Medical Consult Service Orientation

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

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

3. 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

4. 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

5. 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

6. 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 • ONE ON-CALL RESIDENT COVERS ALL SITES • Round only on sick patients (update signoutlist 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

7. 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!

8. Teaching rounds scheduleCanMeds 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 • MSH PAU classroom • 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

9. 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

10. Sign outCanMEDS 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 • consult.otremba.org • UN: consult PW: consult

11. 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

12. 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)

13. 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 Consultorder 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

14. Suggest orders/communication

15. MSH Suggest orders Insert Title here

16. 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

17. Half days, Lieu days, away timeCanMeds 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

18. 🗣 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

19. Optional information • Role of the consultant • Problems in consultation medicine

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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