S L I D E 1

Internal Medicine Clerkship

Orientation

S L I D E 2

Outline

• Welcome• Structure of inpatient medicine service at YNHH• Clerkship Goals and Expectations- website• Responsibilities

– As a team member– As a student group

• Didactics• Portfolio• Assessment

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Identify your own goals!

S L I D E 4

Structure of Inpatient Medicine

YNHH Hospitalist

(nonteaching)

YSM FacultyYNHH IM Residency(teaching)

YNHHWHVAMC

YSM facultyYPC

Residency(teaching)

SRC

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Goals and Expectations

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Responsibilities w Team

• Med 1• Perform full H and P on at least one pt per call (average 7-8 per

block)• Submit detailed write up including H and P, labs,

assess/differential/plan within 24 hours attg to review and give comments. DO NOT PUT IN EMR until your attg thinks they are ready

• Read up on major topics represented by your patients• Follow patient progress and present this on daily work rounds;

write f/u notes in EMR and have them co-signed• Assist intern in other chores as needed for your patient (and

other patients if you have time)• Attend all team education activities • Meet with attending twice a week- practice presenting, go to

bedside, review write-ups, etc• Start to do procedures with supervision (LP, thoracentesis,

paracentesis)• Present at attending rounds, if asked.• Get midway feedback from attending; document on pertinent

form supplied. ( in packet and available on line)

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• Med 2 • Perform full H and P on at least two pts per q 4 call (average 13-

15 per block)• Submit detailed write up including H and P, labs,

assess/differential/plan by next day attg to review and give comments. DO NOT PUT IN EMR until your attg thinks they are ready

• Rest as per med 1

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Expectations apart from the team

• Come to core curriculum activities- see schedule for each site

• Prepare portfolio (see check list)• 1 attending-reviewed H and Pà submit electronically to Angie

Perrotto• Patient Log (see packet for suggested format; no identifiers used

e.g. don’t use patient name or DOB)• Teaching presentation – something you may have put together for

attending or student faculty rounds• MiniCEX- structured observation of H and P (all or part) by attg.• Complete Exam Master during last week of Med II • Evaluate clerkship (med hub )

All medical students from all sites must attend last Friday of each month sessions on 1) Delivering Bad news (end of Med I) and 2) Palliative Care workshop (end of Med)

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Clerkship Checklist

S L I D E 10

Didactics- sample

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Evaluation

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Presenting- new patients

• Set the STAGE

– Style: Team dependent- medicine presented here

– Timing: usually 7-10 minutes. (depending upon rotation)

– Audience: attendings, residents, interns, nurses, pharmacists, respiratory therapists +/- PATIENTS/FAMILIES.

– Goals: Convey story of HPI, pertinent findings, summary statement, brief ddx and plan. Create interest in patient!

– Elicit feedback- after rounds/that day

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Oral Presentation Outline- TOTAL 5 minutes

• CC- one or two key complaints

• HPI- (2 min)– start w pertinent identifiers– Usually start w when current event/illness began– Brief 1-2 paragraph story– End with pertinent +/- elements from past hx, social hx, fam

hx, ROS

• PMH- very brief – no detail unless asked

• Meds- group by indication• Allergies, FH, SH, ROS- only striking issues should be

mentioned (15-30 sec)

• Exam- ALWAYS start w vitals- aim to interpret when

possible; do NOT rattle off entire physical exam (60-75

sec)

30-45 sec

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Outline- cont

• Data- only report pertinent positive/neg and with interpretation (30 sec)

• Summary statement- Two to three sentences that put cardinal features of history, physical exam findings, and lab data together– Tip: After write up identify 10 cardinal features narrow to 3-

4=main problem

• Assessment/Plan- (1-2 min)– Identify main problem: State leading diagnosis– Evidence supporting– Other possibilities (3-4 more in ddx)– Evidence against– Plan- BY PROBLEM: diagnostic studies/therapeutic plan

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Specialty Specific

• Ob-Gyn- always note gravidity/parity; LMP

• ED- Source of usual medical care; “iatrogenic stimulus”

• Surgery- VERY truncated but concise presentation style

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Pitfalls and Solutions

#1. Presentation too long

THE CAUSE

• Fear of not presenting all data

• Can’t prioritize information

• Too much unnecessary commentary throughout

THE TREATMENT

• 60% rule

• Emphasize relevance- packing for a trip

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Pitfalls and Solutions

#2. Use of distracting Expressions

THE CAUSE

• Student can’t think and talk simultaneously

• Concerned he/she will be interrupted if period of silence

THE TREATMENT

• 60% rule

• Tell a story; practice ahead of time

• Attending should allow no interruptions

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Pitfalls and solutions

#3 Lack of eye contact/boring THE CAUSE

• Discomfort• Dependence on notes

THE TREATMENT• Practice in the mirror; “note card taper”

#4 Nervousness THE CAUSE

• Early in year; “imposter syndrome”

THE TREATMENT• Remember everyone else on team has been doing

this longer• Visualize success!

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Example

• Read Written presentation

• Watch Oral Presentation

• Feedback

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Final Tips

• Include only the most essential facts; but be ready to answer ANY questions about all aspects of your patient.

• Keep your presentation lively.• Do not read the presentation!• Expect your listeners to ask questions.• Follow the order of the written case report.• Keep in mind the limitation of your listeners.• Beware of jumping back and forth between descriptions of

separate problems.• Use the presentation to build your case.• Your reasoning process should help the listener consider a

differential diagnosis.• Present the patient as well as the illness.

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Presenting- follow up patients

• Set the STAGE

– Style: (remember to check with your team) but always problem based.

– Timing: usually 3-4 minutes.

– Audience: attendings, residents, interns, nurses, pharmacists, respiratory therapists and PATIENTS/FAMILIES.

– Goals: updates on patient’s condition, diagnostic testing, plans for the day and progress toward discharge.

– Elicit feedback.

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What information does the follow-up presentation contain?

1. A brief preamble to remind the team who the patient is and why the patient is admitted to the hospital.

2. A summary of the patient’s current status and overnight issues in the patient’s (or caregiver’s) words.

3. A logical summary of interpreted objective data (vital signs, physical examination findings, and diagnostic test results). These are best presented by problem by problem but CHECK WITH YOUR TEAM.

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Tips for pre-rounding

• Talk to the patient and caregivers to find out what happened over night.

• Talk to the nurses to hear what happened overnight. If you can listen to night to day nurse sign out, do so!

• Check the orders in the computer. Was a blood culture ordered overnight? Why?

• Review the patient’s vitals, daily weight, ins and outs, look for trends and interpret the values. Same for labs and radiographic studies.

• Perform a focus exam and remember that pertinent negatives are as important as pertinent positives.

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Pitfalls and Solutions

#1. Recapitulation of the full presentation.

THE CAUSE

• Fear of not presenting all data

• There is one person in the room who missed your full

presentation yesterday

• Poor preparation

THE TREATMENT

• Put the admission note away.

• Prepare your introductory/summary statement in

advance.

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Pitfalls and Solutions

#2. Presenting patient data without interpreting it.

THE CAUSE

• The temptation to read back a list of vitals or lab values

• The worry that you will interpret incorrectly

THE TREATMENT

• Get in early enough to collect data AND read about it

• Review all of the data as you collect it and interpret it

ahead of time

• Never read off vitals and labs unless asked specifically to

do so

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Pitfalls and solutions

#3 Omitting progress toward discharge THE CAUSE

• Losing sight of the big picture in the face of details

THE TREATMENT• Force yourself to go through the exercise of

thinking about discharge and what needs to happen with your patient to get there

• Prepare ahead of time

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Pitfalls and solutions

• #4 Having the intern know things that you don’t.

THE CAUSE• The interns are around when you are not.

THE TREATMENT• Know where to look: check the chart and CHECK

THE ORDERS.• Ask the nurses.• Don’t count exclusively on the patient/family to tell

you what you missed overnight.

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Final tips

• Make sure that YOU understand all of the information that you present before you present it.

• Leave extra time for yourself to read if this is what you need to do to understand the data you hold.

• If you don’t know the answer to a question, the appropriate answer is “I don’t know.”

• Never say you checked something that you didn’t.• Let your personality come through as you present.