School of Medicine Wards Guidebook For the Class of 2020
Courtesy of Tulane Owl Club 2017‐18
Table of Contents
Overview of Medical Team 3
A Typical Day in the Hospital 4
How to Write an H&P 7
How to Write a SOAP Note 10
Presenting a Patient 11
Hospital Locations 13
Hospital Computer Programs 14
General Resources/FAQs 15
Clerkship‐Specific Information 18
Family Medicine 19
Internal Medicine 21
Neurology 25
Ob‐Gyn 27
Pediatrics 30
Psychiatry 35
Surgery 40
Electives 44
Overview of Medical Team
The hospital team consists of several members, including:
The Attending: This is the physician who is leading the medical team. He/she has completed residency (and fellowship, if they chose to specialize). He/she makes all final decisions about patient care and oversees the rest of the team.
The Fellow: This is a physician who has completed residency and is now training in a sub‐specialty (Ex: Cardiology, Stroke)
The Resident: This is a physician who has completed medical school and the first year of residency and is now training in a specialty.
The Intern: This is a physician who has completed medical school and is in his/her first year of residency training in a specialty (also known as PGY‐1 ‐ Post‐graduate year 1).
Ancillary Staff: This includes the nursing staff, social workers, psychologists, physical therapists, occupational therapists, respiratory therapists, and anyone else involved in patient care. These people are crucial members of the team and have the power to make your and your team’s lives very easy or very difficult.
The Sub‐I: This is a 4th year medical student who has (usually) chosen the specialty in which they are the Sub‐I. “Sub‐I” stands for “Sub‐Intern,” and this student is doing exactly that—acting as an intern before they become a real intern the next year. They are being evaluated for their ability to do intern‐level work.
The 3rd Year: That’s you!
YOUR JOB AS A 3RD YEAR MEDICAL STUDENT:
Make your best attempt to contribute to your patient’s plan of care. This includes seeing your assigned patient(s) each day, knowing what is going on in their hospital course, and writing H&P’s and SOAP notes about them as requested by the team. While in the hospital, your job is to ensure sure that anything that needs to be done is done. This often includes “scut work,” or little tasks that need to get done but don’t necessarily fall under anyone else’s job description, such as faxing paperwork, dropping orders, calling the pharmacy, calling the consulting physicians/teams, and communicating with nurses and other ancillary staff. If you can do all these seemingly small tasks, your team (and especially the interns’) lives will be made a great deal easier. This is the main role of the 3rd year medical student on the team: to know what your patients need in order to advance their treatment on a given day, and to help get these tasks done. Focus on doing this for patients under your care; only help with other students’ patient on a needed basis, and always inform the student who is caring for that patient before doing so!
While not in the hospital, read up on your patients by using either UpToDate or another resource. Also keep up with studying for the Shelf Exam that is at the end of every rotation, as the Shelf Exam is usually a significant portion of your grade. From time to time, an opportunity will come about (usually after a discussion on rounds) that will lead to an opportunity to look up a topic and present this to the team. Mention this to your residents and fellow students in advance (i.e. day before) so that they know it is coming and can prepare accordingly.
A TYPICAL DAY IN THE HOSPITAL
This will vary depending on what rotation you are on, especially what time you are expected to arrive at the hospital and how long of a work day you will have. However, the general schedule for the day will be some variation of the following:
1. Coordinate with your fellow 3rd years to arrive at the hospital well in advance of the time your residents expect you to round. This time will usually be discussed the day before so that students will know when to be prepared. The specific time to show up will vary depending on service and number of patients you need to see (for example, Internal Medicine and Psychiatry require more time per patient in the mornings; surgical subspecialties less so).
2. Look up your assigned patients (usually 1‐3) on the computer medical record system (which varies by hospital). Write down 24 hour ranges for vitals, recent labs (including trends from previous day if it is core to the patient’s treatment plan), Ins/outs (fluid intake and outputs, as tabulated by nursing) for surgical subspecialties, and updates on their progress in the hospital (see next few pages for how to write a proper note). Read all notes from consulted teams and other interdisciplinary teams (nursing, physical therapy) as relevant. If something has happened since the last time this patient was presented to an attending, you should know about it.
3. Print the team’s list (usually coordinate with team to ensure everyone has one). If you arrive first, print enough for your fellow students. This is the list of all of the patients that your attending is assigned to, and for some services, you are the one expected to keep it up to date (residents will tell you this if so). Work with your team to ensure that patients are accounted for, and that all patients that are being followed are on the list. Most students use the list to write down what the tasks are for each patient, even if he/she is not “your patient” as this will be useful when updating the list for the signout team at the end of the day. Secondly, knowing the tasks that will need to be completed will make your
residents’ lives easier. Attempt to write tasks that are discussed on rounds, and confirm with fellow students that they are aware of what their patient needs. DON’T simply do the tasks without consulting the student in charge of the patient ‐ this is a CLASSIC gunner move and will not be appreciated.
4. Go see your patients. Ask them how they are doing, if anything happened overnight that bothered them. For various specialties, there are specific questions that will need to be asked ‐ please look on in this document for these specifics for each rotation. Once this is done, complete a focused physical exam (i.e. CV, Pulm, Abdominal and anything else as pertaining to your patient’s issues if you’re on Neuro, you know what you have to do). You may also want to ask your patient’s nurse for any overnight updates.
5. Once you are done seeing your patients, some specialties will expect you to write up a proper progress note on the patient, i.e. a SOAP note (more on this on the following pages).
6. Present the patient to the intern in charge of the patient’s care (more about presentations on the following pages) at an appropriate time. Ask them if it is a good time to discuss a patient prior to doing so ‐ they are very busy prior to rounds and you don’t want to get in their way. They will make time for you if they are competent ‐ don’t be pushy if they seem frazzled. It is ultimately your upper‐ level’s job to make sure med students are ready to present to the attending.
7. Present the patient to your upper‐level resident, if appropriate. This will be during pre‐ rounds, with no attending around. The timing of this and thoroughness of the presentation will vary by specialty, so it is ok to ask how they like to do things.
8. Present the patient to your attending during rounds. Rounds might take place as “table rounds,” which means that you all sit around a table and discuss each patient individually before going to see the patients, or as “walking rounds,” which means that you all walk around the hospital and stop at each patient’s room, and present each patient before walking into his/her room.
9. After rounds, your intern and/or residents will “run the list”, which will tell you what work needs to be done. This may include making appointments for your patient, requesting medical records and sending faxes, making phone calls, and writing discharge summaries. Be willing to help out and take notes on all tasks for your patient; even if the tasks seem small, getting those things done is a great help to your interns and residents. Make sure you let them know before embarking on a task, so you’re not doubling up on something they already plan to do. Sometimes, they will be happy to let you do it; other times, they may re‐direct you to a more pertinent task. Always double‐check if you’re unsure.
10. Update the list (this is the same list mentioned above) in advance of sign‐out at the end of the day. The night team will use this list to know what to look out for overnight, so this is a very important task. In some specialties, it is too important to be left up to students, but you will be able to update at least parts of it (med changes, new labs, etc. . Each student should update his/her patients on the list as determined by your residents. Each upper level likes the list to have more or less detail, so check what to put on/delete first. Before leaving for the day, always make sure the list is updated.
HOW TO WRITE AN H&P
The History & Physical (H&P) is a comprehensive note that gets written about each patient the first time that the patient is seen and admitted to the hospital.
***Here’s a great template: http://www.medfools.com/downloads/H_P_medicine.pdf***
Chief Complaint (CC): The main problem for which the patient is in the hospital and length of symptoms i.e. “shortness of breath for 3 days”. If post‐op should be in the form of, “post‐op day 3 after inguinal hernia repair”
History of Present Illness (HPI): Consists of 2 paragraphs. 1st paragraph is a brief history of what led the patient to coming into the hospital and a description of the problem, i.e. FAR COLDER. Tell it like a story and write events in chronological order to keep the sequence of events clear. If they are here for an operation, give a background of previous history that led to this. The 1st paragraph should focus on the chief complaint, and give the listener an idea of the patient’s progression of symptoms (as relevant)
The 2nd paragraph is a Review of Systems (ROS), i.e. the relevant positive and negative findings that the patient tells you about after you ask them questions about their symptoms beyond FAR COLDER (i.e. was there any fever/chills, nausea/vomiting, diarrhea, pain after eating, etc.). This paragraph is where you will show attendings your medical reasoning ‐ i.e. what symptoms/signs you attempted to rule in/out to help clarify the differential diagnosis. If someone has shortness of breath, you should clarify the source as cardiac vs. pulmonary, for example, based on the questions you ask. This is where you can shine!
Past Medical History (PMH): List all medical problems and diagnoses.
Past Surgical History (PSH): List relevant past surgeries. For example, if they had an orthopaedic surgery, write it down in your note but don’t present it automatically if it is not relevant to the Chief complaint.
Family History (FH): Include any relevant family history, especially parents, siblings, and grandparents. This will very by specialty (Ex: IM‐ Ask about diabetes, HTN, heart disease, etc. In OB‐ ask about cancer history related to the female organ systems)
Social History (SH): Remember to transition appropriately before asking these questions! Smoking/Alcohol/Drug use are always important to ask. Ask about living situation, particularly if you are concerned about this, as it relates to discharge (esp. In IM/Psych). You may ask about profession if relevant. In Peds, this will include questions about smokers in house, etc., so be aware of what is appropriate for each field.
Medications: List any medications the patient is taking at home and in the hospital.
Allergies: List any allergies the patient has and what happens when they come into contact with that allergen (i.e. if they say they have a penicillin allergy, clarify if it is a rash vs. anaphylaxis).
Review of Systems (ROS): This will vary by specialty, but it will be be most important in non‐surgical specialties to be thorough with this. In written notes, you will likely need to list 10‐12 systems, and +/‐ for the relevant questions (see example below). In presentations, you can often simply say “10‐point review of systems negative other than as stated in HPI). You will see residents write this in their notes, but this is usually not OK for students to do, as they want to see what you have asked.
Physical Exam (PE):
Always list vital signs first: Temperature (T), Pulse (P), Blood Pressure (BP), Respiratory Rate (RR), O2 sat (include if this is on Room Air or if they are on Oxygen ‐ and what amount of oxygen if so)
General: Is the patient well‐appearing or uncomfortable? Are they in any acute distress? (Ex: Patient resting comfortably in bed, in no acute distress) HEENT: Are extraocular movements intact? Pupils equally round and reactive to light (PERRL/A)? Any pharyngeal exudates? Are airways clear? Do not report if you haven’t checked it. Neck: Is neck supple to palpation? Any cervical lymphadenopathy? Any thyromegaly? Any jugular venous distention? What needs to be checked will vary significantly by specialty. CV: Regular rate and rhythm? Any murmurs, rubs, gallops? Normal S1/S2. Check extremities for pulses and report findings here if relevant to CC (i.e. vascular issue in legs would require this). Lungs: Normal lung sounds bilaterally? Any wheezes, crackles appreciated (if so, note if basilar, unilateral vs throughout, etc.) Abdomen: Soft? Tender? Distended? Are bowel sounds present/loud/muted? Any signs of ascites/organomegaly?
Genitourinary (GU): This is mainly relevant in Ob‐Gyn and Urologic CC’s. Includes pelvic exam (if performed). Include whether the external genitalia are normal appearing, if there is any discharge, erythema, adnexal tenderness, other findings as relevant. Urinary: (only if relevant to CC): Any costovertebral angle tenderness?
Extremities: Is there normal range of motion in the extremities? Any edema? Neuro: Are cranial nerves 2‐12 grossly intact? Any focal neurological deficits? If CC may be related to neurological concern, complete appropriate neurologic exam (Be thorough ‐ coordination, gait, etc.) Psych: Include complete Mental Status Exam here if on Psychiatry rotation. Otherwise: Alert and oriented to person, place, time? Appropriate affect/reasoning?
Labs: Write these in “stick‐figure format.” This looks confusing at first, but you’ll get used to it pretty quickly.
Also include any relevant imaging or test results (i.e. HIV/Biofire/Pathology results) in this section.
Assessment: Example: Ms. Smith is a 60 year‐old woman with a past medical history of [relevant medical issues] who presents today for [chief complaint]. This is the opportunity for you to demonstrate your clinical reasoning and work through your differential diagnoses. For example, if someone comes in with shortness of breath, you’d say your top differential diagnoses (usually in order of likelihood) and explain relevant evidence for or against (usually HPI paragraph 2 questions/labs/imaging) each possible
etiology. Mastering this portion of the history (both oral and written) is the key to 3rd year. Try to think of a broad range of diagnoses and narrow down as appropriate, as residents and attending will want to see your thinking process.
Example: CHF exacerbation vs. Pulmonary Embolism vs. Pneumonia
CHF exacerbation is most likely etiology of SOB. Patient’s history is significant for PMH of CHF, SOB upon climbing one flight of stairs, sleeping requiring propping of 4 pillows behind head, and onset of symptoms after a fatty meal. Physical exam findings in support of diagnosis include 3+ pitting edema up to her knees and bilateral basilar crackles on lung auscultation. CXR is indicative of cardiomegaly and bilateral pleural effusions.
Pulmonary Embolism is possible due to patient’s history of DVTs and sudden‐onset SOB. There is no supportive physical exam findings for this diagnosis, as patient exhibits no pain with inhalation or signs of DVT at this time. CXR also does not support PE.
Pneumonia is possible….and unlikely because of….
Plan: List each problem that the patient has (with issues that are keeping them in the hospital/most problematic at the top) and then write treatment plans for each. Write prophylactic measures/diet after the problem list, and include plan for discharge (labeled Dispo ‐ short for Disposition)
Example: 1. Shortness of Breath
‐Obtain CXR
‐Administer 2.5 mg Lasix bid
2. Diabetes Mellitus Type 2
‐Start Insulin sliding scale
‐Accuchecks q4h
3. Diet—Continue regular diet.
4. Hypomagnesemia
‐Replete as needed.
Diet: Diabetic Diet Prophylaxis: SCDs, Lovenox Dispo: Patient will be discharged with follow‐up upon alleviation of symptoms.
HOW TO WRITE A SOAP NOTE
A SOAP note is a progress note. You write these every day after the patient’s initial admission to the hospital. SOAP stands for the order in which to present findings, as seen below.
Subjective (S): Report acute events overnight (if none, write “no acute events overnight”). This is “subjective”, so this will generally be in the words of the patient. Depending on service, you may want to report fevers/sustained abnormal vital signs/issues overnight as reported by nursing here. Basically, ask the patient and nurses what happened overnight and document it here. Make sure to only include what has been TOLD to you—what the patient or nurse says; this is not analysis or any objective information that you pick up. That should be kept for the physical exam or assessment portion of the presentation.
Objective (O):
Physical Exam: See above in H&P for details.
Labs: Write CBC and BMP in “stick‐figure format.” You will want to report them in the same order that the residents/attendings are used to. This is generally WBC‐Hgb/Hct‐Platelets. For BMP, Na‐K‐Cl‐Bicarb‐BUN‐Crt‐Glucose. For SOAPs, trending critical values is important. If patient has high WBC count or is anemic, note what it was the day before. If their BUN/Crt are elevated, note changes. If patient is diabetic, include 24 hour range of accuchecks for glucose as opposed to single BMP reading.
Also include any relevant and updated imaging or test results in this section.
Assessment and Plan: Abbreviated form of H&P assessment and plan. You’ll want to summarize how the patient is responding to treatment here. This will give an overview of the treatment’s progression and barriers to discharge. May warrant discussion of differential diagnoses if this is still being examined, but will often be more simple than H&P.
Example: Ms. Smith is a 60 y/o woman on hospital day 2 for management of acute heart failure exacerbation. She is progressing well on current treatment plan, and reports alleviation of symptoms overnight. Physical exam indicates 2+ edema up to mid‐shin level, an improvement from yesterday. Light crackles are audible bilaterally, also improved from yesterday. Additionally, BUN/Crt levels are back to baseline.
List Plan, as in H&P, with current status (i.e. Resolved, unresolved) and explain any relevant labs/issues for each. List any changes in medication levels or new pharmacological treatments here.
Example: Acute Kidney Injury ‐ Resolved
Patient’s BUN/Crt are 10/0.9 today, down from 26/1.5 yesterday. Will continue to monitor for changes with BMP tomorrow
PRESENTING A PATIENT
Use your written note to guide your presentation. Attempt to not read straight off your note, although you can reference it as needed. You are communicating important information; so try to tell a story about your patient if giving an H&P, but make sure you get the details right. You will need to be more thorough for an H&P than a SOAP note, but always follow the structure/order of the presentation outline, as this will allow people to follow along more easily.
A sample presentation might go something like this:
What you say during the presentation (example) Part of note you are referencing Ms. Smith is a 70 year‐old woman with a past medical history of CHF, DM, HTN CC, HPI, ROS and CAD who presents today with shortness of breath for the past 3 days. Her symptoms have been worsening over this time, and she can no longer ambulate up a flight of steps without having to rest. She reports that she has had symptoms like this a handful of times over the past year, but has never previously been admitted to the hospital for these issues in the past. She reports that the shortness of breath is exacerbated by ambulation and from laying down horizontally in bed. She usually props up 4 pillows behind her head to sleep comfortably. She has noticed worsening swelling in her hands and feet, and no longer is able to fit into her shoes. Her symptoms are relieved by sitting up and by resting for a few minutes after movement.
She denies any chest pain, cough, pain on inspiration, subjective fever or chills, or pain with movement of extremities at this time.
Her past medical history includes CHF, DM, HTN and CAD PMH Her past surgical history includes {list here}. When presenting, report only PSH PSH relevant to CC (ex: don’t include toe surgery in a case like this). Her past family history includes [list FH]. In this case, heart disease under the FH age of 50 in parents/siblings would be extremely relevant to report. She is a current PPD smoker with a 25 pack‐year history. She only drinks on SH holidays, and has never used drugs. She lives at home with her daughter, and is retired. Her home medications include [Medications]. Medications Report any allergies and reactions (ex: Penicillin ‐ Hives). If none, write/report Allergies No Known Drug Allergies (abbreviated as NDKA). Report: Review of Systems was negative other than as stated in HPI. ROS Remember that this should be more thorough in a written note. Vital signs today on admission should be reported first in an H&P. Can follow by Vital Signs reading past 24 hours range. Remember that this is technically the first part of a physical exam. Note: Some attendings will want specific numbers, some will just want to know that they are within normal range. Always have them on hand, but may not need to report, particularly if this isn’t relevant to patient’s care. For SOAP, last 24 hours will do. If an abnormal reading happened, explain trend. Last reported fever may be relevant if patient was febrile previously.
On physical exam, (read all relevant systems performed) Note: Some attendings Physical Exam will want the full physical exam while others will want just relevant information. If you’re not sure what they want, just ask residents beforehand if possible, or ask the first time one of you is presenting what they would prefer. If normal: Labs today were stable from yesterday and within normal limits. If Results you are trending a certain lab (i.e. WBC/Hg/Crt, mention the trend so that they (Labs/Imaging/Pat know you are being analytical. You will want to report imaging here as well (ex: h) CXR indicated cardiomegaly and bilateral pleural effusions) Note: Similar to before, some attendings will want numbers reported (CBC then BMP, usually), while some will just want to know those numbers being trended. Ms. Smith is a 70 year‐old woman with a past medical history of CHF and CAD Assessment who presents today with worsening SOB for 3 days. Go through differential diagnosis here if H&P (refer to H&P note for detailed example). If diagnosis established, list hospital day and describe current status/progression with treatment. Read off the plan in order of importance, with those issues keeping her in the Plan hospital prioritized in your list. Repeat relevant lab trends and imaging with appropriate problem, and indicate any changes to treatment/meds that you are suggesting (this should be confirmed with residents/intern prior to presentation). End by reading Dispo so that everyone knows what is keeping the patient from being discharged.
HOSPITAL LOCATIONS
University Hospital (UMC) Address a. 2000 Canal Street, New Orleans, LA 70112
The resident room is located on the 5th floor of Tower 3 (Purple). Take a right out of the elevators, then a left toward the double doors. Take a right after passing through the double doors and go through a second set of double doors (will require ID swipe‐in). Take a left once inside and you will be in the hallway with the resident room and locker rooms (further down, to the right) where you can use the fridge and lockers.
Parking ‐ You should be able to find free parking on the street on Canal st. or on Tulane ave, depending on time of day. It’s sometimes a bit sketchy the further away from the hospital you get.
Patients ‐ Inpatient are in towers 1‐3, located on different floors by specialty. If patient’s room is 5201, this means floor 5 of tower 2. When entering hospital from Murphy‐facing entrance, the first tower to your right will be 3 (resident room tower), the next is 2, and the last one will be
Patients are usually in towers 1 and 2. There are elevators on the first floor for each tower on your right as you walk down long hallway. Once you get off on the appropriate floor, look for numbers beside double doors to indicate specific room locations. Floors and towers are connected so you can go across as necessary.
ER is on floor 2 in the middle towers of hospital. When walking in front doors of UMC (facing Murphy) take a left into first door on your left. Take elevators up to 2. Make a left out of elevators and take a right down the first hallway, which will lead you to ER.
Clinic ‐ Located on opposite side of hospital from patients, in the back part of the hospital if walking from Murphy. Take front entrance, walk all the way down past cafeteria, take a left at the end, walk all the way down and take a right. You will see double set of elevators past atrium. Take these to appropriate floor for clinic (specialties listed by elevator doors).
Tulane Medical Center Address: 1415 Tulane Ave., New Orleans, LA No parking provided. Just park in the usual Murphy lots when you’re downtown.
Different floors Map: http://tulanehealthcare.com/util/pdfs/TMCFloorMaps.pdf Labs: 2nd floor Radiology: 2nd floor Endoscopy: 3rd floor Surgery: 3rd floor Outpatient Surgery: 3rd floor Medicine: 5 Center, 5 East, 7 East Abdominal transplant: 7 Center (TATU) Peds: General Inpatient: 6 East PICU: 6th floor
Clinics: On med school side of TMC. Ask for specific locations from residents. Can call operator (0) and ask to be connected to clinics for appointments, etc.
OCHSNER Address: 1514 Jefferson Hwy, Jefferson, LA 70121
Parking ‐ There’s the big lot on the lake side of Jefferson Highway that is free. If you get there early (before 7 am), you’ll find parking easily and it’ll take about 15 minutes to park and get to the hospital. If you get there after 7 am, you’ll have to park a little farther away and it’ll take about 20 minutes to park and walk over. There’s a shuttle provided too if it’s raining or if you’re lazy.
HOSPITAL COMPUTER PROGRAMS
Each hospital uses a different computer system, and it will take you a little while to figure out each one.
Tulane Hospital (TMC) or Tulane‐Lakeside Hospital:
System used: Meditech. Really old system that was just updated to include electronic notes. You basically toggle through each screen using the arrow keys and “enter” button. At the beginning of each rotation, you need to call the Meditech Help Desk at (504) 988‐1716 and tell them what rotation you are starting so that they can change your access accordingly. Notes are all written electronically, but students don’t write electronic notes. Just write a paper note and keep it handy for your patient presentations, and in case your resident or attending asks to see it.
University Medical Center (UMC):
System used: Epic. You’ll go through a special training before and during orientation to learn how to use Epic. Some residents and attendings will want you to write your notes electronically, while others will just want you to write them on paper. As of now, students are not able to save a draft of their Epic notes on the computer at UH, so any changes to your note need to be made by adding an addendum.
Submitting Orders: If you want to learn (maybe later in your rotation), ask your resident to show you how to place an order. It will show that you requested it but will not be placed until it is approved by a resident.
Ochsner:
System used: Epic. You’ll need to do a special Ochsner‐specific training before you will be able to use Epic at Ochsner. Some residents and attendings will want you to write your notes electronically, while others will just want you to write them on paper.
Submitting Orders: Same as at UMC.
Baton Rouge Our Lady of the Lake (OLOL):
System used: Powerchart. You will do a Powerchart training during orientation at OLOL. Dropping Orders: Can only be done by physicians, so don’t worry about it.
General Resources
Medfools: This is a great resource with many templates for taking notes in the hospital and clinic http://www.medfools.com/downloads.php
Apps for your phone 1. UpToDate ‐ Key reference app for all medical issues. Requires HCA log‐in 2. Epocrates ‐ Pharacologic drug information 3. Med Calc / MD Calc ‐ Key medical score/risk calculator (ex: MELD, PE risk, etc.) 4. GoodRx – Info on specific prices at pharmacies. Useful for low income patients, especially those in rural areas. 5. AHRQ ePSS by US Department of Health and Human Services (by age and problem) a. Most useful for Family Medicine b. AAFP Question bank also great for Family 6. NIHSS: NIH Stroke Scale Calculator a. Most useful for Neuro 7. Pregnancy Wheel Calculator a. Most useful for Ob‐Gyn 8. UWorld QBank a. When you have time to study but it’s only a few minutes and you don’t want to carry a book
General FAQs
How do CHITs work?
As with first and second year, CHITs are excused absences that students are required to take when they miss a day of a clerkship. In third year, you get three CHITs per 8 week rotation (IM, Surgery, Peds, OB), you get two CHITs per 6 week rotation (family), and one CHIT per 4 week rotation (Neuro, Psych). These can be used for sick days, mental health days, or vacation time.
The ultimate CHIT policy resides in the student handbook. See the following:
When I take a CHIT, do I have to make it up?
As stated above, how to make up missed days is up to the specific clerkship. Therefore, different clerkships have different policies. For example, OB generally makes you make up days when you miss, while peds does not. Is that fair? Not really. But this is the policy we have now.
The best way to maintain the freedom to use CHITs in the broadest way possible is to be conservative with how you use them. Clerkship directors, attendings, residents, and your fellow students get annoyed when you miss a lot of the clerkship. Your job third year is to be present, so try not to take advantage of the CHIT system.
How does grading work?
Every clerkship has different breakdowns for how evaluations, tests, standardized patient exams, and other assignments impact your grade. All clerkships have a Shelf, so it is generally important to do well on that to get a good grade in the course. Some clerkships have hard cutoffs for certain things, like the Shelf, so knowing all that in advance is important for your grade. All this information will be in each clerkship’s syllabus, which you will always go over during orientation.
Grades matter more third year because we have moved beyond the pass‐fail binary to the pass‐high pass‐honors grading system. As in first and second year, courses have ways to challenge grades. Like with CHITs, course directors get annoyed when people challenge grades too much, so please try to reserve your challenges for true borderline cases. Otherwise, your classmates will suffer when course directors stop considering grade changes later on.
Why are other people having better clerkship experiences than me?
The nature of third year means that people will have different experiences based on their team and their clerkship site. You will definitely have a clerkship where you have longer hours, less helpful residents and attendings, and less interesting cases than some of your peers on the same donut. This can be extremely annoying and lead to you feeling like you are missing out.
The only thing we can say is to try to maintain a positive attitude while you get through it. A lot of third year is dealing with unpleasant situations and learning how to be an effective team member when things don’t go right. A strong performance in a difficult clerkship reflects well on you, and you will be a better doctor because of it!
How can I do well third year?
Success and satisfaction in third year is based entirely on what you bring to the experience. Here are a couple tips to get the most out of third year, and get good grades while you are at it:
1. Study early – you will struggle with practice questions early in the block, but the more you do them, the more prepared you will be for the Shelf. 2. Use down time wisely – sometimes you will have to be at a site and there won’t be much going on. Try to fit in studying, projects, or other fruitful activities when you have down time. 3. Be flexible – there are times when you will (reasonably) ask, “Why am I here?” Going with the flow and not getting annoyed with seemingly pointless tasks will serve your mental health well throughout third year 4. Self‐care remains crucial – exercise, eating well, leisure activities, and all the things you like to do shouldn’t go away third year. 5. Be a good team member – show up on time, don’t take advantage of other people, help your fellow students and residents out when they need it, and try to figure out what the most helpful thing you can do. It never hurts to ask! 6. Don’t lie – there is literally nothing more damaging to your credibility (and your grades) among residents and attendings than lying about doing an exam or something like that. If you didn’t do it, just admit it, and try to remember next time. 7. Remember your patients – cases you see will be the best way to learn about diseases. Try to link diseases and other information with real life cases you have worked with. 8. Take advantage of being a medical student – there are so many people that work in the hospital, and most of them are happy to talk to you. Check out the path lab, the radiology suites, and the MRI machines. Curiosity will help you be a better doctor! 9. Try to have fun – you have to be at the hospital, so keep up a good attitude! It definitely gets harder as the year goes on, but you can do it!
Clerkship‐Specific Information
Overview of Requirements/Resources/Additional information by clerkship
FAMILY MEDICINE
Family medicine gives you a taste of what the majority of practicing physicians in the United States do— engage directly with patients, catch diseases before they become a problem, and manage long‐term maladies. You need to have a depth and breadth of knowledge that cannot be found anywhere else in the program. You will become a master of the physical exam as well as interviewing and will have the opportunity to hone your procedure skills.
Each student works one on one with a preceptor and will work the clinic with him or her. You may be sent far and wide by the coordinator, Adam, who is a fantastic coordinator and person. Adam will send you a survey to find out your interests and your desired living situation, but he prefers to talk in person with students to talk about site placement. If you are dead‐set on being a surgeon and have no interest in primary care, you may be placed with a family med surgeon who will do cholecystectomies all day. Want to work on giving stitches? Work with a doc that specializes in dermatology. Want to inject a sketchy substance into an LSU football player’s knee? Go up to Baton Rouge in the fall with LSU. They will do their best to accommodate you, if they can.
THE PRECEPTORS
You will be by yourself in many of your placements, although you may be roomed with a fellow classmate at some site. Remember that all of the preceptors are unpaid volunteers. These people love to teach and are almost unanimously well‐liked by their students. Some may espouse views that you are uncomfortable with, and this is OK. Remain professional and discuss concerns with Adam as they arise. Some preceptors have made problematic statements to students about sexuality, gender, race, and other sensitive issues. If this happens, please tell Adam as soon as possible! He will tell you the appropriate course of action. Preceptors that makes troubling comments to students or to staff will be discontinued when appropriate. The department expects students to be proactive in asking for exposure to procedures and patient interaction.. If you want to do something that they do not know much about, they sometimes offer to send you to another doctor in town who can meet your needs for one or two days a week. The only way to really upset a preceptor is to not show up. Be sure not to schedule any long vacations or interviews in the middle of the block. Weekends are generally free, and some sites with also have a weekday off or half‐day, so this is a good rotation for weddings, etc.
TRAVEL
It is more likely than not that you will be traveling to a rural location, sometimes as much as 3 or 4 hours to your preceptor site. If you absolutely cannot travel, there are a handful of preceptors in the metro area, but you really must demonstrate need [married and sharing a car, have children, etc...] as it is part of the experience to go outside of your comfort zone. Adam coordinates accommodations for each and every med student at every site—these range from rented houses, hotels, and hospital rooms to spare rooms in your preceptor’s house, their summer house on a lake, or even a bed and breakfast. Some sites even accommodate pets, just make sure you talk to Adam ahead of time if this is a priority for you.
COURSE STRUCTURE
The course will mostly be spent in clinic at the preceptor site. There are didactic sessions on various topics that are mostly in the first week but may appear throughout the block. The clerkship is also working to include more simulations for procedures like joint injections in case students aren’t able to do that at their clinic site.
RESOURCES
‐AAFP Boards Review QBank. Free for all members, and membership is free! This is a key resource used by most students, and will be advertised by Adam as well. Approximately 1300 questions for review. http://www.aafp.org/aafp/cme/cme‐topic/all/bd‐review‐questions.html
‐Step Up to Medicine: Ambulatory section ‐ Overview of guidelines and treatments relevant to family medicine. Provides good content overview.
‐Pretest: Family Medicine — ~500 questions focused on Family Medicine. Answers to questions can be used as a textbook.
‐Blueprints Family Medicine — Broad overview of the most common diseases and symptom presentations seen in Family Medicine. Includes 100 questions at the end of the book with explanations and page references to review topics.
‐Case Files: Family Medicine — Thorough discussion of 60 cases with questions at the end of the cases to use for review.
‐UWorld QBank — difficult to isolate questions for Family Medicine, but Pediatrics, OB/Gyn, and Internal Medicine questions may apply. It would not hurt to do a block of questions on random mode every few days.
The NBME website has practice questions available that reflect shelf content.
fmCases http://med‐u.org Family medicine no longer has a final exam based on these cases. May be used as an additional resource if desired.
Maxwell Quick Medical Reference‐ 6th edition This quick reference covers ACLS algorithms, electrolyte calculations, basic note templates and components, history and physical details and some useful reminders about neuro! This book is useful for any rotation and is a great investment in general! Its small size also makes it easy to keep in your white coat.
Procedures for Primary Care by John L. Pfenninger, Grant Fowler Not required by any means, but the definitive source for all primary care procedures from vasectomy to ingrown toenail removal. It’s a large book to keep at home.
INTERNAL MEDICINE
The medicine clerkship consists of 4 inpatient weeks at two of three locations: University Medical Center (UMC), Tulane Medical Center (TMC), or Veterans Affairs (VA ‐ currently housed within TMC) There are 2 weeks of subspecialty medicine built into the rotation as well, and these can be in any 2 week block in your rotation. There is also a new outpatient portion for 2018‐19, which will also be a 2 week block.
This rotation is a fast paced and intense rotation that will be foundation for many of your future clinical skills including the physical exam, oral presentations, using evidence based medicine, patient data tracking and writing detailed history and physicals. This clerkship is very well organized and that allows you to get all your requirements done in time. The trickiest thing to keep track of during IM is your schedule and where you are supposed to be and when. Be aware of your schedule of events calendar so that you don’t miss your didactics sessions, etc.
There are three major components to this clerkship: being on the wards, going to clerkship school and fulfilling all requirements for completing the clerkship. Expect to be on the wards six out of every seven days a week with the seventh day off. Your day off is to be coordinated with your team and is typically controlled by your resident and/or attending, with all 3rd year students taking the same day off. The easiest way to approach this subject is to ask your resident how he or she would like to handle days off during your expectations talk on your first day with the team (ask for this expectations talk, every team knows to do this but may forget, its OK to ask as it shows forethought). If you are having trouble getting approximately 1 day off per week over the course of the rotation, bring this up with Dr. Chakraborti. This happens, particularly if students are changing teams a ton, and he is happy to work with you if you haven’t had a day off in a couple of weeks. However, don’t complain after 1 week ‐ its always possible this will be made up for in the 2nd week of a rotation. Remember, the rule is an average of 1 day off over the course of a rotation, not one day off every week.
The second major component of the rotation is clerkship school in the afternoons on typically Mondays, Wednesdays or Fridays (varies per week). Each session will go over one major IM topic and may have a mystery case at the end that you will work together with your team to solve. A general suggestion is to try to read up on the topic being discussed in clerkship school before going so that you can get the most out of the session.
Lastly, the clerkship requires that you do 2 evidence‐based medicine presentations and submit 2 full H&Ps. The 2 student presentations are on any IM related topic that should be 5 to 10 minutes long with a cover sheet summarizing the major points. You can ask your attending/upper‐level to present a topic if one comes up with a patient, or a topic may be suggested on rounds that you can volunteer to research. The H & P should typed up on one of your patients that you picked up during a call day, which you will then turn into your attending to be graded (Look back at the H&P overview for details. Be thorough ‐ there’s a checklist). Overall, this is a fun but very busy rotation. Remember to be a team player and to help out your interns and residents with whatever you can, and be nice to your nurses!
Call Schedule Overview
Your schedule on IM inpatient wards revolves around the call schedule. Call occurs every 4 days, and the cycle repeats on a rolling basis. On call day, the team is responsible for admitting new patients as they come to the hospital. This day will involve students and Sub‐Is seeing patients along with the interns and residents, and may culminate with afternoon/evening rounds with the attending at night. If not
presented that day, students will present patient the next morning (this day is labeled Post‐Call). Students are expected to present full H&Ps on new admissions. Post‐Call day is traditionally a longer morning as new patients are being presented, so be prepared with snacks and coffee as needed. Some attending bring snacks for the team, but don’t assume this unless told otherwise. The rest of the post‐call day is focused on completing tasks as needed to discharge patients, and the students are key to this process. The day after this is post‐post call, and involves students seeing patients in the morning prior to rounds (more on this below). Students usually present SOAPs on this day. This day is often the day that students are given the day off, particularly if it falls on a weekend day. The next day is Pre‐Call day, which involves SOAPs from students on remaining inpatients, and is usually spent trying to discharge patients who are ready to leave, tying up loose ends on current patients and organizing the list. This day is also a preferred off day for students depending on the timing of weekends.
The Daily Routine
Seeing Your Patient(s): You will usually start the rotation with 1 patient and build your way up to a max of 3 patients by the end of the rotation. Of course, the amount of patients on the team’s census will play
a part of how many patients you will see. It is great, if possible, to see your patient before your intern does in the morning. Your goal is to ascertain what happened overnight and how the patient is doing today. Check the chart for vitals, new medications and/or orders, talk to the overnight nurse and finally interview and examine the patient. It is helpful to catch overnight nurses before they ‘sign out’ to the day nurse if possible (shift change occurs at 7 am/pm). One of the hardest parts of this rotation is learning to organize yourself with all of the patient information which builds on itself each day – ask your interns/residents for examples of their own organizational schemes.
Pre‐Round with the Intern/Upper Level Resident:
This allows you to touch base with people following your patient and discuss relevant findings/issues and the plan for the patient that day. It is also a great time to ask any questions that you may have. Team dynamics are different, and you may only pre‐round with an intern or upper level or both at times. Ask this on day 1 and you will avoid confusion later on. When presenting, give them the quick overview of changes/findings you have, and ask any remaining questions you may have (including if they have heard from consults, etc.). Usually you will practice your oral presentation with the resident. If you have a sub‐I, they may offer to help you with your presentation if they have some extra time. Never turn down an opportunity to practice presenting!
Round with the Attending:
Rounding with the attending consists of presenting all patients to the attending, starting with new patient H&Ps and followed by SOAPs. Sometimes, this is done at table rounds (particularly on post‐call day), followed by going to see them in their rooms. On pre‐call and post‐post call days, presentations are usually done during walking rounds, with students presenting their patient outside followed by the team going into see patients as a group. Rounds can take anywhere from a couple to several hours, depending on patient census and attending style. It is wise to pack a snack in your white coat pocket, especially on your first day with a new attending.
AFTER ROUNDS
‐Assist your interns and residents with any tasks that you have noted throughout rounds (keep this info on your copy of the list for ease). This may include consults, making appointments, following up on labs/imaging, contacting social work, etc.
‐Update the patient list/Phaedrus as required/requested by the residents. Discuss with the team prior to doing this unilaterally; make sure you know what you are responsible for updating, etc.
‐Check in on your patient. If they are to be discharged, check in and make sure they have all info regarding follow‐ups, medications, etc.
‐If there is time, give a student presentation or receive teaching from the intern, resident and/or attending. Post‐call day is a bad day for presenting as rounds are typically already long. Call day is too busy for this, usually. Thus, plan to give presentations on pre‐call or post‐post call days (ask the attending and/or residents the day before so that they can make time for this after rounds; don’t surprise people with presentations out of the blue!).
‐You will have afternoon report, which involves a chief resident going through a case with students, on Tuedays and Thursdays of every week. Students are expected to attend this unless there are extreme circumstances (call day may be an exception to this), so make every effort to be there.
‐Wednesdays at noon, there are grand rounds, which will involve a presentation by a speaker during lunch. Students are expected to attend or inform Leigh‐Ann if they are going to be absent (there are sign‐in sheets). If rounding extends into this time, make sure to email Leigh‐Ann to not get penalized.
Guide to Studying
It is best to bring study materials with you every day so that if there is downtime you can study; however, due to the feast or famine nature of the wards never expect to get studying done. Most of the studying is done after hours. This rotation can tend to wear you out, so attempting to get a few questions in every day, or read a few pages on a given night is an accomplishment. Set a modest goal for studying on a daily basis, so that you’re not struggling to finish the material at the end of this block. Sub‐specialty time is golden for studying, don’t waste that opportunity whenever this falls in your block.
Textbooks, Question banks, References
Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine (Pocket Notebook) – Fifth Edition
This is a great wards resource with outlines of definitions, management and treatment that are easy to consult during wards. This resource is often also used by residents and attending so it’s definitely a keeper. This allows for a quick reference and differential diagnosis help, and has relevant ACLS algorithms, electrolyte calculations and more. This book is useful for any rotation and is a great investment in general. It is small which makes it an essential tool to keep in your white coat.
USMLE World Question Bank for Step 2
https://www.usmleworld.com/purchase.aspx
The majority of students study for the Internal Medicine shelf by mostly using these questions, as this
shelf is too broad to adequately prepare by simply reading a book. Uworld questions are typically slightly harder than shelf questions. Dr. C estimates that students should do approx. 1000 questions to be properly prepared for the shelf. You know yourself better than he does, however, so do what you need to do to succeed given your learning style. If you read, do so. If questions are your thing, you have plenty to do. It’s best to start off doing a few questions a day to not overwhelm yourself late in the block.
Review Books: Step Up to Medicine, First Aid Step 2, Master the Boards
Review books that will give you several answers to the clerkship school questions and provide a broad overview to the material you will be encountering. There are “Quick Hit” pearls and bullet‐outline format make it an easy resource to use. Unlike Step 1 First Aid, there is not one paramount guidebook for Step 2 material. Step Up to Medicine is more comprehensive, but also much longer than the Internal Medicine sections of the other two. Step Up is the most commonly used review book for IM based on last year’s Owl Club surveys.
Internal Medicine Essentials (formerly known as MKSAP for Students)
This is a textbook recommended by Dr. C for the course and a great resource. It is available in online and in print at a discount for medical students. It has short and informative chapters that cover all the basics of internal medicine. The online format has questions that serve as a comprehensive review; these tend to be slightly easier than shelf questions but reinforce key principles of internal medicine.
Online Med Ed
This resource involves video lectures that go through approaches to different Internal Medicine topics. Dustin Williams went to Tulane medical school and therefore utilizes the same framework that you will be taught through clerkship school and the Weiss book. This is a great resource for a general overview of algorithms and treatments, and a favorite resource based on Owl Club evaluations.
UpToDate
This website is a great resource while on the wards; however, you need to be on hospital computers or on campus to have full access (or sign up using your Epic log‐in).
If you want an EKG textbook to supplement your studies there are two that have been useful:
The Only EKG Book You’ll Ever Need, by Malcolm Thaler
http://ecg.bidmc.harvard.edu/maven/mavenmain.asp
Rapid Interpretation of EKG’s, Sixth edition, by Dale Dubin (Google him when bored, by the way)
NEUROLOGY The neurology clerkship is a 4‐week rotation designed to expose students to both inpatient and outpatient neurology. There are various locations where students are assigned and the experience/learning/schedule varies greatly based on where you are placed. The majority of patients will be seen in the hospital but students are required to attend afternoon clinic four times total over the four week clerkship (generally once a week, but you can decide how to space out your clinic sessions). These mostly include the UMC Outpatient Clinic and the Tulane Outpatient Clinic. Several attendings may have clinic elsewhere that is also acceptable (such as the new VA), and you will be provided with a list of when/where these clinics are held at the Neurology orientation. Regardless of where you do your rotation the name of the game is localizing the lesion. In this sense, neurology is a lot like real estate…it’s all about location, Location, LOCATION. And the way you do this is with the help of a thorough history and comprehensive neuro exam. One of the great things about neurology is the physical findings correlate directly with localizing the lesion and deciding about the diagnosis. Almost everyone with a neurological disease will have some abnormalities on their exam. You should do a complete neuro exam on all your patients, at least for the initial work‐up. It’s also a good idea to refresh your neuroanatomy.
LOCATIONS
TULANE MEDICAL CENTER
2 weeks of stroke service This is a very busy service and you will work harder than the rest of your classmates on neuro during these 2 weeks. Students often are better prepared for shelf due to excellent teaching and hands‐on stroke experience. Days typically start at 7:00 AM and last anywhere between 4:00‐7:00 PM. Rounding typically ends by 12:00‐1:00 PM, but can vary depending on attending and on the number of patients. Dr. Salerian’s rounds typically are longer. Students then help with updating the list in Resident Passdown, writing discharge summaries, procedures, following up lab/test results, and attend clinic if it is your assigned day. Always listen for the stroke activation alert “Paging Dr. Brain” to sound on the intercom. When you hear this, you pretty much drop everything and go to the ER to assess the patient with the resident and determine whether or not to give tPA.
Attendings: Dr. John Freiberg, Dr. Aimee Aysenne, Dr. Justin Salerian
2 weeks of consult This service is much less hectic than stroke service and allows for much more study time during the day. Generally, the team is only following a handful of patients at one time so not every student will have a patient to see in the morning. Days typical begin a little later than stroke service, often starting around 8:00‐8:30, depending on your resident and patient load. If Dr. Aysenne or Dr. Dunn is covering consult, they may also take you to round on her neurocritical care patients. This is a valuable learning opportunity and student feedback has been very positive. After rounds, much of the time is spent studying in Matas. Attend clinic with the residents, usually on Wednesdays.
Attendings: Dr. Angela Traylor, Dr. Aysenne, Dr. Colon, Dr. Lafaye, Dr. Jessica Kraker, Dr. Casey Dunn
UMC
4 weeks of consult and stroke service Historically, this was a lighter service than TMC but has since picked up in patient volume since the move
to UMC. You follow the residents and attendings on stroke, consult, and ED service and also do afternoon clinic.
Attendings: Dr. Kraker, Dr. Angela Traylor, Dr. Kristina Lafaye, Dr. Antzoulatos, Dr. Carbtree
Spectrum Neurology Center (SNC):
Students work with Dr. Troy Beaucoudray at his Metairie clinic, specializing in the diagnosis and treatment of painful neurological disorders but also treating all neurological conditions. All diagnostic and treatment procedures are performed at the center, which is a brand new, state‐of‐the‐art facility that offers a multidisciplinary approach to treating, diagnosing and evaluating neurological disorders. Typically, only 1 student works here per rotation.
Baton Rouge General (BRG): You will follow Dr. Kevin Callerame at the hospital and their clinics for an overall inpatient/outpatient experience. Housing will be provided at Baton Rouge General in call rooms adjacent to a student lounge with numerous amenities.
CLINICS
1. UMC Oupatient 2. TMC Outpatient Clinic 3. Others – new VA, etc.
RESOURCES
On Call Neurology by Drs. Randolph S. Marshall, MD, MS & Stephan A. Mayer, M.D., FCCM
This is the official textbook for the Neurology Clerkship. It is detailed and better for quick reference while on the wards rather than reading from cover to cover. The book is broken down by presentation ataxia, weakness, coma, tremor) and gives a quick overview that can be skimmed in 2 minutes, and gives specific management advice.
Blueprints Neurology An excellent resource for this rotation. It is inexpensive (~$30) and covers all of the important topics for a quick reference. It is about 200 pgs and is very helpful when studying for the Neuro exam. One of the most commonly used books on this rotation.
THINGS TO KEEP IN YOUR WHITE COAT
● Penlight ● Reflex hammer
● MD pocket/Maxwell’s – good reference for cranial nerves, mental status exam, GCS, and progress note format ● Download a Stroke Scale app for use while on the stroke service ● Vibration tuning fork ● Ophthalmoscope ‐ optional
OBSTETRICS & GYNECOLOGY
Ob‐Gyn is an 8‐week‐long rotation at either Tulane, Baton Rouge, Rapides, or West Jeff. At Tulane, one month is spent at the University Hospital Ob‐Gyn clinic, and the other month is spent at Tulane‐Lakeside Hospital for L&D and inpatient service. If you go to Rapides you have one month L&D at Lakeside, one month in Rapides that is gyn clinic and gyn surgery. At West Jeff, your time will be divided between L&D, OR, and Clinic, with some of the clinic shifts taking place at UH Ob‐Gyn Clinic. The hours on this rotation will be some of the longest you have during third year. The schedule can be confusing at times, so it will take a few days to get used to it. The Lakeside rotation features Night Float, which can be some of the most educational of your third year. Night Float is an awesome opportunity to get involved and potentially assist in the delivery of a baby. Finally, at the beginning of the rotation and during mid‐block (ZOE session), you will have SP sessions that teach you the breast and pelvic exams and will help you prepare for the clinical skills assessment (CSA) at the end.
LOCATIONS/SCHEDULES
UMC OB‐GYN
Clinic is located on the 5th floor in the clinic tower at UMC. Clinic generally starts at 8 am. On Mondays at 7‐7:30 AM and on Thursdays at 7‐7:30AM, the Maternal‐Fetal Medicine Specialist on for that month (either Dr. Gambala or Dr. Dola) will run teaching rounds (for which you usually have to do a reading beforehand).
When you are at this clinic, you can be assigned one of four services:
Clinic: This is regular clinic week, with shifts divided into AM and PM. AM Hours are 8‐12:30 on days without teaching rounds. PM hours are 12:30PM to the end of clinic, usually no later than 5PM. Write your name on the whiteboard and assign patients amongst yourself and your fellow students. To find the list of patients for the day, create a list in Epic and search for “Women’s Health” under provider group. In that group, select Tulane’s residents individually by name and add them in the provider column. The clerkship coordinator will send an email with instructions on how to do this. If you ever feel like you don’t know what’s going on, just ask a resident.
Gyn: There are usually 3 students on this service at a given time. You will get to the UMC or TMC hospital around 5:30 (sometimes earlier) and see your patients. Text the lower‐level resident the day before to figure out the timing of pre‐rounds and give yourself time to see patients before this. Then you will present them to the intern and resident, after which you (may) present them to the attending around 7 am, depending on how the attending prefers to do things. You will be responsible for dividing up cases among students, and will be following the inpatients throughout the day, as necessary. Sometimes, this will involve being alongside residents all day, but sometimes they will let you “go study”, which means you should be available by text. Wednesdays are surgery days which can end really early or really late (i.e. 7 pm). You may sometimes be expected to attend clinic with Dr. Robinson (resident may tell you if this is so, or you may have to ask outright.) This service’s hours are variable depending on residents and attendings, so ask the group the preceded you how things are done to get the most applicable details.
Lakeside
This month of the rotation will be a mix of labor & delivery day shifts, night float, MFM, and Gyn. The schedule is very confusing until you actually see it, but suffice to say that you will get the hang of it once
you have worked there for a few days. During this month you will have two days of night float as well. You will be expected to attend morning rounds if you are on L&D A, MFM, or Gyn, and if you were on night float the previous evening. L&D B is the only group excused from morning rounds at Lakeside. Schedule is detailed below, but generally expect to show up at 5 am, divide up patients among students (they will tell you how to do this on Day 1, depending on your service ‐ don’t worry as the List will make it clear). Pre‐rounds are at 6 with the upper‐levels, and rounds are usually from around 6:30 to 8. You can step out with a resident if you are scrubbing in on a case. Otherwise, be there on time and stay for the duration of rounds.
West Jeff
Likewise, if you are assigned to West Jeff, the entire rotation will be spent at WJ except for 2‐4 weeks where you will be assigned to UH Ob‐Gyn clinic (see above). WJ students work half day clinics. Hours at WJ vary depending on the resident you’ve been assigned but generally are shortest among the ob‐gyn sites.
Baton Rouge
If you are assigned to Woman and Children's Hospital in Baton Rouge, you will spend 4 weeks of Labor and Delivery at Lakeside in New Orleans and spend your 4 clinic weeks in Baton Rouge. You will be given a schedule when you arrive that will have you follow several different physicians in a variety of women's health sub‐specialties at the hospital.
Rapides
You live with 3 of your classmates in a two bedroom apartment in a "gated community" with pool, hot tub, and gym in Alexandria, LA about 10 minutes from the Rapides Hospital. Students and residents run the clinic under the supervision of Dr. May. Clinic begins around 8am. Students see patients, write notes and do gyn exams under the supervision of residents. Clinic goes till about 5pm. Lunch and breakfast are free in the doctors’ lounge. Students are responsible for dividing up surgeries amongst themselves and are permitted to leave clinic to attend surgeries if ok with resident. Surgeries and C sections are all fair game and students are encouraged to attend these with residents before clinic starts in the morning as well. 1 student per night takes call which means going in to the hospital for emergent surgeries if called in. This is a great rotation for gyn with tons of hands on experience and time to really get to know your fellow classmates and residents.
Google doc from prev students about life in Alexandria: https://docs.google.com/document/d/1XSCfwGO9mPsAJz_t2R_QXAY0GmSW74t2LfD8eEjrBhk/edit
DAILY ROUTINE: INPATIENT
Note: this example refers primarily to the Lakeside schedule, including L&D A, L&D B, GYN, MFM, and Night Float (NF). When you receive your schedule, you will also receive a description of the expectations for each of the roles and a daily schedule to use as a guide. It may be useful to print out or download the guide and schedule to your smartphone so you can refer to the pages quickly. Schedules also are subject to change depending on your chief resident.
0500‐0600 ‐ Arrive and see patients, write 1‐2 notes in Meditech, print a copy to have with you 0600‐ 0630 ‐ Present patients to residents 0700‐0900 ‐ Present patients to attending rounds. How much presenting is done depends on attending.
(Note: GYN student may go to surgeries, L&D star usually attends C‐sections if they occur during rounds) 0900‐1400 ‐ Daily tasks: L&D A attends deliveries, GYN goes to cases and sticks around till around 2, MFM goes to clinic specific to that day and sees cases as appropriate. 1400 ‐ L&D B arrives, receives sign out and relieves L&D A 1700 ‐ On Tuesdays and Thursdays, Dr. Herrera has teaching rounds in the afternoon, where an APGO Practice Bulletin is discussed. Someone on L&D B should let students on other services know if they are expected to be there (this hasn’t always been the case, so play this by ear). Night Float comes on at 5. NF stays on until patient safety rounds the following morning. 2200 ‐ L&D B goes home. Sometimes let out earlier if things are light
PRECEPTOR
Each student will be assigned to a preceptor group that meets once a week. You will go over a packet of questions that you receive on the first day of the rotation.
RESOURCES
ACOG UWise Questions: These are free through Tulane using your username and password, and are excellent review for the shelf exam. Separated by subject, about 10 per subject.
APGO Videos: 46 short videos on a wide variety of topics, great review for
UWorld: Generally good questions, about 220 in total.
Online Med Ed: Good videos for review of concepts.
Obstetrics & Gynecology by Charles R.B. Beckmann. This is the textbook for the course, and is actually shorter than Blueprints. Many students liked the straightforward nature of this book.
Blueprints Obstetrics & Gynecology by Tamara Callahan and Aaron Caughey. Many students liked this Blueprints more than other books by the same series.
Case Files by Eugene Toy, Benton Baker III, Patti Ross, and John Jennings. A good book to go over the most salient points of Ob‐Gyn, but probably needs to be supplemented with another resource.
PEDIATRICS
This is overall a very pleasant rotation! Attendings and residents are nice and helping kids is fun. The rotation is 8 weeks total, with 4 weeks of inpatient wards, 2 weeks of NICU and Nursery, and 2 weeks of clinic. The possible locations are Tulane, Ochsner, Lafayette, or Baton Rouge. You will also have a weekly preceptor meeting with about 7 other students. The preceptor will decide how each session is spent, and can vary widely. These are the people who are going to know you the best, and will be grading you as well (worth 10%).
LOCATIONS
TULANE Lakeside
There are 4 teams at Tulane: ‐Red team, General Pediatrics and Pulm Inpatient ‐Green team, Heme/Onc ‐PICU/NICU are generally pretty light
Red and Green Team
Red and Green team are both on 5th floor Center. You will need to get buzzed in as your ID won’t let you in. Arrive around 6 am for resident sign‐out, see your patients (1‐3/student), pre‐round with residents briefly, and then round with attending at around 9/9:30 (varies from attending to attending). There’s a nurse’s break room with a fridge, microwave and table. It’s unlocked and it seems to be OK to put your lunch in there.
PICU This is on the 5th floor as well. You need to buzz and get let in; your ID won’t work. Arrive before night float’s sign out (7 am). The time that the day ends is very variable as it depends on what the census is and also depends on the attending and his/her interest in doing teaching. There’s a resident work room in the back behind the nurse’s station. Meet the resident there in the morning to see what the plan is for the day. You can leave your stuff there. For progress notes, the PICU uses pre‐printed outlines that are by system. This is different than the format they use on the wards. Ask the resident for help to fill out the sheet the first time. Check the flow sheets that are by each patient’s bed for vitals, I/Os, etc. to fill in the note. There is a fridge in the back by the Resident Call Room that you can put your stuff in. Just ask to be directed.
NICU + Nursery See below under Tulane/Oschner
OCHSNER They really aren’t going to push you too hard at Ochsner and it is definitely regarded as an enjoyable experience. One thing you can count on is that they always have patients which means you can really learn a ton if you put in the effort with the extremely receptive faculty. The residents are all Tulane residents (Pediatrics or Med/Peds).
How it’s broken down: ● 4 weeks inpatient at Ochsner, 2 weeks clinic (outpatient clinics held at Ochsner’s Pediatrics building across the street from the hospital) and 2 weeks NICU/Nursery at Lakeside) ● The inpatient 4 weeks changed very recently due to the increased number of University of Queensland students now rotating at Ochsner. It is divided into 4 weeks: ‐1 week is general inpatient pediatrics. ‐1 week is inpatient subspecialty (patients for whom the primary team is cardiology, heme/onc, or pulmonology). ‐1 week is ‘nights,’ meaning managing both the general pediatrics and the subspecialty patient during a shift from 3pm‐11pm. This week can be a great opportunity to work on H&Ps since many admits are in the evening/at night and you are the only student there. However, if there aren’t any admits or acute changes in current patients, it can be pretty slow. ‐The final inpatient week is experiencing different aspects of patient management, outside of the physician. For this, you basically shadow a different person every day. The 5 days include nursing, respiratory therapy, pharmacy, the PACU, and the cardiac cath lab. ● Morning Report sets Ochsner apart. It is held by Dr. Warrier (Heme/Onc) and Dr. Steele (ID) every morning at 7:30 (you may need to see your patients beforehand depending on when the attending intends to round) except for the morning when there is grand rounds. A case is presented and they lead a discussion about the differential, studies, and diagnosis. They are incredible physicians with an absolutely incredible amount of combined experience. It is the only time 3rd year you will hear people talk about being sad about missing morning report. ● Inpatient pediatrics is on the 4th floor of Ochsner, where morning report is held also. ● Clinic is located across the street by where we park; both floors are pediatrics.
NICU FOR TULANE/OCHSNER
● Anyone who does their in‐patient month in New Orleans (Ochsner or Tulane) will rotate through the NICU at Lakeside. ● Staffed by a neonatologist, a Nurse Practitioner, and lots of nurses. There are 24 NICU beds, often close to capacity. The patients are split between the Tulane neonatologist and the 1‐2 NPs. As a Tulane student, you’re only responsible for the Tulane babies, each of you will have 1‐3. ● Location: 2nd floor. Your ID won’t let you in, so you’ll have to get buzzed in every time. ● Schedule: Depends on when the attending wants to round and also depends on if the resident wants to pre‐round. Generally, arrive by 7 am and see 1‐3 babies/student. Rounding is usually from around 8:30/9 to around lunchtime. When you can leave changes every day. If nothing’s happening, then 2‐3 pm.
NURSERY FOR TULANE/OCHSNER ● These babies are all healthy! ● Location: 2nd floor Lakeside. Your ID won’t get you—must get buzzed in. ● How it works: once you enter the nursery, first make sure to scrub in at the sink! There are a few computers back there and you can print the below template. The nurses will wheel in the babies and there’ll be a bunch (10‐15) in the nursery area. The babies’ charts are all in that outer room and most of the background info can be found by flipping through (time of birth, weight, gestational age,
complications, etc). Go into the nursery and look at the nametag to see who is who. Have the intern/resident show you how to do the first well‐baby exam and then it’s very simple. ● Schedule: Arrive by 8 am, see 1‐2 patients and present them. When you can leave depends on how much teaching the attending wants to do and can be as early as 10 am, or later if you round with the team to see the mothers. ● Afternoons: When you’re done in the well‐baby nursery for the morning, you may also have some afternoon assignments. This could be to a clinic or to the Lakeside ED.
CLINICS AT TULANE
● This will be 2 weeks long, divided up between morning and afternoon clinics. Some are at Lakeside (the shiny glass building next to the hospital) and some are at the Downtown hospital. You will rotate between general peds and various subspecialties. It’s generally a low‐stress 2 weeks.
BATON ROUGE
How it’s broken down: ● 4 weeks inpatient: 2 weeks on the general hospital pediatrics floor where you are on teams that admit patients from the ED or as direct admits for general outpatient pediatricians, 1 week on PICU, 1 week on the heme/onc ward. ● 2 weeks well baby/NICU: You’re with either Dr. Albrecht or Dr. Tran at the Baton Rouge General Hospital, both of whom are extremely nice. See moms and examine babies (1 or 2 per med student), round with the attending (+/‐ family med resident), meet as a team with the neonatal NP and do conference room NICU rounds, dismissed around 11am with the option of seeing NICU babies. ● 2 weeks outpatient: Each day is different and you rotate through general pediatrics and subspecialty clinics. These are flexible clinics so if you have a special interest in a specific field (ie. med/peds HIV), you can arrange a day with Dr. Vicari’s help. ● Hospital pediatric service: Attending, upper level, intern, medical student, +/‐ pharmacy student. You follow 2‐4 patients. If you want to demonstrate your breadth of knowledge, always present the newest patient. Like medicine, they want to see your thinking via the assessment and plan. Also, they do plan in a systems‐based format, for example: o FEN/GI: “stable, currently on maintenance IV fluids” o CV/Resp: “hemodynamically stable, stable on room air” o Heme/ID: “febrile, white count with left shift, therefore, empiric treatment with…” o CNS/Pain: “Motrin” To be helpful to the team, update the list of patients on the white board in the physician conference room, put away the residents’ paper SOAP notes in the patients’ charts, offer to do re‐checks on patients whose discharge is pending on improved condition in the afternoon. Arrive by checkout (6am) and depending on your resident, you leave between 4pm – 6:45pm. ● PICU: Attending, resident, medical student, nurse in charge of each bed. You present one patient. Get to the point, always look at the sedation meds, new acid/base printouts, ventilator settings, etc. Review ARDS, sepsis, ventilator settings, CXRs, acid/base problem solving. ● Heme/Onc: Attending, resident, medical student. Works like the general ward. Heme/onc docs are smart and enjoy teaching, so brush up on some cancer fundamentals and how to explain the differential diagnosis of an abnormal finding on CBC.
● Well‐baby/NICU: Attending, two med students, +/‐ family med resident. A break during the rotation where you show up for 3 hours a day, so get some studying done. Presentations are informal so relax during these two weeks. ● Outpatient clinics: Depends…mostly shadowing. At the Pediatric Academic Clinic which is the residents’ longitudinal clinic, they may let you see a patient by yourself first, then see the patient with the resident, and then present to the attending. Otherwise, the clinics are mostly shadowing. ID clinic with Dr. Bolton is pretty quiet with 1‐3 patients, with the possibility of all no‐shows. He’ll go over antibiotics with you, which is quite helpful. Dr. Williams allows you to see patients and present to him. At neuro clinic, you are with another LSU student and a resident. Dr. Hollman treats you like a resident so you see and examine a patient, type a note in Epic, and then she reads your note to revise. Together, you re‐examine the patient and talk to the parents about the plan. ● You receive 5 lunch cards/week up to $6 each at OLOL. While on PICU and H/O you usually get lunch with the team in the doctor’s lounge. ● At Baton Rouge General (where you do NICU/nursery), you have unlimited access to the doctor’s lounge so you can have breakfast and lunch there. ● Morning report is on MWF. Resident lectures are Thursday afternoons and can be hit or miss. Preceptor sessions are on Tuesday afternoons. ● The faculty is extremely accessible here. If you’re interested in peds, med/peds, or a specific peds subspecialty, they are more than willing to talk with you.
LAFAYETTE You and another student will work with Dr. Rita Boustani in both inpatient peds and in the nursery doing well baby checks. It’s a great combination of different aspects of peds and a good experience working in a hospital without many medical students. Generally see a few patients, round with Dr. Boustani around 9, check the nursery after lunch, done by 2 or 3. You are able to hop in on surgeries with the peds surgeons if you want. You live in an apartment with another student for three week. The apartment complex is close to the hospital, has a gym and pool, and the apartment has cable and internet. Lafayette is a college town in Cajun country, so there is a lot of good food and fun things to do. Light breakfast and lunch is provided in the doctors’ lounge. More details on this site are provided by the Peds department, but it’s a good choice for students from the Lafayette area and those who want the opportunity to work in a smaller hospital with fewer medical students and residents around.
BOOKS/RESOURCES Top choices for Review Books
‐PreTest in Pediatrics (Yetman) is said to be the most accurate for shelf review. If you can get through PreTest more than once, you should be golden.
‐USMLE World: Students have anecdotally reported two passes at USMLE World Peds placed them in the
75th or better percentile on the Shelf.
Textbooks ‐Illustrated Textbook of Pediatrics (Lissauer) is recommended by the course coordinator and has sold the most from the Bookstore. It is available online (via library website) through MD Consult.
‐Essentials of Pediatrics (Nelson) is extremely dense and it is unlikely you will read it all. However if you want to be a pediatrician or ever want THE source on a peds subject, you will want this book handy. It is available in the bookstore and online (via library website) through MD Consult.
‐Pediatrics for Medical Students (Bernstein) is also coordinator recommended, but not many people from the course actually liked it.
PSYCHIATRY
The psychiatry rotation is 4 weeks long and usually done in one or two of the following locations (listed below). The rotation goes by relatively quickly since it is only four weeks long but is not overwhelming in material. Focus on definitions, classifications, and time periods necessary for psychiatric diagnoses as well as heavy emphasis on pharmacology (study the book First Aid Psychiatry Clerkship and the two pharm lectures and you'll be set for the pharm topics).
Some of the academic classes will be case conferences where they will go over two packets of cases. It’s best to attempt these cases beforehand so that any questions that you may have can be answered at those sessions. The two required assignments are a psychiatric reflection on your experiences and a case summary (H&P) on one patient. There is a good amount of information on Blackboard that will instruct you how to complete these assignments.
Lastly, don’t forget to practice your psychiatric interviewing skills because there is a required Standardized Patient exam the day before your shelf. Easy points can be gleaned on any SP exam by consulting the MIRS criteria (described at the beginning of our green books by Dr. LeDoux). Additionally, Dr. Weiss will give you a handwritten document during orientation that goes over what to ask in a psych interview. If you do this for every patient you will know it cold for your SP exam and pass with flying colors.
Week 1 Orientation, Academic Class (typically Friday) Week 2 Academic Class (typically Friday) Week 3 Academic Class (typically Friday) Week 4 SP Exam, Shelf Exam
LOCATIONS
These are the ways your schedule could work out:
● 4 weeks at UMC (inpatient) ● 4 weeks at Northlake ● 4 weeks at OLOL in BR ● 4 weeks at EJ ● 4 weeks at Biloxi VA ● 2 weeks at Jackson, MS/2 weeks at Tulane Consult
NORTH SHORE
Northlake Behavioral Center Mandeville, LA
Attending: Dr. Levy plus 1 psych resident
The place: An inpatient psych unit located on the north shore of Lake Pontchatrain (45 minute commute over the causeway bridge).
The patients: this is mostly acute psych treatment for major depressive episodes, schizophrenia, bipolar. There are a few token patients who have been there for a long time but it is mostly a place where patients will be there for 3‐7 days.
The details: arrival time is dependent on who your resident is but can vary from 7‐9am arrival. You will be assigned to 1‐3 patients depending on the patient load at that current time. You will see your patients before rounds with Dr. Levy at 9‐10. You are responsible for writing the patient note for the day (the hospital is all paper charts). On rounds each patient is brought into the workroom to speak with Dr. Levy. Dr. Levy will ask you to tell her about how the patient did overnight and how they are doing before the patient comes in the room. Dr. Levy will interview them and may ask you to interview them as well. Once all the patients have been seen take care of any tasks that you need to do for your patients for the day, mostly making calls for "collateral information". After you are done with your tasks you can leave (typically around 1‐2.
OUR LADY OF THE LAKE (OLOL)‐BATON ROUGE
OLOL Regional Medical Center Hennessy Blvd Baton Rouge, LA 70806 Approximately 1.5 hours out of New Orleans
Attending: Dr. Trask – You don’t work with him directly; however, he is the one filling out your evaluation at the end of the rotation. You will meet with him for preceptor sessions. He also leads the orientation for this site, expects one presentation from each student per week and has you write 4‐6 progress notes each week, which you need to submit to him for review.
This clinical site has less stringent clinical supervision, which means that you are independently expected to meet expectations. These expectations are clearly explained during orientation. This rotation is really what you make of it individually; however, a general rule for doing well is showing enthusiasm, seeing all your patients at least once a day and meeting all the expectations given to you by Dr. Trask. Since this site is in Baton Rouge Tulane puts you up in the TAU Center, which is directly across the street from the main hospital. Make sure to pick up your keys form the front desk when you arrive at the TAU center. You get your own room that contains a small living area, a bed and private bathroom. Linens are provided but it is up to you to wash them in the provided laundry area. Make sure to bring your own detergent! There is a mini fridge in the room, 1 communal microwave and access to a coffee maker but no real access to a more extensive kitchen. There is free parking at both the Tau Center and at the hospital. You also get 5 weekly meal passes to the OLOL cafeteria worth $6 each, and possibly free food in the doctor’s lounge. The hours change depending on what part of the rotation you are on. The first week is at the COPE unit, a Mental Health Triage unit where you work with specially trained social workers, and where hours are from 7 am‐5 pm. The three weeks after that (inpatient psychiatry) are generally 7 am‐1 pm. There is no official sign in or sign out for the day and you are not assigned to a particular resident or attending. Therefore, you will be expected to work independently with your patients and then check in with the corresponding residents and attending when they arrive on the ward.
EAST JEFFERSON HOSPITAL
4200 Houma Blvd Metairie, LA 70006
Attending: Dr. Kinzie‐ Typically he will require you to do two ER on‐call days over the weekend instead of one.
There is a parking garage attached to the main hospital that is on the far left side of the roundabout in front of the main entrance. It is free to park in as long as you are in public spaces. The typical day begins around 7:30am to 8am and rounding happens around 9am with the attending. An average day will finish around 1PM or 2PM; however, it depends on how many patients you have. You will have to do two ER weekend on‐call days (either Saturday or Sunday) where you are required to stay till 4PM. You are typically rounding or busy writing notes while at East Jeff so there isn’t a lot of down time. Once you are done with your clinical responsibilities you are typically dismissed to study at home.
UMC
Attendings: Dr. Weiss, Dr. Detrinis
This is an excellent rotation for students interested in psych or med‐psych. It has become slightly time‐ intensive compared to other psych sites. Each student typically sees 2‐4 patients each morning, and works the part of an intern for the most part. The day will typically start at 7 am with nursing sign out and rounds with the attending will typically start at 8:30 or 9 am. Weekend rounds have been implemented intermittently depending on attending, so this could be a 6‐day work week and more time intensive than most sites. Rounds will typically last till for the entire morning at times; however, it depends on patient load and the attending’s schedule. You will be expected to write notes on your patients, and keep the list up to date on your patients. You will be allowed to leave upon completion of your tasks, including any patient work that needs to be done.
On Mondays and Wednesdays there is Resident Group, which is led by students and will typically take 30 mins. This involves facilitating a group discussion on a topic related to health and wellbeing. In practice, it can be a disruptive group due to the acuity of patient illness, but each intern’s team will teach one of the sessions that week. You will have the opportunity to see court proceedings and electroconvulsive therapy if desired (if applicable to a patient’s care). Patients are psychotic and usually acutely ill. You will become very comfortable with the nuanced medical regimens for bipolar and schizophrenia. You are also expected to do one student presentation on a psychiatry‐related topic by the end of the service.
JACKSON
East Louisiana State Hospital 4502 Hwy 951 Jackson, LA 70748 Approximately 2‐2.5 hours away from New Orleans.
Attendings: multiple
Jackson is NOT a four‐week rotation site. Typically you will rotate there your first two or last two weeks. You typically go with one or a few other students and you share a house. There are lots of interesting sites to see when not on service including haunted houses and cool Cajun restaurants. The house onsite for student use is a 5 BR house located on the grounds of the hospital. It has a full kitchen with dishwasher and microwave, a washer and dryer and TV with cable and movie channels. There is WiFi available; however, it is reported to be slow and underpowered. The beds are twin size with thin mattresses (bring extra padding if you need it). Make sure to bring sheets, a pillow, blanket, laundry detergent, and/or sleeping bag. When you arrive at the gate you will get your Visitor’s Parking Pass and a Visitor’s Pass. The parking is available in front of the house and the hospital itself. Expect to drive from your house to the hospital every day. Morning report starts at 8:15am and quickly goes over patients in the acute forensic wards. On Monday, Wednesday and Thursday the staffing for Men’s ward starts at 9:30am and goes till 11:30am and consists of the attending interviewing each patient briefly. Staffing for the women’s side starts at 1:30pm and goes till about 3pm. Students are typically free after the morning session on Thursdays so that you can return to New Orleans before rush hour but make sure to confirm this with your team. Tuesdays are done with Dr. Garriga at the Forensic staffing and start at 10am. This is followed by placement hearings in the afternoon, which typically finishes by 3:30pm. Expect to be assigned a patient on whom you will do a history and mental status exam during Forensic staffing. Dr. Garriga usually expects you to report back on this patient the next Tuesday. There are varied hours throughout the week but ample time to study after clinical responsibilities.
TULANE Consult/Liaison
Consult/liaison service: there is a 2‐week consult/liaison service at Tulane. You see patients in the ED and in the hospital. They are then considered for placement at outside facilities. Hours are not bad at all; approx 7 am ‐ 3 pm. You may have multiple attendings during your service, but you’ll usually be with the same residents.
Child psych: changes from rotation to rotation ‐‐ your best bet is to contact the student who did it before you. This service can be very rewarding for students who are interested in gaining exposure in child psych.
BiloxiVA
400 Veterans Ave Biloxi, MS 39531
Another 4 week rotation. Housing is provided near the beach (rumored to be Rondel’s old beach house??). Inpatient workdays involve seeing 1‐3 patients before multidisciplinary rounds befor 8:30am. After rounds and lunch, you usually attend afternoon group therapy sessions, admit ER patients, and follow up from rounds until about 4:30. Some afternoons are spent in clinic, which also goes until about 4:30. Try to get the VA paperwork done as soon as possible, however the VA ID is notoriously difficult to obtain.
See more here: https://docs.google.com/document/d/1FGra93qO‐JBbIa‐4WoeXG5R5Gdy1UJ_‐_1Sx70w5x5I/edit?usp=s haring
RESOURCES, TEXTBOOKS First Aid for the Psychiatry Clerkship
This book is everything you need to know about psychiatry in 218 pages. It is dense but will give all major diagnoses classifications needed to do well on the shelf. Top resource for students.
Psychiatry Pre Test Self‐Assessment and Review Great question bank source and gives detailed explanations. This is a great resource and preparation for the shelf exam.
Case Files Psychiatry These 60 cases cover all the major topics of psychiatry and give you a general overview about diagnosis and treatment. Generally these cases and questions are easier than the shelf exam question; however, it is still great review.
USMLE World Question Bank for Step 2, Psychiatry Portion https://www.usmleworld.com/purchase.aspx There are about 150 questions in the UWorld Qbank for psychiatry.
NBME Exams Great review resource, questions on exams often are similar to these.
SURGERY Surgery is an intense 8‐week rotation. The OR requires Tulane clean green scrubs, which is the dress code everyday except Fridays when white coat attire is expected for lecture and conference. You are allotted two sets of scrubs from the scrub dispensers located in locker rooms on the 3rd floor of TMC hospital. The locker room code is 2719 for women and 1632 for men. You will need a user ID and PIN to access the scrubs, this can be found on Canvas. In addition, there are lockers available to store your belongings.
The access codes are: Men: 14 (40, 6, 34); 22 (33, 49, 43); 49 (5, 37, 35); 50 (7, 47, 41) Women: 28 (28, 14, 38); 29 (22, 34, 4); 30 (34, 12, 28); 37 (28, 18, 46)
Note: Children’s Hospital requires that you wear their scrubs. You will get these from them on your first day of rotation. They will only give you one set unless you ask for two!
LOCATIONS/SCHEDULE
8 weeks of surgery total, divided into 4 weeks at one location and 4 weeks at another site. Most sites require weekend work, but you should be given at least one day off per work on average.
GENERAL SURGERY LOCATIONS
Tulane Medical Center (TMC): TMC hosts Elective, Acute Care, Transplant Service, Cardiothoracic/Vascular, and VA services. In the mornings you will see your patients on the 5th, 6th, or 7th floors, or Outpatient Surgery or Surgical Intensive Care Unit (SICU) on the 3rd floor. The OR is on the 3rd Floor.
● Elective: Get there about an hour before rounds (which is at a different time every morning) to get the inputs and outputs for your patient and to examine them. You report to your intern, who presents the patient to the chief and attending during rounds. Then you go to clinic or surgery each day. You get a break for lunch during clinic, but if you have surgery, you may not get lunch (you are expected to go to clinic when you finish surgery). Sometimes clinic involves seeing and presenting, sometimes shadowing. You usually finish clinic at 4‐5 and then finish floor work. Hours are highly variable. Per one student, hours were typically 5 am‐6 pm. Practice being very concise. ● Acute Care (ACS): This is a time intensive site. Expect to arrive at 5:00am and stay until 5:00pm, 5‐6 days a week. As students your primary role is to update the patient list and perform wound dressing changes. The breadth of cases covered is extensive. Clinic is every Monday and Thursday afternoons with Dr. Brown, and your primary duty is to document the patient encounter. ACS is a particularly difficult service due to the time constraints so being efficient with your time is vital. ● CT/Vascular (Cardiothoracic and Vascular Surgery): The hours and workload are less than Acute Care. 5 am‐5 pm 5 days a week, no or minimal weekend work, and cases are not too long (1‐4 hours). Bread‐and‐butter cases are fistula placement, femoral‐popliteal bypass, and Coronary Artery Bypass Grafts (CABG). This service can get fairly specific as you do not get to see any abdominal surgery, but seeing a CABG and vascular repair is truly an amazing experience. Grading is pretty fair, but work outside of the hospital hours is required to keep up on the breadth of surgery knowledge for the shelf. Additionally, only 1 student at a time is on this service, so you will need to be assertive and prepare well for the cases if you want the surgeons
to take you seriously. Transplant: Arrive at 4:30 am. Obtain labs/updates for 3‐4 patients, get inputs and outputs for all patients on service (collective task with other students), and print round reports (collective task with other students). Resident rounds at 6 am. Floor work and either clinic or surgery for the rest of the morning. Attending rounds at 1 pm generally. We sometimes then had teaching sessions and other floor work responsibilities. Food is at cafeteria with no set time for lunch. Usually get out between 3‐5. You work one weekend in your month there (both days). ● VA: A very chill service. There are usually only 2‐3 patients so the day is fairly short.
Tulane‐Lakeside: Breast service. Good hours and a service that makes it easy to have face time with attendings. Run by Dr. Jones, an attending who is very relaxed and easy to work with. Overall a very well received service.
Children’s Hospital: Pediatric Surgery service. Per one student, you generally arrive at 5 am to see 1 patient and write up a SOAP note. Resident rounds are around 6:30‐7 am, followed by cases until early afternoon. Other responsibilities include seeing consults in the ER or other floors, taking out lines, and writing orders.
UMC:
UMC includes Trauma and Green services. Food is in the cafeteria. Parking is either in the parking structure (you must pay) or via shuttle from TMC.
● Trauma is a unique experience. You have to take call which generally goes something like “an AK‐47 just tore someone in half. Literally. Sew them together.” You arrive by around 4:45‐5 am. You write out the inputs & outputs, lab values, and vitals for each patient on the list and see your 1‐4 patients. You run the list with the interns around 6 am and then pre‐round with the 4th year resident and present the patients at 6:30 am. 7 AM is trauma conference. Then you either go into surgeries or round with the attending. Clinic is half day on Monday and all day Tuesday. Most elective surgeries are Wednesday and Thursday. In the afternoons/freetime, you do dressing changes, help with consults, and do floor work for the patients. Throughout the day, there are trauma activations so you run down to the ER. Dismissed anytime between 3 pm – 9 pm. Weekends are not necessarily off. Trauma call days happen every 3‐4 days and you take notes and help the intern during activations. You will also do at least one overnight each. Trauma is a lot of managing patients, but not always a lot of surgeries. ● Green is a newer service, and pretty light. You are expected to round on inpatients in the morning, usually post‐operative patients who are being monitored. There are surgeries scheduled for Tue‐Thu with varying attendings, and clinic once a week (day might be variable, Mondays as of this writing). You see mostly elective cases with all attendings, but some Onc cases with Dr. Hamner as well. Students get to do a ton, and work closely with the residents. Work on Mondays is variable, and students are expected to be on call for a weekend. Pretty light service overall.
West Jefferson: Excellent experience covering general surgery, oncologic surgery, and a lot of bariatric surgery, with attendings who enjoy teaching. Days begin around 6:30 am. After pre‐rounding and rounding with residents, you go to surgeries with Drs. Treen, Ballot, and Minnard. Residents do not scrub with, or see patients of Dr. Minnard. On Mondays and Wednesdays, you will attend clinic with Dr. Minnard. The only attending who evaluates you is Dr. Minnard, but you still need to attend cases with
the residents. Usually, you are allowed to leave around 4 pm. You will have access to free food almost daily in the doctor’s lounge. There is free parking in the outside lot or parking structure.
East Jefferson: This rotation requires you to work with colorectal surgeons and to follow patients with the residents that are assigned to the service. Students should prepare the list (rarely more than five patients) in the morning, usually by 6:30 or 7, depending on the resident’s preference. Students should try to cover the colorectal surgeries with the attendings assigned, but exceptions may be appropriate if a student is seeing a rare or unusual case. There are many surgeons at the hospital that will allow the students to scrub for cases. The breadth of exposure really depends on how much the student wants to do.
Baton Rouge: For this rotation you will be working for one month at Our Lady of the Lake (OLOL) or Baton Rouge General (BRG). Attendings are very friendly. The OLOL service is resident‐based and you will be working with LSU residents. The BRG service has more one‐on‐one time with the attending, as he does not have residents. You generally arrive around 5:30 am and see your patients (patients whose surgeries you scrubbed in on). The team meets at 6:30 am to pre‐round on the patients, and during the meeting, surgeries for the day will be divided among students. All cases need to be bird‐dogged by the student assigned to scrub into the case. Sometimes you help with floor work and consults, but you primarily attend surgeries. You leave around 5‐7 pm each night. You will be living in the residential portion of the Tau Center, the psychiatric ward at OLOL which is 5 minutes from the main campus of OLOL. At OLOL, use the free food vouchers (5 per week, each worth $6) for meals; occasionally the residents will take you with them to the Doctor’s lounge. If you are rotating at Baton Rouge General, you have access to the Doctor’s lounge and the free food there. Parking is free at both locations.
Lakeview: This is a relatively light service, and you are given freedom to participate in any surgery that you are interested in. The hours are from 7:00am until cases are done for the day (usually mid‐ afternoon). You will work with Dr. Wehrly (orthopedics) on Monday and Thursdays. On Wednesdays you will work with Dr. Hidalgo and he will also have clinic at 10:00am. On Tuesdays you will work with either Dr. Hidalgo, Dr. Gambrell, or Dr. Harkness (all general surgery) depending on who has cases that day. It is important to watch the OR board for their schedules. You will need to obtain an ID badge (from the HR office) and access to Meditech (from Sue) on your first day. Breakfast and lunch is provided in the doctor’s lounge (accessible with your ID), and parking is free. The commute to Lakeview from Tulane takes about 45 minutes but can be longer if there is fog (which are common). Note: Police are usually checking for speeders across the Causeway so beware of the speed limit.
RESOURCES
▪ Pestana Notes/Pestana Audio (Kaplan): A series of vignettes with diagnosis, treatment, and management. This is an excellent resource, the top resource for Shelf for Tulane students. Find Audio on Google Drive.
▪ UWorld QBank: Surgery has approx 150 questions, but it is a good idea to do Medicine GI and Renal questions, as they are very Shelf‐related. The shelf is very medicine‐based and management‐focused, so preparation for the exam needs to be more broad than surgical books alone.
▪ Surgery Pre‐Test: Very Shelf‐like resource used by many students in advance of Shelf. Broken
down by topic, so allows for focused study.
▪ Online MedEd: Videos going over algorithms and basic overviews on testable surgery topics. Useful resource, particularly early in blocks.
▪ Surgical Recall: the most concise preparation for the questions you’ll get on rounds and in the OR. Not useful for shelf.
▪ Abernathy’s Surgical Secrets: Only get this book if you are going into surgery. It is resident level material. Great for rounds or impressing your staff, USELESS for the shelf. ISBN‐10: 032305711X, ISBN‐13: 978‐0323057110
▪ NMS Surgery Casebook: Good for the shelf once you have run through other more foundational books. Walks through basic cases and variations upon the basics. It is most useful for learning about the variations on the basic ideas of surgery. Easy to read, case‐based structure. ISBN‐10: 0781732190, ISBN‐13: 978‐0781732192
▪ Some students like Case Files and Blueprints for this clerkship.
Other Resources:
▪ Sabiston Textbook of Surgery (via ClinicalKey). ▪ Schwartz’s Principles of Surgery (via AccessMedicine).
THINGS TO KEEP IN YOUR WHITE COAT
Penlight, pens, Maxwell’s, small notepad with removal pages, Surgical Recall and/or something else to read, phone, blank progress notes/orders, trauma shears (scissors), 4×4 gauze pads, alcohol pads, some form of bandage or tape (some like paper, some like cloth, some prefer the big 4” rolls), stethoscope (you’re the only who’s going to have one, and they expect you to have it), food (that’s what the inside pocket of your white coat is for).
Note: You’ll acquire all these things as you go, so don’t worry about having them on Day 1.
Required Rotations (non‐core)
2 Week: EM, Radiology, Outpatient Surgery.
4 Week: Ambulatory Medicine, Community Health
Electives are 3rd and 4th year rotations that are not a part of the “core” group of clerkships. One of the strengths of starting our third‐year rotations earlier than other schools is the ability to investigate areas of medicine outside the major clerkships before having to decide on what to do with the rest of your life. Elective rotations are either 2 weeks or 4 weeks long. Remember that 4 week long electives almost always offer a grade of Honors/High Pass/Pass/Fail, while 2‐week electives are Pass/Fail unless otherwise specified.
Students do get exposure to some specialties during their core rotations. For example, during Ambulatory medicine, students can ask to rotate in Gastroenterology or Cardiology. Alternatively, during the two‐week Outpatient Surgery, students can request to rotate in Urology, ENT, Orthopedic Surgery, Plastics, Ophthalmology, Breast Surgery and Hand Surgery.
Details on these rotations will be given at a later date, but this is a general overview for you guys right now, particularly those who need to select their 2 week elective after family.