Intro to Clinics - Penn Medical Student Government

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Intro to Clinics
Tips and Tricks for Internal Medicine and Family Medicine

From Your Upper Classmen Friends
It all became worth it when…
“...When I had the chance to work with one of the best, most
caring physicians that I encountered in medical school,
following him from his solitary private practice to the hospital
several times each day, where he cared for his patients’ both
acute and chronic concerns and addressed their needs
completely.”
“...When I got the chance to bring in the son of my patient
with dementia, and ask him about how he was doing as a
caregiver and what we could do for him. He told me no one
had ever asked him that before.”
What should you buy?

Essentials:
 USMLEWORLD!!!
 Step Up to Medicine
 Kaplan Step 2CK Book
 Pocket Medicine
 Penlight / Stethoscope light
 Pens, snacks (Clifbars, etc)


Case Files
Smart phone: Epocrates, some med calc software
What should you buy?

Non-Essentials:
 Maxwell Cards

Reflex Hammer
 Pretest
What goes in all these pockets

Pocket Medicine

Maxwell Cards (if you want)

Reflex hammer (again, somewhat optional)

Papers: H&Ps, signout, articles

PDA

Penlight

Lots of pens

ABG kit, tape, etc (maybe…)
General Useful Shorthand
Advice: On Imaging
Computer Systems

Coast: Check your team, call schedule, etc


Username: ahupuser; password ahupuser
Just type “coast” into the address bar of any Penn Comp

Penn Access Manager --> Link all your signons

Sunrise: All orders; most results --> be the first to know! Flag
orders!

Signout: ask your interns/residents if they want you to
update. Some do, some don’t. Ask first!

Epic

Medview

Extranet: Log onto Medview from Home

UpToDate from home
Sunrise
A good way
to figure out
what
happened
overnight if
you don’t
hear signout.
You can see
what orders
were placed
Where you can see
patients’ labs and
studies. Cardiology
studies (ECHOs),
EEGs, and some
special radiology
may only be
available on
MedView
The Sign-Out: Don’t
touch unless you’ve
asked, but a great
way to keep track of
the patients overall
clinical picture and
To-Do list: CHECK
OFTEN
These are where
you can find vitals
and other things
like Is/Os
The MAR: where
you can check
what pills nursing
has given, when
the next
scheduled dose is
More Sunrise
How to be in the know!
Computer Systems: Intranet
Structure of Team

Attending

Fellow (on sub-specialty services)
 Resident
 Two Interns (occasionally 1 intern + 1 sub-I)

You (with perhaps another 200 student)

Nurses

Other staff: Social worker, PT, OT, CNA (Certified Nursing
Assistant), Case Manager, Floor clerk, Phlebotomist, etc
Typical Day

Pre-Rounds:


Go see your patients, learn about o/n events, check vitals
and lab --> get ready to present
Rounds
 Work Time
 Calling consults
 Getting outside records (**ways to make your intern love
you**)!

Call

Where you pick up patients and do H&Ps
Advice: On Vitals

Bad: Vitals? What vitals?

Good:BP 134/86, HR 72, RR18
 Better:BP 121-147/75-92, HR 73-87, RR15-22
 Best: BP 120s-140s/70s-90s, HR 70s-90s.. You get
the idea
Patient Presentations

Be methodical and thorough with history & exam

In order, same way every time, go back if needed

At least at the beginning, write it out (Type!)

Know everything, but only say what you actually think is
important

Think about your assessment as a thesis (ie you think the patient
has a pneumonia flare), include any aspects of the H&P, Labs,
Imaging that support your thesis

Be prepared to answer other questions

Know the normal values for any labs you state

Follow-Up Presentations: SOAP
Topic Presentations
 Start with a summary source: UpToDate, NEJM,
American Family Physican

Be focused --> brevity is the soul of wit here more than
ever

Make a handout, but say more than is on the handout

Incorporate actual evidence (use UpToDate or review)

End strong: Zinger, 3 take-away points
Your Greatest Fear … The Shelf!
 Find your own studying style
 Our basic suggestion: Read StepUp as quickly as possible
--> familiarize yourself with the diseases, vocabulary, etc


Questions, Questions, Questions U SMLE!!!! Try to do all
the questions, but there are a TON so don’t worry if you
don’t do all, but definitely have that as your goal
Know: Common presenting symptoms, Best diagnostic
tests, Treatment
 Use Family Medicine time wisely
Attire
 My basic approach: Never give anyone a reason to
dislike you or judge you
 Assume nothing: Wear nice clothes + white coat as
baseline
 For call days, ask your resident about scrubs

Cell Phone etiquette: People will assume you’re
texting or goofing off.
 Always on vibrate
 Never use on rounds --> announce exceptions loudly
Feedback
 Ask for it from Attendings / Residents

Attendings like to be asked proactively for feedback,
midway through your time with them

Residents are more likely to offer real, constructive
feedback to help you improve
 ASK SPECIFICS: ie, I’m really working on making my
presentations concise and to the point, do you have any
feedback for me on that or suggestions for how I could
continue to improve? That way you can do something
very concrete and they can say in their evals that you
used feedback to improve!
Family Medicine
 You will be placed at an outpatient practice… some will
have residents, but in most you will work directly with
the attending
 Be ready to get thrown into seeing patients
 Your H&Ps will be less thorough than in the hospital.
 Be “problem” oriented and try to help the patient
identify the biggest “problem”… Some will come in with
many issues that you may not be able to address in one
visit
Family Medicine: What to Review
 Look over the last chapter in Step Up to Medicine
before beginning the rotation
 Know Framingham Risk calculation
 Review musculoskeletal exams – knee, shoulder
(will need this for the exam too)
 Some practices will see more ob-gyn than others…
if you feel like you are seeing a fair amount of OB,
may be helpful to review the prenatal/postnatal
care section of an OB-GYN book
Family Medicine Exam
 One component is preforming a joint (shoulder or knee)
exam on a standardized patient
 The other component is a multiple choice test based on
the computer modules you are required to do
 The test is somewhat detail-oriented and less big-
picture. Do not skip over the sections about cultural
competency in the online cases… they can be tested
(know the latino principals of respecto… etc)
 Review all the guidelines presented in the online
modules – like when to do pap smears, stress test, etc
Staying Sane
 Biggest challenges
 Schedule
 Interpersonal work load
 Not seeing your friends

Tim’s Solution:

Institutionalize time with those you care most about
 Don’t let your empathy get fatigued! Taking an extra
moment to listen to your patient is a good way to
improve patient care, help your team, and make the
experience more fulfilling for you!
Random
 Go to Intern Report --> good learning and good
eating
 When your resident tells you to leave, leave! ␣
 Always be on time

Have fun
Advice: On Clinic Grades
 The Three A’s:
 Affability (enthusiasm for everything!)
 Availability
 Ability
Support Systems
Suite 100:
- JoMo, Barb, Helene
- Tutors set up through suite 100
Organized counseling:
- CAPS: http://www.vpul.upenn.edu/caps/
- Therapists in the community (Barb from Student Affairs can provide names and
contact info)
- Paired mentoring: SNMA, LMSA, Elizabeth Blackwell, House mentors
Other people to turn to:
- Doctoring preceptors
- Advisory deans
- Clerkship directors (it’s really ok to talk to them!)
- Mentors you have connected with in pre-clinical years (through clinics,
volunteering, etc)
- Friends and family outside of medicine
Supplemental Stuff

UpToDate from Home

Access the hospital's Extranet at https://extranet.uphs.upenn.edu/

Use your MedView username / password to log in

Create a bookmark on your home page for UpToDate

Click on the "+" that's on the far right side of the "Web Bookmarks" heading

Name your bookmark and put this URL in the URL spot: http://uphsxnet.uphs.upenn.edu/uptodate

Click on new bookmark that's now on your home page

Use UpToDate like you would from on campus

HUP OR Schedule:

Homepage: Left hand side, click on Departments-->Perioperative Services-->OR Schedule. The user name and
password are both hupor
Supplemental Stuff
 Bug Drug: UPHS guidelines for anti-microbial therapy

Pulse:



Phonebooks for each hospital
#s for Consult services
Lots of assorted resources, guidelines, forms
 Phone #s to store in your cell

Hospital operator
 General lab

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