The Medical Internship : your first step into the medical career

1. Saudi Arabia Chapter Council of Young Physician (CYP) The Medical Internship : your first step into the medical career Fadel A. AlRowaie , MD ,FACP ,FNKF Chair Person ,Council of Young Physician – ACP Assistant Professor of Medicine ( KSAU-HS) Consultant Nephrologist (KFMC)

2. The medical internship

3. The medical internship

4. Outlines • What is an internship ? • What is job description of the intern? • How to plan your clinical/ elective rotations ? • Documentation • Characteristics of successful intern • Advices for successful internship • Introduction to next lecture • Q & A The medical internship

5. What is the internship ? • A medical intern is a term used for physician in training who has completed medical school. • An intern has a medical degree, but does not have a full license to practice medicine unsupervised. The medical internship

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7. Internship in KSA • 1 years of supervised and paid training . • It usually includes rotation in : IM , G.S , Pediatrics , Obs/gyn+ ER and elective • MBBS certificate will be given only after successful completion of the internship . • Intern considered part of the medical team and his/her name is usually the first one in the on-call schedule The medical internship

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10. Job description of the intern • To participate as a member of a multi-disciplinary team in the hospital to take care of patients. • Interns are responsible for treating patients under appropriate supervision. They have to ensure that their functions are carried in a good manner and more priority is given for the patient' s safety. • Check the patients while they are getting admitted or discharged and fill in the right details about them. To order and interpret diagnostic tests is one of the duties which are carried by intern doctors. They are the one who initiate and monitor the treatments given to the patients. • Communication with patients and their relatives is essential. Intern doctors are the ones who take responsibility for communicating with them and other hospital clients. These doctors also attend meetings at their work place that are related to any particular complicated case. • They co-operate with investigations, audit, or enquiries that are related to the provision of health. They do take a daily round through all the patients for their regular check up and assistance regarding any health issue. The medical internship

11. Summary • As an intern, you'll have all of the experiences that a resident would have, but without as much responsibility. • You won't be expected to make major decisions, but you will more than likely get to watch how others make these decisions. • This will help you be prepared for an upcoming job where mistakes are not easily forgiven. The medical internship

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13. Role Model The medical internship

14. How to plan your clinical / elective rotations ? The medical internship

15. How to select your future speciality ?

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19. Speciality selection An analysis of the 1993 graduating medical school class found that the following factors were the most influential in choosing a specialty: • The type of patient problems encountered, • The opportunity to make a difference in people’s lives and to help others, and • The intellectual content of the specialty The medical internship

20. Other factors • Generalist , specialist , or none of the above • Intellectual content and clinical issues • Amount of patient contact • Type of patients encountered • Prestige , status , and social expectations • Life style considerations • Length of residency training • Difficulty of obtaining a residency or fellowship position • Future income and earning potentials • Job opportunities and predictions about the specialist workforce The medical internship

21. Internship Application for residency Residency Medicine or elective ( Medicine ) Medicine (1 October 2013 ) Jul Aug Sep Feb Apr Oct Mar May Jun Nov Dec Jan • Know the speciality • Get people to know you • Get recommendation letters • Know the place you are interested to work in The medical internship

22. Internship site • Hospital that you want to work in • Bench mark hospital in teaching /training • Hospital with higher rate of acceptance rate The medical internship

23. Documentation • Documents : Admission ( H&P), admission order , progress note , consultation, discharge summary ,physician orders , consents , death summary and others . • Time and dates . • Signature or stamp . The medical internship

24. Physician progress note • Use SOAP format for physician progress note. • Always start with seen with or end with plan discussed with your seniors. • Add any updates to patient condition or any new ( lab or radiological )investigation The medical internship

25. SOAP The medical internship

26. 16 Oct 2012 14:00 • Subjective : Still c / o cough and yellow sputum but no more chest pain or SOB and no more vomiting • Objective : • Tem ( 38 °C to 40 °C , BP 125 / 55 mmHg , HR 90 BPM ,RR 12 / m , O2 sat 99 % on 2 L Oxy ( was on 4 L ) • Gen. exam : not pale or jaundice and no respiratory distress • Resp :normal chest expansion , dullness on the left lung base with reduced breath sound , bronchial breathing and coarse crepitation • Rest of exam unremarkable • Labs : WBC 8 ( 14 on admission) , blood & sputum culture grew strept. Pneumonia that is pan-sensitive • Assessment : A 34 Y O M with CAP ( pneumococcal ) , responding to Abx therapy • Plan : • Stop azithromycin and continue ceftriaxone • Stop IVF as patient has no more vomiting and tolerating oral intake • Encourage mobilization • Possible discharge tomorrow Dr. AlRowaie ID 59050 Pager 3232 Patient seen with Dr.Arshad and agreed on the above plan The medical internship

27. Admission order 16 Oct 2012 14:00 • Admit to MMW under care of Dr Arshad, IM section • Diagnosis :CAP others : DM , HTN • Allergy :NKA • Vital signs : Q 4-6 hours ( if DM add gluco check) • Activity: As tolerated • Diet : Regular • Investigation: CBC , Electrolyte , LFT , blood and sputum G.S and culture , CXR ( done in ER ) • Medication: • Oxy to keep sat above 94 % • IVF , D5NS @ 100 cc / hr • Paracetamol 500 mg every 6 hours PRN for pain and fever • Ceftriaxone 2 g IV OD • Azithromycin 500 mg OD for 3 days • Enoxaparin 60 mg subcut OD Dr. AlRowaie ID 59050 Pager 3232 The medical internship

28. Discharge summary • Patient demographic data • Diagnosis ( discharge or admission diagnosis) • Other Diagnoses : • CC, HPI , PMH ,FH ,SH, Allergy and BT hx • Systematic review • Investigation ( labs , radiology , pathology etc ) • Hospital course • Discharge medication • Discharge plan Dr. AlRowaie ID 59050 Pager 3232 The medical internship

29. Consultation • Before calling, be sure you understand why you’re calling a consult . • Always start by introducing your self • Never say we just wanted to get you on board. • Never call the consultant directly . • Prepare and document all related labs , investigations , reports , medication list . The medical internship

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31. Consultation to Cardiology • From :Dr.Arshad ( IM ) to : Dr. Ahmad Cardiology ( Pager # 5555 / date & time ) • Reason for referral : ACS for transfer to ICU and further management. • Summary : a 65 years old ,male ,DM , HTN , smoker with prior history of AMI treated with thrombolytic therapy ( 2 years ago), admitted under IM last Saturday with CAP. Now c/o stabbing left sided chest pain associated with sever SOB ,orthopnea and PND ,BP 75 mmHg ,sat 89 % on 10 L , JVP high with S3 gallop and bilateral basal crepitation . Trop is high and ECG showing ST elevation in anterior lead , giving ASA , Enoxaparin ,Morphin but no NTG because of low blood pressure. Dr. AlRowaie ID 59050 Pager 3232 The medical internship

32. Characteristics of successful intern • Reliable • Bring energy and enthusiasm • Dress well • Balance self-sufficiency with asking questions • Participate • Stay flexible • Pay attention to detail • Network The medical internship

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34. Advices for successful internship The medical internship

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36. Try to present in the morning report The medical internship

37. If you are not ready , do not present . • Always discuss with your seniors, to take their support • Read very well about your case and be ready for any question • Do not feel offended if criticized The medical internship

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39. Daily round The medical internship

40. Try to go to the floor before the morning report • Collect all the labs and examine your patients before you round with your senior • Be the first one on the floor at the time of round • Always read about your cases and be ready for any question • Special attention to medication ( mechanism of action , interaction and major side effect ) • Try to be active , show your motivation by generating questions higher than your level • Try to attend clinics / ambulatory ( consultation ) • Learn as much as you can of medical / surgical procedures ( ABG ,Injections , LP , aspiration …etc ) • Always endorse your sick patient to the on-call team • Appropriate documentations • Participate in section or departments educational activities • Start or complete your research project The medical internship

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42. On-calls The medical internship

43. Floor ER The medical internship

44. Floor • Start seeing the sicker patient • Do not hesitate to ask for help from your senior • Never ignore any patient complains • You can give orders for minor complains e.g for headache , vomiting and pain • Always go and examine the patient , inform your senior and document that in patient chart The medical internship

45. ER • Be the first one to see the patient • Take full history and perform complete physical exam • Utilize the EMR / patient old chart • Come with your own differential diagnosis and plan • Act promptly in certain situation ( investigation / medication ) • Read about your case • Discuss it with your senior • Ask to present the case in the morning report The medical internship

46. Next lecture ( application for residency program ) • What is residency ? • Choosing specialty • Application process ( CV / recommendation / statement of purpose) • The entry exams ( SLE , USMLE , CCE) • The interview The medical internship

47. fadelrowaie@yahoo.com falrowaie@kfmc.med.sa The medical internship