Inpatient Responsibilities

On first coming to the Medicine Service, you will be assigned one to two patients already in the hospital. You are expected to work-up approximately two to three patients per week, 12-18 patients per the six-week inpatient portion of the clerkship. On the day of admission, you should review a general medical text and be prepared to answer questions about your patient the next day during team rounds.

Call

Most services will be admitting new patients on at least 3 days of every 4 day cycle.  The timing of the admissions will be variable according to which day in the cycle the team is on. Your resident will assign to you patients in order to keep pace with 2-3 new patient evaluations per week.  Do not wait for the "perfect" patient.  Every patient admitted to General / Subspecialty services has a tremendous number of learning opportunities at this stage of your medical education.  Only with increased patient exposure will you improve each of the core competencies. 

There is no overnight call.  However, if you would like to take overnight calls with the night-float team, you are permitted to do so. You can work out the schedule for this with your resident.

Many mornings there are new patients for the team to admit.  Your resident will instruct you on whether you are to evaluate a new patient before attending rounds, as it is difficult to gather all the necessary information in such a short period of time.  Because most patients are evaluated early in the day, students usually have time to work-up the patient and write the admission note before 6:00 p.m., but if your patient comes in late in the afternoon, it is permissible to have your H and P write-up finished on the following day.

Write-Ups and Progress Notes

Each of your new admissions must be completely written up and your note must be in the patient's chart within 24 hours of admission. You will present your new patients on post-call rounds in less than seven minutes.  You will also present your follow-up patients on rounds and write daily progress notes on each of the patients that are followed using a S.O.AP. note format. VSTAR Learn contains materials to assist with oral and written presentations of newly admitted and follow-up patients.

A detailed assessment from a History and Physical consists of a thoughtful review of the prioritized differential diagnosis that includes the framework/schema that one approaches the problem, as well as the supporting history / exam / epidemiology / diagnostic data that was used to help prioritize the differential.  Students are encouraged when appropriate to focus on an aspect of the case (e.g. diagnostic testing considerations, prognosis, therapy, pathophysiology, ethics) with references not to exceed 1 page.  It is important that students assignnotes to the appropriate VC3 problem in Star Panel throughout the clerkship. 

Daily Team Rounds

On daily work rounds, you will review your patient's course for the previous 24 hours and submit your assessment and plans for the patient for the day.  Unless directed by your team/attendings, to prepare yourself for team rounds, you should pre-round on each of your patients.

Pre-Rounding

For each patient, you should review the chart for any notes left by consultants or cross-covering caregivers. Next you will determine your patient's symptoms, vital signs, relevant physical findings, labs and x-rays, and medications. Pre-rounding requires approximately 10-15 minutes per patient.

Writing Orders

Writing orders is not an essential curricular goal for the clerkship. Rather, as you gain experience in evaluating and managing your medicine patients during the eight-week block, you will have opportunities to learn to write orders. The house-staff will assist you in this endeavor. Orders written by students are unofficial and cannot be carried out until the house-staff cosign them.

Procedures

You are encouraged throughout your third year of medical school to become proficient with basic procedures on your patients (nasogastric tube, IV, ABG, Foley catheter, blood culture). You will know what procedures you have and have not mastered as you progress on the clerkships in the third year. Since members of the support staff perform most basic procedures at all of the hospitals, you must be assertive and ask your residents for assistance to perform procedures you have not mastered. Residents may allow and assist you in more advanced procedures (lumbar puncture, paracentesis, thoracentesis) if the intern has mastered the technique.

Prioritizing Your Own Patients vs. Others' Patients

You are considered personally responsible for the welfare of your patients. For this reason, your main priority is to get to know your patients and their problems. Spend extra time with them, establish rapport and show your keen interest in them. Read extensively about their problems. Accompany them to major procedures e.g. surgical procedures. Still, there are many learning opportunities to be gained from other patients than your own. Through open and frequent communication, you and your resident can determine the expectations for you to prioritize your own patients or see another's admission on an admitting day, participate in codes, or evaluate a cross cover patient with an acute problem. As the clerkship progresses, students generally gain experience and speed in working up new patients, leaving time for them to take on more new patients (two during a call day) or encounter other patients on the team.

Lectures, Conferences, Preceptor Rounds

Students are expected to be on time and participate in the discussions of all lectures, conferences.  If there is a key patient activity that requires your attention, please email/text the course director to alert of your impending absence. 

Doing Talks

It is the supervising resident's or attending's prerogative to assign a student a talk to provide to the team, usually as a part of team rounds. This is acceptable with the condition that the teachers provide the students with ample time and guidance in preparing a topic.