Professional Development Series: Part 2

Surviving the clinical years

What to Expect

• From the 3rd and 4th year clerkships:– Long hours, lots of standing, system of hierarchy– Rewarding, exhilarating experiences– Clinical education/Learn! You’re still paying for it!– Basis for choosing a lifelong career

Team Players:

• Ward/unit secretary• Dieticians• Pharmacists• Therapists: OT, PT, RT• Social workers• Techs/RMA• Nursing• Physician ancillary staff• Medical students, Interns, residents, fellows• Attendings• Custodians• Third Party Reviewers

Unit Secretary

• Also known as ward secretary or clerk• Organizes everything• Knows where every patient is• Arranges transport• Knows about incoming admissions• Day to day operations• Notes orders

Pharmacy

• Pharm.D: doctors of pharmacology• Sometimes round with the team• Monitor expensive and dangerous meds• Helpful with hospital formulary

Therapists

• Respiratory: vent settings, ABG specimens• Occupational:help impaired pts function more independently• Physical: focus on mobility and strength

Social Workers

• Help plan for discharge• Solve non medical problems related to pt care• Big role in psych and in peds

Third Party Reviewers

• “lurk” around the hospital preying on unsuspecting newbies

• Be careful!

Technicians

• EKG• Phlebotomy• Radiology

• Can teach you tricks of the trade/clinical skills

RMA• Registered Medical Assistant• Perform routine administrative and clinical tasks to keep the offices

and clinics of numerous health professionals running smoothly. • Accredited Medical Assisting Programs are offered in

postsecondary vocational schools, junior colleges and in colleges and universities. Postsecondary programs usually last either one year or less which results in a certificate or diploma or two years with an associate degree.

• There is no licensing for Medical Assistants, however, some states require them to take a test or course before they can perform certain job duties.

Nurses

• CNA• LPN• RN• NP• Nursing students

CNA

• Certified nursing assistants (CNAs), also known as nurses aides, orderlies, patient care technicians, and home health aides, work under the supervision of a nurse to provide assistance to patients with daily living tasks.

• CNAs are responsible for basic care services such as bathing, grooming and feeding patients, assisting nurses with medical equipment, and checking patient vital signs.

• In addition to a high school diploma or GED, you'll need to complete a 6-to-12 week CNA certificate program at a community college or medical facility.

LPN

• Also Licensed vocational nurse (LVN) • Working under the direction of physicians and

registered nurses (RNs), LPN nursing schools and educational programs typically involve one year of study and training at a hospital, community college or technical vocational school.

• After earning a nursing degree through a state-approved program, graduates must pass the National Council Licensure Examination (NCLEX-PN).

RN

• Credentials can be acquired by completing one of these three programs offered at many registered nursing schools:

• Associate's degree in nursing • Bachelor's of science degree in nursing • Nursing diploma • The most popular program is the associate's degree in

nursing, which takes an average of two-to-three years to complete. Going straight for the bachelor's program takes four years, and a nursing diploma can take three-to-five years.

• After completing any of these programs a nurse must pass a national licensing examination (NCLEX-RN).

Nurse Practitioners

• Education: graduate, advanced education and clinical training beyond their registered nurse preparation. Most have master’s degrees and many have doctorates. Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP) degree.

• Job duties: Order, perform and interpret diagnostic tests such as lab work and x-rays • Diagnose and treat acute and chronic conditions • Prescribe medications and other treatments • Spend time counseling/educating patients

Prescribing Rules for NP

Oklahoma

Advance Practice Nurses are authorized by the Board of Nursing to prescribe as

Advanced Registered Nurse Practitioners, Clinical Nurse Specialists, or Certified Nurse Midwifes subject to the medical direction of a supervising physician. They have prescribing authority and may obtain a mid-level DEA number to prescribe CDS, Schedules III, IV and V, limited to a seven day supply. The nurses have an Exclusionary Formulary — a list of drugs they cannot prescribe. The name of the Advance Practice Nurse will be placed on the prescription label.

Nursing staff

• They provide the bulk of one to one pt care• Can be an invaluable source of information• Read the nurses notes• First to observe changes in pt status• ICU nurses are the best

Physicians Assistants/PA/PAC• Physician assistants (PAs) are health professionals licensed to practice

medicine with physician supervision. • PAs perform a comprehensive range of medical duties, from basic

primary care to high-technology specialty procedures. PAs often act as first or second assistants in major surgery and provide pre- and postoperative care.

• Programs offering baccalaureate degrees require a minimum two years of college credits, and virtually all require health care experience prior to admission.

• The average PA program takes 26.5 months to complete. The first year generally is composed of classroom studies — the essential medical sciences such as microbiology, anatomy, and physiology — followed by a year of clinical rotations in private practice and institutional settings.

PA Oklahoma • Physician Assistants have prescribing authority as set out by their

supervising physicians.• They may obtain a mid-level DEA number to prescribe CDS, Schedules

III, IV and V. Prescriptions for CDS are limited to 40 dosage units with only (1) refill or a 10 day supply maximum (whichever is smaller).

• Non-controlled drugs are limited to a 34 day supply with (2) refills of a drug prescribed for the first time for the patient. A 90-day supply or 100 dosage units (whichever is greater) of drugs prescribed for chronic, stable conditions, may be prescribed.

• P.A.s have a Formulary that excludes certain drug categories. • The name of the physician will be placed on the prescription label with

a slash/P.A. (Dr. Jones/PA)

Interns

• Doctors without prescribing privileges• Longest hours in the hospital• Most uncomfortable/possibly unfamiliar in the

hospital• Most sleep deprived• Lonely, stressed

Interns

• Take care of daily tasks as quickly as possible• Discharge and transfer patients quickly• Learn• Sleep• Wont do a lot of teaching• More interested in how to accomplish practical

tasks than have academic discussions.• Broad, general approach to treatment/extreme

thoroughness

Residents

• 2nd year post medical school• Prescribing privileges• Don’t do intern scut work• Have more time to teach students• Rely more on experience that the intern

broad- based approach• More focused exams

Fellows

• Are in subspecialty training• Have completed residency• Often on attending level of knowledge without

the experience

Attendings

• Leader of the team• Responsible (maybe) for your eval/grade• Concerned about patient care and teaching• Responsible for everyone

Consultants

• Subspecialty attendings and their team of residents, interns, students

• Called in to give expert opinion/answer a specific question. Do not write: “Evaluate this patient.”

• Verbal feedback and formal consult note• Do not write orders on the chart• May or may not follow the patient

Med students

• That’s you!• Even though you may feel like an unimportant, redundant

part of the team, the more responsibility you take on, the more of an asset you will become.

• Your main goal is to learn and decide on a career in medicine.

• Your secondary goal is to get good grades and connections by making a good impression on your superiors

• You have to balance these 2 roles between scut work, feelings of inferiority, and competition.

Med Students

• This will be the easiest time to learn from a book, but you also have the least amount of time available.

• Very tempting to “quit” at the end of the day.• Opportunity to know your patients inside and

out.• Be proactive and speak up.

Daily Routine

• Managing patients: leaving, coming, and staying (reviewing charts, writing notes, procedures, dictations, reviewing films)

• Attending lectures• Learning/Presenting/Studying

Daily Routine: Pre- Rounds

• 6 am: Interns and students arrive to see patients, review overnight events and admissions, write notes, order am labs/tests.

• Pay attn to overnight events: new meds/impt vitals/new symptoms and signs/new labs

• Talk to the nurses.

Daily Routine: Pre- Rounds

• 630-7 am: residents arrive to see, patients, review intern and student notes, check orders.

• Interns usually present new patients but this can be handed off to students.

• Interns and students give an informal/formal reports to the residents.

Daily Routine:

• 8am: Attending arrives to see all patients.• Goal is to present each patient with a plan for

treatment.• Students, interns, and residents give formal

presentations to the attending.• Attendings will modify plans, write addendum

notes, and teach.

Daily Routine:

• Could attend morning report/department meeting with case presentations prior to attending rounds.

Daily Routine

• The team may go to radiology to look at films or be called to the ER to see a patient.

• Depending on the length of rounds, the team may or may not have breakfast. Could work through until lunch.

• After rounds, the attending may leave for outpatient clinic or may join the team for breakfast.

Daily Routine:

• If the attending does leave after breakfast, the team will continue assessing lab results, new patients, ER consults.

• Minus a break for breakfast, this type of work continues until noon conference.

• Noon conferences are usually some type of learning opportunity and food: grand rounds, student lectures

Daily Routine:

After lunch:• New admissions • continue to f/u up on labs/tests• Go to department meetings/and or outpatient

clinics• Day could end at 4pm or, depending on if the

attending wants to do afternoon rounds, go well into the evening.

• Check out to the night staff

Daily Routine:

• Differences in surgery: bump everything up by 1.5 to 2 hours

• Day usually ends by 5pm for students

Admissions

• Review old charts• Orders/flag them• ADC VANDALISM

ADC VANDALISM

• Admit to ? Service, ? Doctor, ? Contact number

• Diagnosis: list primary suspected/important secondary

• Condition: critical, guarded, poor, stable, air, good

ADC VANDALISM

• Vitals: q shift, q hour, daily weights. Call house officer if temp more than 102’F

• Allergies: NKDA, ASA, sulfa• Nursing: FSBS q ac and hs, guaiac stools,

isolation, Foley cath or in/out cath• Diet: NPO, clear liquids, full liquids, soft

mechanical, ADA, Renal, low sodium, low protein. Specify calories

ADC VANDALISM

• Activity: ad libitum, bedrest, walk with assist, restraints, commode at bedside, self toilet

• Labs: fasting lipids, cbc, cmp, ua, lfts• IV fluids: KVO, heplock with flushes, dextrose

(D5W), normal saline (NS), potassium (K)• Specials: RT, PT• Meds: don’t forget renal or hepatic dosing

Other tips:

• STAT orders need verbal verification with the ward clerk• Frequently review the MAR to see how often the prn

meds are actually being given, if a patient is refusing meds, meds added or discontinued by the house officer

• Use only approved abbreviations• Sign and date every order.• Be overly clear by using words like change this to that

or replace x with y• Verify the correct chart• Use generic drug names

Other tips:

• TID means through waking hours vs. q 8 hrs means exactly that!

• Balance prn orders with close follow up. Check the MAR to see how often they are getting pain meds. Consider tylenol dosing when looking at pt temps.

• Ped meds need to be adjusted for body weight• Be prepared to be pimped on the drugs you

order. Know them well.

Admit note:

• Informants• CC: precise and to the point“chest pain and nausea later ruled an MI in the

ER”• HPI: chronological order/pertinent positives

and negatives. “no radiation or SOB”• PMH/PSH:• Meds/All:

Admit note:

• Developmental Hx and Immunizations (for peds)• Psych Hx (for psych)• OB/GYN (for OB/GYN)• SH (include pets and home smokers in peds)• FH• ROS: often redundant if HPI is done well• PE (include height in peds)• Labs: ER, pending

Admit note:

• Problem list/assessment/diagnostic impressions: can list differential diagnoses

• Plan

Daily Progress Note:

• Subjective: pt and nursing reports

• Objective: vitals, i/o’s, PE, labs, meds

• Assessment

• Plan

Discharge Note

• Serves as temporary dictated d/c summary• Dx• Hospital Course: interventions, studies, sx• D/c meds “see orders”• D/c instructions

Discharge Orders:

• Discharge to home, nursing home, etc• Diagnosis• Meds• Follow up appt• Instructions

Surgery

• Before each case review the anatomy and pathophysiology

• Prepare for a potentially hostile environment• Lots of pimping• Touch as little as possible• Surgery etiquette

Surgery notes

Preop note• S:state the procedure• O: labs, cxr, ekg, consent• A:• P: NPO, consider meds (insulin, blood

thinners)

Surgery notes PPP SAFES FCDD

• Operative note:• Pre-op dx• Post op dx• Procedure• Surgeon names• Anesthesia• Fluids• Estimated blood loss• Specimens• Findings• Complications• Drains• Disposition

Surgery notes

Daily progress notes• S: pain reports, flatus, bm, diet• O: VS (tmax/with meds), i/o’s, include wound

on PE, labs especially WBC, hgb/hct• A: post operative day #• P: don’t forget to d/c foley caths and change

central lines

OB

Delivery note:• Stage 1: 23 yo G1P1 at 38 weeks presents with

PROM/document time of presentation to completion of Stage 1. Anesthesia/other drugs/quality of fluids

• Stage 2: Length of active labor/tools used in delivery/describe rotation of occiput and position of delivery (breech, footling), nuchal cord, baby wt, APGAR, sex

• Stage 3:placental delivery, EBL, episiotomy or degree of tear

Neuro tips:

• Include more extensive cognitive exam: LOC, GCS• Orientation, speech language, memory,

cognition• Cranial Nerves I-XII• Motor function: tone, bulk, strength• Coordination• Sensory• Reflexes

Psych

• MMSE: • General appearance• LOC• Attn/Conc• Speech• Orientation• Mood/affect• Thought form and content• Memory• Judgment• Intellect

Final Tips

• Use index cards with pt stickers• Electronic options• Reading list• Procedure list

Source of Support

OSU-Tulsa graduate students provide services under the supervision of a faculty member.

5 free sessions Additional sessions at $10 each.

Sources:

How to be a Truly Excellent Junior Medical Student

by Robert J. Lederman,MD

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