PacMed Clinics

Internal Medicine Resident Orientation Guide

Table of Contents

  • Section 1: Quick Reminders
  • Section 2: Basic Information
    • Resident Job Description
    • Schedule
    • Getting Help
    • Physician Work Areas
    • Charting
    • Mail Boxes
    • Voice Mail
  • Section 3: Expanded Information
    • Resident and MA Responsibilities
    • Test Result Reporting
    • Requesting a Study
    • Patient Panel-Building
    • How to Admit a Patient
    • How to Prepare E Cases
    • Chart Review
  • Appendix
    • Reference Information
      • Primary Care reference books
      • Patient resources
      • Useful medical websites
    • Palm pilot medical software resources
    • Introduction to IDX
    • Voicemail Directions
    • Useful PacMed Phone Numbers
      • King County Community Resources
    • Directions to Clinic
    • Dictation Guide
    • Billing Guide
    • Pocket Reference to documentation guidelines
    • Sample patient notification letter
    • USFHP formulary

Using the PacMed Resident Manual

SECTION 1-Quick Reminders: A quick run through of the daily clinic responsibilities. Review this list prior to each clinic session.

SECTION 2-Basic Information: Provides information essential to functioning effectively in your PacMed clinic.

SECTION 3-Expanded Information: Contains information on various tasks and responsibilities required of PacMed residents. It includes skills such as presenting, writing e-cases, chart review, billing, dictating and patient care and communication. In addition, it reviews patient panel building strategies. This is mostly unique to PacMed residents, and is an essential practice skill to develop in order to develop a patient panel.

Appendix: Contains reference information about medical resources and some of the nuts&bolts of clinic (voice mail, directions, dictation guide, billing, USFHP formulary, etc.)

PacMed Clinics: Brief Overview

PacMed was established in 1933 as the Seattle Marine Service Hospital, and later served as the regional Public Health referral center for the retired military, Native American and Seattle's immigrant communities. Today our clinic population remains culturally diverse. We are known for providing comprehensive multispecialty care to a complex and medically challenging adult patient population. Residents are paired with attending preceptors who are always available to help evaluate patients and assist in treatment decisions. Other attributes of our clinic site include an interpreter services program, co management with an inpatient hospitalist team, and realistic training in a mixed fee for service and managed care marketplace. Overall, PacMed facilitates clinical teaching within a "real world" practice allowing residents to focus on the practical application of skills in addition to traditional academic medical training in preparation for future careers in academic and community medicine.

PacMed Beacon Hill is the old Public Health Hospital. It now houses Family Medicine, Internal Medicine, Pediatrics, Physical Therapy and Behavioral Sciences (as well as Amazon.com). There is general radiology including mammograms and Dynacare lab draw and STAT lab service. Parking is free for residents with the appropriate pass.

PacMed 1101 Madison is connected to Swedish hospital via the sky bridge. In addition to Internal Medicine, it houses medical and surgical specialties, OB/GYN , a full lab, and diagnostic center. Free parking stickers are available from Sharelle Lindsay in the 3rd floor check-in desk (x1543). Also be sure to let the parking attendant know you are a resident – they will only charge you a maximum of $5 in stickers.

There are additional PacMed training sites at Northgate and Renton. They also have lab facilities and parking is free.

Section 1: Quick Reminders

Name Tag Please wear your nametag every clinic session as patients and staff will want to get to know you.
The week before clinic

Review the E-cases and attached articles. These are discussed with the attending of the day after clinic.

You may call your MA/nurse to review your schedule. However, please plan to come to clinic at your scheduled time and stay the full session as empty slots often fill the day of clinic.

Every clinic session Check in with your MA and attending of the day.
Review schedule with MA and determine if lab slips need to be printed or if recent studies should be located. (Review “Resident MA Responsibilities”)
Check with your nurse and ask if there are any patient issues.
Check your mailbox for lab results, correspondence and recently dictated notes.
Check your voice mail.
Seeing patients Present all patients to the attending.
Have the attending see complex patients (i.e. all Level 4 or 5 billings) with you. Attendings see all intern patients for the first 6 months.
Charting PacMed emphasizes brief dictations to minimize costs (transcription is expensive).
If the visit is simple (e.g. UTI, sinusitis), then write the note out in the chart, and type or dictate a brief assessment and plan.
If the visit is complicated, then type/dictate a more extended note as needed.

CC notes appropriately. Inter-physician communication is essential for good patient care.
Billing

Review all billing sheets with attending.
Include:

  • Attending name and IDX number if not properly printed out on the sheet already.
  • Visit level. (See “Billing Guide”)
  • Procedures performed and supplies used.
  • Mark diagnoses in order of importance (1, 2, 3 etc.).
Follow up Notify all patients of lab results with phone call or letter.
Talk with the attending of the day and your nurse to coordinate follow up of urgent or stat studies. Arrange patient follow up if they need to be seen before your next scheduled clinic.
Know your MA/nurse's phone number so you may check in periodically if there are pending patient issues.

 

Section 2: Basic Information

Resident Job Description

  • Enjoy clinic.
  • Treat your colleagues with respect.
  • Strive to learn.
  • Review e-cases before each clinic.
  • Check with your nurse at the beginning of clinic.
  • See your patients in a timely manner.
  • Give patients your card with the clinic phone numbers.
  • Document all clinic visits by writing, typing, or dictating; review and sign dictated notes.
  • Follow up on all your patients’ labs and studies.
  • Notify your patients of all test results.
  • Arrange for follow up if you are not available.
  • Leave pager on from 8:00 a.m. to 6:00 p.m. Monday through Friday.
  • Check your clinic schedule monthly.
  • Check your voice mail twice weekly.
  • Answer clinic pages within 30 minutes.
  • Notify your nurses of days off.
Your Schedule: Betty Lou Partridge, bettylp@pacmed.org, 621-4211 will have your schedule. It will be distributed to you via email in four three-month blocks. Always double-check your clinic and call schedule to be sure there are no conflicts. Contact Betty Lou with any schedule difficulties.

Clinic sessions begin at 1:30. If you will be late notify the clinic staff ASAP. Cancellation of clinic session requires approval of the Residency Office and Dr. Christopher Smith in advance. Same day cancellations are not permitted except under extraordinary conditions and must be approved by the attending of the day as well as Dr. Smith. Do not ask staff to cancel clinic sessions.

E-cases are generally discussed with the attending at the end of the clinic sessions or when residents have a break in their schedule. Plan to spend at least 10 to 15 minutes at the end of a session on the e-case. The discussion can be postponed on particularly busy days.

Getting Help in Clinic: The nurses’ station has the daily schedule that will tell you which MA (Medical Assistant) you are working with. They will in turn know who the attending of the day is. Ask you MA first for any help with patient care – see “MA duties.” You can also talk with your nurse for IV’s, dressing changes etc.

Physician Work Areas: Residents do not have a separate workroom or office. At Beacon Hill and 1101 workspace is available at desks at the back of the clinic. Valuables can be placed in the attending’s office if necessary. At 1101, residents can often use the desk of an attending who is absent that day.

Charting: PacMed relies on paper charting to control all patient data. Charts will be pulled for each patient prior to their visit. The IDX system (both DOS and web based) contains a lot of good patient data including notes, labs and radiology. The system is a bit cumbersome but can perform key tasks for managing patient information that will make clinic run more smoothly. (See introduction to IDX in appendix.)

Mail Boxes: Each resident has a mail slot in their respective clinic where all correspondence goes (including university mail when you are on clinic block). This includes labs, dictations and notes cc’d to you. Outgoing mail is available. MA’s can help address the standard patient lab letters.

Voice Mail: This is an important communication tool for the PacMed system. You can ask consultants questions, hear about your admitted patients and tell other providers about their patients when you see them. See appendix for directions on using voice mail. Residents once had voice mail boxes of their own, but they became redundant when we obtained voice mail connected with our pagers.

Section 3: Expanded Information

Resident and MA Responsibilities

You and your MA are a team. Together you efficiently organize the clinic session so patients are seen in a timely manner and any emergencies/problems are dealt with proficiently. Communicate early with your MA to plan your day.

It is standard procedure that an MA will call your patients on a day prior to clinic to remind them of their visit. In addition, patient charts will be prepared for you with up to date notes, radiology and lab reports. This will greatly streamline your visits and help address patient needs more completely. If this is not being done for you talk with your clinic attending.

Also, review your schedule with you MA prior to starting so he/she may start printing needed lab slips and tracking down studies. Having this info before a patient arrives will save much time.

When patents fail to keep their appointments, have the MA note that on the chart and a send a standard letter. You may send a personal letter or call them if you prefer.

MA’s can address the standard patient lab letters and send them out for you.

In addition to the above, MA’s update your schedule, room patients, record chief complaint and vital signs, give vaccinations and hemoccult cards, assist in checkout by making routine follow up appointments and other minor clinic procedures (e.g. EKG, oximetry, spirometry, audiometry, cerumen removal).

MA’s are often helping each other and other doctors as well as performing clinic maintenance duties such a restocking. Be aware of the demands you place on them.

Test Result Reporting

We have been working with representatives from Dynacare and SeaRad to improve the reporting of radiology and lab test results to residents. If you are having any problems with lab reporting talk to Dr. Chris Smith (505-1108) or your attending of the day in clinic.

In the past reporting was inconsistent and results have often only been sent to the supervising attending. It is essential that residents receive their own test results so that they can direct appropriate evaluations as they follow and treat patients when at PacMed. At the same time however, SeaRad and Dynacare require an attending-level billing provider for all tests ordered.

SeaRad and Dynacare have updated their provider lists to include PacMed-based primary care residents and their addresses. When ordering a test (lab or radiology), it is essential that the requisition form contain both the resident and supervising attending's names written in the appropriate places. This will ensure that test results will be sent to both the attending and residents.

Responsibility for responding to resident-ordered tests will be as follows:

If the tests are normal (or essentially normal) the attending can assume that it will be the resident's sole responsibility to notify the patient of the results.

If the results are meaningfully abnormal, the attending should check the resident's clinic schedule, and decide whether the results can wait until the resident is next in the office. The attending may choose to write comments or treatment suggestions on the report and leave it in the resident's box for his/her review (i.e., "consider stopping Lisinopril", "recheck in two months", "discuss with me").

In the infrequent instance when they can't wait for the resident's return to clinic, the supervising attending should ask the team RN to page the ordering resident to discuss an appropriate care plan. The RN/resident may also choose to secondarily review this plan with the responsible or covering attending. (Each team RN has a list of resident pager numbers and clinic schedules.)

We hope that this system will improve the educational experience for our residents and also clarify test-reporting responsibilities. Please reach Christopher Smith or the PacMed Ambulatory Chief Resident by phone, email or voice mail with any questions or comments.

Requesting a Study

All common blood work is ordered on the lab request form printed up by your MA and performed by Dynacare Labs. Each test requested requires an ICD-9 code. The common ones are posted around the clinic; there is a thick ICD9 book at each MA station as well. Be sure to put the attending name and IDX number as well as your name and IDX number in the resident line. This way the attending will know to place the lab result in your box if Dynacare fails to send you a copy. You can call Dynacare directly for results and you can request additional lab tests (if they have the appropriate sample) on their automated phone line. You will need patient name and SS#. (Dynacare Labs 386-2672).

General radiology including mammograms can be obtained at Beacon Hill. 1101 Madison has full radiology capabilities.

  • The white Radiology request form is used for:
    • General Radiology, CT, MRI, ultrasound, duplex studies and nuclear medicine.
  • The white Consult form is used for:
    • Consults / referrals
    • Physical Therapy
    • DEXA Scans
    • Echo
    • Cardiac Stress tests
    • PFTs
  • Separate forms (ask your MA) used for:
    • Holter monitoring

Each clinic keeps a general radiology file but films are read off site. The final reads come through your mailbox (be sure to write your name on the “additional copy” box on the request form) or can be found on IDX after some time. If the final read is not on IDX when your patient comes to follow up, ask your MA to track it down.

For stat or urgent studies, indicate on the form that you want to be called with the results. If you want the patient to return to the clinic with the film, specify that; and write “wet read with jacket” if applicable. If this does not happen, then you should call the department and get the result yourself. In some cases results are available on the Swedish dictation line. (See appendix). Be sure to have a plan in place with the attending of the day before the end of clinic that accounts for all possible results

How to Admit a Patient from Clinic

Occasionally a patient will need to be admitted from clinic. Your nurse will help arrange transportation with family, cab or ambulance. 911 will be called for all emergencies.

The patient will be admitted to Swedish or Providence hospital depending on patient and attending preference. If the patient requires ER evaluation, call the triage nurse or attending at the corresponding hospital (your nurse can get them on the line for you) and give the history.

For direct admissions have your nurse help you call the admitting PacMed hospitalist for Swedish admissions or call the admitting house staff at Providence.

If your patients are admitted, we encourage the attending to notify you. You may feel free to visit either your patient or patients you admit in the hospital and assist with their care where appropriate.

The clinic has 24/7 consulting nurse and on call attending. Notify potentially ill patients this exists and encourage them to call the main clinic office Beacon Hill or 1101 Madison after hours if they have any urgent health needs.

Patient Panel-Building Strategies For PacMed Residents (Drafted by Karen Hibbert CR 1999)

Background

Building a patient panel in continuity clinic has seemingly become more difficult in recent years. The reasons are myriad and include changes in clinic location and clientele, changes in the resident/attending mix, insurance plans requiring an attending PCP (primary care provider), computerized patient information system, and possibly changes in the “corporate culture” towards the educational mission of the organization, to name a few. This review is a composite of ideas elicited from residents, attendings, and support staff. It is our hope that by employing these strategies residents will have more success in panel-building, leading to more learning satisfaction in one of the best ambulatory teaching settings in the UW residency training program.

Recruitment

New/same day/walk-in patients: Briefly review health care maintenance issues in chart before you see patient. Is there a reason to suggest the patient follow-up and/or establish care with you? Offer to see this patient for follow-up of the current acute issue or if new issues arise.

When seeing another provider’s patient for an acute issues or PE, give the patient the option of following-up with you regarding the acute issue(s) you have identified. Review problem list/health care maintenance issues and offer to see them back if other issues are identified. Read the attending-PCP’s last note for plans such as “recheck cholesterol/TSH/hemoglobin A1C in 3 months.” If appropriate, order the test and ask the patient to follow-up with you to discuss the results.

On inpatient wards, recruit patients without a regular primary care provider to your clinic. PacMed accepts most insurance plans, including DSHS. Patients on some health plans will need to notify their plan of a change in choice of clinic/PCP.

Get to know the attendings in your clinic and ask them to send interesting/challenging patients your way. Sending patients to you for a PE visit is one way to provide you more time with them at the first visit.

Developing and Maintaining The Doctor-Patient Relationship

Schedule newer patients for more frequent follow-up to address multiple issues identified and to continue building your relationship/gathering information: “I will need to see you more frequently at first, while we adjust the dose of your high blood pressure medication.”

Share your agenda for addressing issues identified by you and patient in subsequent visits: “At our next visit I’d like to discuss diabetic foot care and examine your feet.”

When seeing another provider’s patient, always send a copy of your dictated note to them.

Utilizing System-Wide Supports

Identify yourself as the PCP for the patient on the follow-up appt. slip that the patient takes to the front desk at the end of each visit. This will be added to the patient information computer screen, which is accessed each time a patient calls, or visits. If it works correctly, you will be apprised of issues that arise when you are not in clinic.

Call patients at home or ask your clinic RN’s to do telephone follow-up with patients between visits. Examples: How is patient tolerating new medication; blood glucose’s on new dose of insulin; smoking cessation call 1-2 days after quit date; patient with emotional/coping issues at home; patient failed to keep appointment.

Send a copy of lab results with a personal note written on it to your patient: “Hemoglobin A1-C improved. Stay on same dose of Metformin and see me in one month.”

Get to know the PSR’s (patient service representatives) at the front desk of your clinic area. These are the folks that make the appointments and talk you up to new patients. The more they know about you, the better they can inform the callers/patients.

Know your own clinic schedule and try to arrange follow-up for patients based on this.

View your fellow clinic residents as your “partners” and see each other’s patients as much as possible when they cannot be seen by their resident-PCP.

Systems glitches, frustrations, struggle? Call Christopher Smith, MD, 505-1108, or your friendly PacMed ambulatory chief resident.

Attending Strategies

Discuss with patients the advantages of having a resident-PCP: 2 MD’s per visit, more appt. availability, up-to-date University training, still followed by attending-PCP, more time available per visit, etc.

Give “permission”/encourage your established patients who are good learning cases (diabetics, multiple medical problems, geriatrics) to be followed for a time by a resident.

Utilizing “bedside” teaching allows the patient to see both providers together.

Informal chart review encourages collaboration of attending and resident providers to plan ongoing care for their mutual primary care patients.

There is a handout that all patients should read over when they are seeing a resident. Review it yourself and offer new patients a copy if they have not seen it yet.

To Patients Seeing A Resident Physician

  1. What are resident physicians?
    Residents are physicians who have completed four years of medical school and at our clinic are in training to become specialists in internal medicine.
  2. Why are they at PacMed?
    PacMed Clinics has had an academic affiliation with The University of Washington for four decades. PacMed physicians enjoy the opportunity to teach doctors in training because it stimulates their own learning and is professionally satisfying. The residents choose to come to PacMed because of the quality of the educational experience.
  3. How are they different from other doctors at PacMed?
    Resident physicians train in a variety of settings. They generally spend one-half to one day per week taking care of patients in their primary care clinic here at PacMed. The rest of the week they work at different hospitals and clinics throughout Seattle. Staff doctors at each of their training sites supervise them.
  4. What are the benefits of seeing a resident physician?
    Residents generally have longer appointment times and thus have more time to spend with their patients. Since residents review their patients with supervising senior doctors, more than one doctor will be thinking about and considering your medical problems.
  5. Will a staff physician see me?
    Resident physicians review your medical problems with a senior physician at each visit. You may or may not also be seen by a staff physician, depending on your medical issue.
  6. Is it possible to have a resident physician as my Primary Care Physician (PCP)?
    Yes, you may select a resident as your PCP, even though most insurance companies require that you also choose a physician from the senior PacMed staff as your PCP of record. You will be cared for primarily by your resident physician, and the senior staff physician will share responsibility for your care. For insurance billing purposes, the senior staff physician's name may also appear on paperwork.

Please tell a front desk checkout receptionist if you would like to choose (or already have chosen) a resident as your regular PCP.

 

How to Prepare an E-case

Review the topics list and select one based upon your interests and recent cases you have seen. It helps to have a patient in mind. Review that patient's chart and draft a BRIEF case scenario from the office notes, providing just enough information to present the key issues. Come up with a few questions that serve to challenge the reader and indicate the important teaching points.

Locate a journal article or other illustrative reference relevant to your case and topic. Please note that the Swedish librarian (Cheryl Goodwin) has agreed to help with our searches. Call or email her (386-6469; cheryl.goodwin@swedish.org.) You do not need to distribute copies of the article yourself.

You may choose to provide a brief discussion of two or three teaching points that you feel should be emphasized and are worth remembering.

If you can type, email your case, questions, reference and discussion to christophers@pacmed.org at least two weeks before your presentation date. If you can't, send your case to Christopher Smith at 1101 Madison via office mail.
Each week's E-case will be available for review in your email account on the previous Thursday.

Residents’ Chart Review

(chart review is for primary care residents who are on clinic block, at 11am Wednesdays)

Introduction

Chart review is an educational tool with much potential: it helps residents recognize complex and often hidden primary care issues; it provides exposure to different perspectives of care; it facilitates one’s ability to receive constructive criticism; and in my experience it benefits patient care. It is a fun, relaxed time when residents and attendings can interact.

However, there are barriers to achieving this potential. Sometimes residents feel they are being criticized without the benefit of receiving education. Attendings may feel that their effort is wasted on disinterested residents. This guide makes several proposals and aims to ensure that successful chart review continues.

Goals

Chart review is designed to give residents the opportunity to discuss patient care issues outside of the time-limited clinic setting. It allows residents to discuss these issues with the assistance of an experienced attending. Overall the goal is for this to be a positive experience for attending and resident(s). This year, we would like to incorporate more evidenced-based journal review when the attending and residents arrange it.

Format

After some discussion, trial and error, the following format for chart review is proposed. If only 1 PacMed resident is scheduled for clinic block/chart review that month, the resident can instead elect to go to the Roosevelt chart review. Otherwise, each PacMed attending is scheduled for two consecutive chart reviews. At the start of the first session resident(s) and attending can briefly discuss an agenda for the two sessions that reflects the attending’s experience and teaching style as well as the residents’ immediate educational goals. Addressing the needs of all present is an essential part of successful chart review.

Attendings generally review charts prior to the session and pick interesting and relevant issues that are exposed upon close inspection of the residents’ notes as well as other chart data. The attending can then ask the resident to briefly present the patient and a discussion can ensue about the issue raised. Residents can also propose questions to the group for help with any additional issues.

Residents can sometime be turned off by the perception of direct criticism. Therefore, attendings should be aware of the context of the visit (time limitations, other attending direction, etc) and seek to provide supportive advice. In turn, residents can be aware that attending opinion and suggestions, which are based on years of clinical experience, are an important part of medical education. Maintaining this perspective can help create a positive learning experience.

If an important issue, question or topic is raised at the first session, the resident and attending may elect to discuss it further at the next review. In that case any of the participants can return prepared for a brief discussion with or without an article. In addition, at the end of the first session goals for the next one can be set to ensure the residents are guiding their educational experience. No one wants to waste time. Keeping communication open between residents and attendings can help create a positive, worthwhile learning/teaching experience.

Attendings/residents may choose to use one of these chart reviews for a journal club-type review of one or more articles. Here are a few websites to help you get acquainted/refresh yourself on the techniques of evidenced-based medicine.

http://www.cche.net/usersguides/main.asp

http://healthlinks.washington.edu/clinical/ebpliterature.html

http://bmj.com/collections/read.shtml