Internal Medicine Resident Orientation Guide
Table of Contents
- Section 1: Quick Reminders
- Section 2: Basic Information
- Resident Job Description
- Getting Help
- Physician Work Areas
- 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
- 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
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.
reference information about medical resources and some of the nuts&bolts
of clinic (voice mail, directions, dictation guide, billing, USFHP formulary,
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
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
There are additional PacMed training sites at Northgate
and Renton. They also have lab facilities and parking is free.
Section 1: Quick Reminders
||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
Check with your nurse and ask if there are any patient issues.
Check your mailbox for lab results, correspondence and recently dictated
Check your voice mail.
||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.
||PacMed emphasizes brief dictations to minimize costs (transcription
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
CC notes appropriately.
Inter-physician communication is essential for good patient
Review all billing sheets with attending.
- 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.).
||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
- Check your clinic schedule monthly.
- Check your voice mail twice weekly.
- Answer clinic pages within 30 minutes.
- Notify your nurses of days off.
Betty Lou Partridge, firstname.lastname@example.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.
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.
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.
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.)
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.
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,
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
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
- The white Consult form is used for:
- Consults / referrals
- Physical Therapy
- DEXA Scans
- Cardiac Stress tests
- Separate forms (ask your MA) used for:
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)
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.
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
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
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.
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
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.
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
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
- 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.
- 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.
- 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.
- 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.
- Will a staff physician see
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.
- 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
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
If you can type, email your case, questions, reference
and discussion to email@example.com
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.
(chart review is for primary care residents who are on clinic block, at
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.
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
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
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.