July 2008

 

 

To:   NMFF Interns and Residents

Re:   NMFF General Internal Medicine Resident’s Clinics

 

Welcome to your outpatient clinic.  We want to make this an excellent educational experience for each of you.

 

The Northwestern outpatient resident’s clinic seeks to develop expert internists who have a broad and deep foundation of the scientific basis of medical practice, exemplary interview and physical exam skills and an appreciation for the subtleties and complexities of patient care in the primary care setting.   In order to provide outstanding patient care, the internist must have excellent communication skills and be facile at identifying psychological factors which modify a patient’s experience of illness.  The general internist must have excellent physical exam skills as well as an appreciation for the limitations of the physical exam. Technology must be used to augment clinical decision-making rather than being the master of it.    We hope you will learn all this and more during the ambulatory component of your residency.   Many of these skills will be invaluable to you in your future career, regardless of whether you practice general internal medicine or a subspecialty.

 

This letter serves as a template to guide your successful introduction to the outpatient clinic.

 

1.        EPIC Hyperspace:  All documentation in the outpatient medical records is through EPIC, our electronic medical record.  You will receive training in how to use this.  An especially important feature is to send a copy of your acute visit note to a colleague when you see a patient for whom you are not the primary care physician.

2.        SCHEDULING:  We will strive to cancel all appropriate outpatient clinics based on the information from your inpatient schedule.  However, please use AMION to glance at your schedule at least one month in advance and confirm that the appropriate clinics have been cancelled. Bumping patients at the last minute is very inconvenient for  patients and reflects poorly on our practice and you as a physician.

3.        NURSING SUPPORT:  The LPNs in our practice will place the patients in a room, take vital signs, perform office base tests such as pregnancy tests, urinalysis, rapid strep tests and assist with PAP smears.    It should go without saying that you should repeat a blood pressure to supplement the nurse’s reading when you are making a clinical decision about management of hypertension.

4.        TELEPHONE NURSING SUPPORT:  The nurses in the triage area are available to assist you with patient care.   A successful collaboration with them will improve your clinical care and make your life easier.  Please check EPIC at least twice each week for messages from your nurse.

5.        LAB FOLLOW-UP:   All lab results should go to your EPIC in box.  Your faculty mentor should also receive a copy.  All major abnormalities (abnormal mammogram, lung nodule on chest X-ray, heme positive stool etc…) require a phone call to the patient and documentation in EPIC.  For lesser abnormalities (e.g. high cholesterol), you should choose the method of communication which is most comfortable for you – phone call  (with documentation in EPIC) or EPIC letter.  All test results demand notification of results to patient;  patients should not feel that “no news is good news.”   It is possible to write letters when you are away from clinic and route them to an assistant who will attach your electronic signature and mail the letter for you.  Your attending can provide more details about this.

6.        ATTENDINGS:   The attendings will mentor you in your outpatient practice.  They will see all of your patients and be as involved as necessary to insure optimal care of your patients.  We encourage presentations in the exam room as there is data which shows that discussion with the patient present improves patient satisfaction and enhances education.  Expect attendings to be more involved initially as you begin your outpatient practice. They will also add their own documentation to your note.  

7.        EDUCATION:  Each half day in clinic begins with a case based conference using the Yale curriculum.  You should plan to meet in the large conference on Galter 18 (or another location as designated by your attending)  to meet with faculty chosen to lead these conferences.   The Yale cases are available through the Ambulatory Care site which you can access through the Curriculum web site (which you access through ResidentNET).  We also ask that residents do one Hopkins module each month.  This site can be accessed through the Ambulatory Care web site.  The Hopkins modules are case based and focus on outpatient medicine topics.  They take 15-30 minutes depending on how much of the supplemental reading you do. I will provide feedback to your attendings about how many Hopkins modules you complete.

 

Welcome to your outpatient practice.  We hope that what you learn over the next several years sets a foundation for a rewarding and enjoyable medical practice in the rest of your professional career, regardless of  the area of medical practice which you ultimately choose.

 

Please contact me if you have experience problems or have questions.

 

                                                                                                                                Sincerely,

 

 

 

                                                                                                                                John E. Butter, MD

 

RESIDENT PRACTICE ORIENTATION:  HOW THINGS WORK

INFORMATION FOR THOSE BEGINNING AN NMFF CLINIC

 

Welcome to the residents’ outpatient clinic practice.  Interns have a weekly clinic at NMFF or the VA. This is a change from prior years in which interns alternated weekly clinics at NMFF and the VA. As in previous years, residents have two weekly clinics, usually at the VA and NMFF but some have their clinics at Community Health, Erie, Winfield-Moody Clinic or in the offices of a few selected private practice physicians. 

 

An attending preceptor will be assigned to you. Your attending is involved with resident teaching because he or she enjoys it.  You should take full advantage of their presence and feel free to ask any and all questions.  Many mentoring relationships have been developed with attendings from resident’s clinic.  It is a relationship you can look forward to.

 

Outpatient medicine is very different from inpatient medicine.  As you begin to see your patients, you will quickly discover several major differences:

 

1.                    Whose agenda is important?-The patient is concerned about their dry skin or bloating- you are concerned about getting their mammogram or controlling their diabetes.  You will need to learn that you cannot address every problem at every visit and if you try to, you may be frustrated and less tolerant of any additional concerns the patient may bring up which will reduce satisfaction for both of you.

2.                    Time- although you need to ask thoughtful open-ended questions, you need to set limits and keep to a schedule.

3.                    Money -  cost effectiveness in the hospital is often only theoretical.  One month of   HCTZ 25 mg costs $3/month;  atenolol 50 mg costs $11/month;  lisinopril 20 mg costs $11/month; Norvasc 10 mg costs $64/month;  Cozaar costs $58/month. To outpatients without insurance, that’s real money.  [Prices verified at www.drugstore.com September 2006]]

4.                    Ambiguity -  In the clinic setting, we often observe, reassure, and think before ordering tests. You will learn to deal with uncertainty.  You need to be much more thoughtful and careful when you don’t order tests.  Appropriate follow up is essential in dealing with uncertainty.

5.                    Counseling- Patients will come in for their diabetes, but you will be ineffective in getting their sugars under control if they are in an abusive relationship, depressed or can’t afford a glucometer.  Asking “Is there anything else?” at the end of the opening interview frequently elicits important issues.  Unfortunately we often feel inadequate to deal with the big psychosocial problems so it is tempting to ignore them and stick to the medical problems.

 

Your attending will be a valuable resource to help you navigate some of the issues mentioned above.  Don’t feel that questions such as “How soon should I see this person back?” or “How do I order this in the computer?” are silly.  These are issues that have not been part of your decision-making repertoire to date.  Your attending will see all of your patients at least  briefly as in some cases it is required by Medicare/Medicaid and other private insurance companies even if the visit is straightforward.  Don’t hesitate to ask your attending to see any patient about whom you have a question. 

 

Your patients will see you as their primary care physician.  This carries with it, great rewards as well as responsibilities.  You will need to keep your pager on to be available to your patients if they call with emergencies.   Each clinic site will have its own system as to how routine patient calls are handled during daytime hours.  I suggest you encourage patients to call the NMFF general number (312-695-8630) and ask to speak to your triage nurse.    When you signed out (on vacation etc…) many people sign out to a friend but you may sign out to the STAR resident (695-4600) and whoever is carrying the STAR resident will triage any urgent problems.  

 

When you have a NMFF clinic patient who needs to be seen and you are not available, you have several options:

  • Schedule the patient with a one of your fellow residents who works with your attending.  Giving your fellow resident a preview (perhaps by EPIC e-mail) is helpful.
  • For an urgent medical condition which is not serious enough to warrant an ER visit, you may ask your nurse to schedule the patient for an Acute Care appointment with whomever is available. The patient will be scheduled with any available physician or our nurse practitioner.
  • Schedule them with you outside of your typical clinic time.   This depends on your ability to make available time.  1) Call your nurse or Joyce in the phone room
    (312-695-8630) and let her know when you want to see patient.  If your usual attending is seeing patients at this time, you will staff the patient with your regular attending.  If your regular attending isn't seeing patients, you will staff the patient with the attending who is working with residents (ask RN or Joyce and let attending know in advance). 

 

When you are in clinic, you will need to arrange coverage for your inpatient duties with another intern or resident on your team.  You should not be dealing with inpatient issues while you are in clinic.

 

Phone medicine can be difficult as you cannot see the patient and sometimes it is difficult to assess the severity of illness.  Don’t hesitate to contact your attending after hours if you have a question about how to handle a particular call. Document your telephone calls with your patients in EPIC.

 

Admissions: With the introduction of a hospitalist model several years ago, the primary care physician has been less involved in providing hospital care.  Your knowledge of the patient, however, is valuable to the hospital team and hence to the patient.  Patients greatly appreciate seeing a familiar face when they are most ill and your visits provide an opportunity to connect with your patients more deeply.  Visits with hospitalized patients can be very rewarding both for you and your patient.

 

 

Many patients admitted to the Teaching Service will not have a primary care physician and will need follow up in the outpatient setting upon discharge.  This is an ideal way to recruit patients to your practice at NMFF.

 

Teaching Conferences: There is a preclinic case based conference lead by an attending at 8:25 and 1:05 and you should plan to attend these conferences.

 

Web based Curriculum:  We use the Hopkins Modules as self study, web based curriculum. Residents are expected to do one case each month beginning in August. These cases are accessed through Medicine ResidentNet > Our curriculum> Ambulatory Care > Ambulatory Reading List > Johns Hopkins Primary Care Modules.  Your attendings are given feedback about how many modules you complete.

 

Clinic hours are:                 VA:                        9-12 AM and 1-4PM

                                                NMFF    :               8:45-11:40 and 1:25-4:30PM

 

Clinic Cancellations:         Please remember that you may  have a full schedule booked on the days you are assigned in clinic.  If you cancel on short notice, often patients cannot be reached and will come to clinic anyway.  In this case, your colleagues will often be asked to see your patients.  All cancellations must be made 8 weeks in advance.  I recommend that you check your schedule in AMION to verify that the appropriate clinics have been cancelled  In case of emergency requiring shorter notice for cancellation, notify your attending and John Butter at 695-0511 or pager 5-2216. Do not rely on the Department of Medicine to notify the clinic of when you are on night float or when you have vacation.  You will need to notify the individual responsible for scheduling at each clinic site of all cancellations.

                                                Joyce Ponicki in General Internal Medicine on  Galter 18 can answer scheduling questions.

 

 

Individual clinics may have additional materials that they will hand out to you when you start.  Please don’t hesitate to contact John Butter at 695-0511 or email at jbutter@nmff.org if you have any further questions or if problems or questions arise as the year progresses.  I hope that all of you enjoy the rewards of continuity relationships with your patients.