Transcript Professional Development Series: Part 2

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:
•
•
•
•
•
•
•
•
•
•
•
•
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 and in peds
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 (NCLEXPN).
RN
• Credentials can be acquired by completing one of these
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 90-day
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 in 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, 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,
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
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
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
•
•
•
•
•
•
•
•
•
•
•
•
•
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
•
•
•
•
•
•
•
•
•
•
•
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
Source of Support
OSU-Tulsa graduate students provide services under
the supervision of a faculty member.
5 free sessions
Additional sessions at $10 each.
Sources:
How to be a Truly Excellent Junior Medical
Student
by Robert J. Lederman,MD
Get this book!