MDU-MDL

Med U/L General Medicine teaching services

Remember: It is a privilege and an honor to serve as an inpatient attending and it is a full-time job and should be prioritized over all other duties while on service. Be available 24/7 while on service. Be flexible and adaptable to the needs of the team on a daily basis. Prioritize patient care and education. Ensure residents can attend their conferences every day. History: Med U (MDU, Burnett Service) is one of three (U/L/W) General Medicine teaching services at UNC Medical Center. It is staffed solely by Division of Hospital Medicine faculty and has the unique privilege of Eric Allman, ACNP who works within the team structure. It is named in honor of Charles H. Burnett who came to Carolina in 1951 as the first chair of the Department of Medicine in the newly expanded four-year medical school. 8 bedtower is the geographic home unit for MDU. Med L (MDL) is our newest General Medicine service, started in 2018 as Med BEST (Bondurant-Ehringhaus Service for Teaching) at the Hillsborough Campus. The service was named honoring Dr. Stuart Bondurant, Dean of UNC SOM from 1979-1994, and his wife Susan Ehringhaus. The service moved to the Medical Center in 2020 during the COVID-19 pandemic. MDL is staffed by Division of Hospital Medicine faculty, alternating with the Chief Residents. 6 bedtower is the geographic home unit for MDL. Expectations and Responsibilities: Teaching is an expectation and one of our three core missions. We encourage use of clinical “pearls” and brief teaching points during daily bedside rounds AND 10-20 minute “white board” talks a minimum of 3x/week. Pearl/MDU: Eric Allman ACNP and Jen Barrow (pharmacist) offer many unique teaching topics and are tremendous resources. Pearl: Consider checking in with Attendings who rotate before and after you to coordinate teaching topics and avoid repetition.

Be clear about Expectations at the beginning of your rotation and as each new team member rotates onto the service. Provide a written list of your expectations and priorities. Feedback evaluations in Medhub (for residents) or One-45 (for medical students) for all team members is expected within 2-3 weeks. In order to ensure the opportunity to provide feedback to residents and students, you might need to specifically request a link from the residency program or student clerkship. Attendings receive anonymous evaluations once annually from the residency program. Consider asking residents and medical students specifically to complete their attending evaluations since many residents never complete them or include it as part of your expectations for the rotation. Feedback is a key educational tool. The DHM uses Feedback Fridays to meet individually with each team member to provide feedback and set goals. Pearl: New medical students, interns and residents often benefit from brief feedback earlier in the week.

Availability 24/7

Attendings should be available 24/7 while on service. The attendings should be signed into the team attending pager for the duration of time on service and be available by pager 24/7. Consider providing your personal/hospital cell phone to the team for rapid communication. MDL Attending pager: 123-2000 MDU Attending pager: 123-7097 The attending should always be available to the team and have active involvement with the team, patients and families. The attending should see every patient every day, independent of the team when necessary. Attendings must be available to see or staff patients in the ED or in other emergent situations, including overnight. Attendings remain available to the team for any questions, teaching and admissions throughout the day. Responsibilities to patients and the team take priority over other duties.

Rounding

Senior resident should “own” or lead rounds Bedside rounding should be the predominant format. Prioritize patients: unstable patients, new admissions/transfers, discharges, ED patients/boarders, stable patients Pearl: Sometimes the order in which you see patients may be impacted by lack of regionalization. Be flexible and encourage the resident to have a plan for seeing patients prior to starting rounds.

Attending communication

The outgoing attending initiates verbal or written “sign-out” to incoming attending and should be available for any follow-up questions or concerns. Attendings should be available to discuss patient/team issues or concerns with attendings from other services when necessary. Attendings must assign themselves as the “Attending Provider” in Epic on the first day of service and for all new patients. Attendings are expected to participate/promote projects involving the team while on service (such as organizational goals, QI projects etc)

Discharge considerations

Attending participation in discharge planning is critical. At time of discharge, the attending should ensure that accurate, problem-based discharge summaries have been completed, follow-up appointments scheduled within 14 days, and “warm handoffs” provided to outpatient providers. Pearl/MDU: Eric Allman ACNP often performs the patient discharges and “warm handoffs”, which is a great help to the interns.

Mobility: We still have rehab aides on 8bedtower. Strategies to be sure we are utilizing them to maximum benefit of patients: Make sure every patient has the most liberal appropriate activity order in place on admission. Early PT/OT orders if indicated. It is highly beneficial overall for the MD team to stress the importance of and set expectation for patient mobilization during hospitalization. Communicate this regularly to the patient and family.

Typical Schedule: Prior to rounds: Independently review new admission H&Ps and updates on current patients. Independently see patients that are scheduled for morning discharge. 7:45-8:30 am: Resident morning report on Mon, Wed, Fri DOM expects all attendings on service to attend resident morning report. Location: 133 MacNider 8:45 am - 10:45 am: Bedside Rounding Bedside Rounds on selection of patients, prioritizing unstable patients, new patients, discharges and patients who present good teaching opportunities. Rounding is a significant teaching opportunity for clinical pearls. Also, consider brief teaching on physical exam findings. Ideal for a team member to touch base with bedside nurse and CM/SW when rounding and before leaving each floor (when patients are not regionalized). Remember: Two hours is only 10 min per patient to see 12 patients and 15 min to see 8 patients. Pearl/MDU: Eric is an excellent resource for relaying pertinent information to bedside nurse and CM/SW when patients are not regionalized Pearl: Bedside rounding can be extremely efficient. Consider deferring more in-depth discussions with patients, families to the afternoon. 10:45 am – 11:00 am: Finish rounding (“table rounds”) “Table Round” on rest of patients not seen during Bedside Rounds. Pearl: Cover the patients for one intern first, then for the other intern, allowing uninterrupted work time for other intern. 11:00 am – 12:00 pm: Attending alone (or with Resident) rounds on patients not seen during rounds with team and in-depth assessments of specific patients. 12:00 pm - 1:15 pm: Resident noon conference It is expected that interns and residents attend noon conferences. Please complete rounds in a timely manner so they can attend. Grand Rounds on Thursdays (except summer months). Afternoons: Interdisciplinary or CAPP rounds with nursing, CM/SW. The time for these rounds often changes so check in with the resident or unit. If the resident cannot attend (or they are involved in patient care such as RRT), the attending should be available to attend. Teaching sessions for team. Check with medical students since they often have other lectures in the afternoon. Staff new admissions Help with patient and family meetings More in-depth assessments of any particular patients Coding and Documentation update with Specialist End of the day: Check-out with team Review patients with the team before departing for the day, especially new admissions, important clinical changes on patients, and plan for next day discharges

Resources

MDU APP: Eric Allman ACNP MDU Physician Service Line Leader: Christina Kahl MD MDU Resident Service Line Leader: TBD MDU Pharmacist: Jen Barrow 8BT Nurse Manager: Nikia Smith RN

Additional documents

DOM Expectations for Inpatient Attendings

Sample expectations document for MDU/MDL

Sample Teaching Topics for MDU

GI/hepatology (cirrhosis and complications, acute liver failure/injury) GI/luminal (GI bleeding, IBD) Palliative care, pain control, symptom management Malnutrition management Electrolytes and acid-base Sepsis management and antibiotics Alcohol withdrawal, complications of substance abuse and treatment Discharge planning and hospital system utilization