Inpatient Rotation

 

The following section will describe the hospital-based 4-week rotation.  There will be different daily schedules at each of the hospitals.  You will be oriented to each hospital on the first day of your rotation.  Each hospital site will provide a separate monthly schedule to rotating students.

 

A.        Team Structure and Roles

 

The beginning of education lies in imitation, wherefore pick someone worth imitating.

            --Martin H. Fischer M.D., 1940

 

Most teams consist of an intern (sometimes two), a team captain (a PGY-2 or PGY-3 resident), acting interns (UC IV), and a faculty attending.  The intern to whom you are assigned will assist you in the day-to-day care and management of your patients, observe your physical examination skills, review your history-taking, and discuss disease processes and treatment plans with you.  The resident will supplement this teaching.  The attending physician will meet with you in Attending Rounds and also separately to review patient cases or practice physical examinations at the bedside.  You will be included at all levels of team discussion and decision-making.  Feel free to discuss any problems with your senior resident or the medical Chief Resident at the site at any time.

 

B.        Attending Rounds and Conferences

 

Think in the morning.  Act in the noon.  Eat in the evening.  Sleep in the night.

            --William Blake, 1757 – 1827, The Marriage of Heaven and Hell [1790-1793], Proverbs of Hell, l. 41

 

As a clerkship student, you are expected and entitled to attend educational sessions before all other activities.  The list includes:

 

            1.         Attending Rounds:  This session is designed for attending-led teaching and discussion of topics related to patient cases, or of textbook and literature review.  On post-call days, you will be asked to orally present the previous night’s admissions.

 

            2.         Medical Grand Rounds:  This weekly conference is the signature lecture of the department, usually featuring a guest or expert speaker covering a contemporary medical topic.  It is required of all students and house staff.  Students will attend Medical Grand Rounds at the hospital in which they are rotating.

 

            3.         Chief’s Physical Diagnosis Rounds (UH and VA only):  This conference was specifically developed for the third-year inpatient clerkship.  One afternoon per week (the Chief Residents will inform you as to which day), the Chief Residents at both University Hospital and VAMC will meet with you for bedside review of interesting physical exam findings.  Specific times for these rounds will vary by rotation and will be announced at the clerkship orientation.  Attendance at Chief’s Diagnosis Rounds is required.

 

            4.         Flessa Rounds:  These are clinically based microscopic hematology slide reviews presented by Emeritus Professor, Dr. Herbert Flessa.  Attendance is required of UH and VAMC students (Good Sam/Christ/Jewish students are encouraged to attend), and the scheduled time slot is Wednesday 1:30 pm once a month (actual dates will be announced each rotation).  Attendance at Flessa Rounds is required.

 

Curriculum

 

                        a.         Microcytic hypochromic anemia (iron deficiency)

                        b.         Untreated pernicious anemia, bone marrow

                        c.         Acute promyelocytic leukemia

                        d.         Chronic lymphocytic leukemia

                        e.         Multiple myeloma

                        f.          Primary thrombocythemia

                        g.         Ringed sideroblasts

                        h.         Thrombotic thrombocytopenic purpura

                        i.          Acute myeloblastic leukemia

 

 

            5.         Houk Rounds:  These are clinically based rheumatologic case reviews presented by Dr. Lawrence Houk, a practicing rheumatologist.  Attendance is required of all inpatient students and the scheduled time slot is Friday 2:00 pm once a month (actual dates will be announced each rotation).  Attendance at Houk Rounds is required.

 

            6.         EKG, Morbidity and Mortality Conference, Clinical Pathophysiologic Conference, etc.:  There are other conferences at which you are expected to attend on a weekly or monthly basis and are noted on your monthly schedule.

 

            7.         Professors’ Rounds Lectures:  These are considered the core lectures of the course.  The lectures are held every Thursday afternoon during the rotation at 1:30 pm in room 6051 MSB (except the last week of the rotation when they are held on Tuesday).  All students - no matter where you are rotating - are expected to attend.  This material will appear at the end of the rotation on your Professors’ Rounds exam, and will form the groundwork for the more extensive NBME exam.  Please read the syllabus material before you come to class, and be prepared to discuss the handout material, any textbook reading assignments, and case-based problem sets that are included in the syllabus for each lecture ahead of time - the speaker may ask questions and expect group interaction.

 

C.        On-Call and Schedules

And the sooner it's over, the sooner to sleep;  And good-bye to the bar and its moaning.

            -- Charles Kingsley, 1819 – 1875, The Three Fishers [1851], st. 3

 

As a member of a ward team, you will take call with your team.  Evening time is provided for you to read up on new patients, follow-up on patients already in-house, and participate in interesting clinical scenarios (i.e., codes, procedures, and physical exam findings).  Please use this time to prepare your presentations for rounds the next day, and review the history and exam findings with your intern or resident that evening. 

 

            1.         Switch Weekend - at the end of the first four-week block of the clerkship, those students scheduled to take call through that Saturday night are expected to do so.  All students are expected to round through Sunday but not take call that evening after their clinical responsibilities are done.  They are expected to report on Monday morning at their new site (times will be announced).

 

            2.         Holidays - as defined by the team call schedule.

 

            3.         Exam Week - students are excused from clinical duties on the inpatient rotation at noon on the Thursday prior to the examination.  Students are expected to report that day for duties.

 

            4.         Excused Absences - up to 2 days/excused absence are allowed during the 8-week rotation before remediation of the clerkship is required.  All excused absences must be cleared through the IM clerkship director first; clearing an absence through your resident is not sufficient.  Absences are only for illness or death in the family.

 

D.        Patient Admission Databases (H & P)

 

You are required to complete 8 H & P’s during the inpatient portion of the clerkship.  Make a copy of all of your H & P’s (omit the patient name and ID) to give to your attending for review.  The attending will comment on strengths and areas that need improvement.  A copy of at least 8 H & P’s must be turned in to the Office of Medicine Student Education by the day of exams to pass the course.

 

E.         Bedside Clinical Exercise

 

During the hospital rotation, you will perform an attending-observed history and physical exam on an unfamiliar patient.  At the end of the H & P, you will orally present the pertinent history, physical exam findings, differential diagnoses and diagnostic tests to the attending.  The entire session should last between 60 to 90 minutes.  The H & P evaluation form is included in this syllabus and must be turned in to take the exam.  The observed H & P will be graded as Pass/Fail and is a required element in order to pass the clerkship.

 

F.         Standardized Patient Clinical Experience

 

During the first week of your inpatient rotation, you will be scheduled a specific time in the Center for Competency Development and Assessment (CCDA) to take a comprehensive history on a standardized patient (SP).  The patient will present to you, the student on-call for Internal Medicine, with a common medical complaint and commonly encountered internal medicine diagnosis.  You will have the opportunity to interview the patient for approximately 60 minutes to obtain a complete history, including history of present illness, review of systems, past medical history, medications, family history, social history, and sexual history.  Please review the example history and physical in your syllabus (pages 24-29) to assure that you include all of the necessary elements in a complete inpatient history.  You may not use the database template or other references to prompt you during these exercises, but you may take notes during the interview.

 

The intent of this exercise is to give you an opportunity to practice essential skills of history-taking which include:  appropriate self-introduction, asking open-ended questions, asking directed follow-up questions, treating the patient with empathy and respect, asking sensitive questions, avoiding medical jargon, and attentive listening.  At the end of your history-taking session, you will be asked to self-evaluate your performance and you will receive feedback from the standardized patient in these areas.  You will be provided with the patient’s pertinent physical examination finding and laboratory findings.  You will write up the elements of the history that you obtained and formulate a problem-oriented assessment and plan on the form provided.  The due date for the completed database will be listed at the top of your form. 

 

You will be provided feedback on your history-taking skills and assessment and plan as soon as possible such that you may use this information to improve your skills throughout the internal medicine rotation.  The intent of this exercise is to be a learning experience and to provide feedback.  However, the rare student may be requested by the course director to repeat the exercise at the end of the inpatient rotation, if the initial performance is far below expected standards.  It is assumed at entry to the internal medicine clerkship that the student has learned basic physical examination skills as well as skills of differential diagnosis during the CFMP courses.

 

General Daily Schedule (details vary per site)

 

 

            1.         You will need to “pre-round” on your patients every morning (before team work rounds).  This means reviewing the chart for any notes from the previous day (things keep happening in a hospital, even overnight), seeing and examining your patient daily (you don’t need to do a complete exam every day; problem focused is fine), and recording the vital signs and any other important information for use later on rounds.  Anticipate needing between 15-20 minutes per patient each morning.

 

            2.         Next you will go on work rounds with your team.  Here you present your patients to the senior resident and discuss preliminary plans for the day.  Work rounds are usually held at the patient’s bedside, but vary per resident and the census of your team.  These presentations should be concise (important details, but quick); probably about 30-60 seconds per patient.  You will have time for more detailed and in-depth presentations with your attending.

 

            3.         Next is Attending Rounds, the meeting with your teaching attending to discuss patient care issues.  You will be expected to present patient data and demonstrate outside reading on your cases.

 

            4.         After Attending Rounds, schedules vary per hospital and there may be other conferences at which you are expected to attend or you may meet with your attending for further didactic or bedside teaching.  You may use this time for scheduling procedures, calling consults, family meetings, etc.

 

            5.         Noon Conferences are scheduled for most days and often include lunch.  They cover a variety of medical topics and are very educational.  You are expected to attend these daily unless you are directly involved with emergent patient care. 

 

            6.         Afternoons are usually times to catch up on patient care issues.  You will need to follow-up on all labs and studies performed on your patients every day.  This is the time to review consultant’s recommendations and make changes in your management plan accordingly.  Please don’t ever sign out at the end of the workday without checking these items on your patients.  If the labs are still pending, make sure the cross-cover team is aware and they will check them for you.  In general, you should expect to be present on the wards until ~ 5 p.m. on non-post-call days assisting your intern and learning about patient care issues.  If your team finishes early, you are also free to leave.  You must “sign out” with the intern/team leader prior to leaving your ward responsibilities.

 

 

Ambulatory Internal Medicine Rotation

 

A.        Introduction

 

The transformation of health care delivery over the past few years has been revolutionary.  The shift from a hospital based to an outpatient-based focus has had a major impact on medical care for both patients and physicians.  This shift in the venue for health care delivery has served as a catalyst for academic health centers to reexamine how we are training students for their future careers in medicine.

 

The University of Cincinnati College of Medicine has been one of the leaders in reshaping the medicine clerkship experience to incorporate an appropriate balance between inpatient and outpatient training.  The introductory material and the syllabus that follows, will give you the information you will need during your four-week ambulatory medicine rotation.

 

 

B.        Structure (Process) of the Ambulatory Medicine Rotation

 

The working day will typically begin at 8:00 am and end at 5:00 pm.  However, you may have some days beginning earlier or ending later, depending upon the clinic schedule.  The schedule contains several “½ day units” per week.  The self-study modules should be done in the blocks of time not already assigned.  Too often we see these modules left until the end of the month and hurried through which can cause availability problems.  These units are allocated among the various activities as follows:

 

            1.         Student Clinics:  (2- ½ day “units”):  The Student Clinics will be held at the Hoxworth Building, 2^nd Floor or the VA Medical Center (see your schedule for details).  You will be expected to work up, on average, 2-3 patients per clinical session.  Your faculty preceptor will work with you in developing diagnostic/therapeutic plans, arrange follow-up and refer patients when necessary.

 

            2.         Community Sessions:  (3- ½ day “units”):  The students will work in the office of a University or community-based faculty preceptor.  This will allow you to gain the knowledge and skills unique to providing health care to patients in a primary practice setting. 

 

            3.         Subspecialty Clinics:  (1- ½ day “unit”):  The sessions are designed to help you gain knowledge and skills in the evaluation of patients from a subspecialist consultant’s perspective.

 

            4.         Professor Rounds:  (1- ½ day “unit”):  These will be held on Thursday afternoons except for the last week of the rotation when the conference will be held on Tuesday afternoon. 

 

            5.         Student Ambulatory Conference:  (1- ½ day “unit”): These will be held on Tuesday afternoons in the morning report room of the University Hospital (Room 7104).  The sessions are designed to make you think through a series of cases as a group to develop your decision-making skills.  You will also be asked to make a short presentation on a drug assigned to you.

 

            6.         EKG Self-Study Tutorial:  This self-study module is designed for you to proceed at your own pace and to individualize your learning of EKG’s based upon your prior knowledge and experience.  It is designed to prepare you for your clinical rotations.  The web-based tutorial can be done on your own time either at home or at a computer in the medical center.  For more details, see pages 37-40 of this syllabus.

 

            7.         Dermatology Self-Study Module:  A CD ROM based educational tool that must be completed in the Clinical Skills Lab.  The CD ROM is a comprehensive review of hundreds of dermatologic conditions.  The parts of the program that are most applicable to general internal medicine knowledge and practice have been specified and those are the sections that are provided for your edification.  The staff in the Clinical Skills Lab will sign off that you have completed this module.  You will need to sign the sign-in sheet to document your participation in this part of the course.  Estimated time commitment:  2 hours.

 

            8.         Ophthalmology Self-Study Module:  Slides of common retinal abnormalities to review.  These slides are located in the Clinical Skills Lab.  You will need to sign the sign-in sheet to document your participation in this part of the course.  Estimated time:  30 minutes.  You will also view a video presentation at the end of your clinical skills session.  Only a portion of the entire video will be viewed.  These sections are as follows:  lids and anterior eye exam, papillary exam, ocular motility exam and ophthalmoscope.

 

            9.         Clinical Skills Training:  The staff in the Clinical Skills Lab will demonstrate venipuncture, arterial blood gas techniques, IV insertion, and nasograstric tube insertion.  Your competency to perform all four procedures in the lab must be signed off and verified by the staff.  A short demonstration on proper bag mask ventilation will also take place.

 

            10.       Nutrition in Medicine Module:  The module assigned to Internal Medicine is Diabetes and Weight Management.  Estimated Time:  2 hours.  See page 40 for specific information on accessing the module.

 

 

C.        Logbooks

 

The logbooks are an important educational tool in designing and modifying the ambulatory medicine rotation.  It also provides you with a record of your clinical activity during the month.  Logbooks MUST be filled out completely and accurately for all patients you work with during the rotation.

 

All logbooks must be returned to the Medical Student Education Office BEFORE you can take the written exam.

 

D.        Minimum Requirements to Pass the Ambulatory Medicine Rotation

 

All ambulatory clinic sessions, self-study modules and clinical skills sessions are required components of the clerkship.  Attendance is mandatory and failure to attend any session or failure to complete any component is grounds for failure of the clerkship as a whole.