Expectations

Assignment of Patients

You should be assigned to a patient at the beginning of the clerkship. Following this you will be responsible for working up at least two or three new patients a week. As a general guideline, you should be able to work-up one patient per call day in Med Block 1 (7-8 total) and two patients per call day in Med Block 2 (14-15 total). See below for more block-specific expectations. Your resident will make patient assignments and care will be taken to vary the type of disease assigned to you as much as possible.

Knowledge of Patients

We will expect you to know your own patient in fine detail and you should have this information at hand at any time. In addition, you should become familiar with major problems of other patients on your ward team.

Initial Work-up

Wherever possible you will be encouraged to work-up the patient before the intern and resident. Ideally a portion of the history and physical will be observed periodically and feedback given to you about exam and communication skills. Exception will be made to this when patients are exceedingly sick; in such cases you should work-up the patient jointly with the resident and your work-up may be curtailed to fit the clinical situation.

Admission Write-ups

Med Block 1

Goal is two full H and Ps per week (total eight write-ups Block 1). Submit for review within 24 hours a detailed write-up including history and physical exam findings, laboratory data, and formulation of assessment and management plan. During Med Block 1 you may not enter the initial H and P into the electronic medical record until the supervising attending has explicitly allowed. This allows the attending to review your work and to give formative feedback prior to the write up becoming part of a legal medical record. Once the attending has deemed that your write-ups satisfactory for placement in the EMR, subsequent initial write-ups may be entered but, as for your EMR documents, should be left marked as “incomplete” so that the resident and attending can review for content and accuracy.

Med Block 2

Goal three to four full H and P per week (total 14-15 write ups Block 2). Changes from Med Block 1 include submission of completed initial write-up by next morning (instead of having 24 hours to complete) and they may be entered into EMR after first has been signed off as adequate by supervising attending.

Progress Notes

You should write daily progress notes on your patients. These should be clearly signed with your name and identification of your role as a student (e.g. "YMS3" or "MS3"). If your patient is transferred to another service, you should be familiar with your patient's progress on that service. You should avoid “copying forward” (a function in the EMR) except perhaps to keep track of patient’s problem list. Always save as incomplete in EMR so resident can review and co-sign.

Patient Case Presentations

We will attempt to have you present as many cases as possible on rounds. Presentations should be clear and concise. Very rarely should any presentation take more than five minutes unless you have been repeatedly interrupted. Rehearse with your resident if you are not sure what is expected. You should expect to present your patients from memory with only occasional need to consult written material.

Attending Interaction

Demonstrate to attending during twice-weekly student-only sessions your ability to elicit history and physical findings from your patients; review salient features of patients you are following. He/she should document 2-4 such directed observation per block on the mobile EPA platform. You should submit the midway feedback on Folio by attending and resident after the first two weeks of the rotation (see laminated cards for EPA requirements; portfolio section).

Reading

It is expected that you do self-directed reading based on your patient’s main medical issues. General sources like Harrison’s Textbook of Medicine (full text available through library website) and recent review articles are good primary sources.

Procedures

You will be encouraged to draw blood and start IVs. Experience with lumbar punctures, thoracentesis and paracentesis is encouraged but may be limited. These must always be done under supervision of a house officer. Whenever possible, you should accompany your patient when major diagnostic or therapeutic procedures are done off the ward.