Transcript Professional Development Series: Part 2

Surviving the Clinical Years
What to Expect
 From the 3rd and 4th year clerkships:
 Long hours, lots of standing, system of hierarchy
 Rewarding, exhilarating experiences
 Clinical education/Learn! You’re still paying for it!
 Basis for choosing a lifelong career
Team Players:
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Ward/unit secretary
Dieticians
Pharmacists
Therapists: OT, PT, RT
Social workers
Techs/RMA
Nursing
Physician ancillary staff
Medical students, Interns, Residents, Fellows
Attendings
Custodians
Third Party Reviewers
Unit Secretary
 Also known as ward secretary or clerk
 Organizes everything
 Knows where every patient is
 Arranges transport
 Knows about incoming admissions
 Day to day operations
 Notes orders
Pharmacy
 Pharm.D: doctors of pharmacology
 Sometimes round with the team
 Monitor expensive and dangerous meds
 Helpful with hospital formulary
Therapists
 Respiratory:
vent settings, ABG specimens
 Occupational:
help impaired pts function more independently
 Physical:
focus on mobility and strength
Social Workers
 Help plan for discharge
 Solve non medical problems related to pt care
 Big role in psych, peds, gero
Third Party Reviewers
 “lurk” around the hospital preying on unsuspecting
newbies
 Be careful!
Technicians
 EKG
 Phlebotomy
 Radiology
 Can teach you tricks of the trade/clinical skills
RMA
 Registered Medical Assistant
 Perform routine administrative and clinical tasks to keep
the offices and clinics of numerous health professionals
running smoothly.
 Accredited Medical Assisting Programs are offered in
postsecondary vocational schools, junior colleges and in
colleges and universities. Postsecondary programs usually
last either one year or less which results in a certificate or
diploma or two years with an associate degree.
 There is no licensing for Medical Assistants, however, some
states require them to take a test or course before they can
perform certain job duties.
Nurses
 CNA
 LPN
 RN
 NP
 Nursing students
CNA
 Certified nursing assistants (CNAs), also known as nurses
aides, orderlies, patient care technicians, and home health
aides, work under the supervision of a nurse to provide
assistance to patients with daily living tasks.
 CNAs are responsible for basic care services such as
bathing, grooming and feeding patients, assisting nurses
with medical equipment, and checking patient vital signs.
 In addition to a high school diploma or GED, you'll need to
complete a 6-to-12 week CNA certificate program at a
community college or medical facility.
LPN
 Also Licensed vocational nurse (LVN)
 Working under the direction of physicians and
registered nurses (RNs), LPN nursing schools and
educational programs typically involve one year of
study and training at a hospital, community college or
technical vocational school.
 After earning a nursing degree through a stateapproved program, graduates must pass the National
Council Licensure Examination (NCLEX-PN).
RN
 Credentials can be acquired by completing one of these
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three programs offered at many registered nursing schools:
Associate's degree in nursing
Bachelor's of science degree in nursing
Nursing diploma
The most popular program is the associate's degree in
nursing, which takes an average of two-to-three years to
complete. Going straight for the bachelor's program takes
four years, and a nursing diploma can take three-to-five
years.
After completing any of these programs a nurse must pass a
national licensing examination (NCLEX-RN).
Nurse Practitioners
 Education: graduate, advanced education and clinical
training beyond their registered nurse preparation.
Most have master’s degrees and many have doctorates.
Master of Science in Nursing (MSN) or Doctor of
Nursing Practice (DNP) degree.
 Job duties: Order, perform and interpret diagnostic
tests such as lab work and x-rays • Diagnose and treat
acute and chronic conditions • Prescribe medications
and other treatments • Spend time
counseling/educating patients
Prescribing Rules for NP
Oklahoma
Advance Practice Nurses
are authorized by the Board of Nursing to prescribe as
Advanced Registered Nurse Practitioners, Clinical Nurse
Specialists, or Certified Nurse Midwifes subject to the
medical direction of a supervising physician. They have
prescribing authority and may obtain a mid-level DEA
number to prescribe CDS, Schedules III, IV and V, limited
to a seven day supply. The nurses have an Exclusionary
Formulary — a list of drugs they cannot prescribe. The
name of the Advance Practice Nurse will be placed on the
prescription label.
Nursing staff
 They provide the bulk of one to one pt care
 Can be an invaluable source of information
 Read the nurses notes
 First to observe changes in pt status
 ICU nurses are the best
Physicians Assistants/PA/PAC
 Physician assistants (PAs) are health professionals licensed to
practice medicine with physician supervision.
 PAs perform a comprehensive range of medical duties, from
basic primary care to high-technology specialty procedures. PAs
often act as first or second assistants in major surgery and
provide pre- and postoperative care.
 Programs offering baccalaureate degrees require a minimum two
years of college credits, and virtually all require health care
experience prior to admission.
 The average PA program takes 26.5 months to complete. The first
year generally is composed of classroom studies — the essential
medical sciences such as microbiology, anatomy, and physiology
— followed by a year of clinical rotations in private practice and
institutional settings.
PA
Oklahoma
 Physician Assistants have prescribing authority as set out by
their supervising physicians.
 They may obtain a mid-level DEA number to prescribe CDS,
Schedules III, IV and V. Prescriptions for CDS are limited to 40
dosage units with only (1) refill or a 10 day supply maximum
(whichever is smaller).
 Non-controlled drugs are limited to a 34 day supply with (2)
refills of a drug prescribed for the first time for the patient. A 90day supply or 100 dosage units (whichever is greater) of drugs
prescribed for chronic, stable conditions, may be prescribed.
 P.A.s have a Formulary that excludes certain drug categories.
 The name of the physician will be placed on the prescription
label with a slash/P.A. (Dr. Jones/PA)
Interns
 Doctors without prescribing privileges
 Longest hours in the hospital
 Most uncomfortable/possibly unfamiliar with the
hospital
 Most sleep deprived
 Lonely, stressed
Interns
 Take care of daily tasks as quickly as possible
 Discharge and transfer patients quickly
 Learn
 Sleep
 Wont do a lot of teaching
 More interested in how to accomplish practical tasks
than have academic discussions.
 Broad, general approach to treatment/extreme
thoroughness
Residents
 2nd year post medical school
 Prescribing privileges
 Don’t do intern scut work
 Have more time to teach students
 Rely more on experience that the intern broad- based
approach
 More focused exams
Fellows
 Are in subspecialty training
 Have completed residency
 Often on attending level of knowledge without the
experience
Attendings
 Leader of the team
 Responsible (maybe) for your eval/grade
 Concerned about patient care and teaching
 Responsible for everyone
Consultants
 Subspecialty attendings and their team of residents,
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interns, students
Called in to give expert opinion/answer a specific
question. Do not write: “Evaluate this patient.”
Verbal feedback and formal consult note
Do not write orders on the chart
May or may not follow the patient
Med students
 That’s you!
 Even though you may feel like an unimportant,
redundant part of the team, the more responsibility
you take on, the more of an asset you will become.
 Your main goal is to learn and decide on a career in
medicine.
 Your secondary goal is to get good grades and
connections by making a good impression on your
superiors
 You have to balance these 2 roles between scut work,
feelings of inferiority, and competition.
Med Students
 This will be the easiest time to learn from a book, but
you also have the least amount of time available.
 Very tempting to “quit” at the end of the day.
 Opportunity to know your patients inside and out.
 Be proactive and speak up.
Daily Routine
 Managing patients: leaving, coming, and staying
(reviewing charts, writing notes, procedures,
dictations, reviewing films)
 Attending lectures
 Learning/Presenting/Studying
Daily Routine: Pre- Rounds
 6 am: Interns and students arrive to see patients,
review overnight events and admissions, write notes,
order am labs/tests.
 Pay attn to overnight events: new meds/impt
vitals/new symptoms and signs/new labs
 Talk to the nurses.
Daily Routine: Pre- Rounds
 630-7 am: residents arrive to see, patients, review
intern and student notes, check orders.
 Interns usually present new patients but this can be
handed off to students.
 Interns and students give an informal/formal reports
to the residents.
Daily Routine:
 8am: Attending arrives to see all patients.
 Goal is to present each patient with a plan for
treatment.
 Students, interns, and residents give formal
presentations to the attending.
 Attendings will modify plans, write addendum notes,
and teach.
Daily Routine:
 Could attend morning report/department meeting
with case presentations prior to attending rounds.
Daily Routine
 The team may go to radiology to look at films or be
called to the ER to see a patient.
 Depending on the length of rounds, the team may or
may not have breakfast. Could work through until
lunch.
 After rounds, the attending may leave for outpatient
clinic or may join the team for breakfast.
Daily Routine:
 If the attending does leave after breakfast, the team
will continue assessing lab results, new patients, ER
consults.
 Minus a break for breakfast, this type of work
continues until noon conference.
 Noon conferences are usually some type of learning
opportunity and food: grand rounds, student lectures
Daily Routine:
After lunch:
 New admissions
 continue to f/u up on labs/tests
 Go to department meetings/and or outpatient clinics
 Day could end at 4pm or, depending on if the
attending wants to do afternoon rounds, go well into
the evening.
 Check out to the night staff
Daily Routine:
 Differences in surgery: bump everything up by 1.5 to 2
hours
 Day usually ends by 5pm for students
Admissions
 Review old charts
 Orders/flag them
 ADC VANDALISM
ADC VANDALISM
 Admit to ? Service, ? Doctor, ? Contact number
 Diagnosis: list primary suspected/important
secondary
 Condition: critical, guarded, poor, stable, air, good
ADC VANDALISM
 Vitals: q shift, q hour, daily weights. Call house officer
if temp more than 102’F
 Allergies: NKDA, ASA, sulfa
 Nursing: FSBS q ac and hs, guaiac stools, isolation,
Foley cath or in/out cath
 Diet: NPO, clear liquids, full liquids, soft mechanical,
ADA, Renal, low sodium, low protein. Specify calories
ADC VANDALISM
 Activity: ad libitum, bedrest, walk with assist,
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restraints, commode at bedside, self toilet
Labs: fasting lipids, cbc, cmp, ua, lfts
IV fluids: KVO, heplock with flushes, dextrose (D5W),
normal saline (NS), potassium (K)
Specials: RT, PT
Meds: don’t forget renal or hepatic dosing
Other tips:
 STAT orders need verbal verification with the ward clerk
 Frequently review the MAR to see how often the prn meds
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are actually being given, if a patient is refusing meds, meds
added or discontinued by the house officer
Use only approved abbreviations
Sign and date every order.
Be overly clear by using words like change this to that or
replace x with y
Verify the correct chart
Use generic drug names
Other tips:
 TID means through waking hours vs. q 8 hrs means
exactly that!
 Balance prn orders with close follow up. Check the
MAR to see how often they are getting pain meds.
Consider tylenol dosing when looking at pt temps.
 Ped meds need to be adjusted for body weight
 Be prepared to be pimped on the drugs you order.
Know them well.
Admit note:
 Informants
 CC: precise and to the point
“chest pain and nausea later ruled an MI in the ER”
 HPI: chronological order/pertinent positives and
negatives. “no radiation or SOB”
 PMH/PSH:
 Meds/All:
Admit note:
 Developmental Hx and Immunizations (for peds)
 Psych Hx (for psych)
 OB/GYN (for OB/GYN)
 SH (include pets and home smokers in peds)
 FH
 ROS: often redundant if HPI is done well
 PE (include height in peds)
 Labs: ER, pending
Admit note:
 Problem list/assessment/diagnostic impressions: can
list differential diagnoses
 Plan
Daily Progress Note:
Subjective: pt and nursing reports
Objective: vitals, i/o’s, PE, labs, meds
Assessment
Plan
Discharge Note
 Serves as temporary dictated d/c summary
 Dx
 Hospital Course: interventions, studies, sx
 D/c meds “see orders”
 D/c instructions
Discharge Orders:
 Discharge to home, nursing home, etc
 Diagnosis
 Meds
 Follow up appt
 Instructions
Surgery
 Before each case review the anatomy and
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pathophysiology
Prepare for a potentially hostile environment
Lots of pimping
Touch as little as possible
Surgery etiquette
Surgery notes
Preop note
 S:state the procedure
 O: labs, cxr, ekg, consent
 A:
 P: NPO, consider meds (insulin, blood thinners)
Surgery notes
PPP SAFES FCDD
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Operative note:
Pre-op dx
Post op dx
Procedure
Surgeon names
Anesthesia
Fluids
Estimated blood loss
Specimens
Findings
Complications
Drains
Disposition
Surgery notes
Daily progress notes
 S: pain reports, flatus, bm, diet
 O: VS (tmax/with meds), i/o’s, include wound on PE,
labs especially WBC, hgb/hct
 A: post operative day #
 P: don’t forget to d/c foley caths and change central
lines
OB
Delivery note:
 Stage 1: 23 yo G1P1 at 38 weeks presents with
PROM/document time of presentation to completion
of Stage 1. Anesthesia/other drugs/quality of fluids
 Stage 2: Length of active labor/tools used in
delivery/describe rotation of occiput and position of
delivery (breech, footling), nuchal cord, baby wt,
APGAR, sex
 Stage 3:placental delivery, EBL, episiotomy or degree of
tear
Neuro tips:
 Include more extensive cognitive exam: LOC, GCS
 Orientation, speech language, memory, cognition
 Cranial Nerves I-XII
 Motor function: tone, bulk, strength
 Coordination
 Sensory
 Reflexes
Psych
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MMSE:
General appearance
LOC
Attn/Conc
Speech
Orientation
Mood/affect
Thought form and content
Memory
Judgment
Intellect
Final Tips
 Use index cards with pt stickers
 Electronic options
 Reading list
 Procedure list
Sources:
How to be a Truly Excellent Junior Medical Student
by Robert J. Lederman,MD
Get this book!