Rotations

GENERAL OUTLINE:

Expected arrival time:

● Floors (all calls): all interns and seniors arrive no later than 6 am

● Cardiology (all calls): all interns and residents must arrive no later than 7 am.

● ICU (all calls): all interns and residents must arrive no later than 6 am.

● Electives: varies based on the supervising attending.

Caps: (this does not include cross coverage provided overnight or on weekends)

● Cap is the total number of patients that an intern is typically responsible for.

● The institutional cap for interns is 9 patients. The cap for admissions per intern is 5 admissions including transfers (from ICU or MET calls) in 24 hours, or 8 new patients in 48 hours. Seniors are capped at 18 patients on the inpatient wards.

Pagers:

● Interns and residents must respond to ALL pagers as soon as possible (preferably within 5 minutes).

Admissions:

● The senior resident will notify the intern when a new patient will be admitted to the team with a short sign out.

● The intern is expected to obtain a thorough history, complete physical examination, review all pertinent labs and imaging studies, review old records from Meditech, Chesapeake Regional Information System (CRISP), eClinical Works (eCW) and/or obtain medical records from outside facilities when applicable; formulate a complete assessment and plan of care to present and discuss with senior resident. The senior is expected to evaluate the patient together with the intern or individually and to review admission orders, proper documentation and support the intern with any challenges encountered.

Code Blue and METS calls (METS = Medical Emergency Team or Rapid Response team):

● The METS team at St. Agnes consists of a senior medical resident, a nurse (typically trained in critical care) and a respiratory therapist.

● Interns on call covering pagers #908 and #909 are expected to respond to METS call and assist the senior resident during the METS call unless the intern is rounding, actively taking care of another patient, or working on a new admission in the Emergency Department.

● If you are NOT on call and you are in the vicinity, then you should respond right away.

● Once the METS call senior/intern reports then you may ask to be dismissed, unless it is your patient.

● The more codes/METS calls you attend, the better you will be prepared for when it is your turn to run one.

● METs response during the weekends (aka with skeleton crew). The 1st METs call will still be handled by the acting MAO. If there is a second METS called while the MAO is busy taking care of the first one:

o The NO CALL senior will respond between 6am to 12 noon

o The LONG CALL senior will respond between 12 noon to 6pm

● Please take into account that all METS calls are protected METS calls, meaning that you will have to wear appropriate personal protective equipment (PPE). Same applies for Code Blue. For code blue, do not call the operator to call a code for you. Please call 5555.

GENERAL HOUSEKEEPING OUTLINE:

● Private and hospitalist patients may be admitted or transferred to the resident teaching team as determined by the medical admitting officer, based on the case’s teaching value, severity of illness, and space availability as dictated by the team caps. The residents are responsible for the care of these patients under the supervision of the private or hospitalist-attending physician.

● All attendings are medico-legally responsible for their patients. Therefore, they must be notified IN A TIMELY FASHION for any SIGNIFICANT changes in the patient’s condition or when new SIGNIFICANT information becomes available e.g. results of tests including critical values, family concerns, need for consults, significant consultant recommendations and/or changes in the care plan, etc.

● Interns must always put the computer order "covering physician" or "covering resident" at admission. This is essential for the covering nurse to know which Intern to contact for patient care concerns. This must also be written in the appropriate section in the electronic admission order set in Meditech. Please avoid short names rather than write full names in EMR.

● If there is a problem or complaint of any sort, please bring it up to your team senior immediately and they will direct it to the appropriate party.

● In case of any urgent matters that you and your senior resident are unable to resolve, please contact your chief resident or your attending.

FLOOR ROTATIONS:

Floor teams:

● There are 4 floor teams and each team consists of two interns, a senior resident, and medical students led by an academic hospitalist (service attending physician). Floor teams are responsible for the care of patients distributed among the medical-surgical floor, telemetry floors, stroke floor, and the intermediate care unit (IMCU).

● The cap for an intern is 9 patients. Cap for each floor team is 18 patients (excluding cross coverage over the weekend, in which interns may be responsible for carrying no more than 18 patients each).

Floor call schedule consists of a 4 day cycle during a 28 day block period.

Day 1 – Post-call/No Call: this is the day after your long call and thus you will be focusing on taking care of your newly admitted patients from the day before. Your team will be the last to get patients from the night float team (9th and 10th night float admissions).

Day 2 – Pre-call (previously known as night float transfer): the night float team will be admitting the first 2 patients to your team. If there are enough admissions overnight you will also get the 7^th and 8^th patients from night float. No new patients will be admitted to you for the rest of the day unless you get a bounce-back*.

Day 3 – Short-call: The 3rd and 4th night float admissions will go to the short-call team. Also, you will be admitting patients from 6 a.m. - 11A.M. Cap for admissions in this time frame is 6 patients (3 per intern).

Day 4 – Long-call: The 5th and 6th night float admissions will go to the long-call team. Then, the team will be admitting patients from 11A.M-5p.m. The admission cap during a long call is 6 patients (3 per intern).

*Bounce-backs: Patients, who were discharged by a floor team and are readmitted within that same floor block, will “bounce-back” to their floor team, regardless of the call day.

The aforementioned night float admission model is a new system that was adopted in 2015 to avoid overwhelming one of the floor teams with all of the night float admissions. This system is called "modified drip system" as night float admissions drip to the floor teams in the following order:

Pre-call → Short-call → Long-call → Pre-call →No-call

- Work hours (typical) are 6 am to 4 pm unless you have a long call at which time your work hours are 6 am to 6 pm. These do vary depending on patient volumes and acuity and your experience/efficiency.

- Night float team will start signing out patients to floor teams at 6 a.m. Sign out process expected to end by 7:30 a.m.

- Long call team will stop admitting at 5p.m. MAO is responsible for admissions between 5-6 p.m. (Evaluate, stabilize, bridging orders, sign out to NF team).

Weekends

• 2 Floor teams in-house.

• Friday and Saturday nights: NF will also drip but will admit a maximum of 4 patients (1 for each weekend intern). Also starts signing out at 6 A.M.

LC team starts admitting at 6 a.m. till 5p.m. Again, caps at 6 admissions (3 per intern).

Floor day breakdown in detail:

Pre-Rounding (6 a.m. – 7:50 a.m.)

6am to 7:50am: intern to pre-rounds on ALL the patients:

1. Always arrive on time! All residents expect to be in the hospital by 6am. If you wish, you may arrive earlier to allow sufficient time to pre-round on all your patients.

2. First: release your pager and cross cover your call pager if applicable.

3. Sign out is expected to occur at the bedside. The night team will introduce the new team members, and answer questions from the morning providers and then leave.

4. Review vital signs and note/address any abnormalities. Record any intake and output (I&Os), daily weights etc., if applicable.

5. Review notes and orders that occurred overnight as this will help you to address any new issues and/or follow up care. Discuss with the night float team intern.

6. Review all available new laboratory results and imaging studies and address any abnormality. You are responsible for replacing all electrolytes before attending/teaching rounds and also act upon laboratory/imaging abnormalities.

7. Review care notes from other healthcare staff such as social workers, care managers, speech therapists, wound care nurses, physical therapist, occupational therapist to help you plan disposition and overall plan of care.

8. If you are seeing the patient for the first time you are expected to perform a complete and thorough physical exam; however if you are following the patient then a focused exam will be appropriate. If your patient is on telemetry you are expected to review the telemetry monitor and note any arrhythmias. Check lines (PIV, central line, dialysis catheter), Foley catheter, Flexiseal, PEG tube site, trach tube, infusions, etc.

9. Interns will “run the list” and/or pre-round at the bedside if needed (especially if there was a significant change in level of care/clinical status overnight) with the team senior resident before the morning conference. Running the list means going over your patients and discussing briefly any acute issues/addressing abnormal labs/medication reconciliation and plan of care.

10. It is advisable to pre-round on your IMCU patients first since these are your sickest patients and to determine the appropriate level of care. Seniors are responsible to notify MAO/IMO before 8am if the patient must remain as IMCU status or if the patient is medically stable to be downgraded. The team senior or intern is responsible to place a transfer as soon as the change in level of care is indicated. If the patient is a private patient the attending must be notified about the change in level of care.

11. Assess the need for continuous telemetry or pulse ox monitoring daily. If applicable, put the DC Pulse OX or telemetry orders or downgrade patients as appropriate after discussing with your team senior.

Morning Conference (8:00am to 8:30am): Morning conference with the exception of Thursday when there is Ground Rounds from 8AM - 9AM September through May of each academic year:

All floor teams, interns, seniors and medical students are expected to attend and to be on time as this time is part of your academic education. The only exception is if you are taking care of an urgent patient-related matter.

During morning conference you are expected to “run numbers” with the chief resident in following order:

● The total number of patients you had the day before (this is not reported on Monday mornings). Another way to think about it is how many progress notes plus new admission notes (if applicable) you wrote yesterday.

● The total number of patients you have today.

● The total number of service patients.

Teaching rounds (9am to 11:45am): The duration may vary from day to day depending on the number of service patients and how sick the patients are. During this time, the interns and students will present each case to the team with assessment and plan of care. Interns will bring up findings and their plan of care, teach the group on a particular topic and suggest adjustments to the plan as necessary; explaining all decisions with evidence-based reasoning wherever possible. Interns are encouraged to seek clarification for any doubts they may have about the case or the care provided. Teaching is an essential part of rounds. While attendings and senior residents share the bulk of responsibility, ‘everyone’ on the team is teaching and learning.

This means the intern and/or medical student will often be asked to present relevant topics including new guidelines and recent research as determined by the attending or senior resident.

The assessment and plan of care may be modified by the attending during rounds.

Wrap up rounds (11:45am to 12pm): Time to place orders discussed in rounds and to continue patient care. If possible, you should strive to sign your notes before 12pm. If you have signed your note and a patient’s clinical status or plan changes during the day you can addend/update your note as many times as you need.

Noon conference/Lunch (12pm to 1pm): Time allocated to teaching. Noon conferences are mandatory; attendance is recorded. Please get your lunch beforehand to be on time for the conference.

Patient care (1pm to 4pm): These are the hours designated for interns completing any unfinished patient care including writing all the necessary orders and completing daily notes. Senior residents may assist interns with patient care. It’s always highly recommended to “run the list” and round again on your sickest patients in the afternoon prior to sign-out.

Sign Out (4pm to 5pm): All teams will sign out to the long call team at 4 pm with seniors present and supervising in the first 3 blocks and periodically thereafter to assess competency of handoffs.

NF Sign out (6pm): Long call team will sign out to night float residents.

Handoff/Sign out Process:

A hand-off is defined as the interaction, communication, and planning required to achieve a seamless transition of the care of a patient from one physician to the other. Other commonly used terms for hand offs are “sing-out” and “changeover”. Hand-offs are better when one combines verbal communication with written/typed information.

● We are currently using a sign out application called Ward Manager. You access it from any device with internet connection. Login through: secure.wardmanager.com/stagnes.

● It will then prompt you to network login. Use your ascension username and password here to login.

● You can then access your patient list according to the team you are working in. You are responsible for adding and deleting your own patients from the list.

● If you have a patient of private attending don’t forget to write the name of the private attending in the Ward Manager.

● Students do have access to wardmanager and they can help you with this process but it is important for residents to double check everything the student wrote on the sign out as ultimately updating handoffs is your responsibility.

● Most medical mistakes occur during handoffs. Note the key elements to a good sign off are:

o Code status, patient’s name, location, reason for admission, any relevant past medical history, allergies, active issues, specific follow ups (e.g. labs/imaging), and potential issues that may come up with a clear plan of execution. Use if-then statements. e.g. IF A-fib with RVR with rate greater than 140 THEN start diltiazem drip. If a patient becomes febrile, THEN broaden antibiotics to vancomycin and Zosyn and obtain 2 sets of peripheral blood cultures. Although all patients in the hospital are considered sick there are some that are considered more critically ill than others and those should be highlighted as “sickie” in your sign out and also emphasized during your sign out. As the new intern assumes responsibility for your patients, they are expected to know enough about them to handle acute events overnight.

o The intern assuming the on-call role must clarify all concerns during sign out before the other interns leave and the intern handing off needs to be appropriately detailed and thorough.

o Sign out should be performed in a quiet and isolated room, not in the halls or in the clinic where other people might overhear you (HIPAA violation) and distractions abound.

o Please do not sign out through voicemail, not only is substandard for patient care, it is also HIPAA non compliant.

o You can also use the following tool for a better sign out:

NIGHT FLOAT ROTATION:

Night float team:

● The night float team consists of one PGY3 resident, one PGY2 resident and two interns and 1-2 medical students.

● The night float seniors take turns every day to come at 6 PM to relieve the MAO and take admissions from the ED.

● Night float call is from 6 p.m. to 8 a.m. (or the end of the sign out process) the next morning. Night float interns will receive complete sign out from long call interns at 6 p.m. After receiving the sign out, night float interns must then cover respective on call pagers (#908 & #909) as well as all floor teams’ pagers. NF seniors are responsible for admissions between 6-8 p.m. and 5 to 6 a.m. (Evaluate, stabilize, write bridging orders, sign out to morning MAO)

● CAP for NF is 10 patients from Sunday to Thursday.

● NF interns will have the weekend off (2 days) during their rotation. PGY2 NF senior and PGY3 specialty clinic resident will cover Fridays. PGY3 NF senior and PGY2 weekend MAO will cover Saturdays.

● During Weekends the NF team will drip a total of 4 patients to each intern present for the weekend coverage; meaning 1 patient each to intern. Sign out at 6 AM. Night float team caps at 4 during the weekend.

** Remember that you are admitting for an attending and you should call that attending for any questions or concerns that you cannot resolve as the patient is ultimately their responsibility.
** If you are admitting for a private attending, you have to call and discuss the plan of care with them.

CARDIOLOGY ROTATION:

● Work hours are from 7 a.m. till 4-5 p.m. during no call days. Call days are 24 hours starting at 7 a.m.

● Cardiology pager number 1897 needs to be covered by the 24 hour call resident.

● Although the start time may vary depending upon the attending on call, you are expected to be ready to round at 9:00am or as determined by the attending. Usually, there will be afternoon rounds as well to discuss and round on new consults and admissions.

● You should pre-round on your service and consult patients as you would on floor patients emphasizing on their cardiac history, cardiac findings, ECGs, telemetry strips, and detailed information about cardiac catheterization and echocardiogram reports (If <48 hours, the recent cardiac cath reports done during current admission can be found in the patient’s physical chart.

● There are cardiology dedicated note templates: “cardiology H&P" “cardiology consult note” and "cardiology progress note” that you should use for both service and consult patients.

● Each resident, including interns, will be on call every 4th-5th day for 24hrs. Cardiology resident on call will admit patients accepted by the cardiologist on call and do consults as well. All the patients should be discussed with the cardiologist on call. Also, he/she will be covering for service cardiology patients. In the case of getting a page from a nurse regarding a consult patient, the resident should direct the nurse to contact the primary team. As a consultation service you should, ideally, refrain from putting orders on consult patients but you should always communicate directly with the primary team to give recommendations.

● When an intern is scheduled for a 24-hour call during the weekend, a senior will work from 7am until 4-5pm.

● PAMI/STEMI calls: this means a patient is in need for urgent coronary intervention due to STEMI. Cardiology residents are expected to attend to those patients in an urgent fashion. Residents will be responsible for admitting and close monitoring of those patients till the arrival of the interventional cardiologist and after the cath.

● The cardiology resident should expect that he/she might get called to assist (if not actively caring for cardiology patients) the AICU night resident if the AICU work load gets overwhelming.

**Note: For patients with Kaiser insurance, check with ED attending and admitting cardiology attending as Kaiser patients may need to be transferred to Kaiser facility depending on the preference from Kaiser physician.

JOHNS HOPKINS (JHH) ONCOLOGY ROTATION:

● During your PGY2 you will be rotating at the Johns Hopkins Hospital solid tumor service for 4 weeks. It is a huge opportunity where you can practice medicine at a big institution. Managing oncology patients with a lot of complicated medical problems, in the presence of strong consulting services from all specialties and subspecialties of medicine, will have a tremendous effect on your practical knowledge in a very short period of time. Exhaustive as it might be however, totally worthwhile.

● During your rotation, you will admit and manage patients on the solid tumor service. The service has an attending, one fellow and two resident teams (yellow team and green team). Each team has 2 residents, one Hopkins resident (can be a PGY2 or PGY3) and one external rotator (always PGY2). You will be on call every 4th day.

● Long call: The call is 28 hours long, 7 am till 11 am the next morning. During your call, you will be admitting all patients coming in till 7 a.m. Your cap for admissions will be 7 patients. You will be presenting and managing your call admissions, including the ones admitted by the moonlighter, the next morning till 11 a.m. when your teammate takes sign out from you. You will do the same for your co-resident when he/she is post call.

● The remaining 2 days of the 4-day cycle, you will be “no call” working from 7 a.m. till 6 p.m when you sign out to the on-call person. You must attend the continuity clinic at Saint Agnes once a week. For that, you will be leaving at 12 noon and your teammate will receive sign out and manage your patients for the rest of the day. You will have to do the same for your teammate's clinic day.

● The aforementioned schedule may vary based on JHH preference.

EMERGENCY JEOPARDY COVERAGE

● In emergency situations, where you are unable to come to work due to a family emergency, illness, accident, etc., please notify your chief resident immediately.

● In these situations, the chief resident will utilize the “Jeopardy schedule.”

● You will be on “Jeopardy schedule” during some non-essential rotations such as electives. Check your schedule on new innovations and make note of when you are on jeopardy schedule. You should be available via pager and cell phone 24/7 while on jeopardy. You should be prepared to be called in for emergent coverage if needed.

● You must be no further than one hour away from the hospital. Failure to respond to pages/calls during jeopardy coverage is a breach in professionalism and of the residency contract.

● You will be expected to pay back your coverage in case you utilize jeopardy. There will be no exceptions to this rule unless decided by the program leadership in unique, extenuating circumstances.

Section III - Guide to Outpatient Rotation and Electives

AMBULATORY ROTATION

Saint Agnes Hospital affiliated group of internal medicine and primary care services among others specialties to the Baltimore community. This outpatient clinic opportunity enhances our residents experience in an established private practice with multiple providers.

Saint Agnes Medical Group clinics: Plan ahead and get your eClinicalWorks training (approximately 30min) and laptop ideally 1 week ahead of your scheduled starting day. DO NOT SHOW up at your first Seton Medical Group clinic without eCW training and laptop!

Karen (program coordinator) will coordinate to schedule your eClinicalWorks training.

eCW user name: ____________________________

Password: ____________________________

● Having trouble with eCW? call: 410-368-2070 option 2

ELECTIVE ROTATIONS

All electives need to be revised and approved by the program director (PD), the chief resident (CR) and the continuity clinic director (CCD) AT LEAST 2 weeks prior to the rotation. The elective form must be signed by the accepting elective attending. If no form is submitted in a timely fashion, the resident will be assigned to a rotation at the discretion of the program.

In general, categorical residents are allowed up to a maximum of two (2) away (off campus) electives over their three (3) years of training; additional away elective time requests are reviewed and assessed on a case by case basis.

A mix of outpatient and inpatient electives should be scheduled to meet the ambulatory requirements of your training. Your chief resident will assist you with that. In order to meet ACGME requirements for outpatient training, one elective in your PGY2 and PGY3 year each must be an outpatient experience.

Approved electives for all residents:

● Ambulatory general internal medicine

● Cardiology

● Dermatology

● Emergency medicine

● Endocrinology

● Geriatrics

● Gastroenterology

● Hematology

● Hospital medicine

● Infectious disease

● Nephrology

● Neurology

● Ophthalmology

● Oncology

● Pulmonary medicine

● Quality improvement and patient safety

● Research

● Rheumatology

● Ultrasound/procedure elective

If you wish to do an elective outside of this list, please discuss it with faculty.

Of note:

● Anesthesiology: No anesthesiology electives are allowed unless the resident is a prelim PGY1 going into an anesthesiology residency afterwards.

● Radiology: rare circumstances only- example, elective neuroradiology for a preliminary PGY1 who is going into a neurology residency after completing his/her internship in internal medicine. ICU: ICU elective is not allowed in house anymore. But this has been replaced by ultrasound/procedure elective. This rotation is for residents interested in spending more time to master bedside echocardiography, emergency abdominal and thoracic US exams, as well as ultrasound guided peripheral venous cannulation.

On campus/in house electives:

Authorization must be given by program director, chief resident and continuity clinic director; the elective rotation form must be signed and handed in to the program coordinator no later than two weeks before the beginning of the rotation. You must of course first talk to the specialist of interest to see if he/she can accommodate you during the desired time frame.

Off campus/away electives:

Training experiences outside of a trainee’s home institution can foster personal and professional growth; interactions with professionals at different institutions and with different patient populations can broaden one’s perspective on the practice of medicine and enrich the on-campus internal medicine training by bringing in different perspectives and ways of practicing medicine.

To be able to participate in off campus electives:

● Resident must be in good standing with the program

● The offsite elective should be a rotation where the resident is able to participate in a comparable experience as compared to the home program and should be at a reputable institution (common off-campus elective sites include JHH and UMMS; arrangements at other locations can be made on a case by case basis)

● There has to be a clinical mentor/preceptor and a structured curriculum for the rotation.

● Approval for the away rotation must be sought out at least three months ahead of time. Start planning 6 months if possible, ahead of time to give yourself plenty of time.

● Make sure you schedule this on your “green electives” when you are not on jeopardy call, especially if you are planning to do an elective outside the state.

For a research elective:

You will need to:

- Identify a "research mentor" for that rotation. Find an attending who will work with you on a project during that time.

- Identify a "project" that you will work on.

- Set goals and expectations with your attending regarding the work you are expected to complete on that scholarly activity by the end of the rotation.

- Complete the research elective form (program coordinator Karen usually keeps plenty of copies of the form in her office) and hand it in to the PD or APD who will give approval if requirements are met.

- If the rotation is to be set up outside St Agnes, for e.g. at Hopkins or Maryland, remember that these places usually will require you to get certain training and paperwork completion prior to being involved in research there. So make sure you complete this prior to your rotation and

Continuity clinic (BMS clinic)

● ALL categorical interns and residents are expected to attend their continuity clinics on all rotations except while in ICU or night float (i.e. rotating on the floors (even when on call), in ambulatory rotations, in state electives, during cardiology rotation, etc.)

General responsibilities

● The intern is considered the main internist taking care of the patient and thus responsible for them including the patients that were signed out from your cross covering team. You are expected to place orders and follow up any concerns arising during your call.

● If you receive a call with a serious or potential critical issue, you should assess the patient at the bedside and notify your senior resident. Don’t hesitate to call the senior residents with any concerns; although we encourage autonomy, interns should not attempt to manage seriously ill or crashing patients by themselves (share responsibility).

● If any significant problems occur with any of the private patients, the intern must notify the private attending physician as soon as possible.

When any significant incident occurs overnight, e.g. if the intern is called for chest pain or if the patient’s BP or pulse ox deteriorates, an incident/event note should be typed clearly documenting when and what the intern was called for, exam findings, the impression or differential, explanation of what was done or ordered and how the patient responded.

Baltimore Medical System (BMS) Clinic:

This is the resident’s continuity clinic where you will practice continuity of care, management of chronic illnesses, and preventive care over time, which is limited during the inpatient setting. Many challenges, a new set of skills, and responsibility are ahead of you! Under the supervision of our outpatient clinic attendings you will be responsible for the care of a panel of patients. It is incumbent upon you to make sure your patients are seen in a timely fashion, have phone calls returned, and abnormal studies/images followed up appropriately. You will be in the front line, developing doctor-patient relationships and plans of care emphasizing primary prevention, prevention of progression or exacerbations, and complications of chronic disease(s) using cost-effective, evidence-based practice guidelines and patient self-management.

Keys to success at the clinic:

Be prepared ahead of time:

● The day before the clinic: learn in advance about the patients you will see, this will help you prioritize their problem list and address their concerns.

● Search in Meditech: recent emergency department visits, admissions to our hospital, or most updated labs/images not available in NextGen.

● Search CRISP, and/or eClinicalWorks (eCW): for nearby hospitals/outpatient visits/controlled substances prescriptions.

Responsibilities:

● Always arrive on time (or better yet early). Categorical interns/residents are required to attend their continuity clinics, even when on call.

● Perform medication reconciliation at each visit, and always check allergies and consider pregnancy test before giving medications to women (ESPECIALLY ANTIBIOTICS). Consider a pregnancy test before ordering radiology studies.

● Be careful with narcotics, benzodiazepines and other drugs of abuse. We prescribe them only after careful consideration.

● If the patient states they are on these meds from another doctor and wants us to continue, we must verify from a pharmacy or CRISP before we would consider.

● Always review your PAQ. You are legally responsible for EVERY test you order.

● Complete your notes in a timely fashion, preferably the day of the visit or you may forget key elements of the visit and when you are not in the clinic someone else will need to be able to read the prior documentation of the patients.

● Unfortunately, some BMS patients do not always follow up as we suggest. Make an extra effort and call them and encourage follow up.

● Your relationship with the patient may determine if they follow-up, take their meds, and follow through.

● Patients are often confused with our complicated names; therefore, give them your card at each visit, you will never run out of business cards! Ask them to insist on scheduling with you. This will make your life easy, as you will continually see your own patients. Also, this will ensure patient safety, as you are the one who knows them best.

BMS clinic electronic health record (EHR) is NextGen:

● BMS applications remote Log in: https://bmsiapps.cloud.com

User name: bms\*******

Password: ____________________________

PAQ password: same as above

● Having trouble with NextGen? Outside phone call: 410-558-4966 or BMS phone dial x 20001

Familiarize yourself with BMS attendings and staff:

● Director of ambulatory medicine: Dr. Deborah Som x 234-5823

● Attending: Dr. Robin Li x 234-2757

● Medical assistant: Monique and Lakeira.

Other important services offered at the BMS clinic:

I. Tell your MA about your high-risk patients so she can provide them with the following as appropriate:

● Care management services: helps patients navigate through the complex medical system and with their psychosocial issues

● Referral to diabetes education

● Free or low-cost dental clinics, eye care clinics

● Charity program if applicable

● High risk lung cancer: referral to low dose CT chest

● Educational materials and log sheets to track blood pressure, blood glucose among others

II. BMS pharmacy services (443-703-3185):

● Match price with any other retail pricing e.g. Wal-Mart’s $4 list

● 35% discount over wholesale price

● Free delivery at nearby community patients

III. Mental health service:

● Referral: Using NextGen HER order psychiatry/psychology referral; task the referral to the Behavioral Health (BH) Group. The patient will be contacted by phone and/or mail to schedule appointments.

● Please do NOT put a psychiatric diagnosis first on your BMS note: consider instead fatigue, weakness, insomnia, palpitations etc.

IV. Preventive health service:

● Do not put a screening diagnosis such as physical v70.0 or any other “v” diagnosis first unless there is no other diagnosis to bill.

V. Drug formularies: list of prescription drugs, generic and brand name, approved to be prescribed under a particular insurance policy based on evaluations of efficacy, safety, and cost-effectiveness.

How to save your patients money?

● Look at the formulary list BINDER for residents or search in the internet by typing patient’s insurance if applicable

● Look for $4 list in the clinic by our BMS pharmacy or $4 Wal-Mart list website

May seem like a lot of work but look at these examples:

● Levothyroxine tablet $4 vs. Tirosint (brand name levothyroxine) $134

● Metoprolol tartrate $4 vs. Toprol XL $45

● Lisinopril $4 vs. Losartan $55

Scheduling a BMS appointment for patients you are discharging:

● Established BMS patients: call 443-703-3124 to make an appointment for the patient or patient may call 443-703-3200 to schedule a hospital follow up appointment.

● Uninsured patients new to BMS: patient to call 443-703-3144 from 9am to 4pm; ask for the service representative for adult medicine, who will schedule a health benefit advisor appointment to obtain BMS sliding fee then patient will be scheduled to see a physician.

● Insured patients new to BMS: call 443-703-3124 from 9am to 4pm to make an appointment.

ADMIN RESIDENT CHECKLIST

● Check in with attending & MA (may see patients at ATTENDING REQUEST only)

● Complete PAQ for ALL residents

● Urgent labs/test results must be addressed. You should call patients to inform about urgent results. If the results are normal, you can send them a letter.

● Document action taken in medical record

● Complete admin basket/folder/NextGen Inbox

● Review clinical questions with attending

● Sign out with attending prior to leaving

AMBULATORY ROTATION

Saint Agnes Hospital affiliated group of internal medicine and primary care services among others specialties to the Baltimore community. This outpatient clinic opportunity enhances our residents experience in an established private practice with multiple providers.

Saint Agnes Medical Group clinics: Plan ahead and get your eClinicalWorks training (approximately 30min) and laptop ideally 1 week ahead of your scheduled starting day. DO NOT SHOW up at your first Seton Medical Group clinic without eCW training and laptop!

Karen (program coordinator) will coordinate to schedule your eClinicalWorks training.

eCW user name: ____________________________

Password: ____________________________

● Having trouble with eCW? call: 410-368-2070 option 2

ELECTIVE ROTATIONS

All electives need to be revised and approved by the program director (PD), the chief resident (CR) and the continuity clinic director (CCD) AT LEAST 2 weeks prior to the rotation. The elective form must be signed by the accepting elective attending. If no form is submitted in a timely fashion, the resident will be assigned to a rotation at the discretion of the program.

In general, categorical residents are allowed up to a maximum of two (2) away (off campus) electives over their three (3) years of training; additional away elective time requests are reviewed and assessed on a case by case basis.

A mix of outpatient and inpatient electives should be scheduled to meet the ambulatory requirements of your training. Your chief resident will assist you with that. In order to meet ACGME requirements for outpatient training, one elective in your PGY2 and PGY3 year each must be an outpatient experience.

Approved electives for all residents:

● Ambulatory general internal medicine

● Cardiology

● Dermatology

● Emergency medicine

● Endocrinology

● Geriatrics

● Gastroenterology

● Hematology

● Hospital medicine

● Infectious disease

● Nephrology

● Neurology

● Ophthalmology

● Oncology

● Pulmonary medicine

● Quality improvement and patient safety

● Research

● Rheumatology

● Ultrasound/procedure elective

If you wish to do an elective outside of this list, please discuss it with faculty.

Of note:

● Anesthesiology: No anesthesiology electives are allowed unless the resident is a prelim PGY1 going into an anesthesiology residency afterwards.

● Radiology: rare circumstances only- example, elective neuroradiology for a preliminary PGY1 who is going into a neurology residency after completing his/her internship in internal medicine. ICU: ICU elective is not allowed in house anymore. But this has been replaced by ultrasound/procedure elective. This rotation is for residents interested in spending more time to master bedside echocardiography, emergency abdominal and thoracic US exams, as well as ultrasound guided peripheral venous cannulation.

On campus/in house electives:

Authorization must be given by program director, chief resident and continuity clinic director; the elective rotation form must be signed and handed in to the program coordinator no later than two weeks before the beginning of the rotation. You must of course first talk to the specialist of interest to see if he/she can accommodate you during the desired time frame.

Off campus/away electives:

Training experiences outside of a trainee’s home institution can foster personal and professional growth; interactions with professionals at different institutions and with different patient populations can broaden one’s perspective on the practice of medicine and enrich the on-campus internal medicine training by bringing in different perspectives and ways of practicing medicine.

To be able to participate in off campus electives:

● Resident must be in good standing with the program

● The offsite elective should be a rotation where the resident is able to participate in a comparable experience as compared to the home program and should be at a reputable institution (common off-campus elective sites include JHH and UMMS; arrangements at other locations can be made on a case by case basis)

● There has to be a clinical mentor/preceptor and a structured curriculum for the rotation.

● Approval for the away rotation must be sought out at least three months ahead of time. Start planning 6 months if possible, ahead of time to give yourself plenty of time.

● Make sure you schedule this on your “green electives” when you are not on jeopardy call, especially if you are planning to do an elective outside the state.

For a research elective:

You will need to:

- Identify a "research mentor" for that rotation. Find an attending who will work with you on a project during that time.

- Identify a "project" that you will work on.

- Set goals and expectations with your attending regarding the work you are expected to complete on that scholarly activity by the end of the rotation.

- Complete the research elective form (program coordinator Karen usually keeps plenty of copies of the form in her office) and hand it in to the PD or APD who will give approval if requirements are met.

- If the rotation is to be set up outside St Agnes, for e.g. at Hopkins or Maryland, remember that these places usually will require you to get certain training and paperwork completion prior to being involved in research there. So make sure you complete this prior to your rotation and