Through the Looking Glass: Transitioning from Student to Practitioner

Abha Khandelwal MS, MDRush University Medical CenterDepartment of Cardiology

My Background• CWRU• Weatherhead• OSU• Rush Medical Center

• Location• Population Density• Hospital Density• Legal Density

Private vs. Academic• Established

relationship amongst practioners

• More variability in management strategies

• More ancillary services

• Established relationship between patient and pracitioner

• Less direct access of patients to Attendings.

• More standard management strategies

• More access to physicians with sub-specialized interests

• Conferences where complicated cases can be discussed in a multidiscplinary fashion.

• Allowance in time devoted to research and academic pursuits.

Abha’s 5 As

Attitude

Apply Appreciate

Acknowledge

Adapt

Success

So I start my first day…• Admit patients• Cross cover• Write orders • Communicate with RN• Write notes• Obtain medical records • Perform procedures • Run codes • Talk with families • Follow up on test results • Arrange Dispositions

Adaptability/Efficiency• At home:

• Schedule: Plan ahead• Outsource: When possible• Hobbies: Continue them

• At work:• Organizing Data

• H&P• Cross cover

• Sleeping• Eating

Be a Cheshire cat

Abha’s 5 As

Attitude

Apply Appreciate

Acknowledge

Adapt

Success

Who are you????

Patient Care Tech

Nurse

Pharmacy

Doctor

Primary physicia

n

Volunteers

Pharmacy

Specialists

Nurse

Nutrition

Social Work

PT/OT

Phlebotomy

Radiology

Transport

resident

intern

fellow

fellow

fellow

student

CNA

techs

Wound care

housekeepingRT

NP

Nutrition Delivery

Intern/Med Student• Accumulate data

• H&P• OSH

• Identify dangerous situations • Learn basic principles • To be a scapegoat

Life of an Intern

• AMI• SBO• DKA• Sepsis• GI bleed• ACLS/PALS

• BM• BS• Pain• BP• Nausea• Insomnia

Resident• Comprehend the clinical situation of the patient being

managed • Master procedural/Exam/diagnostic skills• Manage dispo and social issues for the patient• Teach the intern/medical students • Keep charge nurses informed

Attending• Manage the complex care teams that are involved

in managing a patient• Ensure patient safety• Ensure education for all levels of the team

Manage expectations• Set expectations at the start of month• Review progress in middle• Summarize at the end

Abha’s 5 As

Attitude

Apply Appreciate

Acknowledge

Adapt

Success

How do I fix this?

• A Give 80 meq of potassium• B Give insulin• C Do nothing this is normal• D Give hypertonic saline• E None of the above

124 100

2.6 13

29

1.0400

Apply

• Talk to colleagues who have done the rotation.• Use evidence based medicine to guide you

management decisions.• Websites:

• www.uptodate.com, www.asco.org, www.shfm.org, www.scutwork.com , www.nejm.org www.idsociety.org www.cardiologysite.com, www.acponline.org, http://www.medicalstudent.com/#Handheld , www.medscape.com/

CHF• Seattle heart failure model• Chads2• TIMI Risk calculator in STEMI/NSTEMI• Ekg guide

SHFM

http://depts.washington.edu/shfm/macosx.php

MICU• Understand

• Acid/base• PNA hospital score• Score for sepsis for Activated protien C• Ventilator extubation criteria• Electrolytes

Application• Rounds:

• Identify pertinent information• Learn to group things together

• (meds, labs, sx)• Synthesize a cohesive management plan based on

guidelines

• Procedures:• Know the indications and potential complications

• Research:• Case Reports • PubMed: gastric massage

Application• Heme/Onc:

• Neutropenic fever, transfusion thresholds, oncologic emergencies

• ID• Sanford, travel hx, antibiotic hx, immunizations

• Surgery• Ileus, nutrition, anatomy, bm, pain control

• Pediatrics• Milestones, congenital syndromes, embryology

• Renal• Electrolytes, urine sediment, nephrotic, vs nephritic.

Abha’s 5 As

Attitude

Apply Appreciate

Acknowledge

Adapt

Success

Patients are MAD

Attitude

In Summary

In Summary• Adapt: and be efficient• Acknowledge: and learn your role in the team• Appreciate: and be respectful to all members of

the team, understand their perspective• Apply: book knowledge into practical/clinical

knowledge• Attitude: Stay positive

Questions?