Art of ID ConsultationArt of ID Consultation

ID Fellowship OrientationID Fellowship Orientation

Paul Pottinger, MD, DTM&HPaul Pottinger, MD, DTM&H

July 1, 2011July 1, 2011

OBJECTIVESOBJECTIVES

• Nuts & Bolts for:Nuts & Bolts for: UW Inpatient Consult ServicesUW Inpatient Consult Services UW Outpatient ID ClinicUW Outpatient ID Clinic

• General principles for consultationGeneral principles for consultation

CAVEATSCAVEATS

• You already know this….You already know this….

• You can do this….You can do this….

• Yes it’s fun (“It’s Good to be the Yes it’s fun (“It’s Good to be the Fellow”)Fellow”)

ID Fellowship: Mission

To create successful physician scientists in academic infectious diseases

•Outstanding clinical training

•Unmatched research opportunities

ID Fellowship: Structure• Year 1: Clinical ID Training

– Inpatient consultations at 4 hospitals

• Year 1: Clinical ID Training– Inpatient consultations at 4 hospitals

• University of Washington Medical Center– General infectious diseases– Solid organ transplant ID– Oncology and stem cell transplant ID– MEDCON ID telephone consults 2 weekends

UWMCUWMCSCCA / FHCRCSCCA / FHCRC

ID Fellowship: Structure

ID Fellowship: Structure• Year 1: Clinical ID Training

– Inpatient consultations at 4 hospitals• University of Washington Medical Center

– General infectious diseases– Solid organ transplant ID– Oncology and stem cell transplant ID

• Harborview Medical Center

Jeannie Chan, PharmDJeannie Chan, PharmDHMCHMC744-5854744-5854jdchan@uw.edujdchan@uw.edu

Rupali Jain, PharmDRupali Jain, PharmDUWMCUWMC598-4416598-4416rupali@uw.edurupali@uw.edu

Pharmacy SupportPharmacy Support

ID Fellowship: Structure• Year 1: Clinical ID Training

– Inpatient consultations at 4 hospitals• University of Washington Medical Center

– General infectious diseases– Solid organ transplant ID– Oncology and stem cell transplant ID

• Harborview Medical Center • Puget Sound VA

WWAMIWWAMI

MEDCONMEDCON

Docs in WWAMI region can call you Docs in WWAMI region can call you 24 / 7….24 / 7….

• Free Free ““educationaleducational”” service service

• They greatly appreciate your help, and They greatly appreciate your help, and will manage pts as you recommendwill manage pts as you recommend

• Please be nice… even if they donPlease be nice… even if they don’’t t deserve it!deserve it!

• Please keep database updated.Please keep database updated.

MEDCONMEDCON

Docs in WWAMI region can call you Docs in WWAMI region can call you 24 / 7….24 / 7….

• VA fellow takes these calls when on VA fellow takes these calls when on duty.duty.

• On days off, UW ID fellow takes over.On days off, UW ID fellow takes over.

• Please run cases by UW General ID Please run cases by UW General ID attending by phone if ANY doubt attending by phone if ANY doubt whatsoever! Calls tend to fall off over whatsoever! Calls tend to fall off over year… but calling is encouraged!year… but calling is encouraged!

Clinical Microbiology LabClinical Microbiology Lab

ID Fellowship: Structure• Year 1: Clinical ID Training

– Inpatient consultations at 4 hospitals• University of Washington Medical Center

– General infectious diseases– Solid organ transplant ID– Oncology and stem cell transplant ID

• Harborview Medical Center • Puget Sound VA• Seattle Children’s Hospital

ID Fellowship: Structure• Year 1: Clinical ID Training

– Inpatient consultations at 4 hospitals• University of Washington Medical Center

– General infectious diseases– Solid organ transplant ID– Oncology and stem cell transplant ID

• Harborview Medical Center • Puget Sound VA• Seattle Children’s Hospital

– Outpatient continuity general ID clinics

ID Fellowship: Structure• Year 1: Clinical ID Training

– Inpatient consultations at 4 hospitals• University of Washington Medical Center

– General infectious diseases– Solid organ transplant ID– Oncology and stem cell transplant ID

• Harborview Medical Center • Puget Sound VA• Seattle Children’s Hospital

– Outpatient continuity general ID clinic• Years 2 & 3:

– Continuity HIV clinic

Additional Clinic Opportunities

•Hepatitis

•STD

•TB

•Hansen’s

•VA

•Travel

•Overseas HIV

Additional Clinic Opportunities

•Hepatitis

•STD

•TB

•Hansen’s

•VA

•Travel

•Overseas HIV

ID Fellowship: Didactics

• Early July of first year: 2 week introduction to clinical infectious diseases, with hands on microbiology course.

• Late July of second year: Principles of STDs training course, with lectures on HIV and STDs, and focus on research practices.

• ID board review and lectures for fellows every Wednesday throughout the year.

Citywide ID Clinical Conference

• Weekly case conferences on Wednesday afternoons provide an opportunity for fellows to present interesting cases, practice presentation skills, and get input from other ID practitioners on management.

• Different ID services rotate presenting cases: UW general ID, UW SOT, SCCA (oncology), Harborview ID, VA ID, Children’s ID.

• Didactic sessions for fellows precede or follow the clinical conference .

ID ConsultantID Consultant’’s Dual Roless Dual Roles

““MandatoryMandatory”” Consults? Consults?HIV pts at HMC seen by HIV serviceHIV pts at HMC seen by HIV service

Scary in micro rounds (Certain MDRScary in micro rounds (Certain MDROO’’s, multiple + BCxs, multiple + BCx’’s, etc.s, etc.

• Review case Review case

• If care or plan sketchy, contact team If care or plan sketchy, contact team and and stronglystrongly offer consultation offer consultation

Think Like a ConsultantThink Like a Consultant

Whose Patient is this?Whose Patient is this?• Name, Rank, & Contact info for callerName, Rank, & Contact info for caller• Attending & ServiceAttending & Service

What is the question?What is the question?• Diagnosis?Diagnosis?• Management?Management?• Mediation?Mediation?

Think Like a ConsultantThink Like a Consultant

Urgency?Urgency?

• Often fine to give preliminary recOften fine to give preliminary rec’’s and s and staff following daystaff following day

• ““My attending wants this staffed right My attending wants this staffed right now:now:”” Please let your attending know, Please let your attending know, regardlessregardless of time of day of time of day

Think Like a ConsultantThink Like a Consultant

Please Remind Caller:Please Remind Caller:

• In order to see the pt, we need a In order to see the pt, we need a writtenwritten request in ORCA: request in ORCA: ““Consulting Consulting ID for assistance with management of ID for assistance with management of XX””

Think Like a ConsultantThink Like a Consultant

Curbside?Curbside?

• Generally NOT recommended… but it Generally NOT recommended… but it happens anyhowhappens anyhow

• ALWAYS offer to see the patientALWAYS offer to see the patient

• If you have to ask > 2 questions, itIf you have to ask > 2 questions, it’’s s probably best to strongly probably best to strongly RECOMMEND a consultRECOMMEND a consult

Think Like a ConsultantThink Like a Consultant

Is this patient infected?Is this patient infected?

If so, does the infection explain the If so, does the infection explain the syndrome?syndrome?

What are the host & bug factors here?What are the host & bug factors here?

This is Your Service!This is Your Service!

““ItIt’’s good to be the fellows good to be the fellow””

Use your own style for teachingUse your own style for teaching

Attending always there to back you Attending always there to back you upup

Dx RecommendationsDx Recommendations

Consider Implications of TestingConsider Implications of Testing

• Want a biopsy or BAL? Instead of Want a biopsy or BAL? Instead of demanding them, suggest consultation demanding them, suggest consultation with performing service to get their with performing service to get their input… if they say no, your attending input… if they say no, your attending will make a call.will make a call.

Dx WorkDx Work

Micro Labs extremely helpfulMicro Labs extremely helpful

• Notify them of tough cases before Notify them of tough cases before micro rounds M/W/F 11-12micro rounds M/W/F 11-12

• You also have access 24/7… use it!You also have access 24/7… use it!

Seek Primary Data Seek Primary Data

• Radiology, Path, OR… go where the Radiology, Path, OR… go where the data are!data are!

Abx RecommendationsAbx RecommendationsDrug NameDrug Name• Generic pleaseGeneric please

RouteRoute• Acknowledge access issuesAcknowledge access issues

DoseDose• May vary by indicationMay vary by indication• Renal or hepatic adjustmentsRenal or hepatic adjustments• Drug interactionsDrug interactions• Prolonged infusions may be helpfulProlonged infusions may be helpful

Abx RecommendationsAbx RecommendationsDurationDuration • Stop date / criteriaStop date / criteria

Monitoring LabsMonitoring Labs• Troughs, CBC, CMP, ESR, etcTroughs, CBC, CMP, ESR, etc• Guidelines at www.uwantibiotics.comGuidelines at www.uwantibiotics.com

FollowupFollowup• IV abx: UW ID clinic within 2 weeks IV abx: UW ID clinic within 2 weeks

when possiblewhen possible

RN Support at UWMC ID ClinicRN Support at UWMC ID Clinic

Please notify Please notify them with home them with home IV plans….IV plans….598-8788598-8788oror598-7750598-7750ororid_clinic@uw.eduid_clinic@uw.edu

Jeanne Wolf, RNJeanne Wolf, RNJeanne Wolf, RNJeanne Wolf, RN

Josette Pierre-Antoine, RNJosette Pierre-Antoine, RNJosette Pierre-Antoine, RNJosette Pierre-Antoine, RN

Orders for InpatientsOrders for Inpatients

Generally we do NOT write them.Generally we do NOT write them.

Exceptions:Exceptions:• Direct request from primary team by Direct request from primary team by

phone (usually orthopedics)phone (usually orthopedics)

• Exotic micro lab maneuversExotic micro lab maneuvers

• Outpatient IV abx for 4-S patientsOutpatient IV abx for 4-S patients

Communication Pearls: NotesCommunication Pearls: Notes

Initial Consults:Initial Consults:

• ““We have been consulted by Dr. X of We have been consulted by Dr. X of service Y to assist in the management service Y to assist in the management of problem Z.of problem Z.””

• ORCA templates saves time.ORCA templates saves time.

Communication Pearls: NotesCommunication Pearls: Notes

Initial Consults:Initial Consults:

• MS may write, but must forward to you; MS may write, but must forward to you; only their PMH, SH, FH counts!only their PMH, SH, FH counts!

• MD (you or resident) must write note; MD (you or resident) must write note; please oh please include ROS: please oh please include ROS: ““all all negative except as noted in HPInegative except as noted in HPI””

• All notes then forwarded to attending All notes then forwarded to attending for signature (not just CCfor signature (not just CC’’d).d).

Communication Pearls: NotesCommunication Pearls: Notes

Initial Consults:Initial Consults:

• You may dictate new SOT consults, You may dictate new SOT consults, and new UWMC consults on busy days and new UWMC consults on busy days (e.g. clinic days).(e.g. clinic days).

• IF YOU DICTATE:IF YOU DICTATE:

1) Call in your recs, and 1) Call in your recs, and

2) Write a summary of your rec’s2) Write a summary of your rec’s

Communication Pearls: NotesCommunication Pearls: Notes

Followup Notes:Followup Notes:

• Please write notes whenever clinical Please write notes whenever clinical issues arise or a change in issues arise or a change in recommendations are made.recommendations are made.

• We are emphasizing time-based We are emphasizing time-based billing… please stay tuned!billing… please stay tuned!

• Please discuss note plan with attending Please discuss note plan with attending each day (who needs a note?)each day (who needs a note?)

Communication Pearls: MDCommunication Pearls: MD’’ss

Get notes done ASAP, but Get notes done ASAP, but callcall with with recrec’’s before writings before writing

If they donIf they don’’t like your rect like your rec’’s….s….

• Acknowledge primary teamAcknowledge primary team’’s expertises expertise

• Frame recFrame rec’’s with evidence & likely odds s with evidence & likely odds of success or failureof success or failure

• Recognize ideal vs. practical Recognize ideal vs. practical approaches, and offer alternatives approaches, and offer alternatives

Communication Pearls: MDCommunication Pearls: MD’’ss

““Honey vs. VinegarHoney vs. Vinegar””

• A teaching opportunityA teaching opportunity

• Take the high road (even 4PM Friday)Take the high road (even 4PM Friday)

• No chart wars EVERNo chart wars EVER

• Engage the attendings (yours & theirs)Engage the attendings (yours & theirs)

Keep Keep ““off topicoff topic”” rec rec’’s out of writing s out of writing (but DO discuss verbally)(but DO discuss verbally)

Communication Pearls: PtCommunication Pearls: Pt’’ss

• You are here at request of Dr. X for You are here at request of Dr. X for assistance with problem Y.assistance with problem Y.

• Be honest, but defer to primary team Be honest, but defer to primary team (no splitting!)(no splitting!)

• Remember, your classmate will Remember, your classmate will probably inherit this pt in f/u.probably inherit this pt in f/u.

Communication Pearls:Communication Pearls:

• What have you liked working with What have you liked working with fellows?fellows?

• What has cheesed you off?What has cheesed you off?

The ObviousThe Obvious

• Never fake it.Never fake it.

• ID attendings want to hear from you ID attendings want to hear from you early & often, especially early in the early & often, especially early in the year, or any time with urgent issues.year, or any time with urgent issues.

• Think about what you did and did Think about what you did and did NOTNOT like from consultants as the primary like from consultants as the primary doc.doc.