Orientation

What do I need to know on Day 1?

You will rotate through one of seven general medicine teams comprised of:

  • 1 Attending
  • 1 Senior Resident
  • 1 Overnight Junior Resident
  • 2 Interns (or 1intern, 1Sub-Intern)
  • 1-2 Students (paired with our Interns)
  • 1 PharmD or Pharmacy Resident
  • 1-2 Case Managers (paired with our Interns)

Prior to the start of the rotation, you will receive handoff from one of your colleagues regarding the team of patients you will be responsible for. This will either be by email or in the handoff section of Epic.

A typical day begins in your workroom at 7AM where our overnight teams will handoff.

  • Gen Med Teams 1 and 6: Meet on 8300
  • Gen Med Teams 2 and 7: Meet in 8270 (outside of unit 8200)
  • Gen Med Team 3: Meet inside 8100
  • Gen Med Team 4: Meet on 8200
  • Gen Med Team 5: Meet on 4300

It will be your responsibility to sign in and sign out as the first call provider at the start and end of your day. Early in the year, interns will cover Team A and sub-interns Team B. 2nd year medical students should not sign in as first call providers.

What are the objectives of this rotation?

During this rotation, each intern will:

  1. Become the primary physician for each patient on their team.
  2. Develop skills for evaluating patients and instituting their plan of care in independent practice
  3. Demonstrate growth in medical fund of knowledge and its application to patient care by reviewing literature on the care of each patient, participating in attending rounds, and attending core conferences and reports.
  4. Become efficient in managing the daily service components of patient care, including daily progress notes, the ordering of all necessary diagnostic tests, follow up of testing,        and timely admission and discharge paperwork.
  5. Effectively communicate with all members of the multi-disciplinary team, including effective sign-out of patients to colleagues and communication with consultants, nurses, therapists, and resource managers.
  6. Develop teaching skills, not only for patient care, but also in order to become the primary teacher for the team MS2’s.
  7. Begin to develop an understanding of patient care within the larger system within which we practice.

Each senior resident will:

  1. Become an effective leader of the general medicine team and take the primary responsibility of determining the plan of care of each patient.
  2. Become the primary teacher and model effective teaching of medical knowledge and procedural skills for all medical students, sub-interns, and interns on service.
  3. Demonstrate growth in medical knowledge and appropriately apply knowledge to an effective, high value and patient-centered care plan at attending rounds, management focused reports, and other conferences.
  4. Effectively communicate the plan of care to all members of the team, including reviewing each plan with interns, ensuring effective communication with consultants, and serving as a role model for communication with nurses, therapists, and resource managers.
  5. Proactively identify barriers to patient care within the larger health system, including issues with progression of care, discharge, or areas within which patient safety can be improved.

When does my team admit patients?

Each weekday, your team will be assigned on of 3 roles:

  • Regular: The regular day is the day of the week in which you can accept overflows
    (no more than 3 as a team) and admit new patients (no more than 4) during the day. Admissions will come no later than 4:00pm and your overnight resident will meet you at 6:30 for handoff.
  • Admit:  The admit day is the day of the week in which you can accept up to 2 overflows as a team and admit up to 4 patients. Admissions will come until 6:00pm. You still can transition care of your patients to your overnight resident at 6:30 PM but may have clinical duties to complete after handoff.
    • The ADMIT senior resident will be back up for the interns on the protected teams if a patient on their team becomes unstable or urgent questions arise.
  • Protected: Your team can accept up to 3 overflows. You will not receive any new admissions during the day. On this day, the senior resident can leave at 5:00pm if patients are stable and clinical duties are near completion.
    • As a note, we always want you to be responsible for patients you know. If a patient you discharge or transfer to the MICU comes back to Gen Med at any point during your Gen Med month, they should come back to your team, regardless of what day it is. This includes protected days and weekends.

What about weekends?

All teams (intern or resident) can accept 3 overflows during the weekend.

  • Resident Days Off (Saturday or Sunday): This is the day in which the resident of the team is off and therefore the interns will receive morning hand off from the night residents at 7am and can receive overflow admissions based on team census. Each intern can admit up to 2 admissions no later than 3:00pm. Night float resident will take evening handoff at 5:00pm, allowing all interns to leave by 5pm on a weekend day.
  • Intern Days Off (Saturday or Sunday):  The senior will receive morning hand off from the night residents at 7am. Team begins work rounds with attending. Resident can admit up to 3 admissions, no later than 5:00pm. Night float resident will take evening handoff at 6:30pm.
  • One Resident On/One Intern Off(Saturday or Sunday):  The team will receive morning hand off from the night residents at 7am.  Intern can admit up to 2 admissions no later than 3:00 PM. Resident can admit up to 2 admissions, no later than 5:00pm. The intern should sign out to the SAR at 5pm and go home.Night float resident will take evening handoff at 6:30pm.

Which notes am I responsible for?

  • H+Ps: Admitting a patient includes completing the entire electronic admission database, entering admission orders, and updating the electronic patient list.  The H&P database form must be complete before you transition care to another provider
    • Overflow (or rollover) admissions are patients that were admitted by an upper level night resident with completed orders and admission or transfer H&P written by the overnight resident
  • Daily progress notes: Timely, focused, succinct yet appropriately detailed documentation of your patient encounters and plans is essential.
  • Discharge Summaries:
    • Interns are responsible for discharge summaries on patients hospitalized for 3 days or less. Senior residents are responsible for other summaries.
    • Discharge summaries ideally will be completed on the same day as the patient’s discharge, however if this is not possible, the summary must be completed within 24 hours of discharge.

Where can I find backup?

You are never alone and help is always available!  So never be afraid to ask for help, it is not a sign of weakness, rather it is a sign of wisdom.  Often, it is better to ask for help early if you are uncomfortable.  The Gen Med back-up team includes:

  • Supervising team resident or nighttime resident
  • Team Attending physician
  • Admit team resident on protected day after 5:00pm
  • RRT Team Hospitalist (970-7409)
  • Hospital Medicine Lead Attending (970-7777)
  • MICU consult resident and MICU fellow
  • Assistant Chief Resident (681-6529) and Chief Resident (681-5918)

If a patient has unstable vital signs, an acute change in mental status, or a clinical deterioration that is concerning, you can call an RRT at any time and the RRT team will always be happy to help. The purpose of this system is to call nurses (including the charge nurse from the CCU), respiratory therapists, and operations administrators to the patient’s bedside for assistance in patient management and triage.  An RRT can be called by any nurse, intern, resident, respiratory therapist, etc. any time they feel they need extra support. It is not a sign of weakness or poor medical care if an RRT is called on your patient. It is simply a recognition that the patient or any member of care team needs additional support. You must go to all RRTs called for your patients. If a patient needs immediate transfer to the ICU, the RRT is the best way to make this happen with the help of the OA.

What reports should I plan to attend?

PGY1

  1. Intern Report:  Interns will attend intern report every Wednesday and Thursday at 3:00 pm in the Medicine Resident’s Library.  All interns are expected to attend. Please ensure to leave your pager with your senior resident. This report will focus on case presentations as well as core intern topics and give interns the opportunity to discuss cases from their services with their colleagues, the chief resident, and the faculty member in attendance.  Typically, presentations are on Wednesdays and core topic discussions by faculty are on Thursdays. The Assistant Chief Resident will send a schedule out prior to the rotation that will list which interns are scheduled to present.  Presentations are informal and do not require preparation of materials (i.e. power points, handouts) before time, so please don’t feel compelled to do this. Students are welcome to this conference so please be sure to bring them along with you!
  2. Chair’s Conference: Fridays at 12:15 with Dr. Cooney for the entire program.

 

PG3 and Above

  1. Resident Report, Monday through Thursday 1:15- 2:00 pm
    1. Management Discussion: Tuesdays with Govert/Dr. Rogers, Wednesdays with Dr. Zaas, and may be scheduled on other days based on case selected, faculty discussant and resident preference. The goal is to focus on management of general medicine inpatient scenarios and to hone critical management decision-making skills. The case should always be about a patient currently on your general medicine service
    2. Cases: Typically Mondays with McNeill, Dr. Arcasoy, Dr. Hargett, or the Stead Attendings. The usual interactive case presentation, the case should be a patient on your service if possible.
    3. Quality Improvement – Thursday with the QI Chief and the Hospitalist Faculty Presenter should bring a case that demonstrates an adverse event, near miss, etc. that the group will analyze for possible quality improvement /patient safety opportunities. Optimal cases will focus on failures and/or interventions at the systems based level. In other words, how can the system be changed to prevent from happening again?
  1. Chair’s Conference: Fridays at 12:15 with Dr. Cooney for the entire program.

Teams are also encouraged to attend Medicine Grand Rounds from 8-9 am on Fridays unless an acutely ill patient needs your bedside attention.

Where can I find more information about Duke Gen Med?

Please feel free to reach out to your Chief or Rotation Director at any time. 

More information can be found in the following tip sheets: