Orientation on day one, they will go over grading criteria, basic expectations, and give you a so-called 'power-chart' training which is so brief that if you blink, you'll miss it, so before hitting the wards, or that first day, call the IT people to make sure you are on it, and then get on it and spend an hour figuring where to find everything. You will be place on a team with 1 resident, 2 interns, possibly a sub-I and 1-2 med students. You'll have a team room on the 5th floor of the hospital that is your home base. You can leave your bag, books, etc. in there. There are computers in the team room, but remember that the resident and interns always have priority over you. Most team rooms have a fridge where you can store a lunch.
Typical day: Morning report is at 7:45 and you have to have seen all your patients, done the physical exam, and written your note by 7:40 so you can make it to morning report on time- what time you need to show up in the morning depends on how many patients you are following and how long it takes you to get your stuff done. Remember, if you haven't read up on your patients problems and you are not adequately prepared to defend your plan for the day, you'll need to show up earlier to do the reading you need to do. Usually show up 6:00 to 6:30. Morning report goes from 7:45-8:45-8:50. Look up those lab values that you were waiting for that hadn't come back yet, and be ready to round by 9:00. Most teams meet in the team room before heading out. Some attendings round in the team room, some round in the halls outside the patient rooms and then you go in to see them after saying hi, and some do bedside rounds (if you do this, know your plan in and out and be careful of what you say in front of the patient! -leave crazy psych or emotional stuff out, and don't say stuff in a differential that is going to give the patient a heart attack or make them super defensive...yes I did this). Rounds usually take a few hours, but it depends on your attending and how many patients are on your service. After rounds, help get stuff ordered and arranged for your patients. Do reading. Some attendings assign you a topic to research and give them a presentation on during this time. 12:30-1:30 noon conference. You must attend. They usually have lunch for you. One day a week you will have to attend science of medicine instead of noon conference, and one day a week after noon conference you will have topics in medicine w/ the chief resident who will teach you about EKGs, ABGs, etc. 1:30 to whenever... Either you will have new patients to work up, more work on your current patients, check in on them, or research to do on your patients' problems. End of the day= when the resident tells you to leave. Never just leave without finding out what else needs to be done.
Schedule: Q4 call. Long call, post call, short call, golden... and repeat. Long call- show up at 6 am and work all day and night (some residents allow students to switch off staying over night, some require all students to stay over night, I think being there over night can be a good educational opportunity sometimes, and sometimes is a waste). Post call- you've been there all night and you need to leave by noon (to stay within 30 hr work shift limits). Again, don't leave until the resident tells you to do so! Short call, your team admits until 5 on weekdays. You could be there until 5, or until 8. Golden, your team admits until noon. You could be there until 3 or 4. You get one day off a week. oh, and post-call rounds start at 7:00am instead of 9. You are not required to go to morning report or noon conference on post-call days. If you are on a specialty service, you don't have overnight call, but you will have long days (admits from 6-6 or so every day).
Responsibilities: Be on time. Know your patients inside and out. Know their problems. About their diseases- know what causes it, the epidemiology, the typical symptoms, the diagnostic work-up, and the treatment. If you want to reach honors, you have to take initiative yourself. The interns are not going to baby you so you can achieve this as most times it is just easier for them to do it themselves. You have to beat them to the punch in terms of knowing what tests to order, putting in the orders on powerchart for them to co-sign, making follow-up appts for the patients, etc. This is tough to do when you have to spend time away at 'awesome' science of medicine meetings, etc.
Read, read, read. Read a review book. Read on your patients (some attendings like you to read uptodate, and some hate it). Do questions. Make a schedule and goal of how many questions you'll do and pages you'll read every day or it will just fly by you and you won't have read anything. Be ready to be pimped and always sound like an idiot no matter how much you study, but let the pimping help your study. Some of these attendings know A LOT and what they pimp you on is extremely useful info.
How do you hide a dollar...
How do you hide a dollar from an orthopod? - Put it in a book.
How do you hide a dollar from an internist? - Put it in a wound.
How do you hide a dollar from a plastic surgeon? - You don't.
... a joke with a lesson... make sure you do a good physical exam on your patient. If they have an abnormality, know everything about it... pull the dressing out of the wound if you must. You are the one on the team with the most time, so you are expected to do this. Also, if you can't accurately describe a lesion or abnormality that you are sending for a consult, with the onset, frequency, severity, etc. of symptoms, they are just going to be annoyed with you for wasting their time. Doing a good exam can be difficult if you are going in there to see the patient for the first time with an intern as they end up doing most of it and you have no idea what they were noting as they were doing the exam. Either ask them or go back and do the exam again yourself.
As scary as it is- it is awesome, and I am loving it so far. Good luck, and see ya around.
Friday, July 31, 2009
Wednesday, July 29, 2009
What the hell is prn?
Hey guys...not to add more "useful" stuff, but I thought I'd share some pharm abbreviations if it was helpful. They are all abbreviations of latin phrases, which is why they look so confusing. I included the translation not to brag about my useless knowledge, but instead because sometimes it's easier to remember if you know the "why" behind all the seemingly meaningless random compilation of letters. Also, they are kinda in order to how often I ran into them while I was a pharm tech. Enjoy.
prn = "pro re nata" = as needed
q = "quaque" = every (example: qday = every day)
h = "hora" = hour
bid = "bis in die" = twice per day (can also be written q12h = every 12 hours)
tid = "ter in die" = you guessed it, three times per day (or q8h = every 8 hours)
qid = "quater in die" = four times per day (or q6h = every 6 hours)
po = "per os" = by mouth
hs = "hora somni" = before bed
ac = "ante cibos" = before breakfast-I've hardly ever seen this but it fits after "before bed"
stat = "statim" = immediately
gtt = "gutta" = drops
supp = suppository
sl = sublingual
iv = intravenous
Not latin, but other abbreviations (in the context of Rx):
SA = sustained action
SR = sustained release
LA = long acting
XR or XL = extended release
From the limited experience I've had with this, docs and pharmacists don't go too crazy with these, although theoretically you could write entire sentences. Mostly this will help with putting in orders (as these directions are given as options in the computer) and understanding what the hell they're talking about on rounds when they say "Mr. Parkinsons is getting levodopa/carbidoba qid (four times a day) with no improvement of his symptoms..."
Another common example is "Mr. PTSD is taking prazosin 10 mg po hs (by mouth before bed) for his nightmares."
Sorry for all the neuro correlates but I'm just finishing that rotation at the VA, which I will eventually blog about.
Miss you crazy kids....
Sunday, July 26, 2009
Not useful
Just so this blog isn't only about useful information, blah blah blah. Here's a riddle.
Two carts of viscera are sitting at the top of a hill;
both carts are pushed at the same time with the same force and sent down the steep decline.
Which cart reaches the ground first?
The one with the greater omentum (ha ha ha, knee slapping)
-Copyright: Jeff Horn
Two carts of viscera are sitting at the top of a hill;
both carts are pushed at the same time with the same force and sent down the steep decline.
Which cart reaches the ground first?
The one with the greater omentum (ha ha ha, knee slapping)
-Copyright: Jeff Horn
OB at the U
First of all, by way of dispelling stories of previous years about OB/GYN, the rotation as a whole is not nearly as soul crushing as some have made it out to be. The residents (at least this year) have all been great to work with, assuming you don't mind working hard.
Before you start the rotation. 1) You should get Powerchart access (pt. charting program for the U) if you don't already have it. This can be done by contacting IT at the U (google) and letting them know you're a medical student who needs to set up their account. 2) Sleep, or otherwise do whatever you need to do to bring your body up to speed for getting up at 4:00 in the AM. 3) On the first day, you have a series of lectures designed to orient you to the rotation, it's too much information to take in all at once, so write some of it down. Importantly, write down what your scrub locker number and combination are. On that point, during the aforementioned orientation, KPJ makes a point of telling you that it is unacceptable to wear your scrubs to and from the hospital (something about disease transmission, blah blah), one of the first things our chief said was, 'I know Dr. Jones doesn't want you wearing scrubs to work, but we get here at 5:00, and everyone wears scrubs to and from home.' So, do what you wish, but for me personally, the only saving grace when it comes to getting up at 4:00 in the morning is that I get to wear pajamas to work.
Typical work day: 1) arrive at 4:50, no later than 5:00. Meet up with the interns over on Labor and Delivery, drop your bags off there, and head over to 2N (postpartum wards). There, the interns print off an excel sheet that has all of the postpartum patients they need to follow on it with a very attenuated pt. history on each one, and some of the previous lab values. Split the patients up between the group of you, and see them with or without the intern (who also has to see your patients that morning) depending on their preference. Then, write a note (the format of which will be in your orientation materials) and have the resident look over and cosign your work. All of the patients need to be seen and have their notes written by 6:45, because of the mandatory attendance requirement for everyone at 6:45 board sign out, back on L&D. Scut work side note; one of the helpful things you can do here is ask, or figure out who is going home that day; everyone needs discharge paperwork filled out and put in their charts. (there are templates for this in your orientation materials as well). Then by 6:45 you head to L&D where the residents go through 'the board' (you'll understand when you get there) and talk about all of the patients currently on service or scheduled to come onto service that day. When that is over, interns and med. students head back over to 2N to present all of the patients they saw on morning rounds. (this is probably your best opportunity to shine during the rotation, so if your going to put your efforts in somewhere, this is probably the highest yield) You'll present at least one patient (likely more depending on how fast rounds need to go) to the chief and attempt your assessment and plan which will be looked over and most likely is 'continue post-op care' like 90% of the time. Then after rounds you all head back to L&D and sign up for patients on 'the board', introduce yourself to the patients you are following and do as much as you can to learn about their history and any complicating problems. Follow them throughout the day and hope that you get the opportunity to either be there/participate in their delivery or assist in the C-section. Additional side note, OB is unbelievably notorious for using acronyms for everything, so do whatever you need to, to get a handle on these early, it will help out. (there is a list of them in the orientation materials). Continue doing this, and whatever else you are asked to do (may not be much) until board sign out which happens at 5:30 during the week. This is essentially the same thing as the morning, except you are recapping the day for the residents coming on service for the night shift. After board sign out, linger just long enough to see if there's anything else that needs to be done, and then you're free to go home.
Call: you take call 5 times during your OB/GYN rotation regardless of where you do it. OB service takes call Sunday night through friday day, GYN is on from Friday night through Sunday day. IMC doesn't do student night call, the U does. If you take call during the week, you work during the day, stay on after board sign out, and work until the next morning. Protocol for making a graceful departure to the med student call room for some zzz's: work hard during the day and early evening, don't disappear for hours at a time, then you need to approach your chief resident and ask them if there's anything else that you can do, he or she should at that point either say 1) yes, do whatever the task is, and retry, 2) no, go to sleep, in which case you are golden until they page you, or you decide it is prudent to come back or 3) they say no, an nothing, in which case you can say well, if you don't mind I'm going to go to the call room for a little while, I'll be back soon, page me if you need me back here. (inevitably they don't need you and won't page you to come back, so if you're interested in helping with a c-section or doing a delivery yourself, you need to stay up).
Well, I know this is probably too much information for some, and not enough for others, but if you have other questions, feel free to ask me.
Note to my OB co-conspirators: feel free to add whatever you think is relevant.
Before you start the rotation. 1) You should get Powerchart access (pt. charting program for the U) if you don't already have it. This can be done by contacting IT at the U (google) and letting them know you're a medical student who needs to set up their account. 2) Sleep, or otherwise do whatever you need to do to bring your body up to speed for getting up at 4:00 in the AM. 3) On the first day, you have a series of lectures designed to orient you to the rotation, it's too much information to take in all at once, so write some of it down. Importantly, write down what your scrub locker number and combination are. On that point, during the aforementioned orientation, KPJ makes a point of telling you that it is unacceptable to wear your scrubs to and from the hospital (something about disease transmission, blah blah), one of the first things our chief said was, 'I know Dr. Jones doesn't want you wearing scrubs to work, but we get here at 5:00, and everyone wears scrubs to and from home.' So, do what you wish, but for me personally, the only saving grace when it comes to getting up at 4:00 in the morning is that I get to wear pajamas to work.
Typical work day: 1) arrive at 4:50, no later than 5:00. Meet up with the interns over on Labor and Delivery, drop your bags off there, and head over to 2N (postpartum wards). There, the interns print off an excel sheet that has all of the postpartum patients they need to follow on it with a very attenuated pt. history on each one, and some of the previous lab values. Split the patients up between the group of you, and see them with or without the intern (who also has to see your patients that morning) depending on their preference. Then, write a note (the format of which will be in your orientation materials) and have the resident look over and cosign your work. All of the patients need to be seen and have their notes written by 6:45, because of the mandatory attendance requirement for everyone at 6:45 board sign out, back on L&D. Scut work side note; one of the helpful things you can do here is ask, or figure out who is going home that day; everyone needs discharge paperwork filled out and put in their charts. (there are templates for this in your orientation materials as well). Then by 6:45 you head to L&D where the residents go through 'the board' (you'll understand when you get there) and talk about all of the patients currently on service or scheduled to come onto service that day. When that is over, interns and med. students head back over to 2N to present all of the patients they saw on morning rounds. (this is probably your best opportunity to shine during the rotation, so if your going to put your efforts in somewhere, this is probably the highest yield) You'll present at least one patient (likely more depending on how fast rounds need to go) to the chief and attempt your assessment and plan which will be looked over and most likely is 'continue post-op care' like 90% of the time. Then after rounds you all head back to L&D and sign up for patients on 'the board', introduce yourself to the patients you are following and do as much as you can to learn about their history and any complicating problems. Follow them throughout the day and hope that you get the opportunity to either be there/participate in their delivery or assist in the C-section. Additional side note, OB is unbelievably notorious for using acronyms for everything, so do whatever you need to, to get a handle on these early, it will help out. (there is a list of them in the orientation materials). Continue doing this, and whatever else you are asked to do (may not be much) until board sign out which happens at 5:30 during the week. This is essentially the same thing as the morning, except you are recapping the day for the residents coming on service for the night shift. After board sign out, linger just long enough to see if there's anything else that needs to be done, and then you're free to go home.
Call: you take call 5 times during your OB/GYN rotation regardless of where you do it. OB service takes call Sunday night through friday day, GYN is on from Friday night through Sunday day. IMC doesn't do student night call, the U does. If you take call during the week, you work during the day, stay on after board sign out, and work until the next morning. Protocol for making a graceful departure to the med student call room for some zzz's: work hard during the day and early evening, don't disappear for hours at a time, then you need to approach your chief resident and ask them if there's anything else that you can do, he or she should at that point either say 1) yes, do whatever the task is, and retry, 2) no, go to sleep, in which case you are golden until they page you, or you decide it is prudent to come back or 3) they say no, an nothing, in which case you can say well, if you don't mind I'm going to go to the call room for a little while, I'll be back soon, page me if you need me back here. (inevitably they don't need you and won't page you to come back, so if you're interested in helping with a c-section or doing a delivery yourself, you need to stay up).
Well, I know this is probably too much information for some, and not enough for others, but if you have other questions, feel free to ask me.
Note to my OB co-conspirators: feel free to add whatever you think is relevant.
Tuesday, July 21, 2009
Internal Medicine at the VA
Internal Medicine at the VA
Paperwork you had to fill out to get there, what, when by, etc.
You will get an email with the details of what you need to get done before the rotation. It takes a LONG time (6-8hrs) to get stuff done to prepare for the VA the first time you come, so plan accordingly.
Step 1 – Do the VA online trainings - VA Cyber Security, VA Privacy Policy, Providing a Safe and Secure Environment for Health Care (http://www.saltlakecity.va.gov/woc/). They are very similar to trainings we do for the U and IMC—long and tedious. Follow the instructions you get from the orientation packet and/or student checklist they emailed you. The “Providing a Safe and Secure…” is the most tedious—you have to print out an answer sheet and take it like a bubble sheet test (with around 50 questions!). The other two are kind of weird to access; just follow the instructions the email. The cyber security one (aka Information Security Awareness) has quiz questions intermixed with slides. You can’t fail the quiz questions, so if you’re short on time don’t read too in depth. Print the certificate when you’re done. On the Privacy Policy training, you only have to have clicked through each screen, and then you’re done—no quiz. Print out the certificate when you’re done. Bring your two certificates and your completed bubble sheet to HR at the VA (they’ll email you a map with the location.
Step 2 – At HR, turn in your certificates and fill out more paperwork to get fingerprints done and to get your name badge. They’ll fingerprint you at HR and send you with a sheet to the library for your name badge.
Step 3 – At the library (again, follow the map to get there) give them the paper HR gave you, get your picture taken, and they’ll give you your name badge.
Step 4 – With a name badge you can finally do computer training (they won’t let you until you have one). Computer training last about an hour and is only done at 11:30am every day (or possibly noon—they’re in the middle of transitioning to 11:30am I believe, though). Associated with computer training is getting your computer access codes (I think they usually do it the same time as computer training, but I got mine just before in some other office).
Parking
If you want a VA parking pass, you need to fill out the sheet they emailed you with the orientation stuff, and then bring it, your registration, and your proof of insurance to the VA police trailer (see the map they sent you) before 11am. The police office is open from like 7am-11am, so if you want to get the pass, try to do it not on the day you do the HR and computer training stuff. You just won’t have time.
Alternatively, if you have an A, U, or E parking pass, there are lots to the west of the VA by the day care place and the swimming pool that are basically just as close to the VA as the VA lots. This is the way I’ve done it and it’s worked great.
Journal articles- how do different people/rotations expect you to present them (you can download DynaMed on your PDA, a good source to start your search for topic articles)
We have a journal club every Thursday. It’s pretty low key. They just email out some articles earlier in the week and tell us something to focus on and have ready for journal club. For example, on the first journal club week we were assigned to define 4 statistical terms from the paper, and then the 2-3 of us who actually did it reported about 2 terms each. I read the abstracts of the paper only and looked up my 4 definitions, and I didn’t get any intense questioning or anything. Like I say, it’s not really something to stress about.
SOAP/H&P format/presentation expectations
Presentations are expected to be organized and formal (depending on your resident and attending of course). When you have a new admit, you do a full H&P, and present accordingly. H&P is essentially the exact format we learned in physical diagnosis—S: CC, HPI, PMHx, PSurgHx, FamHx, SocHx, ROS, allergies, meds; O: Vitals, pertinent organ systems (too much better than too little), labs, studies (imaging, ekg, etc); A/P: Number and list each problem that needs be dealt with while they’re in the hospital, starting with the most significant/urgent and then write/say your plans to address that problem. Finish with disposition (expected plans and timing for discharge). Both the write-up and the oral presentations are long, so plan on it. Orally present in the exact format as the written H&P, adjusting to what the attending/resident prefer. Avoid interpreting anything (physical findings, labs, etc.) until the assessment/plan. Just report the finding/number.
If you’ve already admitted the patient and you’re just following daily progress, you don’t need to do the long H&P. Start with a short one liner to identify the patient and help the attending remember who it is that we’re working with (e.g. Mr. Doe is the 72 year old man with CAD, diabetes, and CHF admitted yesterday for evaluation of unstable angina). Next give significant 24 hour events (e.g. His chest pain returned at 10pm last night and was relieved by 2 nitroglycerin). Then go to the SOAP format with the info you gathered pre-rounding. S: report what the patient tells you has happened over the last 24 hrs and how they’re feeling now, focusing on pertinent symptoms. O: check and report the range of vitals all night (e.g. BP was 110-132/65-74. HR was 66-74…) and the Tmax (max temp) through the night (or just report “afebrile” if that was the case). You can’t get the current vitals from the computer, you have to go to the patient’s room or the nurses’ station and physically look at the chart for vitals through the night. Next report your physical findings, then labs and studies (which you should check while pre-rounding). Then discuss (knowing what you learned in the last 24hrs) what your plans are and any changes from previous (in the same method as before—in numbered order of problems).
Type up your notes. The H&P ends up being busy-work, but I try to finish early enough that the interns can copy and paste whatever they want from my note to save them time. Progress notes I write (with “Scribed by Benjamin Wilson, MS3” at the bottom) and then change the author name to the intern I’m under so they can check the note and sign it officially.
Day-to-Day what you do (i.e. intro day; every other day; you show up at __ a.m., then do, then…)
Intro day (if I can remember): general internal medicine orientation with Battistone at the U, then brief VA orientation with the chief resident, then meet your team and start getting used to logistics and expectations.
Other days – Q4 call. Generally show up about 6:30-7am and pre-round on your patients. Morning report is 7:45-9am or so, so you should get pre-rounding done before 7:45am. Morning report is a discussion of an interesting current case presented by one of the residents. You’ll get some pimping now and then. Rounds follow from about 9am-noon, where you present the patients you’re following as discussed above. You’ll also get called into tele rounds at some point in the morning where the team discusses cardiac patients with the cardiologists. Depending on the cardiology attending, this can be anywhere from low-stress chats about the patient to very strictly organized presentations with lots of detailed pimping, so ask around and see what level you should be prepared for. After rounds you have noon conference (which starts at 12:30pm, not noon). It’ll be a lecture on some topic, but the important thing is that you get food there. You’re expected to go to both it and morning report. The rest of the day is getting plans done. When you’re on call, your team covers any codes on the floor (not very common). You’re generally not expected to stay overnight with the team, but it depends on your resident. I’ve stayed over once. The call rooms are like small hotel rooms. If you don’t stay over, you will probably still stay until 9-10pm, and then you’ll still need to come back early the next morning (6am or so) because post-call rounds start at 7am. If you stayed overnight, you’ll probably get off with the interns around noon. If you went home and slept, you’ll probably stay until 2-3pm to help tie up loose ends for the interns. The day after post call you’ll be short call, where you do admits until about 4pm. You’re hours will typically be 7am-6pm or so. The day after that you’re golden and generally get off by 3-4pm. You’ll get one day off per week. Your resident will tell you when, often just a couple days before it comes (again, depending on the resident).
Books/resources
For the shelf, everyone recommends MKSAP for Students for practice questions. Alternatively, you could use USMLE World. For functioning in the clinic I would buy Maxwells and Pocket Medicine. They’re both way over-priced, but useful.
Location specifics… IMC /U of U/VA
The VA is across 500 S to the south of the LDS institute building (which is south of the Huntsman Center). Park west of the hospital. You’ll mostly be working on the 2nd floor of the main hospital building.
Lunch/Food
Lunch is provided during noon conference (pizza, pasta, or Panda Express). The only day you don’t get it is when you’re doing Topics in Medicine with Cannon. You don’t get any breakfast or dinner unless you’re on call, then you get both dinner and breakfast trays.
Where to put your book bags
Leave everything in the team room to which you’re assigned.
Hours per day/time for reading
Usually an average of 10-12 hour days, but quite variable. There is usually time for reading (or to write a long paper like I’m doing right now) in the afternoon or evening, but it all depends on the day.
Equipment that you need to have (little things to have; i.e. penlight, reflex hammer, etc.)
I’ve carried around my stethoscope and penlight, and I’ve gotten by just fine. A measuring tape may also be useful to carry around. I also keep my PDA Epocrates and Harrison’s with me on my phone, as well as Maxwells and Pocket Medicine for on-the-go references. Also, it’s really hard to find an otoscope or ophtalmoscope, so you may want to bring one from home (I’ve only brought and used mine once in 2 weeks).
Paperwork you had to fill out to get there, what, when by, etc.
You will get an email with the details of what you need to get done before the rotation. It takes a LONG time (6-8hrs) to get stuff done to prepare for the VA the first time you come, so plan accordingly.
Step 1 – Do the VA online trainings - VA Cyber Security, VA Privacy Policy, Providing a Safe and Secure Environment for Health Care (http://www.saltlakecity.va.gov/woc/). They are very similar to trainings we do for the U and IMC—long and tedious. Follow the instructions you get from the orientation packet and/or student checklist they emailed you. The “Providing a Safe and Secure…” is the most tedious—you have to print out an answer sheet and take it like a bubble sheet test (with around 50 questions!). The other two are kind of weird to access; just follow the instructions the email. The cyber security one (aka Information Security Awareness) has quiz questions intermixed with slides. You can’t fail the quiz questions, so if you’re short on time don’t read too in depth. Print the certificate when you’re done. On the Privacy Policy training, you only have to have clicked through each screen, and then you’re done—no quiz. Print out the certificate when you’re done. Bring your two certificates and your completed bubble sheet to HR at the VA (they’ll email you a map with the location.
Step 2 – At HR, turn in your certificates and fill out more paperwork to get fingerprints done and to get your name badge. They’ll fingerprint you at HR and send you with a sheet to the library for your name badge.
Step 3 – At the library (again, follow the map to get there) give them the paper HR gave you, get your picture taken, and they’ll give you your name badge.
Step 4 – With a name badge you can finally do computer training (they won’t let you until you have one). Computer training last about an hour and is only done at 11:30am every day (or possibly noon—they’re in the middle of transitioning to 11:30am I believe, though). Associated with computer training is getting your computer access codes (I think they usually do it the same time as computer training, but I got mine just before in some other office).
Parking
If you want a VA parking pass, you need to fill out the sheet they emailed you with the orientation stuff, and then bring it, your registration, and your proof of insurance to the VA police trailer (see the map they sent you) before 11am. The police office is open from like 7am-11am, so if you want to get the pass, try to do it not on the day you do the HR and computer training stuff. You just won’t have time.
Alternatively, if you have an A, U, or E parking pass, there are lots to the west of the VA by the day care place and the swimming pool that are basically just as close to the VA as the VA lots. This is the way I’ve done it and it’s worked great.
Journal articles- how do different people/rotations expect you to present them (you can download DynaMed on your PDA, a good source to start your search for topic articles)
We have a journal club every Thursday. It’s pretty low key. They just email out some articles earlier in the week and tell us something to focus on and have ready for journal club. For example, on the first journal club week we were assigned to define 4 statistical terms from the paper, and then the 2-3 of us who actually did it reported about 2 terms each. I read the abstracts of the paper only and looked up my 4 definitions, and I didn’t get any intense questioning or anything. Like I say, it’s not really something to stress about.
SOAP/H&P format/presentation expectations
Presentations are expected to be organized and formal (depending on your resident and attending of course). When you have a new admit, you do a full H&P, and present accordingly. H&P is essentially the exact format we learned in physical diagnosis—S: CC, HPI, PMHx, PSurgHx, FamHx, SocHx, ROS, allergies, meds; O: Vitals, pertinent organ systems (too much better than too little), labs, studies (imaging, ekg, etc); A/P: Number and list each problem that needs be dealt with while they’re in the hospital, starting with the most significant/urgent and then write/say your plans to address that problem. Finish with disposition (expected plans and timing for discharge). Both the write-up and the oral presentations are long, so plan on it. Orally present in the exact format as the written H&P, adjusting to what the attending/resident prefer. Avoid interpreting anything (physical findings, labs, etc.) until the assessment/plan. Just report the finding/number.
If you’ve already admitted the patient and you’re just following daily progress, you don’t need to do the long H&P. Start with a short one liner to identify the patient and help the attending remember who it is that we’re working with (e.g. Mr. Doe is the 72 year old man with CAD, diabetes, and CHF admitted yesterday for evaluation of unstable angina). Next give significant 24 hour events (e.g. His chest pain returned at 10pm last night and was relieved by 2 nitroglycerin). Then go to the SOAP format with the info you gathered pre-rounding. S: report what the patient tells you has happened over the last 24 hrs and how they’re feeling now, focusing on pertinent symptoms. O: check and report the range of vitals all night (e.g. BP was 110-132/65-74. HR was 66-74…) and the Tmax (max temp) through the night (or just report “afebrile” if that was the case). You can’t get the current vitals from the computer, you have to go to the patient’s room or the nurses’ station and physically look at the chart for vitals through the night. Next report your physical findings, then labs and studies (which you should check while pre-rounding). Then discuss (knowing what you learned in the last 24hrs) what your plans are and any changes from previous (in the same method as before—in numbered order of problems).
Type up your notes. The H&P ends up being busy-work, but I try to finish early enough that the interns can copy and paste whatever they want from my note to save them time. Progress notes I write (with “Scribed by Benjamin Wilson, MS3” at the bottom) and then change the author name to the intern I’m under so they can check the note and sign it officially.
Day-to-Day what you do (i.e. intro day; every other day; you show up at __ a.m., then do, then…)
Intro day (if I can remember): general internal medicine orientation with Battistone at the U, then brief VA orientation with the chief resident, then meet your team and start getting used to logistics and expectations.
Other days – Q4 call. Generally show up about 6:30-7am and pre-round on your patients. Morning report is 7:45-9am or so, so you should get pre-rounding done before 7:45am. Morning report is a discussion of an interesting current case presented by one of the residents. You’ll get some pimping now and then. Rounds follow from about 9am-noon, where you present the patients you’re following as discussed above. You’ll also get called into tele rounds at some point in the morning where the team discusses cardiac patients with the cardiologists. Depending on the cardiology attending, this can be anywhere from low-stress chats about the patient to very strictly organized presentations with lots of detailed pimping, so ask around and see what level you should be prepared for. After rounds you have noon conference (which starts at 12:30pm, not noon). It’ll be a lecture on some topic, but the important thing is that you get food there. You’re expected to go to both it and morning report. The rest of the day is getting plans done. When you’re on call, your team covers any codes on the floor (not very common). You’re generally not expected to stay overnight with the team, but it depends on your resident. I’ve stayed over once. The call rooms are like small hotel rooms. If you don’t stay over, you will probably still stay until 9-10pm, and then you’ll still need to come back early the next morning (6am or so) because post-call rounds start at 7am. If you stayed overnight, you’ll probably get off with the interns around noon. If you went home and slept, you’ll probably stay until 2-3pm to help tie up loose ends for the interns. The day after post call you’ll be short call, where you do admits until about 4pm. You’re hours will typically be 7am-6pm or so. The day after that you’re golden and generally get off by 3-4pm. You’ll get one day off per week. Your resident will tell you when, often just a couple days before it comes (again, depending on the resident).
Books/resources
For the shelf, everyone recommends MKSAP for Students for practice questions. Alternatively, you could use USMLE World. For functioning in the clinic I would buy Maxwells and Pocket Medicine. They’re both way over-priced, but useful.
Location specifics… IMC /U of U/VA
The VA is across 500 S to the south of the LDS institute building (which is south of the Huntsman Center). Park west of the hospital. You’ll mostly be working on the 2nd floor of the main hospital building.
Lunch/Food
Lunch is provided during noon conference (pizza, pasta, or Panda Express). The only day you don’t get it is when you’re doing Topics in Medicine with Cannon. You don’t get any breakfast or dinner unless you’re on call, then you get both dinner and breakfast trays.
Where to put your book bags
Leave everything in the team room to which you’re assigned.
Hours per day/time for reading
Usually an average of 10-12 hour days, but quite variable. There is usually time for reading (or to write a long paper like I’m doing right now) in the afternoon or evening, but it all depends on the day.
Equipment that you need to have (little things to have; i.e. penlight, reflex hammer, etc.)
I’ve carried around my stethoscope and penlight, and I’ve gotten by just fine. A measuring tape may also be useful to carry around. I also keep my PDA Epocrates and Harrison’s with me on my phone, as well as Maxwells and Pocket Medicine for on-the-go references. Also, it’s really hard to find an otoscope or ophtalmoscope, so you may want to bring one from home (I’ve only brought and used mine once in 2 weeks).
Saturday, July 18, 2009
Hardware
Just a couple of nuts and bolts type of things, if I left anybody out of the invite list, please let me know, I don't think I have a complete address list, though this is slightly complicated by the fact that we are only allowed 100 authors for the blog. That being said, we haven't maxed out our author list yet. So shoot me an email if you know somebody that wants to be able to post, with the thought that this is supposed to be for our class. Cheers.
Welcome to The Raphe Underground
The idea here is to have a place where anybody in our class can post ideas, advice, and most importantly, experiences that we have encountered on rotations. Feel free to bitch, moan, sympathize, call out, and humorize your posts. Hopefully this can be one more resource to stay connected during this year of school. As this site can be viewed by anyone, make sure that posts don't include too much identifying information... that could get you into trouble. Having said that, this blog is supposed to be about, and for the whole class, so make it what you want. Enjoy, and if you have any questions or suggestions, feel free to let me know.
Subscribe to:
Posts (Atom)