Medical Consult Service Orientation Welcome!!! Updated: APRIL 2018 Mirek Otremba, MD

Outline Structure of the service Schedule & Call Teaching & Feedback Clinics Misc.

Structure of the service Hospitals covered TWH – 2 residents max UNIV AVENUE = TGH (+PMH, TRI), MSH – 2-4 residents 🗣 – Discuss where elective students/residents will spend time Inpatient consultations Services requesting consults Surgery, Psychiatry, Gyne, OB (after 5/weekends) 🗣 - Discuss Common reasons for consultations Clinics Pre-op clinics – 3 sites OB clinic – OPG site – 700 University

Room 431 at MSH (Dr. Otremba’s office) Your space There is a room designated for med consult residents/students Room 431 at MSH (Dr. Otremba’s office) Sign out entry key from Patricia in room 431 and return at end of rotation Computer & phone available there Water/Fridge/Microwave/etc. available there Insert Title here

Requests for transfer of care & PESU at TWH At times, we will be asked to see patients on surgical services with the request for transfer to medicine TWH: For medical issues in psychiatry patients in ED, psychiatry will call med consults first 8-5, M-F and CTU team after hours and weekends/holidays Med consults will see and decide: A) Patient can remain under original service with our service following B) Patient benefits from GIM admission/transfer: discuss with MC staff and then GIM on call resident/staff and pass on information

Schedule 🗣 Review the on-call schedule – HOME call 8am-5pm – designated resident at UNIV and TWH RESIDENT RECEIVING CALLS ROTATES WEEKLY 5pm – 8am ONE ON-CALL RESIDENT COVERS ALL SITES Weekends: 8am – 8am Round only on sick patients (update signout list on FRIDAY with ‘TO SEE’) 🗣 Review the clinic schedule AM CLINICS – all UNIV AVE residents attend Huddle in AM & decide if all stay in clinic or cover ward/consults PM CLINICS/OB – one TWH resident attends

Obstetrics - MSH Dr. Shital Gandhi Pager 416 380 5557 Office 17-4857 OB medicine covers consults Mon-Fri 8AM-5PM Weekend/Evening coverage By med consults OB hands over any acute issues UNIV ave med consult staff reviews new consults/issues Hand over to OB medicine next AM Wednesday OB clinic (1-5pm) OPG – 3rd floor - 700 University Ave R3 level clinic – attendance required!

Teaching rounds schedule CanMeds 2005 Roles – Medical expert; Scholar Monday 8 AM – Harvey Rounds TWH 8th floor New East Wing – Cecilia Miller Conference Room Tuesday 8 AM – Evidence based rounds (🗣 REVIEW RESIDENT ASSIGNMENTS) MSH PAU classroom Wednesday 8 AM – Staff teaches rounds Wednesday 12 noon – Grand Rounds Thursday 8AM – OB Medicine Rounds 60 Murray St. 3rd floor Seminar room 4 Friday 8:30 AM – Bedside Physical examination Location rotates based on patient availability Friday noon once/month - OB medicine rounds OPG 3rd floor classroom A – see monthly consult schedule for details

Feedback Please seek out Feedback from staff on an on-going basis UNIV AVE Staff with the UNIV AVE residents TWH Staff with the TWH residents Competency by design - Seek assessments during your rotation 1 per week End of rotation evaluation at the end of the month with input from all staff

Sign out CanMEDS 2005 Roles: Communicator Sign out website Accessible through the med consult website (under Useful Links) consult.otremba.org Sign out login Use your Cerner/Powerchart credentials Secondary password: ‘consult’ Med consult website UN: consult PW: consult

Sign-out ETIQUETTE For ON-CALL - please indicate only MUST-DOs for known patients with issue overnight/weekend needing follow-up For new patients seen but NOT reviewed with staff add: NEW PATIENT - STAFF TO SEE For patient seen in clinic and needs follow-up add patient and location as PRE-ADMIT and date of planned surgery New consults to be seen following morning add patient to list as “NEW CONSULT – PLEASE SEE” Patients signed off but possible re-consult in future change location to SIGNED-OFF

Computer access & dictation Computer access & training required UHN – EPR (416 340 5091) MSH – PowerChart (416 586 4800 x 2100) Dictation UHN (416 340 4800 x 6000) OR via email MSH (416 586 4800 x 2649)

Suggest Orders At MSH suggestions should be placed electronically: Decide with the consulting service if you can order direct or as suggestions Suggest Orders – Medical Consult order allows you to enter suggestions to be activated later by the primary team Urgent/emergent orders should be placed directly so they are active without primary team needing to be contacted

Suggest orders/communication

MSH Suggest orders Insert Title here

Computer CPOE – TGH/PMH/TWH Leave your suggestions on paper orders Most patient care orders still on paper only Urgent orders to be placed directly into EPR

Half days, Lieu days, away time CanMeds 2005 Roles – Physician as a Manager Half-day Coverage Covered by another resident at the site or staff Academic sessions Staff/resident colleague covers Lieu days Arrange time with your colleagues/staff Doctor’s appointments & other away time Arrange coverage with your colleagues

🗣 REVIEW Contact information Staff contact information Ensure accuracy of resident contact information Elective student/resident contact information Admin - Patricia Davison 17-3823 Patricia.davison@SinaiHealthSystem.ca Director - Mirek Otremba 17-3016 Mirek.otremba@SinaiHealthSystem.ca

Optional information Role of the consultant Problems in consultation medicine

Role of the consultant – The 10 commandments (1/4) Determine your customer Ask the requesting physician how you can best help them, if a specific question is not obvious They may want co-management Establish urgency Emergent, urgent, elective

Role of the consultant (2/4) Look for yourself Be as brief as appropriate Need not repeat in full detail data that were already recorded Be specific, thorough, and descend from thy ivory tower to help when requested Do they need help order writing/entry

Role of the consultant (3/4) Provide contingency plans and discuss their execution Thou may negotiate joint title to thy neighbour’s turf Frank discussion defining which specialty is responsible for what aspects of patient care is needed Teach with tact and pragmatism Judgement on leaving references should be tailored to level of training and service

Role of the consultant (4/4) Talk is essential There is no substitute for direct personal contact with primary physician Follow-up daily Daily written follow-up is desirable When patient’s problems are not active, consultant should discuss signing-off with the requesting physician beforehand

Problems in consultation medicine (1/3) Based on Detsky’s article in your book Reasons for requesting Consultation Knee jerk/reflex reaction to a clinical entity Threat of litigation after an adverse event occurred Supervisor requests consultation even though residents do not feel it is indicated Resident or medical student requests consultation without knowledge of the attending staff

Problems in consultation medicine (2/3) Failure to Request consultation when help is needed Strategy during the consultation process Too many consultations – the Double Whammy Poor communication Holding the patient hostage

Problems in consultation medicine (3/3) Problems of Ego, Pride, and Embarrassment Consultee is embarrassed because of criticism contained in consultant’s note Consultant’s advice is not taken Consultant is told to mind his/her own business Request for help is viewed as a sign of weakness