Art of ID Consultation ID Fellowship Orientation

1. Art of ID ConsultationID Fellowship Orientation Paul Pottinger, MD, DTM&H July 1, 2011

2. OBJECTIVES • Nuts & Bolts for: • UW Inpatient Consult Services • UW Outpatient ID Clinic • General principles for consultation

3. CAVEATS • You already know this…. • You can do this…. • Yes it’s fun (“It’s Good to be the Fellow”)

4. ID Fellowship: Mission To create successful physician scientists in academic infectious diseases • Outstanding clinical training • Unmatched research opportunities

5. ID Fellowship: Structure • Year 1: Clinical ID Training • Inpatient consultations at 4 hospitals

6. ID Fellowship: Structure • Year 1: Clinical ID Training • Inpatient consultations at 4 hospitals • University of Washington Medical Center • General infectious diseases • Solid organ transplant ID • Oncology and stem cell transplant ID • MEDCON ID telephone consults 2 weekends SCCA / FHCRC UWMC

7. ID Fellowship: Structure • Year 1: Clinical ID Training • Inpatient consultations at 4 hospitals • University of Washington Medical Center • General infectious diseases • Solid organ transplant ID • Oncology and stem cell transplant ID • Harborview Medical Center

8. Pharmacy Support Rupali Jain, PharmD UWMC 598-4416 rupali@uw.edu Jeannie Chan, PharmD HMC 744-5854 jdchan@uw.edu

9. ID Fellowship: Structure • Year 1: Clinical ID Training • Inpatient consultations at 4 hospitals • University of Washington Medical Center • General infectious diseases • Solid organ transplant ID • Oncology and stem cell transplant ID • Harborview Medical Center • Puget Sound VA WWAMI

10. MEDCON • Docs in WWAMI region can call you 24 / 7…. • Free “educational” service • They greatly appreciate your help, and will manage pts as you recommend • Please be nice… even if they don’t deserve it! • Please keep database updated.

11. MEDCON • Docs in WWAMI region can call you 24 / 7…. • VA fellow takes these calls when on duty. • On days off, UW ID fellow takes over. • Please run cases by UW General ID attending by phone if ANY doubt whatsoever! Calls tend to fall off over year… but calling is encouraged!

12. Clinical Microbiology Lab

13. ID Fellowship: Structure • Year 1: Clinical ID Training • Inpatient consultations at 4 hospitals • University of Washington Medical Center • General infectious diseases • Solid organ transplant ID • Oncology and stem cell transplant ID • Harborview Medical Center • Puget Sound VA • Seattle Children’s Hospital

14. ID Fellowship: Structure • Year 1: Clinical ID Training • Inpatient consultations at 4 hospitals • University of Washington Medical Center • General infectious diseases • Solid organ transplant ID • Oncology and stem cell transplant ID • Harborview Medical Center • Puget Sound VA • Seattle Children’s Hospital • Outpatient continuity general ID clinics

15. ID Fellowship: Structure • Additional Clinic Opportunities • Hepatitis • STD • TB • Hansen’s • VA • Travel • Overseas HIV • Year 1: Clinical ID Training • Inpatient consultations at 4 hospitals • University of Washington Medical Center • General infectious diseases • Solid organ transplant ID • Oncology and stem cell transplant ID • Harborview Medical Center • Puget Sound VA • Seattle Children’s Hospital • Outpatient continuity general ID clinic • Years 2 & 3: • Continuity HIV clinic

16. ID Fellowship: Didactics • Early July of first year: 2 week introduction to clinical infectious diseases, with hands on microbiology course. • Late July of second year: Principles of STDs training course, with lectures on HIV and STDs, and focus on research practices. • ID board review and lectures for fellows every Wednesday throughout the year.

17. Citywide ID Clinical Conference • Weekly case conferences on Wednesday afternoons provide an opportunity for fellows to present interesting cases, practice presentation skills, and get input from other ID practitioners on management. • Different ID services rotate presenting cases: UW general ID, UW SOT, SCCA (oncology), Harborview ID, VA ID, Children’s ID. • Didactic sessions for fellows precede or follow the clinical conference .

18. ID Consultant’s Dual Roles

19. “Mandatory” Consults? • HIV pts at HMC seen by HIV service • Scary in micro rounds (Certain MDRO’s, multiple + BCx’s, etc. • Review case • If care or plan sketchy, contact team and strongly offer consultation

20. Think Like a Consultant • Whose Patient is this? • Name, Rank, & Contact info for caller • Attending & Service • What is the question? • Diagnosis? • Management? • Mediation?

21. Think Like a Consultant • Urgency? • Often fine to give preliminary rec’s and staff following day • “My attending wants this staffed right now:” Please let your attending know, regardless of time of day

22. Think Like a Consultant • Please Remind Caller: • In order to see the pt, we need a written request in ORCA: “Consulting ID for assistance with management of X”

23. Think Like a Consultant • Curbside? • Generally NOT recommended… but it happens anyhow • ALWAYS offer to see the patient • If you have to ask > 2 questions, it’s probably best to strongly RECOMMEND a consult

24. Think Like a Consultant Is this patient infected? If so, does the infection explain the syndrome? What are the host & bug factors here?

25. This is Your Service! “It’s good to be the fellow” Use your own style for teaching Attending always there to back you up

26. Dx Recommendations • Consider Implications of Testing • Want a biopsy or BAL? Instead of demanding them, suggest consultation with performing service to get their input… if they say no, your attending will make a call.

27. Dx Work • Micro Labs extremely helpful • Notify them of tough cases before micro rounds M/W/F 11-12 • You also have access 24/7… use it! • Seek Primary Data • Radiology, Path, OR… go where the data are!

28. Abx Recommendations • Drug Name • Generic please • Route • Acknowledge access issues • Dose • May vary by indication • Renal or hepatic adjustments • Drug interactions • Prolonged infusions may be helpful

29. Abx Recommendations • Duration • Stop date / criteria • Monitoring Labs • Troughs, CBC, CMP, ESR, etc • Guidelines at www.uwantibiotics.com • Followup • IV abx: UW ID clinic within 2 weeks when possible

31. RN Support at UWMC ID Clinic Josette Pierre-Antoine, RN Please notify them with home IV plans…. 598-8788 or 598-7750 or id_clinic@uw.edu Jeanne Wolf, RN

32. Orders for Inpatients • Generally we do NOT write them. • Exceptions: • Direct request from primary team by phone (usually orthopedics) • Exotic micro lab maneuvers • Outpatient IV abx for 4-S patients

33. Communication Pearls: Notes • Initial Consults: • “We have been consulted by Dr. X of service Y to assist in the management of problem Z.” • ORCA templates saves time.

34. Communication Pearls: Notes • Initial Consults: • MS may write, but must forward to you; only their PMH, SH, FH counts! • MD (you or resident) must write note; please oh please include ROS: “all negative except as noted in HPI” • All notes then forwarded to attending for signature (not just CC’d).

35. Communication Pearls: Notes • Initial Consults: • You may dictate new SOT consults, and new UWMC consults on busy days (e.g. clinic days). • IF YOU DICTATE: • 1) Call in your recs, and • 2) Write a summary of your rec’s

36. Communication Pearls: Notes • Followup Notes: • Please write notes whenever clinical issues arise or a change in recommendations are made. • We are emphasizing time-based billing… please stay tuned! • Please discuss note plan with attending each day (who needs a note?)

37. Communication Pearls: MD’s • Get notes done ASAP, but call with rec’s before writing • If they don’t like your rec’s…. • Acknowledge primary team’s expertise • Frame rec’s with evidence & likely odds of success or failure • Recognize ideal vs. practical approaches, and offer alternatives

38. Communication Pearls: MD’s • “Honey vs. Vinegar” • A teaching opportunity • Take the high road (even 4PM Friday) • No chart wars EVER • Engage the attendings (yours & theirs) Keep “off topic” rec’s out of writing (but DO discuss verbally)

39. Communication Pearls: Pt’s • You are here at request of Dr. X for assistance with problem Y. • Be honest, but defer to primary team (no splitting!) • Remember, your classmate will probably inherit this pt in f/u.

40. Communication Pearls: • What have you liked working with fellows? • What has cheesed you off?

41. The Obvious • Never fake it. • ID attendings want to hear from you early & often, especially early in the year, or any time with urgent issues. • Think about what you did and did NOT like from consultants as the primary doc.