1 Orientation Outline Third Year Inpatient Internal Medicine

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1 Orientation Outline Third Year Inpatient Internal Medicine Powered By Docstoc
					                                                                         Document updated: August 11, 2009

         Orientation Outline: Third Year Inpatient Internal Medicine Clerkship at
                   Ronald Reagan UCLA Medical Center (RR-UCLA MC)
                              Site Director: Neveen El-Farra, MD
  nelfarra@mednet.ucla.edu (preferred contact method), UCLA phone (310) 267-9643, pager
     Course Coordinator: Elizabeth Santiago, esantiago@mednet.ucla.edu (310) 794-2283
                 for Jonathan David, jdavid@mednet.ucla.edu (310) 794-3563

Contents of Orientation Outline
   1. Course Requirements While at RR-UCLA Medical Center
   2. Logistics of Clinical Care
   3. Orientation, Feedback, and Grades
   4. Tips for Success on Internal Medicine
   5. Schedules

1. Course Requirements While at RRMC
Discussion of Major Diseases Course
The DMD course is a one-hour case-based learning session given three times a week throughout
your rotation. The cases are coordinated across the sites so you will not discuss the same topic
during your 8-week rotation. The topics are listed on the schedule but the days on which they are
covered are withheld. The DMD cases at RR-UCLA Medical Center are kept a mystery because
one of the goals of the course is to learn how to build a differential diagnosis and work-up an
unknown problem. To do so successfully, you must have an open mind. A list of recent review
articles for each topic is posted on Angel. You can access most of them by clicking the link
These sessions are mandatory; arriving on time and participating in the discussion is expected.
One excused absence is permitted for situations such as going out to lunch with your team, or one
of your days off. You should page the attending teaching that day if you are unable to attend. Do
not miss the sessions to do “scut” on your patients or for your routine work.
Clinical Examination (CEX)
During your eight weeks on Internal Medicine, you need to have two faculty members observe and
evaluate one examination of the cardiovascular system and one examination of the respiratory
system. You should turn in the CEX forms on the day of your test.

Number of Patients to Admit and Follow
Because opportunities to pick up new patients only occur twice a week under the current call
schedule at RR-UCLA Medical Center, you should plan on taking every long and short call with
your team, and admit at least one patient per call. Early in the third year, students should admit at
least 3 patients per week and strive to follow 2 to 3 patients at all times. Later in the year, students
should strive to follow 3 to 5 patients, which means admitting more than one patient on most call
PDA Patient Logs
The PDA patient log data are used to determine that students are seeing the minimum number of
patients required to pass the course and to better understand the type of clinical experiences
students are having at each site. You MUST enter patients in your PDA logs at least weekly; the
Deans’ office tracks this. If you experience any difficulties, you should contact Katherine Wigan
at kwigan@mednet.ucla.edu ASAP. They need to hear from the students to make sure they get
their data and to learn of any system issues that need to be addressed.
Course Textbooks
The text book is Internal Medicine Essentials for Clerkship Students, by the American College of
Physicians (ACP) and the Clerkship Directors in Internal Medicine (CDIM), the organization of
individuals responsible for teaching internal medicine to medical students. According to the
authors, “The purpose of Internal Medicine Essentials is to provide medical students with an
authoritative educational resource that can be used to augment learning during the third year
internal medicine clerkship.” The book provides an overview of Internal Medicine and basic
information about essential topics. It is not comprehensive enough to be your only resource. It is
available at the Biomedical Bookstore, on-line from ACP (http://www.acponline.org/essentials/)
and at Amazon, among other websites.
The UCLA Internal Medicine residency publishes a manual, titled the Internal Medicine
Housestaff Handbook. It is a resource that explains the logistics of caring for patients at RR-
UCLA Medical Center and has a great deal of information on clinical care, including approaches
to diagnosing and treating various conditions. You can purchase it for about $16 at the book store.
If you cannot find it there, the chief residents may be able to help you locate a copy.
2. Logistics of Clinical Care
Computer Passwords for RR-UCLA Medical Center
In order to take care of patients, you will need a user id and password for two computer systems.
These should be available to you prior to your arrival at RR-UCLA Medical Center. One system
is called the Patient Centric Information Management System (PCIMS, soon to transition to
cView), which includes demographic information, laboratory tests, radiology studies, pathology
results, consultations, ER visits, and more. The second system is called Essentris; it contains
information generated by nurses and ancillary providers, such as vitals, ins and outs, blood glucose
monitoring, and notes from the following services: nutrition, physical therapy, social work and
respiratory therapy. PCIMS, cView, and Essentris have separate icons on the website and separate
login systems. The information needed to login to these systems should have been emailed to you
before the start of your rotation. If you have not received this information, please contact the
Student Affairs office at least one week before your rotation: Dana Moore (310) 206-0958.
Alternatively, the PCIMS Help Desk may provide assistance: (310) 319-4792.

Writing Notes
Policies toward medical students writing notes at RR-UCLA Medical Center include the
       1.        For admission H&Ps, the medical student writes an admission note. The intern
                 is also required to write a complete H&P. The intern may not solely co-sign
                 your (the student’s) admission H&P.
       2.        For daily progress notes, your note can qualify as the daily note as long as it has
                 been reviewed and a detailed addendum is attached by the intern or resident
                 caring for the patient. Their addendum must include an assessment and plan.
                 These rules may differ from your rotation at the VA or Olive View.
       3.        UCLA residents and interns now write most of their notes electronically via the
                 “ClinDoc” in the cView portal. Unfortunately, students do not have direct
                 access to ClinDoc at this time. Therefore, you have two options for writing your
                 notes, depending on the preference of your interns/resident:
                 •   Writing Electronic Notes: Students can write notes in Microsoft Word or
                     another program. Type “****MEDICAL STUDENT NOTE****” at the top
                     of the document, and send the note(s) to your intern(s). The intern(s) can
                     chose to use this note as their daily note by inserting it into ClinDoc using
                     their account or write their own daily note. The interns should change the
                     title of the document to “MSIII Note and Intern Addendum,” add a line at the
                     bottom stating that they reviewed the note, and add any clarifications.
                 •   Writing Paper Notes: You have this option; these can be placed in the chart.

Performing Procedures
At RR-UCLA Medical Center, residents and interns perform arterial blood gas sampling,
paracentesis, thoracentesis, lumbar puncture, central venous catheter line placement, joint
aspiration, and NGT insertion. Students may have an opportunity to observe and perform some of
these procedures.
Residents and interns seldom draw blood or insert IV lines at RR-UCLA Medical Center.
Consequently, students are unlikely to acquire much experience drawing blood and inserting IV
lines. However, if you are particularly interested in acquiring such skills, you should approach the
nurses caring for your patients to see when you might have an opportunity to perform these tasks.
3. Orientation, Feedback, and Grades

RR-UCLA Medical Center Site Training
All third-year students will receive an orientation by one of the internal medicine residents at RR-
UCLA Medical Center, titled “RR-UCLA Medical Center Site Training.” This two-hour
introduction to patient care at RR-UCLA Medical Center will occur from 3 to 5 pm on the first
day of your rotation. (i.e., Wednesday if rotating at RR-UCLA Medical Center first, Monday if
rotating at RR-UCLA Medical Center second).
Orientation by Residents during First Week at RR-UCLA Medical Center
The senior resident on your team is responsible for overseeing your rotation experience, including
assigning patients, reviewing clinical care plans, approving days off, ensuring you are supervised
when doing procedures, etc. During the first week or so on service, the resident should make sure
you are becoming comfortable with systems at RR-UCLA Medical Center, including how to write
orders, use computers, find float notes, use PACS, get around, call consults, etc. Ideally, your
resident should also inform you of their expectations regarding your role as a third year student on
the team. This may occur in a more or less structured fashion, and parts of the orientation may be
delegated to interns. However, residents have many other responsibilities that may distract them
from orienting students. You should always feel comfortable politely telling your resident that
you would find it very helpful if someone could explain “something” (whatever this may be),
particularly when asked to do something new. For example, it is best not to call a consult until
you have been instructed how to do so, and ideally have observed someone doing it.
Students need positive and constructive feedback in order to develop; however, not all supervising
physicians may be equally comfortable with giving feedback. Some physicians may be indirect in
how they give you feedback. You may want to diplomatically and judiciously prompt supervising
physicians to give you feedback on key issues, such as your case presentations, notes (including
H&Ps), and physical examinations. For example, you might ask your resident or attending to
examine a patient with you at a time that is mutually convenient. Any discrepancies between your
examination and the supervising physician’s are a form of feedback. You could also ask
supervising physicians for tips on how to do certain things well; people may be more forthcoming
with advice on how to excel.
History and Physical Examination Write-Ups
All students should have an attending or resident review an H&P, either in writing or in person. If
you have not had an H&P reviewed by the end of the third week at RR-UCLA Medical Center,
please copy one and I will do this myself.
You are free to refer to a handout that is posted on Angel on how to do a proper H&P to ensure
you include the desired content in all your medicine H&Ps. To write excellent H&Ps, you may
want to interview and examine your patients, then read about their problems in a textbook or
another source. Following this, return and re-interview and re-examine your patient to make sure
you have all the details covered. Your H&Ps will likely be more polished if you take the time to
do this.
We will ask all interns, residents, and attendings who work with you for more than three or four
days to submit an evaluation on your behalf. Please complete the form at the end of this document

at the conclusion of your rotation and submit it to Neveen El-Farra, the Site Director at Ronald
Reagan-UCLA Medical Center. Please also indicate which residents and interns were excellent
teachers; those selected will receive a commendation to recognize their efforts (attendings are
evaluated separately).
Before the grading meeting, the Site Director summarizes the ratings and comments into a
summary evaluation for the RR-UCLA Medical Center site. At the grading meeting, all the
site directors meet and the two site grades are summarized into a course grade. Since 2005,
the requirement for passing is a raw exam score of 67 (14th percentile). The criteria needed
to earn a Letter of Distinction include an outstanding performance in both 4 week blocks of
the clerkship (that is scores of all or mostly 7), and a score of approximately the 80th
percentile on the Internal Medicine Subject Exam (the exact score is determined yearly by
the Junior Medicine Clerkship Committee). Letters of distinction are awarded by
unanimous vote of the Junior Medicine Clerkship Committee at its bimonthly meeting.

In Case of Problems
Occasionally, medical students experience difficulties with their supervising physicians or
disruptive problems in their personal lives. Misunderstandings occur. Sometimes, hopefully not
often, supervising physicians may have unrealistic expectations or behave in an inappropriate
fashion toward students. PLEASE LET ME KNOW ASAP if problems occur because it is much
easier to solve or mitigate them during the rotation. You can page me at 21714, email me at
nelfarra@mednet.ucla.edu, or call me at 310-267-9643. Once you let me know there is a problem,
we can formulate a mutually acceptable strategy for addressing it.
4. Tips for Success on Internal Medicine
Five main suggestions for succeeding on your internal medicine rotation:
One: Know your patients.
You will be expected to know your patients well. If you do this you will be the “go to” person for
your patients when anyone on your team has a question or wants something done. Sometimes, it
is the medical student that obtains that one missing, essential piece of information that will affect
patient management. If your patient is on a medication and you don’t know what it is or why the
patient is taking it, go the next step and find out. Be your patient’s advocate.
Two: Read-up on Issues As You Write Your H&Ps
Consider writing up your H&Ps in two stages. First, evaluate the patient as best you can, and
advise them that you will likely come back to ask them more questions and examine them again.
Second, create a list of conditions in the “differential diagnosis” for each major complaint and read
up on each one. Make a list of “pertinent positives and negatives” for each condition. “Pertinent
positives and negatives” include anything that would support or go against a condition being
present, or that would affect how the condition is managed. These include risk factors, symptoms,
signs, and complications of the condition(s) in question. Complications and associated conditions
may help make a diagnosis or influence management. After you have created this list, re-
evaluating the patient will enable you to make sure you include all of the pertinent positives and
negatives in your H&P. Reading as you write up your H&P will also enable you to understand the

diagnostic and treatment plan. Practice self-directed learning whenever possible; this is a skill
that will last you throughout your career.
Three: “Use Your Patient As Your Book.”
The days of memorizing lectures, syllabi, and texts are over. Your number one priority should be
to learn the complex clinical issues surrounding your patients in exquisite detail. You should read
about every diagnosis your patient has and understand why they have received each of the
therapies provided to them in the past and present.
There are several reasons your patients should be your focus, for the rotation and for the rest of
your career. First, your team expects you to learn and understand everything about your patient.
Your notes and presentations will be much better if you understand every detail. Second, it is very
difficult to focus on studying during your busy medicine rotation. Over the two months you will
cover a majority of the core Internal Medicine topics just by reading about your patients. Finally,
you will find that you follow and remember material much better when you tie it to a given patient
and their clinical situation.
For reading about your patients’ conditions, there are many review resources available through the
UCLA Medical Center home page.
Four: If You Want to Excel, Give Mini-Presentations
These are not expected of students, but going the extra mile to give one or two mini-presentations
relating to your patients has several advantages. A polished presentation will, hopefully, impress
your team and give them something concrete to write in your evaluations. It demonstrates
motivation and initiative, and it shows off your oral presentation skills.
But presentations are far more valuable than just for your evaluations. You will never know
material better than when you have to explain it to someone else; you may remember the content
of your medical student presentation(s) for the rest of your career. Mini-presentations can educate
every member of your team, including your attending, because medicine changes so fast and
because many UCLA patients have very unusual diseases. Your presentation may even alter your
team’s approach to a patient, particularly for clinical problems they have not encountered before.
To choose a topic, select a clinical problem that relates to one of your patients and that you find
particularly interesting. Let your resident know several days in advance that you would like to
give a ten-minute presentation on that topic during attending rounds. Make sure that the team will
also find the topic interesting and that they have not heard a presentation or lecture on it recently.
If you are planning to go into a field other than Internal Medicine, you can choose a topic from
that field, and teach your team what Internists should know about it. Then search MEDLINE for a
small number of high-quality review articles or other relevant literature. Organize your talk by
epidemiology, risk factors, pathogenesis, clinical presentation, physical findings, work-up (labs,
radiology, etc.), treatment, and prognosis.
Five: Let Your Natural Enthusiasm and Curiosity for the Novelty of Clinical Medicine Show
Medical student enthusiasm and curiosity are the very reasons faculty choose to work at academic
medical centers. You may not be able to perceive this but your positive attitude contributes
substantially to the mood and chemistry of your team.
5. Schedules

Monthly Call Schedule
The intern and resident call schedule can be found at http://www.amion.com/. The password is
ucla im (in lower case letters). For each resident and intern, you will see a designation: short,
long, off, designating their call schedule for that day according to the designated team (A-E).
Here is what each designation means:
       •   Long Call.
           o The team admits up to 10 patients.
           o The team typically starts receiving new patients in the afternoon and continues
             admitting overnight.
           o You should leave by 12 midnight or 1 a.m. You may ask your resident if you can
             sleep in a housestaff call room if you are too tired to safely drive home. You MAY
             NOT stay to work later than 1 a.m.

       •   Off
             o The team will not admit any new patients.
             o Post-Call days:
                         When an “Off” day follows a Long Call day, the team is “post-call.”
                         On these days, attending rounds start at 7:30 a.m. and the team leaves by
                         1 p.m.

       •   Short Call.
             o The team admits up to 3 patients.
             o The team typically starts receiving new patients in the morning; until they reach
               their cap or until 4 p.m.

       •   C = Clinic, Not Admitting.
           o The resident or intern has clinic in the afternoon and is not admitting.

Days Off
Students get three days off during their four weeks at RR-UCLA Medical Center, plus the
weekend off between the first and second blocks, which equals eight days off during the eight
week rotation (per Course Director). If approved by the team resident or attending, you may take
up to two days off together in order to attend conferences, family events, weddings, or for other
reasons. Long and short-call days and Discussion of Major Diseases days should not be taken off.
You may choose to use ONE of your three days off the day before the final exam; this is NOT an

extra day off because some students have doctoring that day. Likewise, holidays are not extra
days off. Please pick tentative dates meeting these criteria then ask for your resident’s or
attending’s approval.
Daily Rounding Schedule
See the grid below for the sample schedule with delineated times. Here is what the categories
     •   Pre-Round.
           o At a minimum, read night float notes on the board in the team office, interview and
             examine patients, check charts for new orders and consult notes, ask monitor nurse
             about overnight events, and check labs and radiology results. This may take up to
             half an hour per patient until you become comfortable with the system.
           o To come across as polished as possible to your team, write most of your daily
             SOAP note during pre-rounds, (write the subjective and objective parts and outline
             the assessment and plan). Allow a few extra minutes to look things up before
             meeting with your team. This will increase the sophistication of your assessment
             and plan.
     •   Work Rounds
           o Most Days = Resident Rounds.
                      Ideally, you should see some patients with your resident and present your
                      patients. At a minimum, make sure you go over each patient’s assessment
                      and plan with your resident before you present to the attending.
           o Post-Call Days = Attending Rounds (see below).
     •   Attending Rounds
           o You should present each patient in about five to ten minutes. Follow the SOAP
             note format but include only the most relevant information to keep the presentation
             concise and focused on the key reasons the patient is in the hospital. Attendings
             will vary in the level of detail they want and whether they expect students to
             present from memory. In general, it is better to err on the side of a more concise
             presentation than to give a long, rambling one; attendings can always ask questions
             if you leave out a detail they want to know.
     •   Student Didactics (mandatory)
           o Discussion of Major Diseases: Monday, Wednesday and Friday
           o Chief Resident Physical Diagnosis Rounds: Monday after DMD
     •   Resident Didactics
           o Mandatory for students: Grand Rounds, Ronald Reagan Auditorium (B-130)
                                         Time: 8:30 to 9:30 am on Wednesdays
           o Optional for Students:
                      Morning Report:

                          •   Location: Medicine Library.
                          •   This is a case-based conference for the residents. Generally, the
                              cases are going to be unusual diagnoses and quite challenging, but
                              there are plenty of learning opportunities so please make every
                              effort to come!
                          •   Currently morning report takes place from 8 to 8:45 a.m. on
                              Mondays, Tuesdays, Thursdays and Fridays. Please refer to the
                              monthly morning report schedule for details regarding presenters
                              and any changes to the schedule. The monthly morning report
                              schedule can be obtained from the chief residents.
                      Noon Conference:
                          •   Location: Please refer to monthly conference schedule. A copy of
                              this schedule can be obtained from the chief residents.
                          •   Time: Noon to 1 p.m.
                          •   This is a lecture series for residents on basic topics of Internal
                              Medicine. You are welcome and encouraged to attend.

**The weekend schedule varies with the call cycle and team preferences. Check with your
resident before you leave to determine when to meet.

I encourage you to refer to The Primer to the Internal Medicine Clerkship posted on Angel for
further tips on how to excel during your clerkship. This primer serves as a guide and is produced
by the clerkship directors in internal medicine.

         Monday               Tuesday              Wednesday         Thursday             Friday               Saturday           Sunday
6:00     6:30? Pre-Round      6:30? Pre-Round      6:30? Pre-Round   6:30? Pre-Round      6:30? Pre-Round

7:00     7:30? Work           7:30? Work           7:30? Work        7:30? Work           7:30? Work           7:30? Pre-Round    7:30? Pre-Round
         Rounds with          Rounds with          Rounds with       Rounds with          Rounds with
         Resident             Resident             Resident          Resident             Resident
8:00     8:00-8:45            8:00-8:45            8:30-9:30         8:00-8:45            8:00-8:45            8:30? Work         8:30? Work
                                                                                                               Rounds with        Rounds with
         Morning Report       Morning Report       Grand Rounds      Morning Report       Morning Report
                                                                                                               Resident           Resident
         8:45-9:30            8:45-9:30                              8:45-9:30            8:45-9:30
         Review your          Review your                            Review your          Review your
         patients &           patients &                             patients &           patients &
         presentations with   presentations with                     presentations with   presentations with
         your resident        your resident                          your resident        your resident
9:00     9:30-11:30           9:30-11:30           9:30-11:30        9:30-11:30           9:30-11:30           10:00? Attending   10:00? Attending
         Attending Rounds     Attending Rounds     Attending         Attending Rounds     Attending Rounds     Rounds (varies)    Rounds (varies)

12:00    12:00-1:00 “Noon     12:00-1:00 “Noon                       12:00-1:00 “Noon     12:00-1:00 “Noon
         Conference”          Conference”                            Conference”          Conference”
1:00     1:00-2:00 DMD                             1:00-2:00 DMD                          1:00-2:00 DMD

2:00     2:00-3:00 Physical
         Diagnosis Rounds


*Post-call days: Attending Rounds start at 7:30am.

                     With Who Did You Work, and Which Residents and Interns Were Excellent Teachers?

Please indicate the attendings, residents, and interns you worked with during this rotation. We use this information to determine who
should evaluate your performance in this course. Do not include individuals whom you worked with for fewer than three days as they
may not have enough information to comment. If a resident or intern was rotating from another program (e.g., VA, Harbor,
Psychiatry at CHS), please indicate this on the form below; it makes it easier for us to find them. For residents and interns especially,
the correct spellings of their names and their actual names rather than nicknames are appreciated as this will make it easier to find
them in the email system.

After you have listed the names, please consider which interns and residents were particularly excellent teachers and type/write “Yes”
under “Excellent Teacher” next to their names. They will receive a “Commendation for Excellence in Medical Student Teaching”
after the final course grades have been prepared. Currently, this is the only mechanism by which students evaluate residents and
interns at RR-UCLA Medical Center. Attendings are evaluated during a formal evaluation process at a later date.

Student Name                  Team Attendings                  Residents (R) and Interns (I)     Excellent       Rotator from VA,
                                   (Evaluated Later)                                             Teacher?        Harbor, or Another
                                                                                                                 Department at RR-UCLA