FMIS Night Float: Senior

These are goals and objectives for the whole intern year. You are not expected to master these skills in 2 weeks. 

• Medical Knowledge: Interns must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care.

• Patient Care: Interns must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. 

• Systems-Based Practice: Interns must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

• Interpersonal and Communication Skills: Interns must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates.

• Professionalism: Interns must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

• Practice-Based Learning and Improvement: Interns must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning.

• Please ensure that you have seen and examined all of your patients prior to the start of rounds at 8:30am M-F and 9:00am Sat and Sun 

• Please ensure that your notes on all your patients have been written prior to the start of rounds. It is expected that your notes reflect day-to-day changes, as appropriate, and are not simply “copy-forwarded” from the day prior. 

• During first quarter, we will expect you to present your “follow-up” patients who are not new to the service in “SOAP” fashion. During your first month, we expect that most presentations should take about 7-8 mins per patient.

• Written and oral presentations should start with the patient’s name/age/presenting chief complaint, hospital day number, a brief review of pertinent events over the last 24hours, and pertinent subjective points elicited from the patient.  

•  >>> Example: Mr. X is our 72year-old male who presented with 2 days of shortness of breath, now on HD3. Over the last 24hours, he completed a chest x-ray and echocardiogram and was weaned overnight from 2L of O2 via nasal cannula to room air. This morning he reports feeling improvement in his breathing from when he first presented. He continues to deny any chest pain or cough. 

• Written/oral presentations should next relay the “objective” which includes vitals over the last 24 hours, any new serum/urine labs resulted in the last 24 hours, any new imaging/procedures that have resulted in the last 24hours, and your physical exam. Vital signs include temperature, heart rate, respiratory rate, oxygen saturation (please be specific about whether these are on room air or “x” liters of O2, pain scale if relevant from 1-10, and blood glucose range if relevant over last 24 hours. It is not appropriate to say “vital signs were normal” or “vital signs were stable” at this stage of your training. Later on in the year, we will discuss modified presentations but for now please follow the above format. 

• Finally, written/oral presentations should end with an assessment and plan. This is the most important part of your presentation/note and is the part you should be spending the most time thinking about and talking about. Your assessment should reiterate the age/gender of the patient, hospital day number, and presenting complaint followed by your differential diagnoses in order of most likely to least likely. Regarding the latter, you should briefly give supporting evidence from the data as to why you have ordered your differential the way you have. 

•  > >> Example: In assessment, Mr. X is our 72 year-old male, HD3, who presented with 2 days of shortness of breath most likely consistent with a COPD exacerbation, based on clinical exam revealing wheezing and improvement with duonebs and prednisone; presentation is less likely to be a CHF exacerbation based on unremarkable echo findings, low pro-BNP, and no clinical evidence of crackles on lung exam or peripheral edema, and finally less likely to be pneumonia based on absence of consolidation on cxr, fever, or elevated wbc. 

• Please work closely with your seniors to discuss the appropriate format for your day admissions. During this quarter, we expect that you to present your admissions in about 15-20 minutes. We will primarily focus on developing your skills in interpreting rather than reporting of data; hence, as above, your assessment and plan is the most important part of your presentation. We will be looking to see how complete your differential is, how you prioritize the likelihood of each differential based on the objective data available to you, and how appropriate your management is based on which differentials you decided to pursue.

• Start to distill the difference between “rounding on a patient” versus “running the list” for interdisciplinary rounds. Rounding on a patient should be done as per the tips detailed above. The structure of presenting for IDT is as follows: Mr/Ms __(surname)_____is a __(age)__year-old ___(sex)___who presented with ___(chief complaint/symptoms)___attributed to __(top differential dx). Discharge is pending ___(state explicit tasks, e.g., stable hb, PT consult, PO tolerance, etc). The estimated date of discharge (EDD) is ___(date)__. 

• It is expected that you start to develop a system that works best for you to get your daily tasks done in an efficient and effective manner. Broadly speaking, this starts with pre-rounding on your patients and writing your notes prior to rounds. After rounds, based on our discussions together as a team, you will have a host of tasks that potentially include consulting other services, ordering tests/studies, discharging patients, etc. Prioritize calling your consultants as early in the day as possible. Ensure that any labs needed for the next morning are ordered before you leave for the day. Get familiarized with the hand-off and how it is updated daily so that you can learn from your seniors how to keep the list current for the team. We understand that the above is overwhelming when you are first starting out and everything is brand new. We know that it will be a process over time for you to get adjusted and be your most efficient self. In general, your seniors are your most useful resource in helping and teaching you to get things done and in getting things done correctly. 

• After overnight admissions are presented by the night resident, you will be given an opportunity along with your co-intern and day senior to voice your comments, questions, and recommendations. You are encouraged to take this opportunity as often as possible. What we are looking for is that you are actively engaged and fully participating rather than making the correct diagnosis or asking a question that nobody else thought of. 

• It is expected that you participate fully in all of the FMIS teaching activities. This means that you should not be multi-tasking and doing other work on the computers while teaching is going on. During teaching activities, you will be giving your pagers to Ramona (or the day senior if Ramona is not available) and will not be interrupted barring emergent issues that arise. 

• It is expected that you review the attending note for each of your patients daily at some point in the shift. Your senior may choose to do this together with you when you run the list so that you can both review simultaneously. 

• It is expected that with the help of the team (seniors and attendings), you are able to complete all of the above in accordance with duty hour regulations, i.e., you should not be working beyond the maximum of 80 hours per week. 

Get sign out on your patients from the intern before you (ie. Intern A to Intern A)

Daily Schedule:

~6am  Pre-round on existing patients 

- Starting time depends on patient volume (recommended ~30min per patient)

- Get signout about overnight events from the overnight senior resident

- Review labs/vitals/telemetry, see/examine your patients

- Write “Medicine Follow-Up Free Text Note” on each of your patients. Assessments and plans should be updated daily, avoid copying forward.

8:30am  Attending Rounds*

- Notes should be complete by this time

- Overnight admissions presented by overnight senior resident

- Interns present existing patients (usually starting with day admission from previous day)

9:50am   Interdisciplinary Team (IDT) Rounds

- Present patients to social work and care coordination team and nursing focusing on discharge needs

- Ex: 60yo F presenting with SOB likely CHF, EDD to SAR in 2days pending O2 wean and PT eval

Time remaining before noon conference should be prioritized for calling consults and completing urgent patient care tasks.

• 12pm:   Noon Conference (see weekly schedule for specific topics for orientation block)

• 1pm:   Work on day admission, “scut work”, update patients on plan of care, prepare hospital courses and discharge summaries, update handoff, order tomorrow’s am labs

• 5pm:   Goal sign-out time for non-admitting resident

• 8pm:   Sign-out for admitting resident, senior takes pager/mobile heartbeat

Admissions: Each day 1 intern is considered the admitting intern. The admitting intern will admit 1 patient during the admission window (8:30am-5pm). The admitting intern will accept 1 additional admission if the extra patient is a “bounce-back” (patient previously on the family medicine inpatient service (FMIS) readmitted while the intern who managed/discharged the patient is still on service) or ICU transfer back to the team within 24 hours. The maximum number of admissions for the day shift is 2 patients. The admitting intern also assumes care of both overnight admissions.