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).