Third Year Student Playbook

You are a redshirt freshman. Your primary goal is to learn the basics of internal medicine.

  • Workup cases assigned by the Team Resident, write a full history, physical, problem-based impressions, diagnostic and treatment plans
  • Present your cases 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. The impressions and plans should be rewritten each day and reflect the discussions on work rounds. They should be completed before 12 noon and handed to the attending.
  • Read the basic medical textbook on each case and learn the basic principles of diagnosis and treatment for each patient they have worked up
  • Utilize Pubmed to search for a key article related to each of your patients and present the paper to your team. Whenever possible use published subspecialty guidelines.
  • Communicate and spend a little extra time with your patients and provide your insights and suggestions to the team on rounds
  • Closely communicate with the nursing staff and the other health team members
  • Watch for system errors and should provide a second order solution to one error during their medicine rotation
  • Feel free to communicate any concerns about their experience with the attending
  • Expect that his/her patients will receive the highest quality care

Suggestions:
Remember you are the redshirt freshman. Your primary responsibility is to learn from your patients. Your learning objectives have been carefully described by the Clerkship Director http://www.medicine.ufl.edu/3rd_year_clerkship/ 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. Go to Game Films and look at the first two videos to learn how to present like an experienced intern. Remember you are judged by your oral presentations, and practice make perfect. Try practicing in front of a mirror or present with a friend and have him or her critique your presentations.
  • Active involvement with the patients and nurses. You should have more time to spend with your patients than the interns. You should sit with your patients and ask them about their concerns. How are they dealing with their illness? Do they understand what is going on? Are there family issues? What will happen when they go home? The nurses can also provide insight. You should also keep an eye out for potential mistakes in care. Did the patient receive the wrong diet, wrong medications? Were there delays in diagnostic tests or consultations? How could these delays and mistakes be prevented?
  • Horizontal communication: Unlike traditional 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). You should apply your knowledge of the internet (Pubmed) to investigate potential new therapeutic approaches for your patients, and provide this information during teaching rounds which will occur immediately following work rounds or in the early afternoon.

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.
  • Write progress notes: Your progress note should mirror you SOAP presentations (see below). Remember don’t copy and paste, and be sure to include the ideas discussed on work rounds for that day. Always try to summarize the rationale for each diagnostic and therapeutic plan. When possible in your impressions include a differential diagnosis. Ideally break down the possible diseases by probability: 90-70% high probability, 50-30% intermediate probability. 20-10% less likely possibilities.

Work Rounds Protocol (Duration < 5 min)
Remember the attending will have read the notes prior to rounds, therefore you only need to include the key points. (“When in doubt, leave it out.”)
Subjective complaints:
–    List Positive ROS
–    Emphasize complaints relevant to the current problems

Objective findings:
–   Vital Signs
–   Positive physical findings
o    Focus on findings related to the patients active complaints
o    What findings were positive on admission (be sure to include these)
–    Abnormal laboratory findings
o    Usually include CBC, Electrolytes.
o    Results of new diagnostic tests

For Each Active Problem Give:

–   Impressions
o    When appropriate give your differential diagnosis
o    Is this problem improving, worsening, or staying the same?
–    Plans
o    Diagnostic

  • List blood tests
  • Radiologic tests
  • Other tests

o    Treatment

  • What medications are you administering for this problem
  • What other modalities are you instituting

Today’s to do list
Potential Discharge Issues

Admission Oral Presentations (Duration < 10 min)
Focus on the key points because the medical attending will have read the admission note prior to rounds.
Always include the Age, sex, race, job of your patient.
Chief Complaint: What brought you into the hospital. Duration of the complaint or complaints
PI: Time line.
Mr L. has suffered with X disease for 10 years, but was doing well until
10 Days PTA x complaint
7 Days PTA additional complaints or symptoms worsenting
Day of admission – x symptom caused him to seek medical attention
ROS both positives and negatives pertinent to the chief complaint
PMH pertinent to the present complaint and do not repeat the facts about PMH already described in the PI
PSH: do not repeat facts about PSH already described in the PI
FH – if not relevant to the PI say noncontributory
SH – habits, where do they live, what job do they have, other epidemiologic facts if pertinent to the PI
Allergies
Medications

PE: Vital Signs Pulse, BP, Resp, Temp
o    HENT
o    Neck
o    Lungs
o    Heart
o    Abdomen
o    Extremities
o    Neuroexam
Laboratory findings
o    CBC
o    Electrolytes
o    U/A
o    CXR
o    EKG
o    Other diagnostic tests

Problem #1 etc
–   Impressions

o    When appropriate give your differential diagnosis
o    Include pathophysiology descriptions here when appropriate
–    Plans
o    Diagnostic

  • List blood tests
  • Radiologic tests
  • Other tests

o    Treatment

  • What medications are you administering for this problem
  • What other modalities are you instituting

–    Potential Discharge Issues