Internal Medicine

Guidelines and Responsibilities

Students will begin the ward rotation as soon as orientation is completed. Consult this packet for your team assignment. Page the resident. Their pager number can be found on page 19 of your orientation packet.

NOTE: VA WARD STUDENTS MUST FIRST REPORT to Mr. Richard Anderson in the Medical Services Office, room 5D100 to get your VA computer access code. You should have already completed an access code application in the Student Affairs PRIOR to this clerkship orientation. No student will be able to gain access to patient computerized records without an access code. If you have not completed an application, you may download it from this site and submit it to Mr. Anderson so that he may assign a code and provide instructions on how to utilize the computer system.

The Chairman, faculty, and staff of the Department of Medicine, wish to make the Junior Medicine Clerkship a valuable learning experience for each student rotating through our Department. It is our firm commitment to make this experience as uniform as possible and to make every effort to assist each student in acquiring the knowledge, skills, and professionalism necessary to be a competent caring, and licensed physician. To this end we have compiled a list of responsibilities for each member of the medicine team.

1. Student Responsibilities
   Emphasis is placed on the acquisition of clinical knowledge and skills such as performing a complete history and physical examination, synthesis of this information into a concise presentation, compiling a differential diagnosis and planning a thorough, yet cost-effective work-up.
   1. Student write-ups
      Each student must do two admission notes and one case discussion for each month of ward service, no exceptions. Base upon your feedback, we have designed a new form for evaluating student H&P's. You are asked to copy one of the actual admission notes from your patient(s) chart, and give it to your attending physician with the Admission Note Face Sheet attached to evaluate its quality. The new form is designed to test the your ability to sequentially accomplish the following tasks (in an order that parallels clinical reasoning):
      1. Immediately identify the chief complaint
      2. Characterize the chief complaint
      3. Students are then asked to use this characterization of the chief complaint to mentally design a differential diagnosis that might explain this chief complaint. While not explicitly written in the HPI, students are asked to use this differential diagnosis as the criteria for targeting the remainder of their HPI.
      4. In the second half of the HPI, students are to record the answers to the questions they asked to evaluate the diagnoses on their differential.
      5. Accurately and concisely record past medical, social, family and ROS data. Data important to the chief complaint and differential diagnosis should have been included in the HPI.
      6. Concisely record the results of the physical examination and laboratory testing. (Again, students are asked to use their differential diagnosis to determine what exam and laboratory data are important for inclusion in the admission note. Both positive and negative findings should be recorded if they help in assessing the diagnoses being considered).
      7. Organize the assessment based upon problems (i.e., problem #1: shortness of breath). The student should clearly formulate a hypothesis as to the most likely diagnosis for each problem, and provide evidence to support their conclusion. They should also list the other diagnoses they considered, and any data that argues for or against these diagnoses.
      8. Each problem should also have a committed diagnostic and therapeutic plan that clearly outlines what is being done, what will be done, and any contingency plans.
      We believe this method has the following benefits:
      1. It allows the attending physician to assess how the student is actually performing while on the wards (not at home in front of a computer).
      2. It forces the student to think about the case prior to writing the note. With the exception of the VA, students do not have the luxury of a word processor to re-arrange data after the fact. It forces the student to prioritize data as the note is written. In doing so, they learn to prioritize data as they acquire it from the history, and as they report in during the spoken case presentation.
      3. Because the second part of the HPI is focused on the student’s differential diagnosis, this method allows the attending to assess the student’s ability to generate a differential diagnosis and to use this differential diagnosis to discern relevant data (see below).
      4. Finally, it gives the attending physician a structured method of assessing the H&P (see below).

      A admission write-up face sheet (obtained from acrylic file jacket on the blue bulleting board outside of room 7150) should be attached to the front of the write-ups and the write-up handed in to the students' ward attending within 4 days of the patient's admission.

      Case Discussion

      Students must prepare a typed 2-3 page report reviewing a clinical problem. The attending and student will jointly select the narrower clinical topic for review, based upon the patient's presentation. The Case Discussion will include the following:

      1. title
      2. brief case presentation (2 or 3 paragraphs)
      3. discussion (could be focused on patient's presentation, physical findings, treatment, prognosis, epidemiology, etc.)
      4. conclusion/summary
      5. bibliography
      The student must cite at least three sources (with page numbers) of which at least two are recent journal articles. The Case Discussion should be completed and given to the attending within one week of assignment. A face sheet to be submitted with the case discussion is available in the clerkship office. A sample admission write-up face sheet and case discussion face sheet is included in this packet. The attending may also ask you to present your case discussion on rounds or in a student teaching session.

      The case discussion and admission notes are reviewed by the ward attending who assigns a score to each. The six scores are then compiled and account for 10% of the students final grade in the Junior Medicine Clerkship.

      Students will receive an "Incomplete" if they do not complete four write-ups and two case discussions. Additionally, the students' grade will be reduced to zero for each assignment not given to the attending physician within five working days of the Final Examination.

   2. On Call Hours
      Your team will take call with their intern/resident and when you are on call you must remain in the hospital from 7:00 a.m. until 11:00 p.m. Teams are on call:
      • University Hospital: Every fourth day
      • VA Hospital: Every fourth day
      • Ochsner: Every fifth day

      Students are expected to fully participate in the evaluation and care of new admissions, and remain in the hospital as necessary. Students should take call even on Sundays of the last night of a rotation if the team is on call. If the students' last call falls on the Sunday before a new rotation, it is not necessary for the student to attend morning report the following day.

   3. Each student is responsible for following 2-4 patients at a time while on the wards. Students are expected to make morning rounds each weekday with their team and assist in routine ward work. Students should return to their ward every afternoon to see their patients, and make afternoon ward work rounds.
   4. The student's resident/intern may ask the student to complete a written H&P for the chart. This is limited to one H&P per on-call.
   5. Students should write daily "S.O.A.P." progress notes on their patients. These are to be reviewed and co-signed by the ward intern/ resident. Notes written the day of attending rounds must indicate the attending's input. T-3 should begin the daily progress note with "Patient seen and examined by Dr. (attending's name)." The assessment and plans should begin with "Dr. (attending's name) Assessment and Plans:". The attending may make additional notes.

      The student will be expected to orally present the patient to the attending physician while on rounds. The student should also be prepared to discuss his/her patient's problem list, differential diagnosis for each problem and management plans.

   6. Morning Report

      Students will attend all morning reports at their respective hospital.

      University Hospital morning report is in the fifth floor conference room from 9:00 a.m. - 10:00 a.m., Monday, Tuesday, Wednesday and Friday.

      VA Hospital morning report is on the fifth floor (5A131) from 8:30 a.m. -9:30 a.m. Monday thru Friday.

      Ochsner morning report is held in conference room A of the cafeteria.

   7. By the end of the clerkship, students should have performed most of the following common procedures:
      1. draw venous blood sample
      2. draw an arterial blood gas under direct supervision at all times by physician
      3. perform a hemetest of stool sample.
      4. perform a 12 lead electrocardiogram
      5. make and interpret sputum gram stains
      6. review peripheral blood smears
      7. obtain a CBG (capillary blood glucose) with a glucometer
      8. insert NG (nasagastric) tube and confirm its placement in the stomach by auscultation.
      9. review urine sediment slides
      10. place a Foley catheter into the bladder of a male and female patient
   8. Students should always be supervised directly by their house officers. All orders must be co-signed immediately by the house officer and/or attending. All progress notes must be co-signed by the house officer and/or attending. All procedures should likewise be supervised.
2. Attending Responsibilities

   The attending faculty wil be responsible for didactic teaching of the ward students and guidance in the art of examining and presenting patients. The attending physician will be expected to make rounds with students at least six times a week for approximately two hours. At least one rounding period per week should be made with the students alone. He/she will be responsible for review of the historical data given by the students and confirming physical findings on ward rounds. The attending will evaluate the students ability to generate a patient's problem list; develop a differential diagnosis for each problem; formulate specific diagnostic and therapeutic plans for the patient; and retrieve pertinent and recent medical literature articles.

   Attendings are required to give the student feedback at the mid-point and end of the rotation. Students should ask the attending to meet with them concerning their performance. The attending is responsible for grading and providing constructive feedback on the required write-ups and topic review and returning the reports to the student in a timely fashion. The students will submit the graded face-sheets to the Student Programs Office (rm. 7012) for each admission note and case discussion review. Attending is also responsible for providing a written evaluation of the student at the end of the rotation.

3. Intern/Resident Responsibilities

   Houseofficer responsibilities may include the following as determined by the attending:

   1. Observe students obtaining histories and physicals and provide constructive feedback.
   2. Discuss the differential diagnosis with students for relevance and completeness.
   3. Review with students - labs, slides, EKG's and CXR's on patients admitted to their service and to assist them in interpreting the data.
   4. Review student's progress notes and co-sign each note.
   5. Co-sign all student orders at the time they are written.
   Please note: Students are not allowed to write orders in the intensive care units.