Greetings Jacobi Housestaff:

 

     I would like to institute a regular (q week or every other week) email from me to you. The point of this would be to make sure we are all “up to date” on policies, changes, happenings and the like. This one is a long one. I have a lot of “pent up” topics, but hopefully future offerings will be shorter. I cc the entire faculty so we can all “be on the same page” and there is less chance of miscommunication.

 

     Occasionally, I will ask for housestaff “votes” or feedback. In the interests of time, although my door is always open (actually closed for temperature control reasons, but knock and come in anytime), I find it even easier to “poll the constituency” by email. If you want your vote to count, you have to respond. Many items/changes involve pros and cons. The only way for me to get a sense of which is the preferred way is to ask you and count the votes. So please take a moment to fire an email back to me (no need to reply all) if you wish to be counted.

 

I will also be asking you to organize yourselves into a “class representative” system. I know this may have been tried in the past, but my view is a smaller group from each class with whom I can meet with some regularity to give info/feedback and most importantly to receive same. By way of treating you like adults, I will simply ask that the names of 4 reps from each class be forwarded to me by April 1st. I leave it up to each class to sort this out, election, acclamation or fiat.

 

I have now met these past few weeks with each of the classes. I will re iterate some points for those who weren’t there. For those who were, thank you for attending and taking the time out to do so. I definitely gained some insights from these meetings. I plan to make them at least semi annual. Again, the rep meetings will be more nimble and frequent.

 

Some items of note:

 

Board Review:

I list here the new policy on use of elective time to take outside board review courses.

Policy for use of elective time to take an external Board Review Coarse:

1.      Only for PGY 3’s

2.      Only during time on elective and ambulatory if procedures followed

3.      Up to 5 weekdays can be used

4.      It is the responsibility of the houseofficer to arrange satisfactory coverage for all back up, calls and clinics

5.      These arrangements have to be done 6 weeks in advance or longer and have to be signed off on by a Chief

6.      All clinic coverage arrangements have to be signed off on by a Clinic Director

7.      If elective time is used, the second week of the elective must be spent in the Outpatient Department with arrangements agreeable to the Chiefs and Clinic Directors

8.      All final arrangements, once signed by a Chief and Clinic Director, have to be signed by the Program Director

 

Blood Bank Policies:

It was brought to my attention during my meeting with the intern class that the exact content and rationale for the procedure in ordering and obtaining and giving blood products to patients is arcane, lengthy and may vary by medical vs. surgeon housestaff and which nurse is involved. I am trying to sort this out.

 

Brief notes and summaries

I have been trying to stress to everyone that your notes and d/c summaries can be quite brief. No need to list data that is easily obtained online. They should not be too short and useless, but verbiage is not a benefit either. My suggestion is to make your notes problem list based. Simply list the patient’s basic identification, then list the problems and within each problem pull in relevant history, PE, lab and other data. The point is the reader should know what you think is going on with the patient and what you are doing. More than this is a waste of the writer’s and reader’s time.

 

Consults:

The residents (PGY 2/3) will be responsible for the quality of the consults called. In most cases, the resident should make the call as they can do so with aplomb and can better articulate the question. If there is not a “question” of sufficient interest to the PGY 2/3 the consult should not be called. Most inpatient medicine can and should be handled by the “home team”. Consultants should be called to answer questions and provide “muscle”, that is procedures only they can do.

 

Electives

As stated previously, elective requests (requests not demands) are to be submitted to the Chiefs months in advance. Unless a compelling case can be made (to the Program Director) electives should be within the AECOM system. Further, PGY 3 electives should be Jacobi Clinical Rotations unless a strong case is made to the contrary. I understand the desire/need to do research as a PGY 2, but as you can imagine (see ITE discussion below) I have concerns about the balance. Residency Programs are primarily clinical teaching endeavors. Yes, we have a wonderful connection to AECOM and the myriad research opportunities, but if your ITE sub section score on Oncology, for example, is poor, you also need to learn some Oncology. Those wishing to do non Jacobi based clinical electives need to submit in writing to me the particulars. Those electing to do research will be required to provide a letter of support from the supervising researcher who will agree to provide accounting of your time and evaluation of your efforts. All research should result in at the least an abstract suitable for presentation and submission to the ACP Associates Competition (or other competitions). I will track these requirements. As a way of “catching up” I ask that all housestaff who have done research electives submit a paragraph to me describing a) what they did, b) when they did it and c) with whom. Please comply voluntarily, I do not wish to have to track you down.

 

Evaluations

Please take advantage of the opportunity to give and receive feedback to/from your colleagues and supervisors. You also have the chance to evaluate, online via MYEVALUTIONS to evaluate your rotations and program. I take this feedback seriously. I cannot promise to be able to “fix it all”, but data such as this will help me sort out priorities and best directions to proceed.

 

Expectations

Resident Expectations I have been giving out at the start of the month:

  1. Answer your pages promptly. All else fails if this does not occur.
  2. If you are admitting with either your team intern or an orphan intern, you must verbally review every admission with the intern before leaving the hospital. COMMUNICATION is key!!!! Know their pager numbers.
  3. You are expected to physically be in the hospital until at least 5PM on weekdays, 3pm on non call weekends. You are the back up for the interns, for their questions and concerns. If you have no notes to write, nothing to look up and no families or consultants to talk with, let us know.
  4. On Clinic days you are expected to return to the wards after Clinic.

 

  1. Please communicate with your co-residents. Sign out any potential ‘disasters’ to the PGY-2’s and 3’s. Think ahead of time. “Who could get worse?” Then give some hints as to next steps. Do not leave the building without speaking with (preferably face to face) with your coverage. This is basic professional behavior.
  2. Communicate with your team. Educate, guide, and supervise.  Leadership skills are essential!!! Think back on a “great” and “not so great” resident you had during your internship. Be one of the great ones. There are no stupid questions, and its OK to hold your team (including yourself) to high standards.
  3. If the medical students are not making more work for you, you are not doing right by them.

 

Expectations for Interns on the Inpatient Service

 

  1. You are expected to ‘pick up’ your sign-out from the covering Night Float intern @ 7AM in the Pulmonary Conference room. Please be considerate and be on time.

 

  1. If you are admitting with either your team resident or a covering resident, you must verbally review every admission with the resident before leaving the hospital. COMMUNICATION is key!!!! If you cannot reach the resident let one of the Chiefs know in real time.

 

  1. You are expected to physically be in the hospital until at least 5PM on weekdays and 3PM on weekends. You can NOT sign out to the covering intern prior to 5PM on weekdays and 3PM on weekends. If you have absolutely no notes to write, no patients or families to talk to and nothing you need to look up/read about, let us know.

 

  1. Be careful and considerate with your ‘sign outs’, especially over the weekends. Do not sign out work that you yourself should be completing. For example, checking x-rays after lines, talking with families, consultants should be done by primary team whenever possible. A good rule of thumb is to only sign out items that will be of immediate importance overnight.

 

  1. On Clinic days you are expected to return to the wards after Clinic.

 

  1. Medical students are NOT allowed to write your notes. Students are there to learn. Teach them. If you find the student on your team is not making more work for you, you are not doing right by the student.

 

  1. You are expected to ‘read up’ on your patients and their disease processes. Most questions are background (e.g. ‘what is CHF’) and best answered by a review article (good journal), chapter or sub-chapter from a good textbook or a card from Up to Date, rather than a Medline search. Please know how to access all such resources at the AECOM library website.

 

Hollie Gaynor:

Ms. Gaynor, a trained PA, will be calling you every so often to ask if your patients can be taken off tele or the MSOU. If you disagree with her suggestion that the patient can be “downgraded” you should be sure to have a clear, valid clinical reason.

 

Inpatient Curriculum:

I attach my Inpatient Curriculum. It is a “first steps” guide to common inpatient situations. It is not instead of more authoritative sources, it is a “what’s first” suggestion guide. It also goes through common inpatient safety issues. Please read it. It lays out, for example, how to intelligently write for pain meds and insulin. I am always open to feedback and corrections.

 

MDR

Each inpatient team is assigned a location and time (max of 30 minutes) for “Multidisciplinary Rounds”. This the time wherein all members of the team, including the attending, housestaff, case managers, social workers and Head Nurse from the team’s “home floor” meet to go over d/c plans, needs and any other items of importance. These are important. Any successful inpatient physician would note that LOS reductions and safe d/c plans require such joint ventures. Key to success however is mutual respect. In no way, are the rounds to go longer, start late or otherwise interfere with the rest of your busy mornings. If your CM, SW or RN are not there on time, they miss out. You are to finish on time. On the other hand, the medical teams are to be there on time as well.

 

MSK:

I have heard a rumor; at least I hope it is a rumor that attendance at the MSK elective is other than mandatory. Please be disabused of this notion. If you are AWOL from the MSK or any rotation for that matter, you will be subject to severe discipline, up to and including dismissal. Such matters are fairly straight forward. If you are assigned to be somewhere, you should be there. In any instance in you cannot you must notify the administrative Chief ASAP.

 

MSOU:

Please see the full MSOU policy for more details, but the nutshell is that we have at least 4 (more will be opened if need be) beds on 4A that will be covered by a lower RN: Patient ratio. As such, patients requiring monitoring of FS (more than q4), neuro checks, VS checks or the like can be sent there. This is to be used only for specific definable nursing monitoring, not simply because you are “worried” about a patient. Of note, the vast majority of alcoholics on benzos do not need the MSOU. If they do, like any patient, it is because you feel the need to write an order for a specific higher level of RN care than is routinely delivered on the floor. When in doubt ask me or a Chief if unsure if a patient qualifies for the MSOU. As in tele, the key will be the time limited nature of the unit. Most patients will be discharged within 24 hours or less, unless and ongoing RN monitoring need is identified, ordered and documented. Of note, IV insulin will be available on the MSOU.

 

Night pages: parameters, renewals

I have come to learn about the very high volume of pages the night coverage is subject to. Thanks to some real time data collection, I was able to bring examples to the attention of the nursing leadership. I will be working with them to provide some education and feedback to the nurses. However, it did become clear that at least some of the pages can be avoided due to two daytime housestaff ordering behaviors; setting clear clinical parameters (holding parameters) around all anti-hypertensives, benzos, pain meds, hypoglycemic agents and making sure all necessary restraints and controlled substances are renewed during the day shift. It was my estimation that up to 25% of the pages could be avoided this way.

 

Noon Conference

Noon conference now starts at noon. There are pros and cons to this. The move was necessary as the clinic afternoon session now begins earlier. (1:15). Attendance is mandatory. I will take attendance intermittently and ask those absent why they were not present. Exceptions will be granted, call the administrative chief, if it is your clinic day and you are truly pressed for time. I will be working with Eileen Singh and the reps from each class on the content and speakers for this conference. It is my expectation that all faculty will participate. It may be once or twice a year, but didactics are a part of our job descriptions as faculty. In the future, I plan to ask the faculty to list a few topics they can give.

 

Off Cycle:

If you are an “off cycle” houseofficer, that is started your training here on a date other than July 1st, please make an appointment to see me. It is against ABIM policy to “forgo” vacation in order to get back on cycle. In any event, I do want to make sure everyone (Program and Trainee) is clear on the timeline and end dates.

 

One to One:

Please bear in mind that use of one to one to keep a patient who has not been deemed to lack capacity from sign-out out is not legal or constitutional. Unless deemed to lack capacity (usually a medical team decision and evaluation) and documented as such, patients have the right to be unwise and ignore our advice. Further, the use of 1:1 should be limited and time sensitive. Specifically, should be a short term plan until a long term plan (medication) is implemented. I have asked the hospital administration to provide the full range of restraints, including poesy vests, mittens and “geri chairs”, as I made clear such items would reduce our use of 1:1. The immediate concern over 1:1 is how expensive they are financially and in labor utilization. Bear in mind, the status of “close observation” can be ordered on any inpatient. This order will have the nurse or PCA visually visit and inspect the patient every 15 minutes. This order status can be used in place of some 1:1 orders. Like all orders, you have to be precise in what you want them to inspect or observe.

 

OPD Continuity

I am aware that a current impediment to optimal Ambulatory Education is the inconsistent continuity of patient care for a given provider. This is multi-factorial. We are addressing on many fronts. One is the inpatient schedule. Once issued for the year, the schedule is final. All trades subsequent are subject to approval by the Chiefs, the Clinic Directors and the Program Director. In this way, the OPD will be able to use our inpatient call schedule to lay out way in advance your outpatient availability. This can be used by you to set up consistent f/u with you. In this way, rather than saying “come back in three months……” you will be able and expected to say, “Come back 6/25 to see me.” The cost is flexibility in your schedule, the benefit is improved continuity.

 

Pending D/C Order

During MDR please use the “pending d/c order”. This order can be found in the d/c order section of MYSIS. It is important that we (doctors) use this as early in the day of d/c as possible (MDR would mean in the system by 10:15 at the latest). Downstream of this order are many  nursing and bed board functions that facilitate timely d/c. Specifically, a member of the team should enter this order during MDR when a potential d/c is noted. On the subject of D/C, a new process is to be implemented. When you are finished with the paperwork (orders, prescriptions) on a d/c, you no longer have to give such to the patient, but simply flag the chart and hand to the patient’s nurse. This is what the nurses do for the surgical services and have promised to be able to do for us. It is important that you notify the nurse however that the patient is set for d/c.

 

Prescriptions:

I will find out the precise rules on this, but be aware that most, if not all, prescriptions given upon discharge, require an attendings stamp and license and signature. I will find out which insurances require this and if a houseofficer with an independent license is acceptable. US medical school graduates who have passes step III and have completed one year of PGY training can apply for a NYS license. I suggest you do so if eligible. IMGs need three years of PGY training. Please note, prescriptions are only to be oriented on the printers on the patient care floors, not the call rooms etc. First off, only the floor printers are properly formatted and it is not allowed to take blank prescriptions sheets off the floors.

 

Resident Report

Resident Report, sometimes presented as Chief of Service Rounds, Journal Club, clinical questions, is from 11-12. Attendance is mandatory. If you will be late or absent you must tell the administrative chief. I will take attendance intermittently and ask those absent why they were not present. The faculty is reminded that attending rounds are supposed to end by 11. I had trouble making this deadline, so moved up my round to begin at 8 am, rather than 9 am. Attendings that consistently run over (not the occasional killer day) will be reminded that the 11-12 educational sessions are important to the housestaff.

 

Schedules

I am preparing to outline the yearly schedules for the rising PGY 2’s and 3’s. I will be doing this differently than has been done previously. My primary concern and goal will be that the schedules are “fair” and that there is minimal differences between schedules in sum. To this end, we may be less “flexible” than in the past in terms of adjustments. After the schedules are put out, those requesting mutually agreeable trades will be encouraged to do so. The Chiefs will have to make sure “all the loose ends” are taken care of in any potential trade. I will then review all trades to be sure RRC rules are not violated. For example, residents, outside of vacation, are not supposed to be away from their continuity clinic for more than a month at a time. This may make some ICU for floor trades not acceptable, by way of example. This is a requirement we have not been in compliance with completely.

            Rising PGY 2’s (current PGY 1s): email to me in a separate email the one activity (vacation, elective, other) that you want to select a particular month. In the case of research electives, you should tell me if you wish to group months together. Bear in mind, that you will be expected, as noted above, at some point to provide details on the project(s) and an abstract. I will make every effort to give folks their first choice of either their vacation or electives, but cannot promise both. Therefore, the price to pay for optimally grouped and timed electives may be non ideal vacation time or visa versa.

            Rising PGY 3’s: email me in a separate email the month you wish to have vacation and one of your electives. I will try to grant both. Bear in mind, I am referring to Jacobi Clinical electives. As noted above, other use of elective time will be granted on an individual basis and only if compelling arguments can be made. For example, if you had 2-3 months of research elective as a PGY 2, you will most likely not be granted more block elective research time as a PGY 3. 4-6 full months of dedicated research time in a 36 month regular pathway Medicine program would be an outlier. In rare cases, in instances of strong ITE scores, strong clinical performance reviews and exceptional research productivity/need, exceptions may be considered. Away clinical elective requests need demonstrate unique need. In general electives are not to be used as “try outs” for fellowships.

 

Sign out expectations

At the class meetings we all agreed on the following sign out expectations: do not accept less than tese from your colleagues. You all, as a group, are the policing mechanism, not the Program.

 

            PGY 1: face to face, printed reports, written to do’s and verbal sign out of all patients

           

PGY 2/3: face to face, printed reports, written to do’s and verbal sign out of “sick patients”

 

Sliding Scale

To clear up any misconceptions. All Medical Floors accept sliding scale insulin orders. Please let me know immediately if you are told otherwise. To be clear, SS alone is not acceptable. SS should be used to supplement a long acting glucose control plan (longer acting insulin, oral agents) and be used daily to up or down titrate the baseline QD or BID regimen. The objection to SS has rightfully been the lack of use of the data from the “sliding” to adjust the longer acting regimens.

 

SMR PAGES

I have learned that some SMR’s have developed the habit or strategy of intentionally not answering ER pages after a given hour out of concern for Departmental bed flow. It is never acceptable under any circumstance to intentionally not answer a page. If there are legitimate concerns over patient safety or flow, we can discuss as a Department. The answer is not to stonewall the ER.

 

Trades

All trades must be approved first by a Chief Resident

 

ITE:

I have spoken with each class individually. The overall results of our In-Training Exam (ITE) were disappointing. Of note, if you have not received your individual report and scores let me know. If you wish to discuss your scores with me, set up a time to meet with Eileen. Specifically, we have too many housestaff who scored in the lowest percentiles (<20th) as compared to their PGY peers. The problem is this test is a good measure of demonstrable medical knowledge so likely does pertain to quality of care delivered, but even more literature evidence supports its use as a prediction of performance on the ABIM. Roughly, if you scored above the 25th percentile in the PGY 2 or 3 year, you are on track to pass the boards. If you scored below this mark, you are at significant risk of failing the boards. The solution is none other than read, read, read. I am working on a program level offering of curriculum and trackable testing, but nothing will substitute for background (you should be reading for 30 minutes almost everyday) reading from a quality source (e.g textbooks, guidelines). In addition, you should develop the lifelong habit of writing your clinical questions (at least one per day per every few patients) and then “looking them up”. We all have access to the AECOM library online and remote from any computer in the world. Every imaginable resource is available to you. In addition, this is how you will develop the skills we have touched upon in clinical questions of finding answers that are valid and finding them quickly via secondary sources (ACP Journal Club, Cochrane, and the like). Without being overly dramatic, if you scored poorly on the ITE and are not a bit scared and concerned, you should be. Don’t panic. Medical knowledge is fixable, via reading, but don’t wash it away as “I’m bad at tests.” This may or may not be the cause (my experience is usually it is the amount of knowledge in the tank, not the test taking) but in any event should spur you to action (practice questions) in any event.

 

USMLE III

Anyone who has not taken or is not registered to sit for the USMLE Step III is strongly advised to do so. This is a test designed to be taken during the PGY 1 year. It is a requirement for licensure. Of note, the test, while “easy” in that 95% of first time test takers pass, is not solely Internal Medicine. Therefore it gets “harder” the further one is from the Ob, Peds, Surgery, rotations of medical school.

 

Vents on 5S

Let there be no misconceptions on this issue. Patients on 5S who need to be intubated urgently, should be intubated. Vent machines may not be “plugged in” in some locations, but all this means is the machine will run on battery power (hours) until transfer to a location where the vent can be plugged in. In no instance is the clinical need to provide mechanical ventilation to be delayed so as to transfer the patient to another floor. Again, if you are ever told otherwise, let me know immediate.

 

 

Again, I apologize for the length; I hope that my weekly or semi-monthly missives will be shorter. Also, do not misinterpret my being straight-forward or “a stickler for details” as being mean or not “on your side”. I have very much enjoyed my six months here so far and hope that my overall reputation is one of being a housestaff and patient care advocate. I also am amazed that I am still meeting some of you for the first time. Bear with me. Please believe me that I am very proud to be your Program Director. The Medical Housestaff here does amazing work. You are serving an underprivileged population in sometimes difficult circumstances and do so with impressive skill and eagerness. Be very proud of your skills, your service and your professionalism. I know I am.

 

Yours,

Bill Rifkin M.D.