Intro to ClinicsTips and Tricks for Internal Medicine and Family Medicine

From Your Upper Classmen Friends

It all became worth it when…

“...When I had the chance to work with one of the best, most caring physicians that I encountered in medical school, following him from his solitary private practice to the hospital several times each day, where he cared for his patients’ both acute and chronic concerns and addressed their needs completely.”

“...When I got the chance to bring in the son of my patient with dementia, and ask him about how he was doing as a caregiver and what we could do for him. He told me no one had ever asked him that before.”

What should you buy?

Essentials: USMLEWORLD!!! Step Up to Medicine Kaplan Step 2CK Book Pocket Medicine Penlight / Stethoscope light Pens, snacks (Clifbars, etc) Case Files Smart phone: Epocrates, some med calc software

What should you buy?

Non-Essentials:

Maxwell Cards

Reflex Hammer

Pretest

What goes in all these pockets

Pocket Medicine

Maxwell Cards (if you want)

Reflex hammer (again, somewhat optional)

Papers: H&Ps, signout, articles

PDA

Penlight

Lots of pens

ABG kit, tape, etc (maybe…)

General Useful Shorthand

Advice: On Imaging

Computer Systems

Coast: Check your team, call schedule, etc Username: ahupuser; password ahupuser Just type “coast” into the address bar of any Penn Comp

Penn Access Manager --> Link all your signons

Sunrise: All orders; most results --> be the first to know! Flag orders! Signout: ask your interns/residents if they want you to update.

Some do, some don’t. Ask first!

Epic

Medview

Extranet: Log onto Medview from Home

UpToDate from home

Sunrise

The MAR: where you can check what pills nursing has given, when the next scheduled dose is

These are where you can find vitals and other things like Is/Os

The Sign-Out: Don’t touch unless you’ve asked, but a great way to keep track of the patients overall clinical picture and To-Do list: CHECK OFTEN

Where you can see patients’ labs and studies. Cardiology studies (ECHOs), EEGs, and some special radiology may only be available on MedView

A good way to figure out what happened overnight if you don’t hear signout. You can see what orders were placed

More Sunrise

How to be in the know!

Computer Systems: Intranet

Structure of Team

Attending

Fellow (on sub-specialty services)

Resident

Two Interns (occasionally 1 intern + 1 sub-I)

You (with perhaps another 200 student)

Nurses

Other staff: Social worker, PT, OT, CNA (Certified Nursing Assistant), Case Manager, Floor clerk, Phlebotomist, etc

Typical Day

Pre-Rounds: Go see your patients, learn about o/n events, check vitals

and lab --> get ready to present

Rounds

Work Time Calling consults Getting outside records (**ways to make your intern love

you**)!

Call Where you pick up patients and do H&Ps

Advice: On Vitals

Bad: Vitals? What vitals?

Good:BP 134/86, HR 72, RR18

Better:BP 121-147/75-92, HR 73-87, RR15-22

Best: BP 120s-140s/70s-90s, HR 70s-90s.. You get the idea

Patient Presentations

Be methodical and thorough with history & exam In order, same way every time, go back if needed

At least at the beginning, write it out (Type!)

Know everything, but only say what you actually think is important Think about your assessment as a thesis (ie you think the patient has

a pneumonia flare), include any aspects of the H&P, Labs, Imaging that support your thesis

Be prepared to answer other questions

Know the normal values for any labs you state

Follow-Up Presentations: SOAP

Topic Presentations

Start with a summary source: UpToDate, NEJM, American Family Physican

Be focused --> brevity is the soul of wit here more than ever

Make a handout, but say more than is on the handout

Incorporate actual evidence (use UpToDate or review)

End strong: Zinger, 3 take-away points

Your Greatest Fear … The Shelf!

Find your own studying style

Our basic suggestion: Read StepUp as quickly as possible --> familiarize yourself with the diseases, vocabulary, etc Questions, Questions, Questions U SMLE!!!! Try to do

all the questions, but there are a TON so don’t worry if you don’t do all, but definitely have that as your goal

Know: Common presenting symptoms, Best diagnostic tests, Treatment

Use Family Medicine time wisely

Attire

My basic approach: Never give anyone a reason to dislike you or judge you

Assume nothing: Wear nice clothes + white coat as baseline

For call days, ask your resident about scrubs

Cell Phone etiquette: People will assume you’re texting or goofing off. Always on vibrate Never use on rounds --> announce exceptions loudly

Feedback

Ask for it from Attendings / Residents

Attendings like to be asked proactively for feedback, midway through your time with them

Residents are more likely to offer real, constructive feedback to help you improve

ASK SPECIFICS: ie, I’m really working on making my presentations concise and to the point, do you have any feedback for me on that or suggestions for how I could continue to improve? That way you can do something very concrete and they can say in their evals that you used feedback to improve!

Family Medicine

You will be placed at an outpatient practice… some will have residents, but in most you will work directly with the attending

Be ready to get thrown into seeing patients

Your H&Ps will be less thorough than in the hospital.

Be “problem” oriented and try to help the patient identify the biggest “problem”… Some will come in with many issues that you may not be able to address in one visit

Family Medicine: What to Review

Look over the last chapter in Step Up to Medicine before beginning the rotation

Know Framingham Risk calculation

Review musculoskeletal exams – knee, shoulder (will need this for the exam too)

Some practices will see more ob-gyn than others… if you feel like you are seeing a fair amount of OB, may be helpful to review the prenatal/postnatal care section of an OB-GYN book

Family Medicine Exam

One component is preforming a joint (shoulder or knee) exam on a standardized patient

The other component is a multiple choice test based on the computer modules you are required to do

The test is somewhat detail-oriented and less big-picture. Do not skip over the sections about cultural competency in the online cases… they can be tested (know the latino principals of respecto… etc)

Review all the guidelines presented in the online modules – like when to do pap smears, stress test, etc

Staying Sane

Biggest challenges Schedule Interpersonal work load Not seeing your friends

Tim’s Solution: Institutionalize time with those you care most about

Don’t let your empathy get fatigued! Taking an extra moment to listen to your patient is a good way to improve patient care, help your team, and make the experience more fulfilling for you!

Random

Go to Intern Report --> good learning and good eating

When your resident tells you to leave, leave! ␣

Always be on time

Have fun

Advice: On Clinic Grades

The Three A’s: Affability (enthusiasm for everything!) Availability Ability

Support SystemsSuite 100:- JoMo, Barb, Helene- Tutors set up through suite 100

Organized counseling:- CAPS: http://www.vpul.upenn.edu/caps/- Therapists in the community (Barb from Student Affairs can provide names and contact info)- Paired mentoring: SNMA, LMSA, Elizabeth Blackwell, House mentors

Other people to turn to:- Doctoring preceptors- Advisory deans- Clerkship directors (it’s really ok to talk to them!)- Mentors you have connected with in pre-clinical years (through clinics, volunteering, etc)- Friends and family outside of medicine

Supplemental Stuff

UpToDate from Home

Access the hospital's Extranet at https://extranet.uphs.upenn.edu/

Use your MedView username / password to log in

Create a bookmark on your home page for UpToDate

Click on the "+" that's on the far right side of the "Web Bookmarks" heading

Name your bookmark and put this URL in the URL spot: http://uphsxnet.uphs.upenn.edu/uptodate

Click on new bookmark that's now on your home page

Use UpToDate like you would from on campus

HUP OR Schedule: Homepage: Left hand side, click on Departments-->Perioperative Services-->OR

Schedule. The user name and password are both hupor

Supplemental Stuff

Bug Drug: UPHS guidelines for anti-microbial therapy

Pulse: Phonebooks for each hospital #s for Consult services Lots of assorted resources, guidelines, forms

Phone #s to store in your cell

Hospital operator

General lab