Intern Playbook

Intern is the running back
Intern is the running back

Intern’s Roles:
You are the running back and primarily carry the ball. You are the primary physician caretaker for the patients on the team.

  • Closely communicates with both the Team Resident and the Attending informing them of any problems, changes, or unexpected events. Feel free to make suggestions for improvement (remember communication needs to be horizontal). You must feel safe to express your views without retribution.
  • On admission writes a complete history and physical and also defines each patient’s active problems and designs a blueprint for care, outlining the likely diagnoses, tests to be performed, treatment plan and what parameters they plan to monitor.
  • Presents succinctly using the standard presentation protocols (See Communication Protocols section).
    1. Your demeanor should be enthusiastic and positive
    2. You should speak loudly and clearly
    3. Presentations need to be highly organized using the protocol template
    4. Show evidence of understanding
    5. Be creative and innovative in your diagnostic and treatment plans.
  • Write clear and concise progress notes that objectively document the changes in each problem. Do not copy and paste the same note day after day in the electronic record. The impressions and plans should be rewritten each day and reflect the discussions on work rounds. Except on early admission days try to complete your progress notes before 12 noon and send them to the attending’s in basket for attestation. On early admission days the team will see the ER patients immediately following work rounds to assure that the  needs of the team’s new patients are quickly met.
  • Closely communicate with each patient and be aware of all their concerns. Keeps the patient informed as to the progress of their diagnostic studies and treatment.
  • Closely communicate with the nurses and Case Manager to obtain a full picture of how each patient is improving or worsening
  • Actively read about each  patient and show evidence of that reading in describing your plans during  work rounds
  • Teaches the students using their patients and encouraging active participation in their care
  • Expects and provides the highest possible care for his/her patients

Suggestons:
Remember you are the running back. You are responsible for carrying the ball (direct responsibility for the pt). Just as each football player needs to learn the basic passing motion, blocking technique, and the proper way to recover a fumble, or the basketball player needs to learn the proper shooting and passing techniques, you must learn and reinforce the fundamentals.

  • Succinct and efficient presentations: You need to speak confidently and efficiently. No mumbling! Follow the communication protocols exactly. Remember efficient communication is a key fundamental. Review what needs to be done for each of your patients at the completion of your progress summary. Keep a running To Do list that you can provide to the team resident and attending at the end of rounds
  • Active involvement of the nurses. Nurses are accustomed to being ignored during work rounds, and are often hesitant to participate. You need to encourage their participation and should verbally reward them for their comments and suggestions. If the nurses contribute to and understand the management plans, care will be more efficient and less error prone. Also the number of pages to the house staff will decrease.
  • Horizontal communication: Unlike traditional residency models, this is not a top-down structure. Each person has unique roles and makes unique contributions. It is important that everyone feel empowered to contribute during rounds. It is critical that you actively participate. It is important for you to contribute your ideas in order to learn and also in order to provide your patients with the best care.
  • Teamwork: All patients belong to the team, not just a single intern. Everyone is expected to know the basic history and active problems of all patients. You should understand and contribute to the management strategies of the team’s patients. You need to focus your full attention on the rounds discussion and contribute to the management of all the patients (no wandering off). At the end of rounds you will provide the team resident and attending with a To Do list. If your list is disproportionately long they will divide up the work equitably. If you have a light load you will be asked to take over some of the tasks of the intern who has excessive work. The team resident will also help, and in some cases the attending may agree to help. We all sink or swim as a team.

Other important tasks:

  • Spend time at the bedside: Too often rounds are carried out in the hallway where it is extremely noisy. Most patients enjoy hearing the team discuss their case. This creates increased trust between the team and the patient, and emphasizes transparency. Furthermore, patients often ask questions or provide additional helpful details that can improve their care.
  • Call all consults and order all tests before 12 noon: When possible order consults electronically. Because rounds will usually finish by 11:15 AM  you have sufficient time to perform these tasks. If you have too many tasks to perform, it is important that you ask for and receive help. The workload should be evenly distributed at the end of rounds to allow you to complete these tasks.
  • Complete your progress notes by 12 noon, except on early admission days: The bulk of each progress note should be written before rounds, and you should only need to make minor changes based on the suggestions made on rounds. Route your progress notes to the attending’s in basket.  The attending can review the notes and sign them while you are in noon conference. Your background work will be comp;ete before noon conference, and will free up the afternoon to problem solve, meet with your patients, process new admissions, and review current literature related to your patients. On early admission days it is important that you see your new patients as quickly as possible with the team. This means going to the ER immediately following work rounds. This assures that initial diagnostic and treatment plans are entered quickly to assure that the team’s new patients receive the care they deserve in a timely fashion. Remember to always act in the best interest of your patients. 

Expectations for Subspecialty Consultations
High quality systems of care dictate that communication be respectful and that members of the healthcare team trust each other. Without trust and respect there can be no teamwork and the care of our patients will suffer. Disagreements among physicians are quickly detected by patients and can lead to distrust of the healthcare system and of the physicians.

Obligations of the Consultant

  • Act as a supplier of a service and make every effort to please the customer (consulting team).
  • Respond within 24 hours of a request, and in a true emergency within one hour (example: ER consults).
  • Communicate with the attending directly, in addition to the house staff responsible for the patient’s care. Provide contact information that will enhance attending-to-attending communication
  • Recommendations need to be logical, practical, and based on an accurate assessment of the data.
  • Respond quickly to any concerns or questions by the team
  • Follow-up visits on all cases in which problems remain active and are evolving

Obligations of the Consulting Physician

  • Clearly define the question you are asking of the consultant and/or clearly define the specific service you are requesting.
  • Consult early in the day and early in the hospitalization. Whenever possible make the request before 12 noon to allow the consultation team to efficiently manage their consultations. Consultations early in the hospitalization lead to more efficient and higher quality care.
  • Follow the recommendations of the expert consultant. Failure to do so conveys a lack of trust and disrespect for the consultant.
  • If the team does not agree with the consultant’s recommendations, the attending is obligated to immediately contact the consultant and discuss the reasons for this disagreement.
  • Respectful behavior and constructive communication are vital. When a disagreement persists, a compromise should be established. There should never be a “chart war”.
  • Constructive feedback is vital in order to improve our systems of care. If after discussing the case with the consultant, the attending is unhappy with a specific consultation because of delay, inappropriate recommendation, or disrespectful communication, he or she should immediately contact the Chief of the Division or Department responsible for providing this service.