PGY-3 to Be Retreat

1. PGY-3 to Be Retreat June 11, 2013 Sumit Bose Crystal Lantz Kamal Shemisa Claire Sullivan NavinVij

2. Congrats!!! You are entering your last year of Internal Medicine residency ! “Don’t count the days, make the days count” -Muhammad Ali

3. Overview 5:30-6                 Dinner 6-7:30          Changes for next year -CICU schedule -New Ambulatory Model                              Patient Safety/Quality Externship Clerkship issues                              Miscellaneous administrative issues Boards Noon conferences Board review series License, jobs/procedures Senior talks                              Dictations                              Professionalism/RECC                              In-training exam                              Weekend coverage/handoffs                              Reading elective 7:30 - 8:00        DACR/NACR Orientation Gen Med Consults 8-8:30                 Questions

4. Changes for Next Year • New ambulatory model • New CICU schedule

5. Current Structure of the CICU Team * Rounds with CICU attending start at 8 AM. Heart failure rounds (separate attending) usually start at 10 AM. Attendings rotate in one week blocks 4 residents do overnight call every fourth night May have rotators from Emergency Dept. as well No nightfloat system Sometimes admit MICU overflow patients Cardiology fellow not in-house at night (though staff admissions with fellow on the phone and if patients sick, fellow comes in) Drawbacks to this system: only one resident at night, can be challenging to leave post-call by 11 AM if busy night

6. The New CICU for Interns *2 interns scheduled in the CICU: -Day intern: works 7 AM-7 PM. May follow/admit one to two patients under supervision of senior resident. -Night intern: works 7 PM-7 AM. Helps with cross-cover, gains valuable night ICU experience including procedures, and possibly allows for on-call resident to take a quick nap. *Interns will do one week of nights and one week of days during two week rotation *Both interns have Sunday off (accommodate switch days and transition from nights to days)

7. The New CICU for Senior Residents • 5 senior residents • On-call • Post-call • Regular day • Day call • Pre-call • Days off will be Pre-call day between Thursday and Monday • Signout should occur after evening fellow rounds (4-5 PM) to overnight resident

8. The New CICU for Senior Residents Every fifth night is overnight call, but resident does not come in until 4 PM that day. Resident then presents the following morning on rounds and leaves hopefully by noon (20 hour call), with wiggle room to prevent duty hour violations. After post-call day, resident has regular day (til 5 PM). No admissions this day. After regular day is day call where resident is responsible for admissions from 7 AM- 4 PM (when overnight resident arrives). Day call resident works until 7 PM. After day call is pre-call day without admissions.

10. The Current State of Continuity Clinic & Ambulatory Blocks Weekly continuity clinic during inpatient wards, electives, and ambulatory blocks Two 1-month Ambulatory Blocks comprised of didactics, medicine subspecialty clinics, VA UCC, Psych CL, and continuity clinic

11. New Ambulatory Model • Four 2-week Ambulatory Blocks • Morning VA subspecialty clinics • For 1 week you will have 5 consecutive afternoons of Clinic *Green Road 5 clinic sessions over 2 weeks including morning sessions *Residents must turn in sessions to Amb Chief • For the other week you will have 5 afternoons of VA UCC and subspecialty clinics • 2 Clinics during Electives • PGY2 = 8weeks • PGY3 = 14 weeks

12. Pros of New Ambulatory Model • No continuity clinic during Wards!!! • Precept with different attendings each day of week to get different clinical perspectives • Improving the outpatient experience of our program and limiting extended periods of time on wards • Continuity with patient panel: guaranteed clinic q8weeks for chronic disease management (CDM) and preventative health

13. New Ambulatory Model • The ambulatory schedule isfixed • Ambulatory blocks cannot be swapped • Elective rotations cannot be switched

14. Summary… • The new ambulatory model is proposed to decrease stress of balancing inpatient and continuity clinic responsibilities • Opportunity to improve continuitywith panel of patients and develop QI projects • Greater autonomy • Increased engagement in the clinic environment • Resident feedback throughout the year is strongly encouraged and leads to continued improvements in your ambulatory rotation!

15. Fellowship Timeline • Applications should be in by July 1; ERAS token can be requested June 18th • Have faculty working on your letters of recommendation • Another meeting with KBA June 18th at 6 PM • July 15, 2013: programs begin downloading applications • Deadline for completed application varies but is as early as July 31st; check with program and be prepared • August - November 2013: interviews conducted • First Wednesday in December 2013: Match results available • *KBA will perform mock interviews upon request

16. REMINDER: Residency Reading List *Primary care and subspecialty specific *Both landmark and review articles *Case Medicine website  Residents  Education  Residency Reading list

17. Research Day • Research poster is a requirement for those who take two or more weeks as a research elective • Can present subspecialty research done during electives • Establish connections with a mentor • Chief residents are available to help find mentors and research opportunities • Research Day is usually in May

18. Transition Dates • New intern orientation 6/13/2013 • Last day of work for current PGY-1’s 6/23/13 • Transition week (Block 0) starts 6/24/13 • First day as PGY3 is 7/1/13

19. Team Caps UH ward teams cap at 10 patients per intern except for the Seidman teams which cap at 8 VA ward teams cap at 8 patients per intern No short call on weekends No shorts if intern has 8 patients (but AI/intern pair with 2 seniors can go to 10 patients on short day) Intern + AI @ VA = 10; AI+AI paired together =12 (if 2 seniors, 10 when one senior) Intern + AI @ UH = 12 when 2 seniors; 10 when 1 senior

20. Duty Hours • Long: 3 patients until 7:00 stay until 9:00 • Medium: 2 patients until 4:00 stay until 7:00 • Short: 2 patients until 12:00 UH and 1:00 VA • MICU transfer/NF only at UH, can be new patients at the VA • No short patients on clinic days or if intern already has 8 patients ANESTHESIA INTERNS MUST LEAVE BY 9 PM IF ON CALL!!! • Senior Resident: • On call residents stays until 9:00 • Staff patients available to be seen anywhere in the hospital until 4:00 (Monday-Sunday) • Weekend team covering resident staffs until at least 1:00PM

21. Staffing • On call senior resident must stay till 9:00 PM must leave by 11:00 PM • Starting Block 4-5 you will be staffing orphan interns on other teams as well when on call • See and examine EVERY patient • No staffing note required for ICU transfers • Focused notes by the senior resident with detailed plan • See PGY1 note for full H&P. Briefly, pt is a … • Helpful to new interns: • Antibiotic doses • Description of imaging- With contrast? Without? • Medications to continue, medications to discontinue • CODE STATUS and Allergies

22. Staffing On call resident should notify the nightfloat resident of tenuous patients Be proactive about staffing patients ***Please note, even if you are not on call, you must staff all patients who are available to be seen if they are assigned to your team before 4 pm (even on the weekend) Weekend coverage resident should staff all patients until 1pm

23. Patient Safety and Quality Improvement • * Introduction to quality improvement during DACR rotation • Hand-washing audits • CLIPPS • Quality Assurance meetings • Write-up cases for Medicine QA • Attend ED/IM QA • Attend Quality Patient Safety Committee meetings • Mortality review, PASS reports, and Risk Management meetings

24. Guidelines for Resident Quality Improvement Project • Each PGY3 resident identifies and completes a quality improvement project as one of the requirements by ACGME • Work in groups of ideally 3 (no less than 2, no more than 4) • Work with one of the chief medical residents and quality center to develop project ideas and aid with data collection • Start by identifying a quality issue, collect background data, design an intervention, and collect post intervention data (Heidi and Meghan in the quality center are good resources) • Present quality poster at Research Day

25. Timeline for QI Project • General Timeline: • Mid-August to early October: define objectives, collect background information, plan an intervention • Mid-October: schedule a meeting with project chief to review objectives and plan • Late October through January: implement your intervention • January through February : collect and analyze post-intervention data and schedule meeting with project chief to discuss results • March through April: write-up project and finalize poster; submit poster for printing to be presented at Research Day

26. To Admit vs. Observe All low risk chest pain, sickle cell pain crisis, gastroenteritis in a young patient, syncope is an observation patient Please follow ER description on blue sheet Instead of admission order, click the “Place in Observation” box Please keep your UH care team lists up-to date! Quality center is tracking admissions by diagnosis Obs vs admit is related to clinical criteria and not expected LOS!

27. Professionalism

28. Professionalism: Attire Men Shirts and ties Women Professional Keep white coats clean No denim Do not show up to Morning Report looking sloppy

29. Professionalism: Absences • Referral to RECC • If you have to call in sick > 1 day, you will need a doctor’s note from the Bolwell Family Practice clinic • You will be able to get a same-day appointment • If you are sick for > 2 days and do not have a doctor’s note, you will be assigned extra weekend coverage and/or weekend jeopardy • Call-offs: You must PAGE 31529 the Ambulatory Chief • DO NOT EMAIL • DO NOT TEXT PAGE • DO NOT CALL THE CELL PHONE OF THE CHIEF YOU KNOW

30. Professionalism: Electives While on elective, you are expected to attend all Grand Rounds and M&M’s Please note that when you are on elective, you are back up jeopardy!! You are expected to have your pager turned-on throughout your elective rotation If you are going out of town for the weekend, please notify the ambulatory chief prior to leaving Elective should not be treated as vacation Please email Barb 2 weeks prior to starting your electives

31. Professionalism: Reading Electives Residents on reading elective are expected to attend morning reports and journal clubs at the VA Must attend Grand Rounds at UH Your pager is expected to be turned on and on you during the entire two weeks of elective All reading electives must be approved by KBA For PGY2s it can only be used to study/take step 3 Please note that when you are on elective, you are back up jeopardy!!!

32. Professionalism: Conference Attendance Be on time! Noon conference: UH: Mon-Wed-Thurs VA: Mon-Thurs-Fri Grand Rounds on Tuesday: UH & VA M&M Fridays @UH, Wednesdays @VA

33. Professionalism: Ambulatory Conference Attendance • Ambulatory conference attendance is mandatory and tardiness and absences are extremely disrespectful to our educators • Late Policy will be strictly enforced: • Sign-in sheet will be available until 8:05AM • At your 2nd instance of being late, extra weekend coverage will be assigned • Any MISSED conferences without prior approval by the ambulatory chief will result in weekend coverage

34. Professionalism: Discharge Summaries Do them the day of discharge Do them for your intern Do them for your friends Do them for your patients Weekend coverage is responsible for discharge summary

35. Coverage and Schedule Switches All coverage arrangements and schedule switches must be approved by the Ambulatory chief Switches must be arranged before 1 week of rotation starting Weekend Coverage switches before 48 hours of day NO SWITCHING AMBULATORY OR ELECTIVE BLOCKS!!!

36. Talks • Senior Grand Rounds -Start in late August -Dr. Mourad is the APD in charge. -Email learning objectives to assigned faculty mentor and ambulatory chief resident two weeks prior to talk -Evaluation process will be in place -Should be evidence-based • Research -All residents doing away and research electives must present at Research Day

37. BOARDS!!! Register by December Plan ahead…costs about $1,365 (more if you sign up late) Noon Conferences to include more board prep sessions Intense June weeklong session for board review Can use ITE exam results to help guide studying In-service Exam Dates are Oct 4 – 19th Remember: no Moonlighting if ITE < 30% of your peers

38. Medical License Remember to keep your BLS/ACLS updated Must have Step 3 results prior to license application Start FCVS by December ($430) State licensing ($335) can often take 5-6 months. DEA license is much quicker but more expensive ($551) Plan ahead!!!

39. VACR Perform medicine consults Be available to help out ward teams as needed Prepare EBM lecture on a topic of choice for morning report Attend all morning reports One Saturday 24 hour VA MICU coverage

40. DACR / NACR:Your education in systems-based practice

41. The NACR as Ombudsman Distribute admissions to teams on call in AM Enforce geographic localization Run codes See medicine consults at night (Ortho co-management) Cover emergencies in CF patients on RBC 7/Lakeside and Hanna House Cover flex patients at night Find out intern census from nightfloat interns for each team Admit BMT and Transplant Medicine patients along with NF (must inform BMT fellow and Transplant attending) Transplants within the past year should be admitted to surgery *ombudsman – one who investigates complaints and mediates fair settlements, especially between aggrieved parties such as consumers or students and an institution or organization

42. “The Book” as it should be… Reality

43. “The Book” according to the ED… How the ER views the world

44. Appropriate Service? Is the patient stable for the floor? No MICU/CICU/NSU/SICU Yes Have ED call FM (30116). If capped, then ED calls NACR back with admission. PCP an FP? Yes Yes Appropriate for FP? No FM capped !?&*#@! Appropriate for medicine? Talk to ER, if attending from appropriate service does not accept, “Medicine will happily accept the patient” No Stroke, SBO, femur fracture, etc Yes

45. Appropriate Service? Look up the patient in Portal and EMR before assigning Patient’s PCP – Family practice patient? Private patient (list of attendings available)? Physician Portal (summary page, physicians) Previous discharge summaries EMR patient info clinical summary (visit history) Ask the patient!

49. Hints as NACR Be proactive – keep an eye on the ED board Admissions require bed assignment Figure out PCP (verify with patient if possible) Quick visit history/portal search for past visits Assign patient to NF or house doc (consider team in the morning for geographic localization) Call admitting with location and ER with pager (or place it in EMR)

50. Types of Patients Private (PCP will attend) – Coviello, Schnall, D. Brown, DeJoseph, Junglas, King, Tomm, Locke ER must call private attendings; but if the patient is on the floor and the ER did not call, it is the DACR/NACR responsibility Assign to med NPs (private spots) during the day! If no spots, then flex versus team (Eckel, Carpenter, or Gen Med; not Ratnoff/Weisman/Hellerstein) D. Brown must be flex (not NP) Staff – NPs (no procedures), hospitalists (few social issues low complexity), general medicine teams *Non-cardiology patients needing telemetry can go to Hellerstein and hospitalists (not med NP)