Internal Medicine

Overall Flow

On the internal medicine clinical teaching unit (CTU), you will work as a large team made up of CC3s, family medicine residents, internal medicine residents, clinical pharmacist, clinical teaching associate and a CTU week lead (internist). Internal medicine is responsible for seeing the more complex medical patients that are admitted to the hospital. Common patient presentations you will see include ACS/heart failure, COPD, sepsis, liver disease, stroke and renal disease. The CTU works in conjunction with the general internal medicine (GIM) unit to care for internal medicine patients. They alternate days on intake, so when CTU is on intake, all newly admitted patients will go onto their patient list to follow.

The general flow to the day is:

7:30- 8:30: Teaching (Journal Club, Internist, Pharmacist, Family Resident Presentations)
8:30-9:00: Review of list (quick update of plan for day) and new patients from overnight if on intake
9:00-12:00: Rounding on patient (usually have 1-3 patients to see)
12:00-1:30: Review of patient list (detailed review of each issue and discuss plan/new orders)
1:30- 4:00: Complete orders, follow-up on lab work, do discharge/ transfer summaries
4:00-11:00: CC3 on call starts with resident

Your Preceptors

Each week, there will be a CTU lead, who are all internists. They generally have their own area of specialty (nephrology, cardiology, GI…), so their teaching will often have a specialty spin on it. There is also a clinical teaching associate (CTA) who helps rounding and discharges.

There are often a lot of residents present, and if there is a senior internal resident, they often play a big role in leading the team/rounds.

Your Role

You will follow patients throughout their stay at the hospital. If you do a consult or have a new patient assigned to you, you will round on them each day and write a SOAP note then present their case during rounds (take a photocopy of their note to rounds with you for presenting).

You will be responsible for dictating the transfer or discharge summary for your patients, as well as any consults that you see.

Call

When you are on-call during the weekday, you are mainly responsible for helping with new consults that come in during the evening. Generally, if a new consult comes in past 3pm and you are on-call, you will take it. A consultation from start to finish generally takes about 3 hours, so you usually only do 1-2 per evening. You are always on call with a resident who is in house and an internist who will be reachable by text or call. Around 4:00pm, it is a good idea to text the internist who is on-call for Internal Medicine-ER to let them know you will be on-call with them that evening. You will likely not get any ward calls while on-call, those are mainly handled by the resident, but feel free at tag along while they handle them if you aren’t busy as it can be a possible learning opportunity. As you do not get post-call days on internal medicine, you should not take any consults past 9:00pm as you are supposed to leave the hospital by 11:00pm at the latest.

When you are on-call during the weekend, you will be on with a resident and on-call internist. The night before, text the internist you will be on call with to see what time and where they want to meet the following morning. In the morning, you will split up the patient list. You will then round on your assigned patients. During the weekend, your notes can be much shorter and generally no big changes to management are made. Basically, the goal is to get patients through the weekend without creating any new issues, unless something new arises and needs to be addressed urgently. When you finish rounding, you will again meet to review the list and bring up any issues that need to be addressed. For the rest of the day, you will see any consults that come in, and otherwise have the opportunity to relax or study.

Tips and Tricks

Overall, the internal medicine rotation is a great rotation to learn a lot of your foundational medicine knowledge. Each day, you have a fair amount of time to see each of your patients and work through all of their issues, then review that with your team. Your team has people from different areas (pharmacy, family residents, IM residents and internists) that are all happy and excited to do a lot of teaching. You also get to work closely with your fellow CC3 trackmates!

Initially during the rotation, there can be some longer days as you get used to how to write discharge and transfer summaries (Dr. Sainchuk, the CTA, will take time to review these with you in the start); however as the rotation progresses, you will become a lot more proficient with these. Overall, the pace of the rotation is fairly relaxed and the IM team is very supportive of you.

Approach to Internal Consult and Rounding

It is easy to feel overwhelmed with the complexity of the patients while working on the CTU. They often have a long list of comorbidities, are on multiple treatments and have had several admissions in the past. With all this complexity, it can be confusing to come up with the next best step. Keep it simple where you can and realize you only have 2 responsibilities when performing an IM consult:

Consider the broad differential, and
Produce an Issues List.

Before seeing a patient, you'll want a differential in mind, however a difficult step is deciding which differential to use! As mentioned above, patients are complicated but lucky for you: you have ample time, and you need surprisingly little information to choose a differential.

In the following example, read the patient information (chief complaint and set of vitals) and take a second to think about this relatively small amount of information. You've already got what you need to create a broad differential diagnosis before even seeing the patient! Having these differentials in mind (or physically on hand) before going to see the patient will help keep you organized and save you time.

Example patient

Note: the tables above are not comprehensive but they outline an important thought process:

Identify an Issue, eg. decreased level of consciousness.
Come up with a differential diagnosis, eg. DIMS approach.
Recall pertinent positives and negatives to look for on history and physical to support these diagnoses.
Order appropriate investigations based on this list of potential diagnoses.

Initiating the consult

You'll want to introduce yourself to the patient (and confirm their chief complaint), their nurse, and hopefully the ER doctor who assessed them. Then you can excuse yourself and go to PowerChart to get some background information on their PMHx. You'll find documentation regarding previous diagnoses, and often clinical status of theses diagnoses (eg. most recent echocardiogram in the case of heart failure, or A1C in the case of diabetes...). You'll typically be able to complete much of your consult on paper before seeing the patient. Think about the different areas of your consult and see if you can find this information in their EMR. Time spent doing this beforehand can save you time while performing the consult, and will allow you to spend more time focusing on the HPI and working through your differential.

Once you've evaluated the patient, both electronically and clinically, it's time to come up with an Issues List:

- This is a numbered list of the patients problems prioritized by acuity/importance and divided into active vs. inactive categories.
  - Issues can be diagnoses, clinical findings (eg. chest-pain, fever, infection, abnormal lab values, etc.), barriers to discharge, etc.
  - For each issue, it's important to consider: primary vs. secondary cause, current management, clinical status (subjective and objective), and finally what the next step in management might be, does the patient need:
    1. 1. Further investigation to clarify the diagnosis: lab work, imaging or specialty consult.
      2. Treatment: empiric vs. definitive, surgical, admission, transfer, community support, etc.

Presenting Consult Notes vs Rounding Notes

- Consult Notes: you describe the information in the flow of the below template, then at the end bring it together with the issues list.
- Rounding
  - A quick ID line (age, gender, presenting complaint, being treated for…)
  - A quick sentence on how they did the previous day
  - Then get straight to the issues list.

Page updated

Google Sites

Report abuse