Inpatient US Clinical Experience in Internal Medicine in Orlando

Information about this clinical experience:

This is an inpatient experience during which you will be under the supervision of a board-certified internal medicine physician. The attending holds a hospital appointment within the AdventHealth Healthcare System. After completing residency training in New York, this physician has been practicing as a hospitalist for approximately 15 years. On a typical day, this preceptor sees 16-18 patients. 

Your day will be structured in the following manner:

Assignment of Patients (Ideally the Day Before)

Before leaving the hospital, you should ideally ask the preceptor which patients you will see on the following day. That night, we recommend you read in-depth about their diagnoses and medical conditions so that you can be ready for pre-rounds. We encourage you to follow these assigned patients all the way through to discharge. With this approach, you will see the entire trajectory of the disease and learn from the full evolution of the illness and its treatment. Your day-after-day involvement with these patients will help you build trust and rapport with the patient.

What are the objectives of your nightly reading?

• Develop a differential diagnosis for the chief complaint that brought the patient to the hospital.

• Understand how these diagnoses in the differential are made (i.e., history, exam, tests, etc.) and how they are differentiated from one another. Why was your patient diagnosed with a particular condition in the differential diagnosis? What made that diagnosis more likely and the others in the differential less likely?

• Dive deeper into the treatment plan. Why has the patient been treated or managed in a certain way? For example, if the patient is on furosemide, metoprolol, and lisinopril for treatment of heart failure exacerbation, why are these medications being used? If a certain antibiotic was chosen, why that antibiotic and not another one?

• Think about what you will do tomorrow based on three potential outcomes (patient is better, worse, or the same) for the patient’s diagnosis/condition. Anticipating possible outcomes will help you develop independent thinking and form stronger assessments and plans.

6:30 AM – 7 AM: Pre-rounds

You will pre-round on 1-2 assigned patients. During prerounds, you will learn how to gather relevant information needed to assess patients and establish the day’s plan of care. You will obtain this information from the nursing staff and from talking to the patient. Here’s an approach you can use to talk with the patient’s nurse:

Good morning [Nurse’s Name]. How are you today? My name is Elliott and I’m Dr. Smith’s student. We will be rounding soon so I just wanted to gather a little bit of information before I meet Dr. Smith. Have there been any concerns nursing has about our patient, Mr. Jones?

Listen carefully to what the nurse says, record the information, and ask follow-up questions. Ask the nurse about the patient’s vital signs, specifically if there’s been any fever, or low or high BP, HR, and RR. End by asking the nurse if there is anything else they would like you to communicate to your preceptor.

At the bedside, start with an open-ended question to inquire about how the patient is feeling. Specifically ask about any symptoms of interest. For example, if they are hospitalized for heart failure, inquire about shortness of breath, cough, chest pain, and leg swelling. The goal is to ascertain how these symptoms have changed from the prior day which will give you an idea of how effective the treatment has been and help you formulate the assessment and plan.

7 AM – 11 AM: Attending Rounds

After the pertinent data has been gathered during pre-rounds, you will meet with the preceptor to begin hospital rounds. As you move from one patient to another, you will have the opportunity to present your findings to the attending. Being able to organize and communicate relevant information to teammates will a crucial part of your role as a future resident; therefore, this will be excellent practice for what’s to come. Discussions during rounds will also provide a means for you to hone your skills in developing differential diagnoses, synthesizing data, and formulating assessments and plans.

After each patient interaction during rounds (your assigned patients as well as other patients on the service), write down key points, interesting cases, clinical pearls, and any questions that come to mind. This will help direct your reading later in the day and will maximize your learning.

As you round, be proactive about asking questions. It shows your preceptor your desire to learn. If you’re not sure why a particular condition is suspected, ask. If you’re not sure why a certain medication was chosen over other options, ask. Asking “why” questions will reinforce your understanding.

11 AM: Multidisciplinary Rounds

Following attending rounds, you will accompany the preceptor to multidisciplinary rounds. This is a meeting attended by your preceptor, case manager, and social worker. During these rounds, patients are discussed as a group. Barriers to patient care and discharge will be raised and addressed.

11:30 AM to 1 PM

During this period of the day, the preceptor will be working on completing the day’s tasks. What are some things you can do during this time? You can practice writing notes. You can take a piece of paper and write a progress note on one of the patients you are following and then share it with the preceptor for feedback. Although your note will not be used for the chart, this exercise will be valuable for your own growth in documentation.

You can also use the time to look up things. If a clinical question arose during rounds, see if you can find an answer to the question. Report to the preceptor what you find.

Please note that on four days of the rotation (Thursdays and Fridays) from 1 to 9 PM, you will accompany your preceptor to the Emergency Department where the preceptor will see patients during an 8-hour shift. Seeing how patients are initially evaluated and managed in the ED and then admitted to the medicine service will give you insight into the processes related to new patient admissions. Being on the frontlines of working up new patients will allow you to exercise your diagnostic reasoning and problem-solving skills.

During your experience, you will learn the following U.S. medical practices under the preceptor’s supervision:

• Taking patient histories.

• Presenting patients.

• Writing notes (please note that these will be simulated notes for the doctor's review and will not be part of the medical chart)

• Have opportunities to research the literature to answer clinical questions at the point of care.

• Working with other healthcare professionals to understand their roles and responsibilities.