MEDU-4157 - Acting Internship (Hybrid Nocturnal) in Inpatient Internal Medicine

MEDU-4157 - Acting Internship (Hybrid Nocturnal) in Inpatient Internal Medicine

Elective Title: Acting Internship (Hybrid Nocturnal) in Inpatient Internal Medicine
Course Number: MEDU-4157
Elective Type: clinical Duration/Weeks: 4 Max Enrollment: 6
Prerequisites: Successful completion of Year 2
Additional Requirements: Successful Completion of IM Clerkship; Students may request a specific ward team, email to Victoria Garcia ( All requests will be on a first-come, first-serve basis & are not guaranteed.
Responsible Faculty Director: Bernard Karnath, MD Periods Offered: 1-5 excluding holiday period 8 
Coordinator: Victoria Garcia Other Faculty:
Location to Report on First Day:
Sign up for a team before elective. Report to assigned team on 1st day of elective.

Develop independent thought process in evaluation, diagnosis and management of Internal Medicine patients. To prepare the student to function as a house officer.

(1) To improve and refine the ability to conduct an interview, perform a physical examination, compile a relevant problem list, formulate differential diagnosis, develop a thoughtful and thorough assessment, and prepare plans for the management of the patient. (2) To refine skills of the oral presentation of the new patient, and follow up patients, to the on-call house staff. (3) To practice and improve the interpersonal skills needed to address the social and psychological needs of the patient and the family. (4) To develop skills in creation and execution of an appropriate management plan for common medical problems. (5) To develop appropriate use of the medical literature as it relates to specific patient problems. (6) To become comfortable with an increased level of responsibility in the management of patients in a nocturnal setting on-call. (7) To coordinate care between daytime and nocturnal house staff.

Description of course activities
Daytime shifts: The student will function in a role analogous to that of an intern during the day shift from 7:00am to 5:00pm. Student will be able to enter orders into Epic EMR and will undertake primary clinical responsibilities for certain number of the patients on the team. Student will be responsible for admit H&P's and daily progress notes.
*Nocturnal Shifts: The student will function in a role analogous to that of a nocturnal intern. Student will be able to enter orders into Epic EMR and will undertake primary clinical responsibilities for certain number of the patients on the team. Orders must be signed by on-call house staff. The student will assist in the admission of patients from 5:00pm to 5:00am. Days off will be scheduled for the student in rotation with the house staff.
Students will generally work a 60-hour week during the nocturnal portion of this elective.

Type of students who would benefit from the course
Any student who plans on entering internal medicine residency who wishes to have experience and training in an on-call setting with patients with acute or chronic disease.

    Weekly Schedule
          Estimated Course Activities (Start-Time/Finish-Time):
Day of Week   AM   PM
Monday 5:00 (Nocturnal) & 7:00 (Day Shift) 5:00 (Nocturnal) & 5:00 (Day Shift)
Tuesday 5:00 (Nocturnal) & 7:00 (Day Shift) 5:00 (Nocturnal) & 5:00 (Day Shift)
Wednesday 5:00 (Nocturnal) & 7:00 (Day Shift) 5:00 (Nocturnal) & 5:00 (Day Shift)
Thursday 5:00 (Nocturnal) & 7:00 (Day Shift) 5:00 (Nocturnal) & 5:00 (Day Shift)
Friday 5:00 (Nocturnal) & As Needed 7:00 (Day Shift) As Needed 5:00 (Nocturnal) & 5:00 (Day Shift)
Saturday 5:00 (Nocturnal) & As Needed 7:00 (Day Shift) As Needed 5:00 (Nocturnal) & 5:00 (Day Shift)
Sunday 5:00 (Nocturnal) & As Needed 7:00 (Day Shift) As Needed 5:00 (Nocturnal) & 5:00 (Day Shift)

 Average number of patients seen per week: 10 - 12
 Call Schedule: Patients are admitted throughout the day

Research / Other Course 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?
    Approximately 4 Days per week.
  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?
    Internal Medicine faculty and residents.
  B. Frequency / Duration of Presentation(s)?
    Three to Five times per night shift
  C. Format - What guidelines are set for the student's presentation?
    Students will be expected to present historical and physical examination data as it relates to their patients.
  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)?
    Day Shift: Daily progress notes and 3 H&P's per week. Nocturnal Shift: Approximately 1 nocturnal H&P per night.
  B. Format - What guidelines are set for the student's written work?
    H&P format is used.
  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.?
    Relate to cases
  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)?
    Students are graded solely on their clinical performance.

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.

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 should meet with their resident at the end of each week for formative feedback. Feedback will include suggestions on how to improve verbal presentation skills, documentation in the electronic medical record (H&P's), ability to enter admit orders and knowledge gaps in patient management.

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.
    Day Shift: Full participation in patient care activities including morning rounds. Nocturnal Shift: Students are expected to admit 2 patients per night. Student are expected to document appropriately on their patients to include a full H&P at the time of admission and admit orders.

How specifically will this AI build on developing skills from the clerkship year to prepare students for internship?
    Students will participate in bedside procedures supervised by house staff. Bedside procedures include central venous catheters, thoracentesis, paracentesis, lumbar puncture, arterial blood gas sampling, venipuncture and insertion of peripheral venous catheters.

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)?
    Students will fully participate in the care of the patient from the time of admission to the time of discharge. Students on nocturnal shift will be responsible for reporting to the resident on-call. Student will generate a daily check-out list on their assigned patients. Students should read about their patients daily. Students will have the opportunity to suggest patient orders.

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?
    The Acting Internship rotation will allow the student the opportunity to fully participate in patient care. Student will be required to attend morning report during the daytime shift followed by morning rounds. Students on the nocturnal portion of this elective will be required to attend activities as determined by the house staff on service for the nocturnal shift. Written requirements are only related to direct patient care (e.g. admit H&P and overnight documentation as necessary).

How is the student demonstrating drawing clinical conclusions and/or developing a management plan and documentation as an intern would do?
    Students should meet with their assigned resident and faculty weekly. The Faculty will evaluate the students ability to present patients, document in the electronic medical record, and provide an appropriate assessment and plan for each patient. Students will have the opportunity to improve their skills based on their weekly and mid-point feedback.

How and by whom will midpoint feedback be provided to the student? How will you remediate deficiencies identified at midpoint?
    Day Shift: Students will make daily rounds and attend morning report. Students will have one day off each week.
Nocturnal Shift: Students are likely to work with 2 internal medicine residents during their 4 week experience. Students will attend nocturnal shifts from 5:00pm to 5:00am

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.
    Rotations are 4 weeks in duration with half the time spent on days and half the time spent on nights. Students will round daily from 8:00am to 12:00pm (noon) with faculty and residents during the daytime. During the night portion of this rotation, students will work with an upper level resident to admit patients and provide cross coverage. Afternoons are dedicated to completing tasks for patient care and educational sessions as time allows. During the nocturnal portion of this rotation, students are tasked with admitting patients and provided cross coverage. They will present to the nocturnal faculty for admit H&P's. Faculty will provide feedback on Oral Presentations and Daily Progress Notes, and H&P's whether working directly with faculty or residents.