatment, and management of medical, psychosocial and ethical aspects of medical conditions requiring hospitalization.

            ---        Learn when and how to appropriately use medical specialty consultants.

            ---        Learn the effective and cost effective use of ancillary diagnostic and therapeutic hospital services.

            ---        Learn to collaborate effectively with a treatment team (nursing, discharge planner, social worker, and ancillary services) to manage hospitalization and discharge planning.

            ---        Learn to counsel patients and their families regarding diseases, prognosis, treatment decision making.

            ---        Learn the physicians role in assuring quality and cost effective care in a changing economic environment that includes managed care.

            ---        Learn skills that facilitate teamwork, collaboration, and leadership, both within the Teaching Service team and in working with other hospital personnel, patient, and family.

            ---        Develop patient education skills.

            ---        Education of colleagues via Morning Report.

 

2.         EXPECTATIONS OF ROTATION:

            ---        Evaluate, admit, conduct history and physical, and develop initial treatment plan for all admissions to the Teaching Service while on call.

            ---        Complete daily rounds, progress notes, staffing, ongoing assessment, and orders on all patients, under faculty supervision. Patients for daily rounding will be assigned by PGY-3 resident.

            ---        Respond to nursing calls and provide ongoing care and treatment decision making for all patients.

            ---        Arrange for appropriate discharge planning and follow-up; dictate or write discharge summaries for all admit patients. Handwrite dictation for all others.

            ---        Present case conferences at morning report  Monday and Thursday mornings.

            ---        Maintaining continuity of care for Clinic patients. Contact primary care physician at admission and ensure patient is seen every 2 business days.

 

3.         SUGGESTED PREPARATION AND REFERENCES:

            ---        Washington's Pocket Manual - handy reference for treatment of medical problems.

            ---        Cecil's Textbook of Medicine

            ---        Harrison's - good reference for more independent reading

            ---        Sandford Guide to Antimicrobial Therapy - useful to carry in pocket.

            ---        Marriott's - good time to review/read about EKG interpretations

            ---        Practical Ethics for Resident Physicians - a short guide to clinical ethics

            ---        Medline/Pub Med for evidence based searches

            ---        Up-To-Date

 

4.         TYPICAL DAY/WEEK:

            6:30 - 7:30         a.m.      -          Pre-rounding as needed on new admissions, complex patients, seriously ill patients, to be completed prior to 7:30 a.m. educational conferences and rounding with faculty.

 

            7:30 - 8:30         a.m.      -          Monday            -           Family Practice Morning Report

                                                            Tuesday            -           All Staff Conference

                                                            Wednesday       -           Journal Club (1st & 3rd Wed.) / M&M (2nd Wed.) / Ortho Lecture (4th Wed.)

                                                            Thursday          -           Family Practice Morning Report

 

            8:30 - 10:30       a.m.      -           Complete rounds on all Patients

 

            10:30 - 12:00     p.m.      -           Staff with Faculty

 

            12:00 - 1:00       p.m.      -           Finish Patient tasks from staffing

 

            1:00 – 4:00 p.m. -           Wednesday  -  Educational Conferences

 

            Afternoons                    -           Varies: Clinic; Teaching Service call; follow up on patient care issues; or manage your time per your discretion.

 

            When on-call                             Provide 24 hour coverage for teaching service.

 

5.         WORK-UPS/WRITE-UPS:

            ---        Residents on Teaching Service will generally take all admissions on their call day.

     ---        The admitting resident completes admission H&P orders and prompt staffing with the faculty.

            ­­­---        When faced with multiple admissions which are overwhelming or greater than 6 admissions in 24 hours call in the back-up resident. If additional help is needed, the clinic call person covers or helps with admissions. If there are unstable patients or assistance is still needed call the attending faculty immediately (see POLMAN).

 

6.         PROCEDURES:

            ---        Opportunities for LP's, arterial lines, thoracentesis, central lines, paracentesis, circumcisions
and other procedures required by patients on the Teaching Service. Bone marrow aspiration
and biopsy are possible if you ask pathologists in advance.

 

7.         AVAILABLE EDUCATIONAL EXPERIENCES/CONFERENCES:

            ---        The usual conferences are available, and Teaching Service will not interfere with attending these conferences except in the event of urgent patient care problems.

            ---        The Teaching Service team is responsible for leading Morning Report under the direction of the senior resident on the service.

            ---        Rounds – All residents will be responsible for bringing learning issues to rounds. PGY-3 resident will be responsible for running rounds.

 

8.         IMPACT ON WFPC OFFICE SCHEDULE/EDUCATIONAL CONFERENCES/FAMILY PRACTICE MORNING ROUNDS:

            ---        While participating in the Teaching Service rotation residents are generally able to attend most residency functions with no interference with Clinic, Morning Conferences, or other obligations.

            ---        Rounds may occasionally run longer than noon, but this can in most cases be avoided with careful planning, time management, and pre-rounding.

 

9.                     CALL AND SHARED CALL:

            ---        Call is shared equally among the 3 Teaching Service residents and the Peds resident, and subject to the same limitations that apply to call frequency throughout the residency. Seven nights of call per block. Typically it is q4.

            ---        During the first 6 months, the 1st and 3rd nights of the rotation will be covered by both the 3rd year and the 1st year to ensure proper orientation.

            ---        If there are no active management issues, residents may take call from home if they stay within 20 minutes of the hospital.

 

   10.     WEEKEND REQUIREMENTS:

            ---        Weekend call is shared equally among all residents on the rotation.

            ---        The resident on call makes rounds as usual Saturday and Sunday and staffs cases with the on-call faculty member.

            ---        Resident on call Friday, rounds Saturday morning. Resident on call Saturday, rounds Saturday and Sunday. Resident on call Sunday, rounds Sunday only.

 

11.        VACATION/TIME OFF:

            ---        One day (however, it may not interfere with the call schedule).

 

12.        STRENGTHS:

   ---        You will get substantial practical experience as the primary care giver for a wide variety of patients.

   ---        You will be taught by a variety of faculty.

   ---        You will have an opportunity to develop skills in leadership, teamwork, and collaboration in a supportive environment.

  

13.        WEAKNESSES:

            ---        Patient volume is somewhat variable. At times the service will be very busy, while at other times the service may be light. These hills and valleys tend to balance out over time and are very typical of medicine anywhere.

 

 

 

 

MAZ: 5/20/05

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INPATIENT CARE:

A CHECKLIST FOR RESIDENTS OF ISSUES TO CONSIDER

TO ENSURE COMPREHENSIVE/COORDINATED QUALITY CARE

OF EACH PATIENT/FAMILY

 

 

Initial Workup

1.         Complete data collection

---        Complete history and physical including medication list, problem list, family history, standard of care history and complete ROS dictated within 24 hours (handwritten in chart within 2 hours)

                        ---        Review of old records, all labs, all radiologic tests (look at films) and other tests

                        ---        Discussed the care with the primary physician, if available

            ---        Contact D/C Planning, social work, PT/OT, specialist consultation as necessary

 

2.         Problem solving

                        ---        Develop problem list and working differential diagnosis

                        ---        Develop plan based on problem list including:

1)      Planned and possible diagnostic tests

2)      Therapies - meds, consults, intervention

3)      Prevention – DVT, incentive, spirometry, alcohol, tobacco withdrawal, etc.

4)      Disp – begin thinking placement

5)      Business – sticker for billing TS list

-          Review subjective and objective physical findings

-          Hunt down results of all testing

-          Talk to nurse caring for patient

-          Update family members, primary care physician, consults as necessary

-          List active problems and working differential diagnosis, thought processes in note

-          Write orders consistent with plan (1st years must write or give all verbal orders “as per Dr. Faculty”.  All residents must write or give verbal orders “as per Dr. Faculty” for ICU and NICU patients).

-          Plan family or treatment team conferences as necessary

-          Be prepared to present patient to staff

 

3.         Who Ya Gonna Call

     ---        To Dr. Ferstenfeld alternating with Family Practice faculty (every 2 weeks)

                        ---        Undoctored adult patients (no doctor or doctor does not admit to WMH)

                                    ---        Undoctored Chemical Dependency patients on odd numbered days and hospitalists on even numbered days

 

            ---        To Family Practice Faculty

                        ---        All patients of WFPC

                        ---        NICU patients (if no resident is on NICU or PEDS)

                        ---        Undoctored pediatric/newborn patients

                                    ---        Undoctored obstetric patients (covered by OB resident on call if available otherwise WFPC call)

                        ---        Nursing Home patients of any faculty member/resident

 

Things to think about during Admission

1.         Nutritional Concerns

                        ---        Is an assessment needed?

                        ---        Is there a dietary assessment/supplement needed?

 

2.         Physical Therapy

                        ---        Can you maintain or increase the functional status during hospitalization?

 

3.         Consultation

                        ---        Do consultants understand their roles and the specific questions that have been asked of them?

                        ---        Daily workup:

1)      Prestaff ICU patients and advanced directives on admission. Almost all patients should
       usually have code status orders on chart.

2)      Staff within 1 hour of evaluation when writing orders

4.         Prevention

                        ---        Heparin/Coumadin for DVT

                        ---        Incentive spirometry pre-operatively

                        ---        If prolonged bed rest, avoid deconditioning, foot drop, and decubiti

                        ---        Assess for alcohol dependency and need for treatment

                        ---        Assess for smoking quit date and consider treatment during hospitalization

                        ---        Assess for other routine health promotion needs based on review of other risk factors; arrange for either inpatient or outpatient counseling or screening.

 

5.         Psychosocial Concerns

 

6.         Economic Concerns

                        ---        Is Social Services needed?

 

7.         Family-Oriented Care

---        Who are key family members who can act as a spokesperson for the family and patient (important if more severe illness so that  there is one identified person who will call instead of each family member indirectly)?

                        ---        If there are communication concerns with patient, contact key family members

                        ---        Consider family conference for significant concerns, change of status, care planning

                        ---        Are you keeping family members involved so they can support the patient?

                        ---        Are there signs of family stress or dysfunction that needs to be addressed?

 

8.         Advanced Directives

                        ---        Has level of care been clearly documented in the admission H&P?

                        ---        Have Code status orders been written?

 

9.         Spiritual Needs

                        ---        Is chaplain needed?

 

10.        Discharge Planning

---        Discharge planning (daily assessment of when discharge is likely) and initiate this at the time of admission.

                        ---        Has discharge planning been ordered?

 

 

 

11.        Primary Care

                        ---        Has the primary care physician been notified and become involved in care?

                        ---        Have you placed the patient on the primary care physicians inpatient list (via order)?

 

12.        Team Issues

---        Is the patient on the correct physician list? Put all patients under Teaching Service list – admitting Dr. should be who most likely will be rounding on the patient the following day. Admitting physician’s should be changed on Monday if needed to reflect which attending will most likely be rounding on them for the week.

                        ---        Has the nurse been included in patient care planning?

                        ---        Are all team members informed of key care decisions of the day?

                        ---        Have teaching issues been defined?

 

13.        Practice Management

                        ---        Have you completed the billing sheet

                        ---        Have you SOAP’d each active problem?

 

At Discharge

---        Arrange placement and follow up (appointments, tests, etc.)

---        Write all prescriptions

                        ---        Discharge summary including medications, problems, diagnostic tests, follow up, procedures within 72 hours of discharge

 

Admin Issues

1.         Morning Report Schedule

                        ---        PGY-3 responsible for ensuring the smooth running of morning report.

                        ---        Typical morning report includes:

-          FP update

-          Case presentation

-          Problem solving

-          Short presentation – background on disease or foreground on clinical question

-          Announcements

                        ---        There are 8 morning reports in a month. Each team member should present at least 1 morning report presentation. The first one is an admin meeting and the last one is jeopardy. Try to present 1 OB case and 1 outpatient case per month.

 

2.         Roles

                        ---        PGY-1 – primarily patient care and presents 1 morning report

                        ---        PGY-2 – patient care, supervision of medical students, billing sheets, continuity of care for the primary care physicians

                        ---        PGY-3 – organization of team assigning patients, organizing morning report, running staffing, education of residents, patient care

 

 

 

 

MAZ: 5/20/05

 

The following is an example of a Teaching Service Chart Sticker

that is to be used by each and every resident on the service.