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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