Orientation for Fellows and Attendings

1.   Expectations

a.    Given that the fellow and the attending are both board certified internists, the attending and fellow will work together to create supervisory expectations at the beginning of the rotation.

b.    The attending should strive to give ample fellow autonomy while providing proper supervision.

c.    The attending must staff all new consults

2.   New Consults

a.    The consult fellow will assign a reasonable number of consults to the consult intern.

              i. The consult intern, when not in clinic, is expected to work with the team until the fellow or attending tell the intern that all the work is done for the day.

             ii. The intern should try to attend all noon conferences and intern report.

            iii. The consult fellow will work with the intern to allow time for the intern to meet with mentors if necessary.

b.    The consult intern will discuss the case with the fellow prior to presenting the case to the attending if time permits

c.    The consult intern will present all new consults to the attending.

              i. The attending will staff and bill for all initial consults.

d.    The consult fellow will present all initial consults to the attending.

              i. The attending will staff and bill for all initial consults.

e.    If the fellow or intern is overwhelmed by the number of consults, the attending will help.

f.     The fellow and intern are expected to accompany the attending for the initial history and physical during new consult work rounds.

              i. The fellow and attending can negotiate this expectation.

g.     The attending will be available for case presentations at a time mutually agreed upon by the fellow and the attending which preferably follows the existing consult schedule.

h.    The fellow or intern will personally discuss the recommendations with the resident or attending from the team that ordered the consult. Communication with other services is key!

i.      The consult service is responsible for consults on Moore Clinic patients with general medicine issues that are not directly related to infectious disease/HIV issues.

j.      The consult fellow may be asked to care for urgent “outpatient” consults in the anesthesia clinic.

k.    We evaluate patients in the psychiatry day unit and the Intensive Treatment Unit (ITU).

3.   Follow-up consults

             a.    Intern follow-up patients

              i. The intern will pre-round and write notes on all patients on which he/she performed the initial consult.

             ii. The intern and fellow will round on all of the intern’s follow-up patients together, and the fellow will write tie-in notes and bill for those patients

            iii. If the fellow is unable to round with the intern, the attending will round with the intern and will bill for those patients. The intern will update the fellow on the plan made between the intern and the attending.

           iv. The fellow will discuss follow-up cases with the attending if the fellow would like additional input.

b.    Fellow follow-up patients

              i. The fellow will write notes and bill for all follow-ups on a daily basis.

             ii. The fellow may ask the attending to see and bill for some of the follow-up patients if the fellow is overwhelmed with the size of the service.

            iii. The fellow may sign-off on patients when it is clinically appropriate and after discussing the decision with the requesting team. Again, communication is key!

4.   Teaching Responsibilities

a.    Attending

              i. The attending will conduct at least three thirty-minute sessions per week with the intern and fellow to discuss core consult medicine issues separate from “work” rounds. (see schedule template)

             ii. The attending will create an atmosphere to foster an evidence-based approach to consult recommendations.

            iii. The attending will teach to the fellow’s training level recognizing that this rotation is not an extension of residency for the fellow.

           iv. The attending and fellow will share ideas and teach each other in a collegial manner.

            v. The attending will have access and be expected to read the consult medicine curriculum.

b.    Fellow

              i. The fellow will teach the intern daily on work rounds.

             ii. The fellow will have access and be expected to read the consult medicine curriculum (http://jhcme.com).

c.    Intern

              i. The intern, with help and encouragement from the attending and fellow, should formulate daily clinical questions and answer them for the team.

             ii. The intern will have access and be expected to read a written consult medicine curriculum (http://jhcme.com).

            iii. The intern will finish at least 5 jhcme.com modules during the 2 week rotation.

5.   Home Call Expectations (please see safety initiative explanation)

a.    The consult fellow is expected to see all urgent and emergent consults called in between 8am and 5pm.

b.    The consult fellow is expected to see all non-urgent consults called in between 8am and 5pm. The fellow may elect to see a non-urgent consult the next morning if the requesting physician agrees to the delay.

c.    If a non-urgent consult is called in after 5pm, the fellow is not expected to see the patient until the following morning.

d.    If an urgent consult is called in after 5pm, the fellow must see the patient in the next 3 hours unless the referring physician states that it is reasonable for the consult to take place at 8am the next day.

              i. For psychiatric, PM&R rehab, or ophthalmology consults that will definitely require a medicine admission, the hospitalist or hospitalist moonlighter can be asked to see the patient if there is an open Halsted 6 bed.

             ii. If patient safety is a concern for an urgent call, please see the urgent call initiative explanation. 

e.    If an emergent consult is called in after 5pm, the fellow may direct the physician to call the SICU/RRT/MICU/CCU resident if appropriate. If MICU/CCU intervention is not emergently needed, the fellow should begin the consult within the next hour. If the consult cannot wait one hour, the requesting should be directed to call the MICU/CCU resident to help with immediate care.

f.     The consult fellow is not to receive panic values on general medicine outpatients.

6.   Weekends

a.    The MEG hospitalist covers all the weekend and holidays. Refer to the schedule.

              i. The schedule is available at http://www.hopkinsmedicine.org/gim/training/consult.html.

b.    The weekend attending will see all new consults and discuss with you any transfers to medicine. As always, you need to have an attending accept a transfer.

7.   Resource Information

a.    Fellows can determine which intern(s) are rotating on the service by logging into http://amion.com. The password is Osler. The interns on the consult service are under the rotation name of “Case 0.5”.

b.    Billing will be done on Tap. http://tap.jhmi.edu/.

c.    The website for the consult service is http://www.hopkinsmedicine.org/gim/training/consult.html. You will find the curriculum, the schedule, consult template forms, and orientation information for the interns there.

d.    Free CME consult modules are available on http://jhcme.com.

e.    The monthly schedule will also be placed on the website.

f.     You should have access to EPR. Please let me know if you do not.

g.    Eclipsys access- the form will be passed out at orientation

              i. To learn how to use Eclipsys, please see the instructions the residents have created for each other on http://oslernet.med.som.jhmi.edu/.

h.    To make long distance calls, call the HAL Line (5-9444).

i.      The residents have created their own survival guide with helpful phone numbers. You can find it on http://oslernet.med.som.jhmi.edu/jhu/survive/SurvivalGuide05-06.pdf.

j.      Names of services:

              i. MEG, Garrett, and Nelson 5 are all names for the same resident service. It does not describe a place, it describes a service. MEG is a hodge-podge service that includes GI, rheum, renal, GIM, and gen med transfers.

8.   Triage Pearls

a.    Always ask if the referring service has consulted more than one IM consult service about a patient. Feel free to decline consult on patients where there would be significant overlap.

b.    The income from the consult service helps to pay the bills for the GIM Fellowship. With that in mind, feel free to ask a referring team during your phone triage to consult an IM specialty if you really believe that would benefit the patient the most.

              i. As part of our consult, we can recommend to consult a specialty service.

c.    Patients in the WICU, NICU, and SICU are cared for by both a primary team and intensivists. The intensivists often feel very comfortable caring for medical problems. Before evaluating a patient in those settings, make sure the primary team has discussed consulting gen med with the intensivists. Gen med can always offer to see the patient after they come out of a unit.

d.    Pre-op evaluations- Before coming in at night or early the next morning to do a pre-op eval, the resident must assure you that the patient is posted for the OR that business day. Feel free to make a chief resident call you personally.

e.    The consult service attending, usually a hospitalist, will help you transfer patients. It is the consult service attending’s job to find an accepting IM attending. Unless the patient has previously been assigned to a firm, the consult attending will usually call the hospitalist unit first to find a bed. If the hospitalist unit is full or the patient needs a higher level of care than Hal-6 can provide, the consult attending will call the MEG attending. The gen med consult service should not be involved with MICU or CCU transfers.

9.   Consult Service Director - Here to help!

a.    Dr. Lenny Feldman. If there are questions or concerns, please feel free to page him at 410-283-4199 or call at 7-3135.

b.    Almost always available for help with political issues and triage questions.

10.  Helpful Phone Numbers

a.    Medical Shift Coordinator Pager- 410-283-3989 (also found on pagerbox.com under medical shift or by pager number)

b.    MICU- 410-955-5570

c.    CCU- 410-955-5572

d.    Hospital Operator- 410-955-5000

e.    Nelson 5/MEG Resident Office- 410-614-0218

f.     Carol Johns Resident Office- 410-955-2543

g.    Hal 6 nursing station- 7-3127

h.    Hospitalist Pager- 3-2648

i.      Hospitalist Cell Phone- 443-248-4651

Patient Safety for Urgent/Emergent Consult after 5 PM

- If needed for safety reasons, the GIM fellow can page the Hospitalist moonlighter to request s/he evaluate the patient in question and perform the consult. 

-o-    If the Hospitalist moonlighter is too busy to be able to perform this, s/he may indicate this and the responsibility will rest with the GIM fellow.

-o-    For very sick patients, the requesting team should be advised to call the CCU/MICU/SICU resident or RRT, as applicable.

- Once agreed upon, the Hospitalist moonlighter would assess the patient, write a note, and discuss by phone with the GIM fellow that evening. 

- Once the moonlighter performs a complete consult, the GIM fellowship program will pay $100/consult to go directly to the Hospitalist moonlighter; except if the moonlighter is a GIM Fellow fulfilling his/her GIM clinical commitment.

- The GIM fellow will make the final determination (in consultation with the consult attending) about the disposition of the patient.  If the patient remains on the requesting service, the GIM fellow is responsible for the handoff to the consult team in the morning.

- If a transfer to a medical service is needed, the consult attending will help determine where that patient should go.   

- The responsibility for arranging the transfer (i.e. contacting the consult attending, the shift coordinator, admitting, etc.) rests with the GIM fellow.

-o-   This can be shared with the Hospitalist moonlighter if agreed upon.

-o-   The Hospitalist moonlighter who saw the patient will generally sign out to the accepting intern. 

- Requests for transfer to a medical service from Physical Medicine and Rehabilitation (PMR, Halsted 3), Psychiatry, or Ophthalmology, after coming to the GIM Fellow via the consult pager, should typically be handled by the Hospitalist moonlighter. Transfers to the Hospitalist unit from PMR, Psychiatry, or Ophthalmology do not need consult attending approval.

-o-   Patients recently cared for on a Firm, Polk, Onc, Carol Johns, MEG (particularly those who went straight from a firm to Rehab or Psychiatry) may be transferred back to that primary service.

 Each time the Hospitalist Moonlighter is utilized in this way, the GIM fellow should email the date/time of the consult handled by the Hospitalist moonlighter, the name and medical record number of the patient, and the full name of the moonlighter to Jeanne Clark, Dan Brotman, and Carolyn Robinson.

Attendings 

Your attending responsibilities will be from Monday morning at 8:00 a.m. to Friday afternoon at 5:00 p.m.  You may be called overnight by the fellow while you are attending on the service. Please keep your pager on at all times.

Please see the attached schedule for full details on fellow coverage.  They should not have clinic during the rotation, but please discuss your schedules and please be available for urgent consult issues if the fellow cannot be.  The fellow can be reached through the Fellows Consultation beeper at (410) 283-4459 which can also be found on pagerbox.com.  Again, the fellows will not have clinic during their 2-week rotation.

When agreed upon between you and the consultation service fellow, she should perform follow-up evaluations on all the consultation service patients and bill for these services under her name. You are not required to see the patients if the fellow is billing for them.

Please use the resident/fellow tie-in note. Take a look at the form, which is on the web-site, and let me know if you have any questions about it.  Attached, you will also find the initial consultation note that should be filled out completely by the intern or fellow. These forms are also available on the website.

The consult service has its own website. Please visit it at http://www.hopkinsmedicine.org/gim/training/consult.html.  The website includes links to the course curriculum, daily schedule, and some orientation materials for the interns and students. The course curriculum link contains PDFs on many of the important consult subject areas. Please let me know if you think we are missing something, or if you find an article that you think should be included. You can also receive free CME by taking consult modules on http://jhcme.com. 

We will often have 2 interns in lieu of a fellow. Please make sure the interns are signing out to the overnight covering fellow.

Please adhere to the consult service schedule as much as you can and discuss the schedule with the Fellows before you begin the rotation. It emphasizes conducting at least 3 half an hour teaching sessions per week dedicated to educating the fellow and interns on the basics of consult medicine. Feel free to teach whatever you believe is most beneficial and appropriate. Attending work rounds should also take place at approximately the same time everyday.

In addition to seeing in-patient consultations, you will be asked to be available for urgent outpatient preoperative evaluations from anesthesia, outpatient optho, and the psych day-service. JHOC faculty members have volunteered to see other urgent outpatient non-preop consultations. That schedule is attached. If there is an anesthesia consult, you will likely be contacted directly by Dan Brotman or the anesthesia clinic. The clinic is located on the ground floor in JHOC. Please call me or Dan if you have any question about those consultations.

There are multiple options for patients who need to be transferred to a medicine service from other inpatient services. The Hospitalist Program is prepared to accept, when beds are available, in-hospital transfers of patients who are not critically ill or rapidly deteriorating.  Transfers to the Hospitalist Program should be discussed on a case-by-case basis with the attending on the Hospitalist Program (beeper 283-2648), also available via text page (www.pagerbox.com). 

Patients transferred to medicine are not required to be transferred to the hospitalist unit. Patients can be admitted to your Firm to be managed by you and the residents.  The Nelson-Baker Service (MEG) hospitalist attending can also accept patients. Please contact the MEG hospitalist to see if he/she is willing to accept the patient. Polk patients, former Firm patients, and Carol Johns patients can be transferred to those services with approval from an accepting attending.

The MEG hospitalist is now covering the consult service on weekends. The hospitalist will see all new consults over the weekend.

You will be responsible for evaluating the fellow and the interns. You should receive an e-mail regarding this duty at the end of the rotation. The evaluation should be completed on-line through e-value.

Please review the accompanying schedule, list of expectations, transfer policy written to help guide the fellows, a policy regarding after-hours consults, and orientation materials for the intern. The fellows have received these documents as well. We are not the “transfer to medicine” service. If another medicine team has evaluated a patient and decided the patient needs to be transferred to medicine, then they can call shifty to help facilitate it.

Lastly, you will maintain complete billing information to bill adequately for all of your services.  If you wish, a copy of the AMA billing guidelines are available and you may request this from Loretta Hoepfner (x5-4027, lorettah@jhmi.edu, JHOC-7150B).  You and the fellow should both bill on Tap. http://tap.jhmi.edu/Logon.php. 

Revised, June 2009