Rotation: General Internal Medicine Ward (NWTH)
Site:
- 5 South, NWTH
- Morning Report - Dining Room #3, NWTH (9-9:50 A.M.)
- Drs. Cutts, Leeper, Jenkins, Khandheria, Pierce, Urban, Weis, and Wilson; also Drs. Bell, Chandra, and Ranin
Makeup of team (responsibility of each team member):
- One junior resident (intern)- performs initial evaluation via history and physical exam, confers with the upper level resident to establish diagnostic and therapeutic plan, carries out day to day care and documents this with a complete daily progress note, evaluates social and behavioral issues that may prevent timely discharge. The intern is responsible for no more than five admissions per call day or eight admissions per 4 day period.
- One senior resident-performs initial evaluation of each patient (often this occurs in the emergency room), writes an admission note on all patients admitted while he/she is on call (the night float resident writes admit notes on patients admitted at night), supervises the ward team, including technical procedures, teaches and nurtures the development of medical students and junior residents, communicates with the attending and consultants in the interest of providing overall effective and efficient care of each patient. Dictates or writes the discharge summary.
- One attending-supervises and ensures quality care for the whole team, fosters a sense of progressive responsibility among junior team members, brings evidence-based medicine to bear on the clinical problem, establishes an environment where professionalism, humanism and scholarship are valued, evaluates and gives feedback to team members.
- Often a third year medical student, a fourth year medical student (acting intern), pharmacy students, nursing students, social worker, discharge planner, etc will participate with the ward team.
Days per week (and call):
- The team rounds seven days per week. Each resident will have 4 days off per month; on these days the other resident and the attending assume clinical responsibilities. Call is every fourth day. The night float resident covers for the senior resident (this includes ER evaluations and admissions) after 9 pm on Sunday through Thursday nights and reports to the attending and the senior resident on the team the morning after call.
Usual time of attending rounds (meeting place): 9:50 A.M. to 11:30 A.M. and also prior to Morning Report if needed (5 South at NWTH)
Types of patients encountered:
- The service includes a broad range of internal medicine inpatients. Genders are equally represented and a broad range of ethnicities are encountered (approximately 30% of our inpatients are Hispanic and 15% African-American). Geriatric patients and those with multiple chronic medical problems will often be seen. Critically ill patients are cared for on a separate ICU/CCU service; most oncology patients are admitted to a separate oncology ward. The average number of admissions per day is 7 to 8.
Educational goals/competencies:
Patient care:
Residents will learn to use the history and physical exam to generate a limited number of diagnostic possibilities. The list should include the likeliest choice and those that, if missed, pose the greatest peril to the patient's life and health. Residents will then develop an efficient diagnostic strategy using the principles of epidemiology, risk/benefit analysis, and sensitivities/specificities of the selected test. Residents will choose therapy that is logical and appropriate, will pay attention to the risk and cost of the chosen therapy, and will be aware of drug-drug interactions and pharmacologic principles.
The resident will learn those procedures that are integral to the management of patients on a general medical ward and which do not require intensive care unit monitoring. These include: advanced CPR, access techniques for venous and arterial blood, abdominal paracentesis, thoracentesis, lumbar puncture, arthrocentesis of the knee, NG intubation, and CVP line placement.
Medical knowledge:
Residents will develop a working knowledge of the differential diagnosis of these presenting complaints: chest pain, dyspnea, febrile illnesses, alterations in CNS function (focal and generalized), severe headache, nausea/vomiting, abdominal pain, diarrhea, GI bleeding, alteration in urinary symptoms, jaundice and altered liver function, disordered function of common endocrine glands, anemia, abnormal bleeding, altered nutrition (especially weight loss), depression and anxiety.
Residents will treat these diseases often enough to know them inside out: coronary ischemia, COPD, atrial and ventricular arrhythmias, pneumonia, cirrhosis (and its complications), GERD, peptic ulcer disease, common GI cancers, stroke, meningitis, coma, pyelonephritis, fluid and electrolyte disorders, malnutrition, depression, and the various dementias. Residents will learn symptom management, terminal care, how to counsel the dying and their families, and how to recognize when the help of a colleague or consultant is needed.
Interpersonal/communication skills:
Since history-taking is the physician's most important tool, residents will spend sufficient time with the patient to obtain a complete and coherent history. Residents will be aware of nonverbal cues (i.e. pain behavior), idiomatic expressions, and the input of other caregivers (i.e. family members, nursing home staff). Residents will review old records but will not place undue stress on received information (i.e. the resident will obtain the medication history directly rather than from the medication list written by the nurses, residents will question when appropriate the validity of past diagnoses on the chart)
Residents will develop an effective style of communicating information back to the patient during the hospitalization and at time of discharge. Written records will be complete and timely. Daily progress notes will be written on every patient every day, and discharge summaries (usually dictated by the upper level resident) will be timely. Residents will learn how to give bad news, how to deal with the angry or hateful patient, and how to determine the patient's decision making capacity.
Professionalism:
The foundation of professionalism is respect, and the resident is expected to treat the patient as if he/she were a member of the resident's own family. Residents will have opportunity to deal with patients who do not share the resident's ethnic group, religious beliefs, sexual orientation, and attitudes toward drug use, alcohol use, sexuality, etc. Residents will treat these diverse patients with respect.
Residents will approach peers with respect. Residents will not "dump" work on others that should be done himself/herself. Residents will check out with the on call team before leaving the hospital. The members of the ward team will work together to get the daily work done. Residents will treat residents on other services and consultants with respect; when conflicts arise, they will be settled promptly and with integrity.
Residents will treat other members of the health care team with respect. All are encouraged to listen to and obtain input from nurses, therapists, technicians etc in the decision-making process.
Practice-based learning and improvement:
No one knows everything all the time. Residents will develop habits of life-long learning on this rotation. Residents will recognize when they are "in over their heads" and need to obtain help from other residents, faculty members, or consultants. Residents on this rotation will learn to use current journals and on-line resources to obtain up-to-date information. This will be especially important for the upper level resident. Mistakes will be honestly acknowledged, never "covered up". Errors will be analyzed so that the resident can learn from his/her mistakes. Residents will be open to input from nurses, respiratory therapists, etc about how the residents' care may be more effective and more humane.
Systems-based practice:
Many different systems are involved in the hospitalized patient. Residents will work on a daily basis with social workers and discharge planners in order to achieve timely but complete discharges. Residents will know the implications of coverage by Medicare, Medicaid, HMOs, and "self-pay" Residents will understand the implications of DRGs, hospital formularies, skilled nursing facilities, and home health care agencies. Residents will see both "private patients" and patients covered by the indigent care system (the J.O.Wyatt health plan). Residents will become familiar with the language of cost-effective medicine (cost-benefit analysis, quality adjusted life years, etc.). Residents will interact on a frequent basis with hospice systems (two are currently available) to provide humane and cost-effective end-of-life care. Residents will learn how to make the best use of this network of various systems to the maximum benefit for the patient.
Text/references to be consulted:
The core text is Harrison's Principles of Internal Medicine (most current edition). Residents are encouraged to read on a topic pertinent to one of the ward patients each non-call night. The Medical Knowledge Self-assessment Program from the ACP is a succinct and current publication; the section on Hospital-based medicine should be perused before starting the rotation. The senior resident should obtain pertinent current journal articles and practice guidelines for the team. Other handy resources are the Washington Manual of Medical Therapeutics and The Sanford Guide to AntiMicrobial Therapy.
Methods of evaluation:
Input will be obtained from the medical student (in particular, regarding the resident's commitment to teaching), from the junior or senior resident on the team (in particular, on the other resident's commitment to mentoring and developing a spirit of teamwork) and from the faculty member. Particular emphasis will be placed on the resident's humanistic qualities, on his/her willingness to sit down and communicate openly with patient and family, and his/her commitment to cost effective, logical, and evidence-based diagnostic and therapeutic plans. Each faculty member fills out the standard departmental evaluation form on each resident; these evaluation forms are available for review by the resident in ther residency office. Each resident fills out an evaluation form on the other resident on the team, but these evaluations are not reviewable by the evaluated resident for reasons of confidentiality.
Junior residents will be observed in a patient care situation by the attending(the so-called mini-CEX) four times in the first year. Nurses and medical students also fill out evaluation forms on each resident; these are particularly valuable to the faculty member in assessing the resident's ability to work with others as a team and the resident's commitment to teaching. These forms are reviewed by the program director as they are submitted. Other evaluation methods used from time to time include chart-based recall and the 360 degree review.