Rotation: General Internal Medicine Ward (VA)
Site:
- Amarillo VA Health Care System
Instructors:
- Inpatient Teaching Attending Physicians: Anuradha Gopalachar, MD; Andrew Stenhouse, MD; Randy Stewart, MD; Dan Jenkins, MD; Tariq Samad, MD; Bang Wan, MD; Stephen Wright, MD; Sergio Muniz, MD; Ako Bradford, MD; and Texas Tech Attending Physicians rotating through the Amarillo VA Health Care System
Makeup of team (responsibility of each team member):
- The team consists of one attending physician, one senior resident, one junior resident (intern), and medical students. Each team member is responsible to participate in direct patient care, perform initial evaluation by history and physical exam, and formulate a diagnostic and therapeutic plan. The junior resident (intern) should confer with the upper level resident to establish appropriateness/accuracy of the diagnostic and therapeutic plan. The intern is responsible for no more than 5 admissions per call day. The senior resident will perform the initial evaluation of each patient, should write an admission note, and supervise the team, which includes the intern and medical students, and will communicate with the attending physician and consultants. All members of the team are responsible for placing the appropriate orders in the computer. H&Ps and admission notes must be signed within 24-hours of admission. Each team member should follow the patient on a daily basis, obtain pertinent information from the nursing staff and consult service, follow the laboratory tests, x-rays, specialized tests, discuss the case daily with the attending, and inform the attending of any changes in the patient's condition. The teaching attending for the team will supervise and assure the quality of care for the entire team. The attending teaches professionalism and humanism, and encourages teaching from the senior members of the team for the junior resident and the medical students. The 3 rd year or 4 th year medical student will participate in the care of the patient and will be allowed to take H&Ps, write progress notes, and follow patients under the supervision of a senior member of the team.
Days per week (and call):
- The team will round 7 days per week. Each resident will have 4 days off per month; on these days the other resident and the attending assume the clinical responsibilities. Call is every fourth day. However, the Night Float resident is responsible for admissions and problems on the floor from 9:00 PM to 7:00 AM.
- Residents are not expected to provide service to "non-teaching" patients except in emergency situations.
Usual time of attending rounds (meeting place):
- The team will meet at 8:00am 5 days per week in the Education Conference Room at the Amarillo VA Health Care System. Attending rounds will last from 9:00am until approximately 11:30am. At this time, case-by-case discussions and formulation of the diagnostic and therapeutic plan should be presented by the residents and medical students to the teaching attending.
Types of patients encountered:
- A broad range of internal medicine inpatients. The majority of the VA population is male patients with different ethnicities and backgrounds; geriatric patients seem to be a majority of the population. Critically ill patients admitted to the ICU are also followed by the internal medicine ward team rotating through the VA system. The average number of admissions per day is 5.
Educational goals/competencies:
Patient care:
A daily morning report is mandatory for all residents and medical students. The residents will discuss admissions and communicate any problems that occur during the nightly on-call rotation. Morning reports are followed by an educational case presentation, Decision Tumor Board Conference, MKSAP review, Journal Club, M&M Lecture, or lecture by specialty physicians. The team's educational goals include performing adequate clinical evaluation (history and physical exams), interpretation of laboratory tests and x-rays, and generation differential diagnosis. Residents will learn principles of diagnostic tests utilization, maintain medical records in a timely manner, and learn to communicate with other members of the team (attendings, nurses, consultants, etc.). Resident will learn to communicate effectively with family members and understand the social issues that may interfere with the patient's medical care. The housestaff should perform daily interview with the patient (early morning rounds, exercise humanistic attributes, professionalism and confidentiality), obtain informed consent prior to any procedure, make appropriate plans to discharge, and gain confidence in discharge-planning to assure follow-up appointment with the primary care provider. The resident is to gain confidence in the management of acute illness during hospitalization and the compensation of chronic illness. The senior physician is also expected to teach the medical students, assure participation, assign responsibilities, and present short lectures to the medical students.
Patient care:
The resident will learn to generate a differential diagnosis using the history and physical examination and diagnostic tests and to develop a diagnostic and therapeutic plan that seems appropriate, paying attention to evidence based medicine. He/she will also learn to integrate test results and gain confidence in the management of common medical conditions.
Medical knowledge:
The resident will develop knowledge of a variety of medical conditions and medical disorders and their presenting complaints. The resident will become familiar with and learn to treat such diseases as coronary artery disease and its complications, COPD, pneumonia, peptic ulcer disease, diabetes and its complications, hypertensive emergencies, gastrointestinal disorders, infectious diseases (such as meningitis and pyelonephritis), strokes, coma, etc. The resident will also learn to handle terminally ill patients and learn to counsel the patient and their families.
Interpersonal/communication skills:
The resident will develop an effective way to communicate with other members of the team including attendings, nurses, consultants, etc., but especially the patients and their family members. The resident is expected to review all the pertinent information prior to presenting it to the attending physician. Resident is expected to be familiar with the patient's condition and inform the patient and their family about any progress and the expected outcome. The resident is expected to treat fellow residents, medical students, and colleagues with respect. If conflict arises, he/she is to show integrity and professionalism.
Professionalism:
The resident is expected to respectfully interact with colleagues, nurses, and other health care teams, to maintain integrity, and to show humility and sensitivity to patients. Residents should learn to respect the diversity of the patient population, which includes differences in ethnicity, religious beliefs, and sexual orientation.
Practice-based learning and improvement:
The resident will need to recognize his/her deficiencies and be receptive to constructive criticism, as well as to maintain an up-to-date knowledge of medical conditions by reading and researching current literature.
Systems-based practice:
The resident will need to be familiar with hospital policy regarding admissions and discharges, and maintain daily communication with social workers and case managers. The VA maintains a limited formulary and processes must be followed to obtain certain specialized procedures. Residents will learn how to utilize the system to obtain needed medications and diagnostic tests for their patients.
Text/references to be consulted:
Harrison's Principles of Internal Medicine, Washington Manual of Medical Therapeutics, Cecil Principles of Medicine, MKSAP from the American College of Physicians (the most current editions should be referenced), The Sanford Guide to Antimicrobial Therapy.
Methods of evaluation:
Monthly evaluation by attending physicians and nurses, quarterly evaluation by the Resident Evaluation Committee.