MEDU-4021 - Acting Internship in the Medical Intensive Care Unit

MEDU-4021 - Acting Internship in the Medical Intensive Care Unit

Elective Title: Acting Internship in the Medical Intensive Care Unit
Course Number: MEDU-4021
Elective Type: clinical Duration/Weeks: 4 Max Enrollment: 1
Prerequisites: Successful completion of Year 2
Additional Requirements: Successful completion of Internal Medicine clerkship.
Responsible Faculty Director: Mohammed Zaidan, MD Periods Offered: 1-7, 9-13 excluding holiday period 8 
Coordinator: Victoria Garcia Other Faculty: Alexander Duarte, MD
Location to Report on First Day:
Jennie Sealy ICU-8B & meet with the residents & pulmonary fellow between 7:30-8:30am to discuss daily workings of the MICU rotation

The elective is designed to allow the student to participate actively in the care of critically ill patients while interacting with multiple medical subspecialties. The emphasis of the rotation will be on bedside diagnosis and pathophysiology, and therapeutic intervention including advanced life support techniques. In addition, emphasis will be placed on the initiation of therapy based on the bedside diagnosis and physiologic abnormalities.

1. Improve skills in bedside physical diagnosis.
2. Be capable of correlating physical findings with physiologic derangements.
3. Gain knowledge in ordering and interpretation of appropriate laboratory tests needed to care for critically ill patients.
4. Have increased knowledge in resuscitation and support of vital organ function.
5. Know the indications for mechanical ventilation and oxygen therapy.
6. Be familiar with indications for, interpretation and implementation of invasive monitoring techniques. Be familiar with sophisticated medical electronic equipment.

Description of course activities
The student will round with the ICU house staff and faculty 6 days a week for the course duration; the student will mirror the shifts of the MICU residents. Two weeks of days and one week of nights is recommended, however, students may choose to do the three weeks during the day shift. Students are expected to work during all shifts, including University December Holidays. The student's role will be to manage jointly one or more patients with an intern. Students should pick up a couple of patients in the MICU and review their charts completely, then prepare to present them during the MICU rounds with the faculty. The students main role is to watch, absorb knowledge, and become a useful member of the team. The students will need to learn and adapt to help in whatever the team needs. This will take a lot of practice.

Students will work shift work along with the residents. The shift will be either 7:00am - 7:00pm or 7:00pm - 12:00pm (noon the next day) Monday - Saturday.

Type of students who would benefit from the course
This course is particularly valuable for students interested in Internal Medicine or acute care medicine, such as emergency or intensive care medicine.

Weekly Schedule
  Clinical Activities (estimated schedule)  
Day of Week   AM   PM
Monday 7:00am - 7:00pm 7:00pm - 12:00pm (Noon next day)
Tuesday 7:00am - 7:00pm 7:00pm - 12:00pm (Noon next day)
Wednesday 7:00am - 7:00pm 7:00pm - 12:00pm (Noon next day)
Thursday 7:00am - 7:00pm 7:00pm - 12:00pm (Noon next day)
Friday 7:00am - 7:00pm 7:00pm - 12:00pm (Noon next day)
Saturday 7:00am - 7:00pm 7:00pm - 12:00pm (Noon next day)

 Average number of patients seen per week: 12
 Call Schedule: Every fourth night.

Research Activities (estimated schedule)
Activity Hours per Week
Faculty Contact-Time
Self-Directed Study

Method of Student Evaluation
1.  Clinical Observation
  A. Where are students observed on this elective?
    Inpatient Service   Ambulatory   Surgery   Standardized patients
Patients simulators   Other
  B. Frequency - How often are students observed clinically?
  C. Format - What method(s) are used to document the student's clinical performance?
    Daily oral feedback   End of period oral feedback   Written feedback

2.  Oral Presentation
  A. Audience - To whom does the student present?
    Attending physician, ICU fellow, ICU house officers, respiratory therapists, nurses
  B. Frequency / Duration of Presentation(s)?
    Daily bedside presentation of their patients
  C. Format - What guidelines are set for the student's presentation?
    Standard oral format, emphasis on organ system function
  D. Assessment - Who assesses the student's presentation performance?
    Self-assessment   Peer assessment   Faculty assessment
  E. Method of content selection
    Current cases  Student-selected topic   Assigned topic

3.  Written Assignment (H&P's, notes, papers, abstracts, etc.)
  A. Frequency of written assignment(s)?
    Daily notes and H&Ps on new admits assigned to them
  B. Format - What guidelines are set for the student's written work?
    H&P: Standard Dept of Medicine format. Daily notes are typed on computer using daily note template
  C. Length of written assignment(s)?
    Abstract   Annotated bibliography   1 - 2 page paper   3+ page paper
  D. Are recent references required?   No    If yes, how are they selected?
  E. Method of content selection - e.g. student-selected, relate to cases, etc.?
    Related to their patients
  F. Audience - Who assesses the student's written performance?
    Peer Assessment     Faculty Assessment     Other

4.  Examination
    Oral   Written multiple choice   Written essay / short answer   OSCE

5.  Extra Course Activities
  What expectations do you have for the student to demonstrate participation in the elective (e.g. small group activities, seminars, thoughtful questions, providing resources, journal club, resident lecture attendance)?
    This is a clinical elective. Students are expected to participate in all facets of the care of the critically ill patient.

6.  Additional Costs
  Please list any additional costs and/or purchases (books, materials, movies to watch, etc.) that are required for this course. Include an estimated total cost. If there are no additional costs, please enter "None".

7.  Other Modes of Evaluation
  Please explain below.
    The evaluation will be subjective by faculty staffing the ICU based upon the student's ability to:
1. Perform a complete history and physical examination of the acutely ill patient and to arrive at a reasonable differential diagnosis.
2. To appropriately order and interpret laboratory tests.
3. To explain the pathophysiology of various disease states.
4. To explain the indications for oxygen therapy, mechanical ventilation and invasive monitoring.
5. To interact with medical staff, faculty, consultants, and allied health professional assigned to the MICU.
6. To interact with family members of acutely ill patients.
7. To consider financial and psychosocial needs of acutely ill patients and their families.

8.  If this course is an Acting Internship, please complete the following:
  A. Objectives for the AI should relate directly to the Entrustable Professional Activities (EPAs). Each AI should describe how the four key Year-4 EPAs that our school has identified as being Year-4 skills are assessed. The Year-4 objectives are:
1. Entering and discussing orders/prescriptions.
2. Give or receive patient handover to transition care responsibility.
3. Recognizing a patient requiring urgent or emergent care and initiating management.
4. Obtaining informed consent for tests and procedures.
Specify how the student will be given formative feedback on their clinical skills.
    Students will have direct performance-based observation and feedback from faculty, residents and fellows while interviewing appropriate patients/family members and caring for critically ill patients in order to teach and reinforce clinical and communication skills the in care of these patients.

Year-4 students should demonstrate mastery of EPAs they developed in the clerkship year, including recommending and interpreting common diagnostic and screening tests, and performing general procedures of a physician. They should be able to demonstrate masterfully and independently skills they mastered in Years 2-3, including efficiently performing comprehensive admission-notes and succinct daily progress notes and perform accurate, concise, and hypothesis-driven clinical presentations, form clinical questions and retrieve evidence to advance patient care. They should be able to demonstrate basic understanding of and beginning mastery of collaborate as a member of the interprofessional team and identify system failures and contribute to a culture of safety improvement.

List advanced clinical skills that a student will be assured an opportunity to practice.
    1. Obtain accurate and relevant histories from critically ill patients and from secondary information sources.
2. Physical exam of the critically ill patient. Includes mechanically ventilated and delirious patients.
3. Appropriately weigh recommendations from consultants in order to effectively manage patient care.
4. Teach and model professional interaction with all members of the health care team
5. Improve trainee skill and comfort with technology required in the intensive care unit.

How specifically will this AI build on developing skills from the clerkship year to prepare students for internship?
    1. Elicit concerns and responds to patients emotions.
2. Placement of peripheral IV and arterial lines when desired and when appropriate.
3. Initiation of noninvasive or mechanical ventilation; intubation.
4. Advanced technology or diagnostics: PAC, ultrasound, vasopressors, noninvasive monitoring, IABP, bronchoscopy, etc.
5. Honoring choices and rights of patients in a non-judgmental way.
6. Code blue.
7. Managing challenging ethical dilemmas and conflicts of interest.

What opportunities will typically be available to all students who take this AI (procedures, required presentations, etc.)? What opportunities may be available based on patient load/presentation or student initiative (ie. Writing a case report)?
1. Timely and accurate follow up of results and procedures for team to discuss and make medical decisions.
2. Presentation on rounds of patients.
3. Presentation of learning issue related to patient care to team.
1. Not expected to perform or interpret advanced procedures: pulmonary artery catheter, intubation and ventilator, leading end of life discussion or codes.

An AI should have expectation of a minimum of 32 hours per week of clinical responsibilities. Duty hours should be capped at ACGME limits for an intern, thus up to 24 hours followed by 4 hours of activities related to patient safety, education, and handoff. Students cannot work more than 80 hours per week averaged over 4 weeks. They can only have 1 day off in a 7-day work week with 8 hours off between shifts.

Clinical responsibilities will vary depending on specialty, but how is the student functioning with work commensurate to a PGY1 with an appropriate level of training?
    Acting interns will be exposed to care of critically ill patients in a collaborative fashion with specialty trained critical care physician. The goal at the end of the rotation is to improve their knowledge of common treatment modalities for critically ill patients, teach and model an organized approach for the diagnosis and treatment of critically ill

How is the student demonstrating drawing clinical conclusions and/or developing a management plan and documentation as an intern would do?
    Deficiencies are identified by either the student or faculty together during daily or midpoint feedback. A plan is formed collaboratively at the time of identification of the deficiency to determine the best course of remediation.
Ex. Knowledge deficit identified may be remediated by having the student present a case conference on the issue for a frank, open group discussion by the team. The salient issue could be a diagnostic dilemma, a therapeutic quandary, or unusual or unforeseen turn of clinical events. The fellows select cases with elements of uncertainty. The act of choosing an appropriate case for discussion at the Clinical Case Conference engages the student to identify a set of circumstances beyond their current level of knowledge and expertise. The topic to be presented is reviewed with a faculty member prior to presentation. The venue is an interactive format between the student, resident and faculty. The presenting student facilitates the discussion of the case, and is encouraged to provide the results of literature searches. After presentation of the case, the faculty and fellows engage in ad hoc analysis of the case during which problematic issues are recognized. The student and team develop an appreciation about which levels of their dynamic cognitive process offer opportunity for improvement. Various methodologies for self-improvement are identified and set into motion.

How and by whom will midpoint feedback be provided to the student? How will you remediate deficiencies identified at midpoint?
    Faculty rotate every 14 days bedside rounds. Bedside teaching occurs based upon patient care. Attendings and Residents teach. There are primary literature article twice weekly. There is brief, teaching bullet points shared by resident on rounds. There is an evaluation of trainee and feedback provided by attending on daily questions, comments, and discussion regarding patient care and application of knowledge while on bedside rounds, during didactic sessions, and during patient admissions. There is 2 weeks or a midpoint for formative feedback that is provided by the critical care attending. There is an evaluation form that reflects the curricular learning objectives The trainee is asked to give feedback addressing their:
1. Learning/knowledge
2. Clinical rounds
3. Didactics, including mock codes and journal club Ability to achieve personal learning objectives
4. Skills germane to ICU arena
5. Acid base
6. Shock management
7. Hypoxia/SOB management
8. Code blue skills
9. Family communication
10 Patient presentation skills
11. Line placement
12. Supervision and independence
13. Attendings
14. Interaction with nurses
15. Suggestions for improving the rotation.

Acting Internship students often seek letters of recommendation following their experience. How many different Faculty will work directly with the student and have knowledge of the student's abilities to detail in a written evaluation? Describe the degree of supervision and interaction with faculty vs. residents or other providers and how feedback will be obtained if more direct work is with residents or other providers.
    The MICU faculty will rotate every week. During the three week rotation, the students will work with 3 faculty. The written evaluation will be developed becoming feedback from the faculty, pulmonary fellows and the residents. The students will get different types of supervision. The students are responsible for patient presentations every morning during rounds. They are to do their best to formulate a plan of care, with assistance of the residents or fellows. The faculty may also test general medical or physiological concepts. The fellows and residents will have more direct daily interactions and patient management with the students. This potentially includes participation in bedside procedures.