Clerkship Responsibilities1) Order writing:
All M4 student orders require a co-signature. Orders should only be co-signed by your team (or by someone who is officially delegated to cover your team- i.e. a night float resident or an air-call resident). Your resident is generally your preferred option for all co-signatures. Interns on your team can co-sign basic orders at any time (examples: labs, non-contrast radiology studies, giving Tylenol for pain, etc…). However, any complex medical decision-making (such as tube feeds, PCA pumps, initiating antibiotics, starting heparin, ordering interventional radiology procedures, etc…) can only be co-signed by the intern if there is confirmation of that order from your resident or attending. This situation typically occurs when your resident has his/her day off. This rule will be strictly enforced. Failure to follow this rule may result in a failing grade. This is a patient safety issue, not a convenience issue. Discontinuing medication orders: powerchart does not allow senior students to write discontinue orders. This is being addressed and hopefully will be fixed by Cerner in the future. For now, only your resident or intern can write discontinuation orders. Your residents understand the problem, so don't feel bad when you are forced to nag them to sign the order. If there is a medication that needs to be stopped urgently and your resident is tied-up, then find the RN for the patient and verbally communicate the issue to avoid any extra doses until the order comes through on powerchart. 2) Cross Coverage:
On weekdays, the long call subintern on the 13th floor will cross-cover on other 13th floor subintern's patients until 700PM (same for 14th floor). The long call subintern will subsequently transfer care to the night float intern at 7pm. You may also be asked to cross-cover for your pgy1 interns patients during their days-off. On the weekends, cover-covering is at the discretion of your resident. Since you need all your orders co-signed, it creates extra work for the residents if subinterns cross-cover, and therefore, some residents prefer to let the PGY1 interns handle the calls. If you are motivated to get more x-cover experience- then specifically ask your resident about x-cover opportunities on the weekend. It is acceptable with your clerkship director if it's OK with your resident. Cross-coverage is a great chance for M4 students to get practice with independent assessments. However, after evaluating the patient, all decision making must be discussed with your resident. If you are asked by a nurse to see a patient on x-cover with a new problem- you should always write a brief note and find your resident to discuss the case. 3) Procedures:
Certain procedures are low risk and can be done without any resident or attending supervision. Examples: starting peripheral IV's and blood draws. All higher risk procedures must be supervised by your resident or attending. This includes (but is not limited to): ABG's, thoracentesis, paracentesis, NGT or feeding tube insertion, spinal tap, arthrocentesis, and central line placement. Procedure notes must be written and must be addended by the resident. 4) Daily Ward Responsibilities:
Your expectations are similar to the responsibilities of the PGY-1 interns. Independent history taking and physical exam is encouraged. Subinterns should attempt to come up with their own independent assessment and plan for each patient. You are expected to write the majority of the daily orders for all of your patients. You are expected to write a progress note everyday of the hospital stay, and you are expected to write discharge instructions, as well as discharge summaries for all of your patients (all discharge summaries should be sent to your residents for review and co-signature). While each M4 subintern should strive to have independent assessments and plans for all of their patients… it is essential that all final medical decision-making must be discussed with your resident and/or attending before orders put into action. Under no circumstances should a subintern evaluate a patient and proceed with medical decision making without the guidance of their resident or attending. 5) Delivering Bad News:
In general, subinterns should strive to be the primary physician for their patients. However, it is not fair (for the student or the patient) to ask 4th year students to deliver bad news alone. Certain diagnoses (new cancer diagnosis, HIV/AIDS, lupus, etc…) should always be delivered with the assistance (i.e. back-up) of at least the senior resident, or preferably (90% of cases) the ward attending or patient's PCP. This also holds true for end-of-life discussions, students should have a resident in the room with them as they counsel patients on DNR decisions. Under no circumstances should subinterns feel pressured to deliver bad news by themselves. In fact, delivering bad news without discussion with your attending (and optimally the patient's PCP) could be grounds for failure of the subinternship. If you would like to gain experience delivering bad news, then ask your attending to go with you into the room where they can observe and help out if the encounter becomes difficult (which it often does). 6) Staffing Services:
- Northwestern service: 1 attending, 1 resident, 1 or 2 interns, 2 junior students: maximum number of patients for sub I is four. It's acceptable to "over-cap" briefly to 5 patients if you are expecting to discharge that same day. But you should never carry more than 4 patients on a regular basis.
- Working with a hospitalist: You may be working with a hospitalist for 2 weeks. During the 2 weeks you will be working one on one with an attending. You will see patients and then make decisions with the assistance of the attending. Hospitalist: 1 attending, 3 senior students. Maximum number of patients is 6.
7) Histories and Physicals:
For all new patients (as well as ICU accept notes)… both the resident AND the subintern should write their own independent H&P's for ALL patients. Attendings should always addend the resident's H&P (not the student note). Subinterns are expected to write an H&P for every patient they pick-up (long call, night float, ICU transfers). Not every H&P needs to be a piece of art- these are working documents- do the best you can. M4 students need to practice writing efficient H&P's in order to be prepared for your pgy1 year. H&P's for NF patient can be shorter- but you must go back and clarify the basics of the PMH, meds, social history, etc… for each patient regardless of how they got on your service. 8) Dress code:
You should be professional in your behavior, as well as your attire. Scrubs are acceptable for long call days when you may be here late performing procedures. All other days you should come in professional attire.
Common issues: - ties are expected for men,
- open toed shoes are against hospital standards,
- patients should not be able to see your waistline,
- clean white coats are expected for daily activities,
- procedures are rare on night float admit days, dress clothes are expected (not scrubs).
9) Team expectations:
Every attending and every resident have individual ideas of how things should be run. There is no “right way” to run work rounds. The only way you know what they expect is if you ask them what they expect. Make your resident and attending go over expectations at the beginning of your rotation. Ask for regular feedback. Do not let the last day of the rotation become the first time you get feedback. | 
