Intern Survival Guide the UNC Department of Medicine

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Intern Survival Guide the UNC Department of Medicine Powered By Docstoc
					                                  University of North Carolina
                                    Department of Medicine
                              Intern Information Guide 2011-2012

        On behalf of the Department of Medicine, we would like to welcome the 2011-2012
Intern Class to UNC Hospitals. We have assembled this guide to assist you in transitioning to
internship and “learning the ropes” of a new hospital and a new Department of Medicine. UNC
is committed to fostering a healthy learning environment where we provide service to patients
regardless of financial background, educate future leading physicians, pursue scholarly work
and maintain the “UNC way” in all aspects of practice. We hope that this guide will start you off
running. Please know that we are always available to help you.

Sincerely,
Kristen Amann, MD Ambulatory Chief Resident, UNC Hospitals
kamann@unch.unc.edu
Phone: 919-843-6942
Pager: 216-1591

Britni Hebert, MD Chief Resident, UNC Hospitals
bhebert@unch.unc.edu
Phone: 919-843-8074
Pager: 216-3513

Paul Johnson, MD Chief Resident, UNC Hospitals
pmjohnso@unch.unc.edu
Phone: 919-843-8073
Pager: 216-6483

Jack Kuritzky, MD Chief Resident, Wake Medical Center
jkuritzk@unch.unc.edu
Phone: 919-350-7326
Pager: 216-2568
Contents
1. Service
       a. Communication
                1. Email
                2. Pagers
                3. Important Numbers
       b. Computer Programs
       c. The Wards
                1. Structure
                2. Call Schedule
                3. Back up coverage/supervision
                4. Daily Routine, Responsibilities / Tips for efficiency
       d. MICU
       e. CCU
       f. Ancillaries
       g. Clinic
2. Education
       a. Online Curriculum
       b. Conferences
       c. Teaching Rounds
       d. Library
       e. Online Resources
3. Scholarly Work
       a. Subspecialty Contacts
       b. Department Information
       c. Clinic Quality Improvement
4. Personal Health/Information/Misc
       a. Important personal work info
       b. Cafeterias and Freedom Pay
       c. Call Rooms
       d. Employee Discounts
       e. Gyms / Intramurals
Service
1. Communication
      a. Email:      You must use your UNCH email account for all work/hospital
      related issues. This is mandatory. Your email limit is 40 MB, which goes fast so be
      aware of the sizes of attachments when sending to co-residents. No one likes to be
      locked out of their email. Address: webmail@unch.unc.edu
      b. Phones: The three prefixes at UNC are 966-, 843- and 445- (the latter being the
      wireless phones). When inside the hospital you only need to dial the last 5 digits (6-xxxx
      for 966-xxxx, etc). If there are extra nurses’ phones, then they can be checked out at
      the HUC’s desk to have for calling consults on rounds, etc. Do NOT take these home.
      They are extremely expensive and work only on the UNC intranet.
              Important Numbers (note all numbers can be found in Web Exchange)
              Chief Residents’ Office: 843-8074
              Hospital Operator: 6-4131 (966-4131)
              Clinic: patient line 966-1459 ; physician line 6-6989
              House Supervisor: 347-1922 (pager)- alert of level of care changes- floor to ICU)
              Hospital Bed Control 6-2041 - when admitting a patient from clinic
              Home Infusion Nurses: 123-4280 (alert of anyone that will need home IV meds
              at discharge)
              Inpatient Pharmacy: 6-2376
              Core Lab: 6-2361
              IT Help Desk: 6-5647
              KICKU numbers: 6-5644, 6-8587
      c. Pagers: We are each assigned an alpha pagerfor the duration of our residency.
      In addition to these pagers there are also team “virtual pagers”. Virtual pagers are not
      tied to a physical pager, but instead the numbers are signed over / forwarded to the
      appropriate covering resident at EVERY shift change.
      *Good Pager Etiquette:
             1. Do not page to pager. Always Include the callback number and who you are.
             3. Listen! for the return call. Be aware that some floors do not page overhead.
             These floors have designated direct lines for doctors (examples: 8BT and
                4ONC). If uncertain, ask your resident or the HUC (they sit at the front of
                every nurses’ station).
             4. The perfect page: “Re: pt name, MR#, reason for page, your name callback #
                * pager number”, ie: Re: Smith 5552424, upper GIB needs scope. - amann 6-
                3131 * 2163311.
      *How to use the pager system: Default to text pages through webexchange.
             1. For 216- pagers (ours) outside of the hospital. Dial 919-216-xxxx and enter
                your call back number.
             2. For 123 pagers (like the virtual pager numbers): call 919-966-PAGE and enter
                the pager number (ex. 123-1234) followed by your call back number. If you
                would like to include your pager number, enter your call back number
                followed by *, then your beeper number, then press #.
             3. Common practice is to tag pages with your pager. Ex. 38073*2163516
             4. Alpha pagers are quite useful and text paging is the norm. There are a couple
                ways to text page folks.
                       a. Webexchange / Web directory is a directory of most folks in the
                       hospital with pagers. This is the fastest way to page someone. It is found at
                       http://directory.unch.unc.edu only from within the hospital.
                       b. For paging just medicine-related personnel (residents, fellows) or to
                       page multiple residents at once from anywhere:
                       https://clipper.med.unc.edu/impager/pagerlist.cfm?dept=IM
                       This is available on the housestaff website:
                    http://medicine.med.unc.edu/education/internal-medicine-residency-program
               5. Signing out you pager – You should sign over team pagers at the beginning
                  and end of each shift.. To sign over the pager, dial 6-1100 and follow the
                  voice prompts.
       d. WebExchange:           Type "directory" into any internet explorer url box on
              campus and you will be forwarded. A few more words on this EXTREMELY
              helpful tool. You can of course use it to page just about anyone in the hospital.
              Also **** ANY desired number can usually be found on
              Web Exchange. Type in the "last name" box for just about anything (ie "6
              west", "pulmonary clinic", “bone reading room”, etc...). This can save you 100s of
              calls to the operator, where wait times can be several minutes.
2. Computers: Help with any passwords, dial 6-5647
      a. Webcis: Electronic medical record including all physician notes, medications,
      labs, xray reports, Rounds report, EKG reports, and links to CPOE and echart. This is
      where you will spend most of your time. It’s worth learning how to set up templates for
      your progress notes and H&Ps. Ask your residents for pointers, or how to subscribe to
      their templates to start.
      **** Resident Assistants: Subscribe to your team’s resident assistant page in
              Webcis on day1 (ask your resident how for your team). Place patients on this list
              when you need follow up scheduled, imaging or procedures scheduled
              outpatient, discharge summaries faxed to dialysis centers / PCPs, outside
              hospital records retrieved, etc. This is a wonderful resource.
      b. CPOE (computerized physician order entry): *** It is highly advisable that you
      change your CPOE password to one letter or number. This will save you so much time
      and hassle through the years as you will use it a LOT. To start with you will spend most
      of your time in the Dx/Tx tab and the Meds tab. Under Dx/Tx you’ll find any test and/or
      procedures. It is normal to get a little frustrated at first when searching for certain things.
      Try a couple then ask for help. As you get more comfortable, you can start using order
      sets. The two order sets that you will use early on are the basic admission and
      discharge order sets. These are found under the order set tab.
      c. E Chart: You can find the link on the left in Webcis. This contains vital signs,
      nursing notes, Physical, Occupational and Speech therapy notes.
      d. Amion: www.amion.com. ‘uncmed’ for the medicine schedule. ‘uncem’ for the
      ER schedule.
      e. Muse: “icon with the dog on it.” Online EKGs. Login with: unch\email name,
      password: email password
      f. IMPAX: High-res radiology studies. These programs are on the high-res viewing
      stations in the ICUs only (with the exception of radiology reading rooms). Otherwise
      images can be pulled up from links in webcis or you can use Webpacs
      (“pacs.unch.unc.edu” in the hospital)
       g. T-System:     ED patient record. You will use this throughout your residency even
      after you complete your ED rotation as you frequently get your patients from the ER.
3. The Wards
      a. Structure:
             A. Med A- Geriatrics [8 Bedtower]
             B. Med B- Nephrology [3 West]
             C. Med C/D- Cardiology/CCU [3 Anderson]
             D. Med E1- Hem/Onc [4 ONC]
             E. Med E2- Hem/Onc [4 ONC]
             F. Med G- Pulmonary [6 Bed Tower]
             G. Med K- Infectious Diseases [6 Bed Tower]
             H. Med U- General Medicine (Burnett) [8 Bed Tower]
             I. Med W- General Medicine (Welt) [8 Bed Tower]
             J. Med I- MICU [4 Bed Tower]
             K. Med M- General Medicine Float Service [6 West]
             K. Wake Medicine--Directions to Wake Medical Center and first day instructions
             can be downloaded from our website
             (http://medicine.med.unc.edu/education/internal-medicine-residency-program)
             “Sister Teams” – The eight medicine ward teams are paired in the
                 following way to help with coverage. A/W, E1/E2, G/K, U/B.
             Med M does not have a sister team.
             Each team is comprised of two interns, one resident, attending.
                 There are usually 1-2 students in non-summer months. Sister
                 teams share a pharmacist, social worker and resident
                 assistants.
       b. Admissions / Call Structure *for UNC-based Ward Services
             1. Your team is on call every other day. You and your co-intern
                     alternate being on call, resulting in call every 4th day.
                     Your call starts at 7 am and goes through 8 pm. During
                     this time you can admit a maximum of 5 patients. If you
             do      not admit all 5 by 8 pm, the night resident will continue
                     admitting to you through the night to a maximum of 5 (7
                     with floats, see below) and present them on rounds the
                     following morning. These will be your patients even
                     though you did not admit them. Expect to always get
                     your 5 and you will have a happier residency.
             2. In addition to your 5 intern admissions, you may receive 2
                     pre-call ‘float’ patients. These patients are admitted by
                     your night resident on the night preceding your call day
                     and are presented to your team on morning rounds by the
                     night float. This totals 7 new patients per call day. If your
                     night resident admits more than 2 patients prior to your
                     call day, all patients over 2 count towards your 5 for the
                     day.
              3. Every now and then, the admission rate exceeds available spots on
                     medicine services. In these somewhat rare occurrences, your team
               may be asked to take a post-call float in addition to your call numbers.
               This is not a frequent occurrence.
       4. Post call day hours are again 7 am to 8 pm. Once all clinical duties have
               been completed for the day, both your co intern and your resident
               will sign out the entire team to you to cross cover until the night team
               arrives.
       5. The following day and your pre-call day both end when you have completed
               your clinical duties for the day. 2-3 times per month you will have a clinic
               on one of these days if you are a categorical resident. On these days,
               you will sign out remaining clinical duties (other than notes) to your
               co-intern prior to going to clinic. You are not expected to return to
               the wards after clinic.
       6. Days Off: You will have four days off in all four week blocks. Five days off in
               5 week blocks. The weekend day that your co-intern is on call is a
               mandatory day off. This usually accounts for 2 of your quota. The
               remainder are divided per your team’s discretion early in the rotation.
       7. Back Up: Who do you turn to for help when help is needed, in order:
                      A. Before 8 PM – Your Ward Resident
                      B. On weekends when your resident has a day off, the sister team
                      resident is your backup (ex. Med U for Med W).
                      C. (On-Call Fellow - applicable on Med A, E1/E2, ICUs)
                      D. Ward Attending
                      E. The MICU Resident; the CCU Resident
                      F. Chief Residents
                             1. Kristin Amann (UNC) pager 216- 1591
                             2. Britni Hebert (UNC) pager 216-3513
                             2. Paul Johnson (UNC) pager 216-6483
                             3. Jack Kuritzky (Wake) pager 216-2568
c. Admissions / Call Structure *Wake
       1. This is a one resident / one intern team, so you both have the same cal
               cycle. You and your team take long call every 4th day. You are
               typically given two float patients on the morning of your call. You
               can receive up to 3 admissions and 2 consults that day. Typically
               there is a time cap as well: Must receive 1 admission by 3pm, the
               remainder by 5pm (these numbers are in flux). You take
               crosscover from all the remaining teams as they sign out for the
               day. At 8 pm the night float arrives and you sign out cross cover for
               all 4 teams. As the intern you should leave no later than 9 pm.
               Your resident should be the one to stay later if necessary so that
               you do not break the 10 hour rule to return the next morning for
               prerounding.
       2. The Postcall day. You will receive a postcall float admission on most
               mornings. There are no postcall floats on the weekends. Otherwise your
               day is over when your clinical duties are finished and you can sign out to
               the on call team.
       3. The Short call day: The third day in the call cycle you will take admissions for
               an abbreviated period. You will receive 1 short call float on weekdays, 2
               short call floats on the weekends. You will admit up to two admissions by
               either 3 or 4pm. This time cap is also in flux.
               4. Days Off: You and your resident will discuss and divide days off. One of you
                       must take off weekend days when you are not on call or post call (You
                       should never take a day off on an on call or post call day). There is no
                       short call on the weekend, therefore one of you should take these days
                       off. Decide early in the month, otherwise you may miss necessary days
                       off.
               5. Back Up:
                       A. Most days, all day: Your resident.
                       B. On your resident’s day off: The long call resident. Or if the long call
                                resident is busy, any other resident around.
                       C. Your ward attending.
                       D. The ICU attending.
                       E. Your Wake Chief: Jack Kuritzky
               6. Misc: The Wake system is completely different from UNC when it comes to
                       computer programs, note writing and paging. You will receive an
                       orientation packet prior to / starting with your rotation that explains these.
                                In short: labs, vitals, meds and admission / discharge notes are
                                computerized. Progress notes are hand written on templates.
                                Orders are hand written in the chart.
      d. Med M Night Float: This is the concentrated night experience for incoming interns.
               Each of you should do at least 5 days of this rotation. Please alert your chiefs if
               you do not have this rotation scheduled currently (it only shows up in the month
               view of amion, where you can see exactly which days your are on call).
               1. Your night float experience occurs nightly Tuesday through Saturday. You
                       have Sunday to recover and return to your consult/clinic rotation on
                       Monday.
               2. Arrive at 8 pm (5-10 minutes early is more professional.)
               3. You will immediately take sign out on the Med M patients from the evening
                       float resident and cross cover these patients through the night.
               4. You will admit 4 patients every night (no more) to the med M service. There
                       are no limits / requirements / exclusion criteria for a med M patient.
               5. Your supervising resident will complete the general medicine consults
                       overnight (usually seen by the Med M team).
               6. Attendance at morning report 7:45-8:30 in the morning is mandatory.
               7. Return to round with the med M team on your admissions. Leave no later than
                       10 am, even if you have not finished rounding.
      e. Notable Tips for each ward service: Some rotations have guides online and can be
               located at: http://medicine.med.unc.edu/education/internal-medicine-residency-
program/rotation-information
               1. Med A/Geriatrics: You will have a fellow on this service. You should get used
                       to performing a brief MMSE prior to your H&P on these patients. Be sure
                       to spend time gauging each patient’s functional state (ADLs, IADLs,
                       drives still?, etc). All patients going to a Skilled Nursing Facility at
                       discharge require a full discharge summary in hand at discharge.
               2. Med B/Nephrology: Dialysis patients - know when, where and by what access
                       (fistula, line) they get their dialysis and their dry weight. They need a full
                       discharge summary at discharge and it needs to be faxed to their dialysis
                       center at discharge. For transplant patients, know exactly what time they
                       take their immune meds. Take extra care putting these in the admission
                       orders.
       3. Med E1/E2, ONC: You have a fellow on this service. There is a great cancer
               network through the nurse navigators. These nurses are assigned to
               particular tumor types and handle things like arranging outpatient
               chemotherapy, follow up labs, PCP appointments, etc. Use them! There
               are several lists posted in the resident workrooms to help you navigate
               the navigators. If you can’t find one, ask the fellow. Simple tips for know
               your patient: What chemo are they on (more advanced, what have they
               ever had) and what did their last imaging/staging work up show.
       4. Med G/Pulm: This is where you will take care of CF patients most often.
               Make sure their getting their ADEK vitamins and creon supplements.
               Ask them about hemoptysis daily and then be patient. They typically
               stay for some time. Urgent ABGs are drawn by the residents. Less
               urgent ABGs can be drawn by respiratory therapy which is a separate
               order in CPOE.
       5. Med K/ID: Know your HIV patient’s home HIV meds / prophylactic meds and
               if they are taking them. Don’t assume they are. Know their last CD4
               count and viral load AND if this was on or off of HAART. If you get an
               HIV patient on a service other than Med K, always let the ID consult team
               know they are in house, even if you don’t have a question for them. As
               soon as you know someone will need IV antibiotics at home, page the
               home infusion team so they can start making arrangements. Many a
               discharge has been delayed because this was not done. You will quickly
               learn the heartbreak of a delayed discharge as an intern.
       6. Med U / W (GEN): You will get the majority of your GI experience on these
               services, along will other general medicine. Designate someone from
               your team to “run the list” with GI a couple of times per day to make this
               run more smoothly. You also have U/W/M lectures and GI attending
               lectures at noon one day per week. These are mandatory. The schedule
               is usually posted in the workroom. Check with your resident if it is not.
f. Typical Intern Day/Expectations/Tips:
       1. Pre-round on your patients (time when you arrive depends on the number of
               patients and their complexity; typically around 6:30).
       2. BEFORE 7 AM: Contact the night resident you signed out to the previous
               night to learn about cross cover issues that arose. Sign your pager back
               over to yourself.
       3. Pre-round on your patients (this should be completed by 7:30):
               a. Check and record vital signs
               b. inquire of patient if there were any problems with his/her night
               c. perform directed physical exam
               d. run labs and review radiology reports (not all important lab information
               can be gleaned from the rounds report! you have to look in webcis.)
               *** Work out a system for organizing this information for rounds, and use
               it every morning, every patient. Every successful intern has a system.
               Period. Some people carry a folder/binder, some carry the H&Ps of each
               patient and write daily information on the backs everyday and have a
               running tally of the hospital course at discharge. Some have devised
               print outs that they fill in each morning so that their information is always
               organized in the same concentrated format. This will improve your
               presentations. If you don’t know where to start, ask your resident what
               system they use. Then modify it to fit your style.
       4. 7:30 - 7:45: Team Huddle. You should have pre-rounded on your patients by
                this time. Meet with your resident and discuss any immediate concerns
                from the morning. This is the time for the team to identify consults
                needed / those ready for discharge as long as the team is stable. This
                way the interns can start work in these areas during morning report.
        5. 7:45 - 8:30: Morning report. For interns: call consults discussed with your
                resident, ready discharges, etc. If your service is light and there is no
                work to be started on, you should attend morning report.
        6. 8:30 - 10:30 Work Rounds
                a. Give report to your resident about each of your patients in the following
                            format:
                    i. Patient’s subjective report overnight
                    ii. Vital signs
                    iii. Pertinent physical examination
                    iv. Relevant labs and studies
                    v. Assessment and plan by problem list
                b. You should be assertive and make your plan for your patient each day.
                c. Keep your presentations brief, aim for 2-3 minutes for old patients, 5-10
                            for new patients. Keeping your presentation problem-oriented will
                            help with concision.
                d. While your co-intern is presenting patients: Some attendings prefer the
                     entire team to see the patients, others are agreeable to have interns
                     not directly caring for the current patient conduct work (make phone
                     calls, place orders). You can also enter the appropriate orders into
                     CPOE for the day for your fellow intern while he/she is presenting.
                     He/she should do the same for you when you are presenting. Grab a
                     COW (computer on wheels) prior to rounds to help this cause.
                       i. Order x-rays
                       ii. Order medication changes
                       iii. Order the next morning’s tests
                       iv. Sign verbal orders
                        v. Sign discharge orders – as a hospital we are trying to speed up
                               the discharge process. If you think a patient may be
                               discharged later that day or the next day, please write an
                               “anticipate discharge” order with the date and time included to
                               notify the nursing staff ahead of time
                         vi. By the end of the year you will be able to do all of the above, start
                               or even finish their own progress notes and have a nurse’s
                               phone on hand for calling consults on rounds. This is
                               advanced interning at its finest. Be sure you are not doing all
                               of this at the expense of catching all orders and inputting them
                               CORRECTLY.
                *** Keep track of every planned task on your patients. Nearly everyone
                            uses the ‘checky box’ system at least through their first year.
                            Trust us, you will NOT remember it all without keeping track on
                            paper. When you forget, your resident will be mad and a patient
                            may suffer. It is YOUR responsibility to make sure these orders
                            were put in, NOT your co-interns responsibility even though they
                            are putting them in on rounds. Double check often.
3. After Rounds: There is a great deal of work to be done after rounds. You must be
        able to triage appropriately. The following order of tasks is strongly
        recommended.
              1. Sick Patients First. If you have any unstable patients, complete all of their
                  consults, orders and urgent procedures first.
               2. Call consults early/next (Web Exchange to find out whom to page, under call
                       schedule at the bottom, type in the service then click “on call now”). See
                       paging etiquette above to send the ‘perfect page’ and have happier
                       consult on the other end of the line.
                       a. When the consultant calls back, they want to know: pt name and
                               medical record number (even if it’s in the page, just repeat it), your
                               attending, reason for consult ( be as brief / specific as possible,
                               e.g. requesting colonoscopy, and whom to contact with
                               recommendations.
              3. Get Discharges out the door (put an ‘anticipate d/c’ order on rounds)
                       a. This is where the resident assistants can be so helpful. Subscribe to
                               their webcis list early. Place patients on the list with requests for
                               follow up appointments, outpatient procedures / additional tests,
                               faxing discharge summaries, getting outside medical records, etc.
                               Ask your resident to help you find the list on the first day. There
                               are instructions on the list for how to use it.
              4. All other orders
              5. Any procedures
              6. Notes- You must write a progress note on every one of your patients EVERY
                 day, even if there is a medical student following. It is not acceptable or legal to
                 co-sign a student’s note or to allow a student to write a note under your log-in.
                 This is, among other things, Medicare fraud.
              7. Update Rounds Report.
              8. Sign out to either your co-intern if you are not on call / postcall, or to the night
                  resident at 8 pm.
                       Good Sign Out includes the following:
                               1. 4 word liner on each patient
                               2. Stable / Unstable
                               3. Anything to follow up (pending labs, check their blood pressure
                                        1-2 times tonight, radiology, etc...)
                               4. What to do with the pending information. This is something you
                                        team should have discussed when ordering said
                                        information.
                               5. Critical information to convey to tell night float: Any issues with
                                        blood pressure or oxygenation, including their current
                                        baseline O2 need. Mental status baseline on those with
                                        altered status. Any procedures performed that day to
                                        anticipate complications. Certain medications you would
                                        like them to avoid (no pain medications, no Benadryl,
                                        etc...)
                   9. Related, your day for the ICUs has a similar basic structure and the same
                       tips apply as above. There are some key differences with call
                       schedule and the way rounds are run......
4. MICU
      a. Structure: The MICU consists of 4 teams, each comprised of one resident, one intern
              and +/- a medical student. While the teams rotate call schedule and have their
              own patient census, the MICU rounds as a whole every morning at 8 am starting
              with radiology rounds, then work rounds, followed directly by education rounds.
      b. Call Schedule:
1. Long Call. Every 4th day:
        i. Arrival
                   1. ~7am
                   2. Complete pre-rounds on all team patients
        ii.Rounds
                   1. Start at 8 am with radiology rounds. The long call intern is
                           responsible for reading the films on all the patients in the
                           MICU. Simplicity reigns: State the patient name / their
                           problem. Picture better or worse than previous, are the
                           lines and tubes in the right place.
                   2. Active participant in all patient presentations (take notes for
                           cross cover)
                   3. Do not depart rounds for codes, rapid responses, or admissions
          iii. Post-Rounds to 12pm
                   1. Participate in teaching, radiology rounds
                   2. Complete notes, patient care
                   3. Depart no later than 12pm
           iv. Break
                   1. Leave no later than 12pm
                   2. Do not return until 8 hours after departure
            v. Admitting
                   1. ~8pm-7am; accept on-call intern pager
                   2. Receive sign-out from departing short call intern
                   3. Complete further admissions with long-call resident
2. Post-Call
           i. 7am-8am: pre-rounds; forward admission pagers/lanyard
           ii.8am: round with entire MICU, present all team patients first
                   1. Rounds = sign-out to the long call team; DO NOT sign out again
                   2. After each post-call patient is seen, the long-call resident,
                           long-call intern, and short-call intern should know the daily
                           plan and follow-up plans
           iii. ~9:30-10am: post-rounding
                   1. Complete all notes and depart
                   2. Do not stay for teaching, radiology rounds
                   3. Do not complete procedures
                   4. Upon departure, complete the ‘to-do’ sheet and hand to the
                           long-call resident
3. Short Call
        i. Arrival
                   1. ~7am, transfer on-call intern pager
                   2. selected/complimentary pre-rounds with short-call resident
        ii. Rounds
                   1. Present in their entirety
                   2. Active participant in all patient presentations
4. Pre-call
        i. Arrive at 7, preround and present your patients in their entirety
        ii. You should put orders in all on other teams’ patients as rounds
                   progress. This is EXPECTED in the MICU as rounds run longer
                   than the wards. Speak up at the end of each patient, recite the
                   orders you caught for verification / check for missed orders. The
                   short call intern can help with some of these, but it is primarily
                                your responsibility. On your day off, your resident will complete
                                this task.
               5. Admissions: There is no cap to admissions in the MICU. You are limited to 5
                       new admissions. You may participate in the care of all additional patients
                       over 5 once admitted by your resident.
               6. Back Up: Your ICU resident is your backup on call at all times. If for some
                       reason you cannot contact your resident (which should never happen)
                       and you have immediate concerns about a patient, contact the CCU
                       resident or the night floats for immediate help. The ICU fellows are also
                       on call for crisis, as well as the ICU attending. AFTER the patient is
                       taken care of using the above resources, you should alert the on call chief
                       of the lapse in appropriate back up/support.
               7. Days Off: The ICUs are extremely tight as far as possible days off are
                       concerned. Therefore these will be scheduled in amion. Your mandatory
                       day off per month is the Friday your team is on short call. It is a
                       necessary evil to get you your days off. The other days may be
                       rearranged between you and your resident as desired, but do let
                       the chiefs know if you are rearranging.
5. Cardiology:
       a. Structure: The rotation consists of 4 teams that rotate call. The teams are comprised
               of 1 intern, 1 resident, 1 fellow, and 1 attending +/- a medical student. Teams
               round separately in the mornings.
       b. Call Schedule:
               1. Long Call / Post Call: Every 4th day.
                       i. 7am: Arrive for sign-out and pre-rounds
                       ii. 7am-11am: Pre-Rounds/Rounds
                                o Write as many notes and discharges as possible
                                o Must leave by 11am
                                o Your resident will NOT be present during rounds
                       iii. 11am: Must leave for 8 hours!
                       iv. 7pm Short Call Intern departs
                       v. 7pm-7am
                                • Arrive at 7pm
                                • Receive sign-out from Short-Call Intern
                                • Admissions for the remainder of the evening
                                • Complete remainder of notes/summaries
                       vi. 7am-11am
                                • admissions stop at 7am
                                • transfer virtual pager to oncoming short call intern
                                • patient care, rounds, notes
                                • leave no later than 11am
               2. Short Call
                       i. 7am – 1pm
                                o transfer intern on call virtual pager to yourself (123-7337)
                                o pre-round, participate in rounds
                                o respond to all new patient evaluations (codes, rapid responses,
                                        ED calls, floor calls)
                                o Admit all status of admissions
                       ii. 1pm-6pm
                                o Admit floor status patients
                       iii. 6pm
                                 o Last call for admissions
                       iv. 7pm
                                 o sign-out to Long Call Intern
                      v. On the weekends, this day is treated as a precall day other than having
                                 to stay until the oncall intern returns (7pm), but you do not take
                                 new admission onto your service. However, in the case of a busy
                                 call day you may be asked to help the lone resident with
                                 admissions to their team until their intern returns.
              3. Pre Call
                      i. Day off OR afternoon short Clinic (categorical interns only)
                      ii. If Intern is working, this is a resident day off;
              4. Admissions: Short call takes admissions from 7am to 1pm, and floor
                      admissions from 1pm to 6pm. Long call takes stepdown and ICU
                      admissions from 1pm to 6pm, then all admissions thereafter. Team caps
                      are 10 for short call and 14 for long call. The 5 new admission cap for
                      interns is the same.
              5. Back up: In order, your resident, fellow, other residents/fellow, attending,
                      chiefs. Please see the MICU Backup section for more details.
              6. Days off: Are assigned as in the MICU. Differences: there is no official short
                      call on the weekends, therefore your intern short call days off are when
                      your short call day falls on a saturday or sunday.
6. Inpatient Ancillary Staff
       a. Resident Assistants. Subscribe to their webcis list. Use it for scheduling
              appointments, getting OSH records, and faxing discharge summaries.
       b. Social Work. You will share a social worker (or Clinical Care Manager, new term) with
              your sister team. Your resident will round with the social worker most days.
              However, on your resident’s morning clinic days, YOU must round with social
              work on your patients. Things they are interested in knowing: Anticipated
              discharge date, needs on discharge including Oxygen, IV antibiotics, PT/OT,
              hospital beds, financial assistance, skilled nursing facility, or hospice.
       c. Home Infusion: Numbers can be found on webexchange. As soon as you know
              someone will need IV anything at home, call them. They have to find a company,
              arrange line education and meeting times, etc.
       d. Phlebotomy: Performed by Phlebotomy Services (order has to be in thirty
               minutes prior to draw in order for it to occur—e.g. order in by 9:30 AM for
               a 10AM draw). 7 days/week hourly between 4AM and 2200 PM
               Questions? Phlebotomy Services- 6-2446
7. Clinic (Categorical interns only)
        a. Structure:
                1. Clinic schedule: You will have approximately one full-day clinic per week.
                During CAR, you will have anywhere from six to ten half-day clinics
                during the entire month. Because of your other ambulatory requirements
                during this month, these may be scheduled in full-day or half-day
                sessions. While on the wards, you will have half-day afternoon clinics
                scheduled no more than once per week. You should sign out your
                patients to your co-intern prior to reporting to clinic. You will have slightly
                fewer, shortened afternoon clinics on MICU and cardiology. You should
                sign out to your resident or the on call team prior to leaving for clinic.
         2. Preclinic conference: Starts at 1:10 PM. All interns and residents are
         expected to attend. If you are on MICU or cardiology, you are excused
         from this conference but we still encourage you to attend.
         3. Patient panels: After the orientation weeks are completed, you will have either
                 six return patients, or one new and four return patients scheduled per
                 half-day of clinic for the first six blocks of the year. For the remaining
                 blocks, this number will increase. The half-day clinics in the AM will have
                 either eight return patients, or one new and five return patients. The
                 half-day clinics in the PM will have either seven return patients or, one
                 new and four return patients.
b. Presentations: These differ from the wards. You should start with an introductory
         chief complaint, and then present in a problem-based format from start to finish.
         For example “Ms. Patient is a 79 yo F with diabetes mellitus, hypertension, and
         coronary artery disease who presents today for routine follow up. For her
         diabetes, her fasting AM fasting sugars are usually 120-170 and she denies any
         hypoglycemic episodes. She checks her sugars before each meal. She is
         compliant with her regimen, which includes Lantus 30 units at bedtime as well as
         Novolog insulin 10 units before each meal plus carb-counting. Three months
         ago, her Hgb-A1c was 7.8 and LDL was 94. I’d like to …<insert your plan
         here>. Next, for her hypertension...” For each problem, you should give the
         pertinent history, exam findings, and data and your assessment and plan.
c. Clinic notes: Can be dictated or written, whichever you prefer.
         1. Dictation instructions: At the voice prompt, enter the following information
                 a. Enter the first 5 DIGITS of your PROVIDER number, followed the #
                         sign.
                 b. Enter the DOCUMENT TYPE number, followed by the # sign.
                         Document Type                                    Document Number
                         Resident New Patient Visit                       305901
                         Resident Established Patient Visit               305902

               c. Enter the 7 digit patient MR number without the check digit, followed by
                       the # sign.
               d. You will hear a tone, which will indicate the beginning of a dictation. At
                       that point, you can begin speaking. You do not have to press a
                       key to begin dictation. IF THE FOLLOWING INFORMATION IS
                       NOT STATED, YOUR DICTATION WILL NOT BE PROPERLY
                       PROCESSED:
                       • YOUR NAME
                       • SPELLING OF PATIENT NAME (Last and First)
                       • PATIENT’S MEDICAL RECORD NUMBER
                       • DATE OF SERVICE - VERY IMPORTANT
                       • ATTENDING PHYSICIAN NAME (IF NOT THE DICTATOR)
               e. To dictate multiple reports press 8 after each report then follow steps
                       “b” through “d.”
       2. Clinic notes should be completed on the same day of the patient encounter.
               Speaking from experience, the longer you wait, the longer they take.
               Once the note is transcribed, it will appear under Unsigned Notes in your
               Activity List. Here, they can be edited before you sign off on them.

d. Follow Up and Patient Correspondence: You are responsible for following up
        on the results of all labs and studies that you order on your clinic patients.
        These results will show up as alerts in WebCIS on the lefthand toolbar in
        your Activity List. For critical lab results, your patients should be notified
        immediately. For non-urgent lab results, your patients should be notified
        of the results within two weeks. You can either call your patient and
        document the correspondence (as an addendum to your clinic
        note before it is signed, in a phone message that gets finalized to the
        record, as a patient correspondence note, etc.). Alternatively, you
        can send your patients a letter in the mail with the results. This is what
        most of us do, as it is much faster.
        1. Patient Correspondence letters: This is under “Create Notes” then “Patient
                 Correspondence.” You can either make your own template or subscribe
                 to Chris Caulfield’s Patient Results template. During your orientation, we
                 will tell you more about this. Once you type the patient correspondence
                 note, you can have it mailed by clicking on the “Mail” option when you
                 sign it. Very easy!
        2. Back Up: If you do not know what to do with a test result or need help with
                 deciding the next step in management, send              a “Phone message”
                 to the attending with whom you saw the patient. If you are having
                 trouble         getting in contact with this attending, ask the Ambulatory
                 Chief to help you.
        3. Patient messages: Patients will often call our clinic with requests for refills,
                 questions about medications, lab results, etc. These will show up as a
                 “Phone message” in your Activity List. It is then your duty to respond.
        *** It is expected that you review your activity list several times per week.
EDUCATION
1. Curriculum: The medicine department and its associated subspecialty departments have
each developed a list of core topics and in some cases recommended readings. These
comprise the expected objectives for each rotation and are located at the following link:
http://medicine.med.unc.edu/education/internal-medicine-residency-program/resident-
information
The curriculum is currently under expansion / editing. Updates should be available in the first
few months of the year.

2. Conferences
       1. Core Curriculum: Monday, Tuesday 12:00-1PM [4th Fl Aud.-Old Clinic]
               Lecture format on core topics. Lunch usually provided.
       2. Intern Conference: Wednesday 12:00PM [2020 Bondurant] Lunch provided.
               Residents take intern pagers for uninterrupted teaching time.
       3. Grand Rounds: Thursday 12:00 PM [4 th Fl Aud.-Old Clinic] Lunch provided.
       4. Evidence Based Clinical Practice: Friday 12:00-1:00PM [133 MacNider] Lunch
               provided.
       5. AM Report: Monday, Tuesday, Wednesday, Friday 7:45-8:30 AM [133 Macnider]
               (this may soon be extended to Thursday as well)
       6. Ambulatory Care Conference: Every Wednesday at noon in the ACC building.
       7. Wake AM Report: Occurs daily at 8-9 am. Mandatory for upper level residents.
               Attend when your work load is light / you finish pre-rounding in time.
       8. Subspecialty Conferences: Each of the subspecialty departments have several weekly
               conferences. These conferences can usually be found on their websites. If
               you are interested in a subspecialty career you are encouraged to attend these
               conferences on elective months or when ward time allows.
       9. There is a running compilation of lecture powerpoints loaded onto the housestaff
               website. If you can’t make it to conference (which should be the exception not
               the rule), you can review the material.
       http://medicine.med.unc.edu/education/internal-medicine-residency-program/conferences
       10. There are also loads of EBM help material on the housestaff website.
       http://medicine.med.unc.edu/education/internal-medicine-residency-program/evidence-
       based-clinical-practice
       9. Want to see the experts of years past giving Grand Rounds? Check out the streaming
               video archive:
       http://medicine.med.unc.edu/whatsnew/grand-rounds-video

3. Teaching Rounds: These should occur daily on your ward team.
       a. Daily from 11:15AM-12:00PM or from 1:00 PM to 2:00 PM; Exact timing can be
               decided with your team. You are not expected to attend an afternoon teaching
               rounds when you have clinic.
       b. You are not to answer pages during Teaching Rounds unless it is an emergency.

4. Health Care Library: This is located right outside of MacNider (where orientation is). You
       can check out medicine text books, locate papers in the archives and perhaps most
       importantly the librarians can help you with difficult literature searches for clinical based
       questions or research.

5. Resources: There are a slew of online references through the health science library. These
     will be extremely helpful. You can access most of these references from home using your
     Onyen (see below in personal work info). This includes access to Up To Date, Electronic
     Journals, Online Texts, etc...
     The following books can be obtained at the Health Affairs Bookstore. You may want to
     ask to borrow these from other residents and then decide if they fit your style of learning
     before buying them. Most resources can be found online through the library :
     http://www.hsl.unc.edu/resources.cfm

     A. UNC Department of Medicine Homepage
                1. Address: http://medicine.med.unc.edu/education/internal-medicine-residency-
                program
                Or it's the first link in Google after typing "UNC internal medicine"
                2. Become very familiar with our House Staff web page. Many useful databases
                can be accessed here, including archived “AM report” case based presentations,
                core curriculum lectures, board review lectures, and EBCP guidelines and
                tutorials. This should be your first stop when looking for help.
(Below is a list of frequently used resources. The bolded are those that current residents tend to
keep on their person at all times.)
       B. The Washington Manual, 31st Edition - most residents carry this daily, keep
                notes in the margins throughout residency.
       C. Netter’s Internal Medicine. Runge, Marschall; Greganti, M. Andrew (Our Bosses!)
       D. On Call: Principles and Protocols, 2 nd Edition Marshall SA, Ruedy J. WB Saunders
                Co.- useful for addressing frequent on call scenarios you will handle this year.
       E. The 2006 Tarascon Pocket Pharmacopoeia- you will use it daily (vs. epocrates)
       F. The Tarascon Internal Medicine and Critical Care Pocketbook
       G. The Sanford Guide to Antimicrobial Therapy 2007 H. Facts and Formulas (a
                pocketbook)- most residents carry this daily.
       I. Diagnostic Strategies For Common Medical Problems- Editors Black, Bordley, Tape
                and Panzer. (available in Housestaff Library)
       J. 2nd Edition Pocket Medicine 2004, Massachusetts General Hospital
Scholarly Work / Career Guidance
1. Finding a career path is the first part. If you are not certain what you would like to do on
matriculation, you are not alone. The fellowship match has recently been moved to December
of your third year, which gives you 6 more months of planning and preparation. Once you are
ready to get your feet wet, all of our departments are very welcoming and eager to have
residents involved in research. It is fairly easy to get involved in research once you send out the
first email. We understand it’s hard to know who to email. Several of our upper level residents
and first year fellows have volunteered to field questions in their chosen field of interest. They
can help introduce you to the receptive faculty or those geared towards your interests.
        a. Cardiology:
                1. Kamal Kolappa, KKolappa@unch.unc.edu
                2. Paul Johnson, PMJohnso@unch.unc.edu
                3. Jack Kuritzky, JKuritzk@unch.unc.edu
                3. John Rommel, JRommel@unch.unc.edu
        b. Endocrinology
                1. Elaine Sunderlin, ESunderl@unch.unc.edu
                2. Sherwin Yen, SYen@unch.unc.edu
        c. GastroIntestinal:
                1. Ed Barnes, ELBarnes@unch.unc.edu
                2. Pat Barrett, PBarrett@unch.unc.edu
        d. General Medicine
                1. Robert Lampman, Robert.Lampman@gmail.com
                2. Andrew Mcwilliams, AMcwilli@unch.unc.edu
        e. Geriatrics
                1. Britni Hebert, BHebert@unch.unc.edu
        f. Heme/Onc
                1. Stacey Cowherd, SCowherd@unch.unc.edu
                2. Britni Hebert, BHebert@unch.unc.edu
        g. Infectious Disease
                1. Anne Lachiewicz, ALachiew@unch.unc.edu
                2. Loren Robinson, LKRobins@unch.unc.edu
        h. Nephrology
                1. Marc Richards, MSRichar@unch.unc.edu
                2. Jason Kidd, JMKidd@unch.unc.edu
        i. Medical Informatics
                1. Ricky Bloomfield, rickybloomfield@gmail.com
        j. Pulmonary / Critical Care
                1. Domenick Roma, DRoma@unch.unc.edu
2. Related, the faculty within our division are extremely receptive and can help guide your
choice in fields and help you navigate any chosen path.
        C. Lee R. Berkowitz, MD
                    Professor of Medicine Residency Program Director Associate Chair for
                        Education
        D. Christopher A. Klipstein, MD
                    Associate Professor of Medicine Third Year Clerkship Director
        E. Paul Chelminski, MD, MPH
                    Assistant Professor of Medicine Assoc. Program Director
        F. John E. Perry, III, MD
                    Associate Professor of Medicine Director, Wake AHEC Internal Medicine
3. Part of your outpatient clinic rotation (CAR - for categorical residents) includes a quality
        improvement project. These are geared towards improving the clinic experience. The
        faculty can provide as much guidance as needed.
Personal Work Info / Personal Health / MISC
1. Important Personal Identifiers / Numbers (there are a LOT of them)
       Keep these on your person (in your smartphone or on a card in your
       wallet), handy for reference. You will need some of them daily (easy) and
       others at seemingly random q 6month intervals. Just enough time for you
       to forget them in between.
       1. Physician ID (the “p number”): This is a 6 digit UNC identifier. It is used for
       WebCis Login (electronic medical records) and for identifying you as the ordering
       physician. This is the number used to log into preclinc conference as well. Otherwise no
       one will recognize it.
       2. DEA: same for all residents at UNC (will be given to you)
       3. PID (personal ID number): This is a 9 digit University identity number useful for
       gaining access to all things UNC run (outside of the hospital), ie: gym, some library
       resources....
       4. EID (Employee ID number): This 7 digit number denotes you as a UNC Hospital
       employee A lot of your passwords will default to this. You will need it for employee
       health as well. This is also the number you will need for completing LMS online training
       at the beginning of each year.
       5. UPIN: Medicare identification number
       6. NPI: National Provider Identifier. This is a unique identifier used by the Federal
       Government (Medicare, HIPAA, etc) and will be obtained for you. This should be placed
       on all prescriptions and billing forms. You will keep this number for the rest of your
       practicing career.
       7. ONYEN: This is an account that you set up and is linked to your PID that grants you
       access to the health science library online resources (including uptodate) off campus. It
       can be managed at onyen.unc.edu .
       *** In order for your prescriptions to print off with the necessary information from
       webcis, you should change your signature in the profile settings (top of each page:
       profile, general settings). The signature should have your name, work mailing address,
       fax and phone number, UPIN, NPI and DEA numbers. Ask your resident to help you edit
       your signiture early in the first rotation.
       *** Empty your mailbox-located on the first floor West Wing. Do this weekly.
       *** Remember to renew your license before your birthday. If this is not
       completed by your birthday, your pay will be docked for each day it is
       not complete: http://www.ncmedboard.org/renewals/
2. Cafeterias:
       The first four options accept your work provided freedom pay card.
         a. Overlook Café: 2nd Floor Neurosciences 7am-7pm - brick oven pizza, fresh salad,
              paninis
         b. Starbuck’s Coffee Shop: Cancer Hospital 6:30 a.m.-9:30 p.m.
         c. Children’s Hospital Café: 1st Floor Children’s Hospital; Everyday 24 Hrs - grill,
               daytime fresh sushi / stir-fry, southern comfort food, pasta/pizza, refrigerated
               selection of meals
         d. Corner Cafe: Children’s hospital, ground floor down hall past the kinetic sculpture.
               M-F 7-2pm. Hospital famous burrito bowels, deli.
         e. The Beach (NOT a hospital restaurant, hence does NOT take your blue freedom pay
               card!). M-F: 7:30am-3pm; Closed S/S. 2nd floor old clinic, across from cath
         lab,
               walk outside double doors and across walkway. Chick-fil-a, Quiznos, coffee shop
         f. FreedomPay: You will receive a FreedomPay card from the housestaff office
during orientation. This can be used to purchase meals in the hospital. You will be given $120
at               the beginning of the year for the entire year and will receive $14 for every 24 hour
shift (for       upper levels) and $7 for every shift over 12 hours throughout the year. You can
check your       account balance at HYPERLINK "https://www.freedompay.com/balance"
by inputing              the number at the back of the card:
https://www.freedompay.com/balance.
3. Call Rooms:
         Med A/B Intern Room – 4 Anderson Call Rooms
         Med E1/E2 Intern Room – (3 ONC)
         Med G/K Intern Room – M6315 (6 Bed Tower, next to room 6314)
         Med U/W Intern Room – 8056 (8 Bed Tower A)
         Med C/D Interns/Residents Room – 3021, Rm B and C (3 Anderson)
         MICU Intern/Resident Room – Physician’s Room (MPCU, next to room 4301)
         Night Resident’s Rooms – 4 Anderson Call Rooms and KICU
4. Lounge (aka the “KICKU”):
       KICKU 5 East- code            5-1-3       (across from the lockers on the 5th floor)
        Any issue with locked call rooms not amenable to your keys --> call security in a
               non-urgent fashion.
5. Discounts: UNC has relationships with several businesses. When signing up for contracts,
        alway ask if there is a UNC discount. Phone companies nearly universally offer up to
15%            off for UNC staff.
6. Gyms / Intramurals:
        a. A membership at the UNC gym is extremely affordable (150/year). The hours are less
                        flexible than some gyms for holidays and the summer, but it boasts pools,
racquet                         ball/squash courts, etc...
        b. Several residents are members at other gyms around Chapel Hill and Durham. If
you’re                  interested, just send out an email asking for recommendations.
        c. The medicine department fields several intramural teams each year, including softball
               (twice per year), football and basketball. A couple of our residents are also
                        involved in ultimate frisbee and tennis leagues. If you’re bold enough,
Raleigh                         boasts a full-on Roller Derby league. Alert emails tend to come
around just prior to            the start of each season.
7. Employee Health: Located on the first floor of old clinic. Used for vaccinations, PPDs, etc.

				
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