the clinical years: third year...ob/gyn mgmnt reproductive, stis, follow-up psych interviewing...

THE CLINICAL YEARS: THIRD YEAR

St. George’s University School Of Medicine

Office of Career Guidance & Student Development

Overview •  The 3rd Year Clinical Experience

–  Description of the rotations –  Your day in the hospital –  Your role & expectations from the clinical staff –  What the clinical faculty expect from you –  Methods to achieve success

•  Knowledge and Learning –  Didactic lectures –  Practice-based learning, Evidence-based medicine –  Sample texts, review guides

•  Examinations & Grading •  Your Goals for the Year’s Experience


Core Rotations


Rotation Duration Internal Medicine 12 weeks Surgery 12 weeks Pediatrics 6 weeks Obstetrics & Gynecology 6 weeks Psychiatry 6 weeks Emergency Medicine*, Family Medicine* 6 weeks each

‘Scheduling Balance Rotation’† 6 weeks

*: may be provided by your Clinical Center, ER does not count for FM

†: will be provided by your Clinical Center, counts as a 4th year elective

Core Rotations


Rotation Goals Cases IM Complete Pt HTN, CAD, Diabetes, Substance Surgery Mgmnt, Skills Acute Abdomen, Trauma, Imaging Peds Observation Congenital, ID, Health Maintenance OB/GYN Mgmnt Reproductive, STIs, Follow-Up Psych Interviewing Depression, Social Work ER* Diagnosis Trauma, Initial Surveys Family* Mgmnt, Screen LBP, Joint Pain, Med Refills

*: may be provided by your Clinical Center, counts for Primary Care fulfillment

†: will be provided by your Clinical Center, counts as a 4th year elective

Your Day in the Hospital

•  Starting Times – Rotation and Location Specific (variable) – Will be provided through the rotation’s

Clerkship Director usually at orientation •  Responsibilities include pre-rounding and

preparation for the day’s activities


•  AM ‘Sign Out’, AM Rounds –  Functions as changeover from the overnight call team to the day team –  Involves the discussion of overnight activities/updates, admissions, and

possibly any interesting cases •  Remember, the hospital is a 24-hour facility!

•  Types of Rounds –  ‘Pre-Rounds’:

•  Headed by a senior resident/fellow to prepare for when the attending rounds –  ‘Formal’ Rounds:

•  An attending is present to review all patients admitted to his/her service –  You should be there for both to learn and help the team!


•  This is not a good time to ask questions as patient turnover is an important task for the team. You may aggravate the overnight residents who want to go home and get attention you don’t want from others. •  If you do have questions, jot them down, try to answer them on your own while pre-rounding and then consult with team members (before rounds) if questions remain.


•  Resident Interaction –  Very important part of your rotation experience!

•  May be paired with an individual resident •  Often responsible to an group/team of residents

•  Resident Hierarchy (indoctrinated throughout modern medicine):


Year Function Cores/Rotations PGY-1 The Intern All PGY-2 Junior Resident All PGY-3 Senior Resident All

PGY-4 Senior Resident, +/- Chief Resident, Fellow (from 3yr residency)

Surgery, Ob/Gyn, EM, Anesth, Fellowships

PGY-5 Chief Resident, Fellow Surgery, Fellowships


•  Resident Interaction, ‘Shadowing’ –  Your responsibilities are primarily to the resident, often an intern –  Pay attention to their directions and share the workload –  Make sure you are being taught:

•  ‘Scutwork’ will occur, but try to learn from these tasks (why is the test being performed, why does it effect the differential, etc.)

•  Hospital work provides many opportunities to practice/refine your skills •  If you feel you are being abused, speak with your Department Coordinator

•  Tips: 1.  If you enter the relationship with a good attitude & work ethic,

this will likely be reciprocated 2.  Don’t wander off without their knowledge, not even to ‘watch a

procedure’ (just ask politely!) 3.  Listen to everything and try to speak only when addressed 4.  NEVER “show up” your resident around the chief/fellow/attending

•  They work more, read less, and sleep minimally compared to you •  Your life can be made miserable if you are perceived as a pest




Rotation MS-III Role* Internal Medicine Ø  Part of the clinic & ward teams, specialty consult services,

intensive care, post-operative care, etc.

q  Responsible for performing H&Ps q  Write daily progress (SOAP) notes

q  Maintain your logs of patients & procedures q  Individual case write-ups for your final examination

q Attend didactic lectures (as directed by your department) q Complete all other required material for clerkship (e.g. modules)

Surgery

Pediatrics

Obstetrics & Gynecology

Psychiatry

Family Medicine

Emergency Medicine

Ø  Will see individual patients & present to specific residents q Other responsibilities as above

*Experiences will vary in practice between Clinical Sites

Your Role in the Hospital

•  History and Physical Examination (H&P) –  Learning & refining an H&P is your #1 education goal

for the clerkship experience! –  Be more complete rather than risking being

incomplete and missing important details –  Efficiency will come through repetition

•  Highlight certain aspects of your patient’s history depending on your current rotation –  Examples:

•  Pediatrics: Birth history •  Surgery: Past surgical events, operative risks •  OB/GYN: Gravidity, pap smears



•  History and Physical Examination (H&P) –  Physical examination skills are crucial to your

advancement as a clinician –  Adjuncts:

•  Barbara Bates’ text, Maxwell’s Guide (highly recommended) •  Pre-prepared H&P forms (varies by site)

•  Rapidity is not as important as completeness –  Efficiency will come with experience –  Tailor your examination for the complaint as well as

the rotation –  Always, always report a sick-appearing patient to a

senior member of the team!



•  Patient Presentation –  Learn how to present the patient for

both pre-rounds and rounds: •  May be alone or in a large group •  Ask during your first day what is

expected during presentations •  Observe resident presentations and

incorporate their methods –  Focus on organizing pertinent info –  Admitting vs Update presentations –  Do:

•  Demonstrate a cohesive thought process; be methodical

•  Read on your patient’s problem and history before presenting!

–  Don’t: •  Bounce around •  Skip right to the plan


SOAP Presentation

S Subjective

O Objective

A Assessment

P Plan



SOAP Presentation

S History of Present Illness (HPI)

Chief complaint, Past History (Medical, Surgical, Family, Social, Occupational, Travel), Review of Systems

O Physical Examination & Investigations/Tests

Primary Survey: General Appearance, Vital Signs, Detailed Head-to-Toe Examination (Organ System),

Recent Updated Labs & Tests

A Problem List vs Concise Pt Summary

System (CVS, PUL) or Problem-Based (1-CHF, 2-Cellulitis) vs 70y/o M p/w CHF exacerbation x6hrs

P What You Want To Do, Update Plan of Action

Address each of the patient’s problems with a concise plan, This is the part where you demonstrate your knowledge and

ability to process multi-faceted information

May also involve input from consulting services here


Your Day-to-Day Activities •  Be Helpful to the Team

–  Check test results on your patients (and maybe others) •  Laboratory examinations, radiologic investigations/formal reads •  Consultant evaluation

–  Assist with patient care •  Some rotations are more hands-on than others •  Observe & perform procedures, offer to help!

•  Learn about Inpatient Care –  Often considered scut work, but very important! –  Observe path from admission to discharge –  Identify coexisting complementary care factors

•  Social work, patient placement, home care, family involvement •  Long-term follow-up, plan for re-evaluation

•  ALWAYS Read About and Follow-up on Your Patients! –  Your sole responsibility is often that singular patient! –  You should know them better than anyone on the team!


Your Day-to-Day Activites •  PM ‘Sign Out’, PM Rounds

–  Official closure of the work day’s activities –  More likely led by a chief/senior resident or fellow –  Presentations usually brief updates (not full H&Ps) –  Report any changes, updates in patient care

•  Examples: New CT results, Updated Hb trend data

•  You must be present for these as well! •  On-call/night float team takes over after PM

rounds


Lectures •  Didactic Learning

Experiences –  Multiple formats

•  Daily Grand Rounds (IM, FM, Peds, Psych)

•  Conference Day (EM, Surgery, Ob-Gyn)

•  Scheduled Lectures (All) –  Types

•  Core Material •  Morbidity & Mortality •  Clinical Case Review •  Journal Club, including

–  Evidence-Based Medicine –  Practice-Based Learning

•  Given By: –  House Attending Physicians –  Visiting Professors –  Senior Residents –  Junior Residents

•  Medical Student Lectures –  Aimed at your individual

group –  An addition to residency

program-based lectures •  Topic Discussion

–  You may be requested to present a topic to your group on rounds (or elsewhere)

–  Generally 10-15 minutes


Being On Call •  On Call Parameters:

–  Minimal off-hours work staff (skeleton crew) –  Primary responsibility is to manage acute/emergent problems –  Non-emergent activities (scans, tests, etc.) put on hold due to

diminished manpower –  Will still carry a team stratification with distinct responsibilities:

•  Led by a chief/senior resident, possibly an attending •  Variable amount of intermediate residents (PGY2, 3) to assist •  Invariably populated by interns with little amounts of sleep

•  You must take call! –  You will one day be an intern/senior/attending –  Take the opportunity to learn how to prioritize!

•  Call schedule depends on your rotation and hospital


•  What Do I Need in the Hospital? –  Short white coat

•  SGU coat doesn’t count – do not wear long coat to work! •  Ideally get an extra coat and keep in locker just in case

–  Smart device (iPad, Android, BB) –  Stethoscope –  Light source (pen light) –  Notepad, Pens (several!) –  Books…(see later)

3rd Year Tips


•  Uworld Qbank Currently Provided to All Students! –  This resource is invaluable, use it!

•  Ideally: –  Check with Department Coordinator during clerkship orientation –  Sakai clerkship page may carry additional recommendations

•  Reality: –  Talk with residents/attendings/upper termers

to gather recommendations –  Understand the difference between source reading and Shelf

preparation (should coincide, but may not) •  Types of Materials (See Next Slides)

–  Current recommendations and reviews available on sguclinicals.com!

Study Material


•  A Word on Smartphone Apps: –  Good for quick reference, but reliability is everything –  Be a smart consumer and get apps that automatically update!

•  Consistent Considerations (See Next Slides):

–  Overall organization –  Drug information, pathology review –  Antibiotic utilization, up-to-date uses –  Help for pre-rounding, rounding –  Staying up-to-date on literature

Smart Device Apps


Smart Device Apps


Organize: Dropbox General: Epocrates, Medscape Round Help: RH Med Labs, MedCalc Extended: JH Abx, USPSTF, Formulary Literature: Read by QxMD

Books: In Your Top Pocket 1.  Always Handy

–  Maxwell’s Quick Medical Reference

–  Helpful to identify commonly used abbreviations and progress note organization tools when first starting


2.  Drug & Antibiotic Reference –  Sanford Guide Other:

Apps:


Books: In Your Coat Pocket

Books: In Your Coat Pocket


MUST HAVE!

3.  Pocket Reference: Sx, Dx, Tx

Books: In Your Bag


4.  Quick Comprehensives:

Books: On Your Desk


5.  Complete Texts

Online References

•  eMedicine (www.emedicine.com) Free – Works well for both patients and MD’s

•  Up To Date (www.uptodate.com) $$ – Most current, updated and comprehensive – Hospital-specific free availability

•  ACP’s PIER (pier.acponline.org) ($$) – New service


•  Currently: –  All cores except for Family have NBME Final Exams

•  Grading is devised from: 1. Medical Knowledge 2. Clinical Skills 3. Professional Attitude 4. Oral Examination 5. Written Examination (NBME)

•  Clerkship Director will also submit written comments regarding your performance –  Keep in mind clerkship comments can go on your

Dean’s Letter!

Grading


Computed by your evaluations while on rotation

Direct end-of-core examinations

•  Grading Breakdown 1.  Medical Knowledge 2.  Clinical Skills 3.  Professional Attitude

•  ALL can be traced back to the duties outlined at the beginning of this lecture:

–  Be present, be responsible, be a team player –  Show interest, be proactive but know your place

Grading


Grading •  Oral Examination

–  30-45min session with Clerkship Director or Department Attending •  Varies between institutions & specialties •  Some teachers are tougher than others

–  Generally drawn from one or more case presentations •  Will have direct questioning of your medical knowledge,

integration of information, processing of cohesive thoughts •  You are expected to know everything about the cases in your Patient Log

–  Patient log choices •  Some common cases without being redundant •  Some interesting cases, but not arcane •  Avoid memorizing esoteric knowledge to impress, concentrate on the usual

•  Be confident without being cocky •  Try to relax during the examination


Grading •  Written Examination

–  NBME Exams: 100 MCQs –  Always a source of student griping

•  Ω ∞ Я / (⌂ * ☺) •  Exam integrity (Ω ) is proportional to question repetition (Я)

divided by the product of clinical centers (⌂) and students (☺) –  Many clinical sites/start dates make it tough for SGU to

give an exam perfectly tailored to your clinical center’s individual experiences

–  Study the material relevant for the clerkship and you’ll perform well

•  Consider breadth of available options (See Previous Materials) •  Ask your team of residents, fourth-year students for advice


Rotation Evaluation


Your Expectations From the Year

1.  Integration of Prior Knowledge Base: –  Basic Sciences –  Clinical Skills –  3Ps: Physiology, Pathology, Pharmacology

2.  Addition of New Skill: clinical gestalt 3.  Beginning of Your Eventual Choice of Specialty 4.  Letters of Recommendation

–  Seek them from a Clerkship Director or Chairman 5.  Preparation for Step 2 CK & CS


34

Your OCGSD Team


Specific Advisers (Based on Student LN) Can Be Found At:

http://ocg.sgu.edu/advisor-contacts/

John Madden, MD DIRECTOR OF OCGSD Emergency Medicine

USMLE Failures [email protected] 800.474.8364

Miriam Jacobs ASSOCIATE DIRECTOR OF

OCGSD Graduates [email protected] 800.474.8766

Paul Barbara, MD ASSISTANT DIRECTOR OF

OCGSD Team Logistics [email protected] 917-903-7475

Matthew Myatt, MD General Practice Canada [email protected] 705.507.9925

John Powell-Jackson, MRCP Internal Medicine UK & EU [email protected] 44 1962 850650

Karen Bell ADMINISTRATIVE ASSISTANT University Support [email protected]

35

OCGSD Senior Advisors


35

Matt Coulson, MD Pediatrics A-B [email protected] 949.333.2997

Melissa Wallach, MD Medicine/Pediatrics C-E [email protected] 732.216.7474

Glenn Brady, MD Anesthesiology F-H [email protected] 203.232.8636

Gary Fiasconaro, MD Obstetrics & Gynecology I-K [email protected] 718.501.8653

Leslie Griffin, MD Family Medicine L, R [email protected] 423.902.8081

Laurence Dopkin, MD Psychiatry M-N [email protected] 917.359.1756

John Madden, MD Emergency Medicine O [email protected] 800.474.8364

Paul Barbara, MD Emergency Medicine P-Q [email protected] 917.903.7475

Sherry Singh, MD Internal Medicine S [email protected] 856.424.2533

Jason Bell, MD Obstetrics & Gynecology T-Z [email protected] 734.277.3692

36 Office of Career Guidance & Student Development

Your OCGSD Team

Not shown: Miriam Jacobs, Karen Bell, Gary Fiasconaro, Matt Myatt

Melissa Wallach

John Powell-Jackson Leslie

Griffin Sherry Singh

Jason Bell

Matt Coulson

Paul Barbara

Glenn Brady John

Madden

Laurence Dopkin

Special Thanks

We’d like to recognize the following SGU alumni for the making and revision of this lecture:

Creator: Ankeet Udani Revisionists: Chey Collura, Matt Melamed


the clinical years: third year...ob/gyn mgmnt reproductive, stis, follow-up psych interviewing...

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