PGY2-to-Be Retreat

June 9, 2014

Scott DenstaedtMarty TamAngel Qin

Khanjan Shah

“With great power comes great responsibility”

-Spiderman

Finished internship…

Success!

Overview4-4:30 PM Snacks and informal discussion

4:30-6 PM Introductions and classroom activitiesGiving feedbackMilestonesChanges in the ambulatory programStudent teaching - clerkship directors

6-7:45 PM DinnerHow to be a ward resident - small groupsIntern class group meetings

8-9 PM Administrative issues/changes for next year/chief residents Ambulatory programElectivesJeopardyTransition datesTeam caps/duty hoursStaffing/new rolesCoverage/schedulesReading listMoonlightingProfessionalism/conferencesIn-training examMICU/CICU scheduleNight floatTwo midnight ruleCodes

Changes for Next Year

•Ambulatory Model 2.0•Electives•Jeopardy

Ambulatory Model 2.0• 2013-2014: four ambulatory blocks and 2-4 clinics in elective• 2014-2015: five ambulatory blocks and no clinic in elective (there is a panel

management day)• “6+2” model

– 6 weeks of ICU/wards/elective– 2 weeks of dedicated ambulatory– 7 half days of clinic each block and 1 administrative half day

• Positive Effect– Continuity: you and three other seniors make up a team (with two interns) and see the

same patients (great for you and the patients!)– Electives Preserved: you can make more of your elective now!– Curriculum: streamlined and less repetitive

• New Challenges– Ambulatory blocks are fixed (cannot trade)– Change is uncomfortable, but we do it to try and make things better

Ambulatory Model 2.0

Ambulatory Model 2.0

Team Flight 1 (1A,4B,8A,10A,12A) Flight 2 (1B,5A,8B,10B,12B) Flight 3 (2A,5B,9A,11A,13A) Flight 4 (2B,6A,9B,11B,13B)

VA 1 Red Perihan John S Anodika Prashanth

VA 2 Silver Andres Rachel Abdullah Alm Perica

VA 3 Purple Alina Katie Philicia Khadejah

VA 4 Yellow Amhed Wissam Nupur Lesley

DMC 1 M Bryan Jacob Rania Neetika

DMC 2 Tu Stephanie K Sadeer John G Nate S

DMC 3 W Maya Carine Patrick Gabe

DMC 4 Th Ahmad Dafina Atallah Vincent

DMC 5 F Stephanie M Brandon Yosra Chris

DMC 6 M Roopa Cassie Won Dhruti

DMC 7 Tu Jack Mo Abdullah Alj Hussain

DMC 8 W Aniket Anthony Rishi Shiv

DMC 9 Th Bouchra Priyam Ning Ziyad

Ambulatory Model 2.0# Residents Mon Tues Wed Thurs Fri

1 Team 1 Team 1 Team 12 3 4 5 6 7 WEEK 18

BOX BOX

Admin Team 1 # Residents Mon Tues Wed Thurs Fri

1 Team 1 Team 1 Team 1 2 3 WEEK 24 5 6 7 8

BOX Team 1BOX

Admin

# Residents Mon Tues Wed Thurs Fri1 Team 1 Team 2 Team 1 Team 2 Team 12 Team 3 Team 4 Team 3 Team 4 Team 33 Team 4 Team 5 Team 5 Team 6 Team 54 Team 6 Team 7 Team 6 Team 7 Team 75 Team 7 Team 8 Team 8 Team 9 Team 86 Team 9 Team 9 7 *Intern 1 *Intern 2 *Intern 3 *Intern 4 *Intern 5 WEEK 1

8 *Intern 6 *Intern 7 *Intern 8 *Intern 9

BOX Team 2 Team 3 Team 4 Team 5 Team 6BOX Intern Intern Intern Intern Intern

Admin Team 8 Team 9 Team 1 Team 2# Residents Mon Tues Wed Thurs Fri

1 Team 1 Team 2 Team 1 Team 1 Team 22 Team 2 Team 3 Team 3 Team 2 Team 3 3 Team 4 Team 5 Team 4 Team 4 Team 5 WEEK 24 Team 6 Team 7 Team 6 Team 5 Team 65 Team 8 Team 9 Team 8 Team 7 Team 86 Team 9 Team 9 7 *Intern 1 *Intern 2 *Intern 3 *Intern 4 *Intern 5

8 *Intern 6 *Intern 7 *Intern 8 *Intern 9

BOX Team 7 Team 8 Team 9 Team 1BOX Intern Intern Intern Intern Intern

Admin Team 3 Team 4 Team 5 Team 6 Team 7

Ambulatory EMR - DMC

• Beginning July 1st, DMC will transition to ambulatory EMR

• Experts will be available to assist with any day-to-day problems

• You need to complete the EMR training via Oracle prior to July 1st (alternative was full day of in-house training!)

Electives

• PGY II: 8 weeks • PGY III: 12 weeks• Quality Chief will now be assisting Barb in keeping a running

list of what you are doing for elective• For ACGME requirements each resident must have a specified

activity and supervisor for each elective

Example Elective Tracking

Electives

• Research Electives:• Must have a mentor/PI for project• If doing two weeks (or more) of research elective, you are

required to present a poster at Medicine Research Day• If you present at a national meeting…travel money!

• Reading Electives:• Requires approval, KBA is designated supervisor• Required attendance at all UH noon conferences, UH

M+Ms, UH Grand Rounds, VA Grand Rounds

Elective Reminder

• Elective Professionalism• Elective is not vacation• You are back-up jep and expected to be in Cleveland• If you are going out of town, please let the Ambulatory

chief know

• “Don’t you remember when you were a resident?”• Having your pager on 24/7 on elective is unreasonable• Everyone on elective is back-up jep any given day, but we

can assign people on specific days to be the first called so you know when to have your pager with you

Jeopardy• Minor changes to the jeopardy system will be made• Use of jeopardy will be tracked for training/support purposes

– Make sure everyone is meeting minimum requirements– Make sure we provide help and resources to those that need it

• Those getting jepped from electives will be tracked as well– Ties into the “first call” back-up jep list, you move down the list after getting

jepped– Makes the system more fair

• KEY Points– Jeopardy still remains for emergencies and significant illness– Unless there is excessive use of jeopardy (decided on a case by case basis), you

are not expected to pay back– There is still a jep rotation, coverage here is not tracked and you do not get paid

back

Transition Dates

•PGY1 end date: 6/23•Block Zero: 6/24 – 6/30•Block One: 7/1 – year of SMAK!

Team Caps

• UH Wards: • 10 patients per intern • 8 patients per intern on Ratnoff/Weisman• Intern+AI: 12 patients if two seniors; 10 patients if one senior

• VA Wards: • 8 patients per intern• Intern+AI: 10 patients• AI+AI pair: 10 patients

• Short Admissions:• No shorts on weekends• No shorts if intern has 8 patients• Shorts for Intern+AI pair to cap of 10 patients

Duty Hours• Long Call:

– 3 patients (4 if paired with AI) until 7 PM– 2 patients if after 5 PM– 1 patient is after 6 PM

• Medium Call:– 2 patients until 4 PM– Can sign out at 7 PM

• Short Call:– 2 patients until 12 PM at UH (NF or ICU transfers)– 2 patients until 1 PM at VA (NF, ICU transfers, new admissions)– No short patients on clinic days

ANESTHESIA INTERNS MUST LEAVE BY 9 PM IF ON CALL!!!

• Senior Resident: – Residents on call MUST stay until 9 PM– No matter what the call, ward seniors staff any patient the seen before 4 PM– Weekend coverage seniors must stay and staff at least until 1 PM or longer

depending on how busy the other seniors are

Staffing• UH wards will have double coverage Blocks 1-4a• There will be minimal orphan coverage in the first few blocks• See and examine EVERY patient• No staffing note required for ICU transfers or interservice

transfers• Focused notes by the senior resident with detailed plan• See PGY1 note for full H&P. Briefly, pt is a …

• Helpful to new interns: • Antibiotic doses• Description of imaging - With contrast? Without?• Medications to continue, medications to discontinue• CODE STATUS and Allergies

Staffing• On call resident should notify the nightfloat resident of

tenuous patients• Be proactive about staffing patients

Your New Role

Be a Manager:•Print out daily patient list for attending at UH•Enter team attendings in the EMR•Lead rounds•Review active medications and orders EVERY DAY!•Direct intern work flow•Help with discharge summaries!•Have teaching topics•Maintain a white board and saved list of patients•Review discharge profiles

Your New Role

Be a Teacher:•Great teachers are motivators, respectful, and treat their students as colleagues/equals•Take time to critically evaluate presentation skills•Find your own method of teaching

Your New RoleBe a Steward of Sign-outs:• What is important? What changes management?• What is not important?• Observe signouts early

Coverage and Schedule Switches

• All coverage arrangements and schedule switches must be approved by the Ambulatory chief so it can be noted in amion

• Switches must be arranged before 1 week of rotation starting

Residency Reading List

• Residency Reading list:• Landmark and review articles in all sub-specialties• Last major update in 2011• Looking a 20-40 year old resident who enjoys long nights

of Boolean searching to help update the site with new landmark trials…

Moonlighting• FLEX – occasionally, when your team is capped and a

patient is in need of your specific team, they can be admitted by you for money, usually go to intern the next day as admission

• PRN SHD – admit 3 patients

• Early and Late SHD – admit 3 patients

• Admitting LHD – admit 6 patients from 6 PM – 6 AM

• Cross Cover LHD – cross covers hospitalist, NPs, and can admit 1 patient (3 if overnight NP present), work from 8 PM – 8 AM

• MICU moonlighter – 9 pm – 9 am Fri/Sat. Responsible for alternating admissions with resident until 2am, then all admissions

• No moonlighting during wards or ICU

Professionalism

Professionalism: Attire

•Men• Shirts and ties

•Women• Professional

•Keep white coats clean•No denim•Do not show up to Morning Report looking sloppy

Professionalism: Absences

• If you have to call in sick > 1 day, you will need a doctor’s note from the Bolwell Family Practice clinic • You will be able to get a same-day appointment

• If you are sick for > 2 days and do not have a doctor’s note, you will be assigned extra weekend coverage and/or weekend jeopardy

• Call-offs: You must PAGE 31529 the Ambulatory Chief• DO NOT EMAIL• DO NOT TEXT PAGE• DO NOT CALL THE CELL PHONE OF THE CHIEF YOU KNOW

Professionalism: Electives

• Attend all Grand Rounds and M&M’s• You are back up jeopardy!! = pager on• If you are going out of town for the weekend, as a courtesy

please notify the ambulatory chief prior to leaving• Elective is not vacation• Please email Barb 2 weeks prior to starting your electives;

Quality chief will be keeping track of electives• Research for more than 2 weeks = present at Research Day

Professionalism: Reading Electives

• Residents on reading elective are expected to attend morning reports and journal clubs at the VA

• Must attend Grand Rounds at UH• Your pager is expected to be turned on and on you during

the entire two weeks of elective• All reading electives must be approved by KBA• For PGY2s it can only be used to study/take step 3• Please note that when you are on elective, you are back up

jeopardy!!!

Professionalism: Conference Attendance

• Please be on time; our speakers usually have prepared a well thought out talk/powerpoint, so please be respectful of the time they spent

• Noon conference: • UH: Mon-Wed-Thurs • VA: Mon-Thurs-Fri

• Grand Rounds on Tuesday: UH & VA• M&M Fridays @UH, Wednesdays @VA• Conference attendance is part of your ACGME graduation

requirements

Ambulatory Conference Attendance

• Ambulatory conference attendance is mandatory • Late Policy will be strictly enforced:

• Sign-in sheet will be available until 8:05AM• At your 2nd instance of being late = extra weekend coverage• Any MISSED conferences without prior approval by the ambulatory

chief will result in weekend coverage

Professionalism: Agre Society

• First Wednesday of each month beginning September

• Organized by Dr. Proweller• Excellent opportunity to hear the career

trajectories of influential clinicians/ researchers

• May be your solution to “I cannot find a mentor…”

Professionalism: Discharge Summaries

•If you put in the discharge order, you do the discharge summary

•Do them the day of discharge•Do them for your intern•Do them for your friends•Do them for your patients•Remember it is now easier than ever to do it in UH EMR

In-service Training Exam• In-service Exam Dates are in September – exam is

completely computerized this year• Includes all PGY2/3, PGY1’s?

• ITE during 2nd year is an important predictor of passing boards

• ITE remediation by percentile rank• >50% - no remediation, continue to study• 31-49% - turn in in 60 multiple choice questions every 4 weeks

to assigned APD for review; continue studying and attend board review sessions

• 16-30% - high risk for ABIM failure multiple choice questions as above with directed notes• If you are not already doing this PLEASE talk with us or your APD, ABIM

failure is no joke• 1-16% - more intense remediation, urgent intervention

required (we are here to help!)

CICU Intern• Two interns scheduled in the CICU

– Day intern: works 7 AM - 7 PM, admits with supervision of senior– Night intern: works 7 PM - 7 AM, helps cross-cover and can admit

• Interns do one week of nights and one week of days• Both interns have Sunday off (accommodate switch days and transition

from nights to days)

CICU Resident• 5 senior residents

– Night call– Post-call– Day call– Helper day– Pre-call

• Pre-call day between Thursday and Monday is day off• The Day Call senior, Helper Day senior, Night Call senior, and

Day Shift intern should be present on evening fellow rounds (5 PM)

CICU Resident• Night call = come in at 4 PM to admit; present patients first on

rounds • Day call = pre-round and admit patients until 4 PM• Helper day = pre-round and carry most team cross coverage• Pre-call = mostly days off• New system with LOTS of hand-offs; remember all patients are

“ours”

MICU Resident• Overnight Call – Post Call – Helper Day – Pre Call• Senior residents get pre-call day off between Friday and Monday (interns

get helper day off during same days)• Five senior residents in the MICU (plus rotators)• If two MICU attendings, there are two teams (Blue and Gold)• If one MICU attending, the entire unit team rounds together• Senior will be paired with intern, your responsibility to supervise but who

“staffs” directly with fellow• Helper day = supervise the post call intern (their senior will leave by 11am)

and help out on-call resident until at least 5 PM

MICU Resident• May have 2 weeks as MICU night resident (have Friday and Saturday

nights off that are covered by MICU moonlighter)• MICU night resident responsibilities

– Comes at 9 PM– Cross-covers unit at night– Alternates admissions with resident on call until 2 AM, then does all

admissions after 2 AM• Patients admitted by NF will be distributed by the MICU fellow in AM• NF residents sometimes stay to present patients on rounds (complex

patients)• Post-call resident will present and leave, sign out to the post call intern

VA Nightfloat Resident• Works from 8 PM to 8AM• Cover the VACR pager (medicine consults)• Run codes• Evaluate CARES Tower 6 patients

– If patient needs more evaluation then direct admission (DO NOT GO TO THE ED)

• VA chief will page you in the morning to distribute patients• Discuss Code status of patients• Change team assignment in CPRS (admission order: team)

The NIGHTFLOAT TEAM

NACR

Nightfloat ResidentRotating MSIII

Nightfloat Resident

Nightfloat InternRotating MSIII Nightfloat InternNightfloat Intern

UH Nightfloat Resident• Works from 8 PM to 8AM• Meets the NACR in the KACR• Admit patients overnight, works with the nightfloat intern to

help answer questions/manage ill patients.• NACR is always available if you need help• Two nightfloat residents, each resident either gets Saturday or

Sunday off (must have 1 nightfloat resident each night)• Must go to all Code Whites during the first 6 months with

intern

Two Midnight Rule

•Arose out of for profit hospital chain fraud•Requires attending to sign and admission order that includes language that the attending expects the patients medical problems to require admission for two days

•Some logistical issues on getting attendings to sign/place order

Running Codes

Code Whites (UH)

** 1ST six months – an upper level must go to all Code Whites with an intern**

•Sick or decompensating patients on the floor or Hanna House

• Initial response from ICU nurse, intern, and PGY2

•DACR/NACR for Level 2 code white• If you want to transfer to MICU, call MICU fellow

•Always write a Clinical Event Note!

Code Blues• Check your own pulse first

• “Too many chefs spoil the soup”• One person leads the code• Make sure interns are involved• Maintain a calm quiet atmosphere

• Keep the ACLS cards in your pocket until you are comfortable with the protocols

• Make sure your BLS and ACLS are up to date

• CODE BLUE NOTE and notify family; DEATH NOTE if patient passes; notify attending

Running Codes• Rule #1: You are in charge

• If uncomfortable, defer to more senior resident

• Delegate, delegate, delegate – assign crowd control, chest compressions, airway, etc.

• Use the DACR/NACR if you need help

• Don’t be afraid to ask people to leave the room

• Call the ICU nurses by their name, closed-ended communication

• Assign someone to call the family

• Use the Code Note EMR, sign code sheet

Running CodesNotifying attendings at night

• Most attendings want to be paged and notified (either of transfer to ICU or death)

• Can clarify with your attending on first day of service what their preferences are

• Don’t get burned by not calling your attending- you may hear about it the next day

We are looking forward to a great year together!!!

-SMAK

Questions?