PGY 3/4 to Be Retreat

1. PGY 3/4 to Be Retreat June 3, 2014 Scott Denstaedt Marty Tam Angel Qin Khanjan Shah

2. Last year of residency… Hoping for the best, prepared for the worst, and unsurprised by anything in between.-Maya Angelou Success!

3. Overview 5:30-6 Dinner 6-7:30 Quality Center (Heidi et al.) Milestones discussion (Dr. Arfons) Ambulatory Changes Medicine Clerkship (Dr. Leizman) Changes for next year Logistics reminders Issues unique to 3rd year Fellowship Boards/ITE Medical License Senior talks Patient Safety/Quality Externship 7:30 - 8:00 DACR/NACR Orientation Gen Med Consults                                                                                 8-8:30 Questions

4. Changes for Next Year • Ambulatory • Electives • Jeopardy

5. 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

6. Ambulatory Model 2.0

7. Ambulatory Model 2.0

8. Ambulatory Model 2.0

9. 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

10. Example Elective Tracking

11. 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 • Reading Electives: • Requires approval, KBA is designated supervisor • Required attendance at all UH noon conferences, UH M+Ms, UH Grand Rounds, VA Grand Rounds

12. 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

13. 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

14. Logistics Reminders

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

16. 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

17. 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

18. Staffing • UH wards will have double coverage Blocks 1-3 • 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

19. Staffing • On call resident should notify the nightfloat resident of tenuous patients • Be proactive about staffing patients

20. 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

21. REMINDER: 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…

22. Professionalism

23. Professionalism: Attire Men Shirts and ties Women Professional Keep white coats clean No denim Do not show up to Morning Report looking sloppy

24. 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

25. 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

26. 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!!!

27. 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

28. Conference attendance during ambulatory • 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

29. 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

30. Issues Unique to 3rd year • Fellowship • Boards/ITE • Medical License • PGYIII QI project • Senior Grand Rounds • VACR • NACR/DACR

31. Fellowship Timeline • https://www.aamc.org/students/medstudents/eras/fellowship_applicants/ • Please review this website! There are many new changes this year • https://www.erasfellowshipdocuments.org/ • Request ERAS token; June 11, 2014 • Ask for letters of recommendation…now! • Start considering your future destinations for fellowship • Work on your personal statement • July 15, 2014: first day to submit application AND programs begin downloading applications • Special considerations (double check now): • Sports Medicine • Hospice and Palliative Care

32. Fellowship Timeline • Deadline for completed application varies but is as early as July 31st; check with program and be prepared • Interviews: August - November 2014 First • MATCH: first Wednesday in December 2014 *KBA will perform mock interviews upon request

33. BOARDS!!! • Register starting in December • Plan ahead…costs about $1,365 (more if you sign up late) • Noon Conferences to include more board prep sessions • Can use ITE exam results to help guide studying

34. In-service Training exam • In-service Exam Dates are in October – 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!)

35. Medical License • Remember to keep your BLS/ACLS updated • Must have Step 3 results prior to license application • Start FCVS by December ($430) • State licensing ($335) can often take 5-6 months. • DEA license is much quicker but more expensive ($551) • Plan ahead!!!

36. Senior Grand Rounds • Noon conference lecture for each senior resident, late August (after intern boot camp has finished) • Dr. Mourad is the APD in charge • Email learning objectives to assigned faculty mentor, ambulatory chief and Dr. Mourad two weeks prior to lecture date • Topic of your choice, should be evidence-based • MORE INFORMATION TO COME!

37. Patient Safety and Quality Improvement • Introduction to quality improvement during DACR rotation • UH Care feedback • Quality Assurance meetings • Write-up cases for Medicine QA • Attend ED/IM QA • Attend Quality Patient Safety Committee meetings • Mortality review, PASS reports, and Risk Management meetings

38. Guidelines for Resident Quality Improvement Project • QI project for PGYIII required by ACGME • Form groups of 2-4 (ideally 3) people • Work with one of the chief medical residents and quality center to develop project ideas and aid with data collection • Start by identifying a quality issue, collect background data, design an intervention, and collect post intervention data (Heidi and Meghan in the quality center are good resources) • Present quality poster at Research Day • Select project/team in July, first meeting regarding the project occurs in August

39. Timeline for QI Project • General Timeline: • July: select project/team • August : meeting with assigned chieg resident and QI RN (complete FOCUS PDCA) define objectives, collect background information, plan an intervention • September-November: collect baseline data (initial survey) • December: meet with chief resident and QI RN to discuss baseline data and intervention implementation • January through February : implement plan • March through April: collect data post-implementation, write abstract for research day, make research day poster • May: present at research day

40. VACR • Many PGYIII’s will have this rotation, not all • Perform medicine consults • Be available to help out ward teams as needed • Prepare EBM lecture on a topic of choice for morning report • Attend all morning reports • One Saturday 24 hour VA MICU coverage

41. DACR / NACR:Your education in systems-based practice

42. To Admit vs. Observe • 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

43. NACR Nightfloat Resident Rotating MSIII Nightfloat Resident Nightfloat Intern Rotating MSIII Nightfloat Intern The NIGHTFLOAT TEAM Nightfloat Intern

44. The NACR as Ombudsman* • Distribute admissions to teams on call in AM • Enforce geographic localization • Run codes • See medicine consults at night (ophtho and ortho co-management if requested) • Cover emergencies in CF patients on RBC 7/Lakeside and Hanna House • Cover flex patients at night and ?additional PRN SHD patients • Find out intern census from nightfloat interns for each team • Admit BMT and Transplant Medicine patients along with NF (must inform BMT fellow and Transplant attending) • Transplants within the past year should be admitted to transplant surgery *****Transplant service is not the Transplant attending! MUST ASK OPERATOR FOR TRANSPLANT ATTENDING!!!!****** *ombudsman – one who investigates complaints and mediates fair settlements, especially between aggrieved parties such as consumers or students and an institution or organization

45. “The Book” as it should be…

46. “The Book” according to the ED…

47. Admitting ED ED enters admitting bed request Patient enters ED, decision to admit NACR OVERVIEW ED pages NACR for signout Admitting pages NACR with bed request Medicine NACR calls admitting and makes appropriate bed assignment Yes Medicine floor admission appropriate? NACR assigns admission to NF or her/himself NACR No NACR distributes patients in the AM with help of KBA and chief Ask ED attending to reconsider triage of patient, work-up, or admitting service

48. Appropriate Service? Is the patient stable for the floor? No MICU/CICU/NSU/SICU Yes Have ED call FM (30116). If capped, then ED calls NACR back with admission. PCP in FP? Yes Yes Appropriate for FP? No FM capped !?&*#@! Appropriate for medicine? Talk to ER, if attending from appropriate service does not accept, “Medicine will happily accept the patient” No Stroke, SBO, femur fracture, etc Yes

49. Appropriate Service? • Look up the patient in Portal and EMR before assigning • Patient’s PCP – Family practice patient? Private patient (list of attendings available)? • Fang Service does not have a cap per Dr. Oliviera; if they have been seen in HF and are coming in w/ HF exacerbation, have ED call the overnight admissions person • Physician Portal (summary page, physicians) • Previous discharge summaries • EMR patient info clinical summary (visit history) • Ask the patient!