INTERNAL MEDICINE
POLICIES & PROCEDURES

Internal Medicine Teaching Service Policy and Procedure
 Policy Number : 7
Date Issued : 11/2002
Prior Revision Date :
  Date Revised : 7/2003
PURPOSE To define the Internal Medicine policy for the Teaching Service
SCOPE Applies to all interns and residents (hereafter will be referred to as trainees or housestaff) in the Internal Medicine training program on the Presbyterian Hospital of Dallas campus.
PROVISIONS
  1. Handling of Patient Admitted Via The Emergency Room

    2. For house staff assistance with patients admitted through the emergency room, the attending physician should always contact the house staff personally.  This clearly establishes a line of communication that is important in the care of the patient, especially during the first and often critical few hours.  This, of course, does not preclude direct communication between the ER physician and the house staff, which is also important.

  2. Policy for Circumstances (Emergent and Non-emergent) Under Which Residents Should Provide Care to Patients Who Are Not On The Teaching Service.
    1. The house staff (interns and residents) in the internal medicine training program do not have independent staff privileges.  When seeing patients in this hospital or its clinics, they do so under the supervision of a staff physician.  Under very special circumstances, they may be called to see a patient who is not on the teaching service.  When this occurs, they are to act within the following guidelines:
    2. Determine the urgency of the patient’s need by the nurse’s description.  If the patient seems to be unstable by vital signs, respiratory status, cardiac status, or mental status, please evaluate that patient immediately.  If the patient is stable, please politely inform the nurse that the patient is not on the teaching service and to please call the attending physician.
    3. While you are evaluating the patient ask the nurse to place a call to the attending physician.  Inform the physician of your findings and ask him what he wants to do.  Your responsibility is to stabilize the patient.  If the attending asks you to do more than that, politely tell him that you are unable to care for non-teaching cases unless it is an emergency.  You may leave when the patient is stable and the attending is aware of the circumstances.
    4. If an Internist calls you to evaluate a non-teaching patient and your own patient responsibilities allow for you to take time to do that, please evaluate the patient and call the attending with your findings.  You may leave the patient when that patient is stable.
    5.  If a non-internist calls you to evaluate a patient and the patient is not in your opinion critical, please ask them to call an internal medicine attending, politely explaining that you are not legally covered to do consults.  If the patient is critical, stabilize the patient and have the attending call an internist.
    6. Cover all METs.  Stay with the patient until he/she is stable.  Have the nurse call the attending physician immediately.
    7. Only a 2nd or 3rd year resident may evaluate a non-teaching service patient.
    8. Please write a complete note in the patient’s chart.

  3. Preventing Hospital Errors
    1. Be polite and considerate if and when your orders are questioned.  Do not discourage questions about your orders.
    2. Write legibly.  Print if your handwriting is difficult to read.
    3. Avoid abbreviations.  These can mean totally different things to different people
    4. Be very careful with orders on narcotics and cytotoxic drugs.
    5. Remember to adjust the dose of narcotics in elderly patients
    6. Be very careful when writing orders on order forms where many medications are listed; be sure your intended medication is written on the correct line.
    7. Avoid decimal points, e.g. 2.0 can easily be read as 20.
  4. The Teaching Service
    1. The majority of patients admitted to the Teaching Service have a private attending, and the private attending has the ultimate responsibility for and control over such patients.  However, by admitting to the Teaching Service the private attending agrees to allow the housestaff to manage the patient under his/her general supervision.

      Thus, the housestaff will play a role in all decisions about diagnosis and treatment; will write all the orders; will carry out the diagnostic work-up and treatment plan; will do the appropriate diagnostic and therapeutic procedures; will write the admission history, physical examination, progress notes and discharge summary; and will take care of the patient in all respects during the hospitalization.
      When on subsequent rotations, the house staff will perform in the same manner.

    2. Good communication between housestaff and attendings is the key to success of our program.  This will be markedly enhanced if the attendings will always call the housestaff directly and if the intern or resident will call the attending each day to discuss progress of the patient.
    3. Elective Admissions
      1. Attending physicians are encouraged to offer their patients to the Teaching Service, provided the attending physician believes the patient in question would be a good teaching case for housestaff.
      2. The attending physician should call the resident who is admitting on the day in question.  During this phone call, the attending physician should discuss the purpose of the admission, special dietary requirements, medication, lab work done recently that does not need to be repeated, etc.  If the patient needs to be seen immediately upon admission, the resident will be so notified.
      3. Attendings who admit to the Teaching Service are requested to do so on a regular basis, and not only for convenience late at night or on weekends
    4. The resident and/or intern should see the patient within one hour of admission in order to introduce himself/herself, write a diet order, and make sure the patient is not critically ill.
    5. On the day of admission, the resident will write a brief admit note and discuss the patient with his intern.  The intern will write and dictate the admission history and physical, and write admission orders.  In addition, he should call the private attending in order to discuss the patient's treatment plan (unless a different communication arrangement has been worked out between the resident and the attending).
    6. If the Patient is a Clinic Patient:
      1. The patient is seen in the Emergency Room by the ER resident or the admitting resident.
      2. The admitting resident assigns the patient to one of the interns if he/she requires admission.
      3. If, after examining the patient, the resident feels that admission is not indicated, the patient will be discharged from the Emergency Room with appropriate follow-up arrangements.  The resident should write a brief note in the clinic chart.
    7. Communication and Interaction Between Housestaff and Attendings
      1. When a resident accepts a patient on the Teaching Service he or she should do so with enthusiasm and thanks.  A negative attitude should not be conveyed to the attending by such remarks as "we have already admitted seven patients."  Such remarks create hostility with almost all attendings, and they serve no useful purpose.  The attending should not be given the impression that he must "sell" the patients to the teaching service.
      2. The intern should discuss the patient with the attending physician on a daily basis.  Progress notes should not be used for personal communications.
      3. Since close contact should be maintained between the housestaff and the admitting physician, the attending should only infrequently find it necessary to write orders on his patient.  The attending should do his/her best to always work through the housestaff.  If the attending does find it necessary to write significant orders, a progress note should be written to explain the reasoning behind the orders that were written
      4. Housestaff should always call the attending at night to discuss unexpected developments or complications
      5. Housestaff should not request formal consultation without approval from the attending.  It may be necessary to break this guideline in case of emergency.
      6. Consultants should work through the housestaff and allow housestaff to do or observe all procedures whenever possible.  Consultants should not write orders without discussing them with the housestaff.
      7. Attendings should discuss any changes in management plans with the housestaff.  All orders must be written by the residents.
      8. Attending physicians should inform his/her patients that they are to be admitted to the Teaching Service.  Patients who will not allow active housestaff participation in their care should not be admitted to the Teaching Service.
      9. Whenever and as often as possible, house officers should go into the patient's rooms with the attending as the latter discusses problems, results of tests, etc. with the patient.
      10. Patients should not be assigned to the Teaching Service simply by orders written on the order sheets.  The housestaff must be contacted and agree to accept the patient
      11. Success in our teaching program depends on a highly supportive relationship between attendings and residents.  Therefore, both housestaff and attendings should make every effort to avoid and prevent hostility, contentious disagreements, etc.  If such situations do arise, the residents should care for the patient first, and report the incident later if indicated.  Conflicts and disagreements between housestaff and attendings should never interfere with giving a patient the best possible care.
    8. Declining Admission to the Teaching Service
      1. The service is "full."  The resident should politely tell the attending that the service has had to be closed and ask him/her to admit to them another time.
      2. Inappropriate admissions generally fall into the following categories:
        1. Patient is being admitted primarily for social reasons.
        2. Patient is being admitted primarily for a diagnostic survey rather than for a specific symptom complex or problem.
        3. When some factor inherent to the patient's care prevents the housestaff from assuming responsibility for the patient.
          • Such factors might include a patient going for cardiothoracic surgery.
    9. Criteria for A "Full" Service
      The resident may decide to close the Teaching Service if and when one of the following criteria are met:
      1. If there have been five admissions per intern.
      2. The total census of the admitting services is greater than twenty patients.
      3. Multiple critically ill patients make it impossible to give good care to additional patients
    10. Physicians Who Should Not Admit Their Patients to the Teaching Service
      1. He/she does not adhere to the spirit and letter of these guidelines.  Physicians who repeatedly admit to teaching and do not follow these guidelines will have their teaching privileges revoked.
      2. He/she objects to the teaching attending seeing and examining the patient on teaching rounds.  Bedside teaching by the ward attending is an important and indispensable aspect of our program for housestaff.
    11. Discharge Summaries
      • Unless otherwise instructed by the attending physician, discharge summaries will be dictated by the intern.
    12. Signing Off a Teaching Case
      1. Residents should almost never sign off of a teaching case on one of the four regular teaching services.  Signing off may be disturbing to the patient and his/her family, and is not in the best interests of patient care.  The teaching service is committed to giving continuous care to anyone we accept on the regular teaching service.  To resign from a case, even if offered the option by an attending, is not acceptable.  This includes transition periods at the end of the month.  This policy precludes the housestaff signing off because "teaching value" is no longer present.  Such thinking makes patients an object for our benefit rather than demonstrating our commitment to continuing care. If it is, in spite of these guidelines, deemed necessary for the housestaff to sign off a case on one of the four regular teaching services, this should be discussed in advance with the Chairman of the Department of Internal Medicine
      2. It may become necessary to sign off of some cases admitted to CCU.  In such instances the resident should clearly notify the attending so that there is no uncertainty about whom is to write orders, etc.  In addition, it is permissible to sign off of a case when a patient is transferred to another service for a surgical procedure when the new service does not intend to let the medical housestaff play a significant role in patient care in the postoperative period.  Tact must be used in such cases to ensure a smooth transition and avoid having the patient feel abandoned.
     
 
MARK FELDMAN, M.D.
Chairman, Internal Medicine
Program Director, Internal Medicine
BRUCE BOUGENO
Vice President, Medical Staff Affairs