Internal Medicine
Salem Veterans Affairs Medical Center
1970 Roanoke Blvd
Salem, VA 24153

(Revised 2-16-10)

Welcome to the Salem VA Medical Center! 

The inpatient Internal Medicine experience is an important and pivotal part of your medical education. In many ways, internal medicine is one of the defining clinical experiences for medical students. It will be challenging and hopefully a very enjoyable part of your medical education. On inpatient medicine, you will be an integral part of a treatment team. You will play a key role in evaluating sometimes seriously ill patients with complex medical problems and multiple co-morbid conditions. As a student, your goal will be to assist in the ward team in not just data collection, but in establishing a healthy and productive relationship with both patient and family. You will learn to interact effectively with nursing and hospital staff. This rotation is designed to contribute significantly to your growth and education.

Goals

To give the third year medical student the opportunity to excel in the discipline of internal medicine by providing an intensive experience on general inpatient medicine with a focus on direct patient care and teaching. The rotation is designed to give the student the opportunities to practice and master basic generalist competencies. Upon completion of this experience, the third year resident will be able to achieve the objectives outlined on the following page.

Objectives

1. Take a medical history and perform a physical examination including admission workup and follow-up care.

2. Formulate differential diagnoses by using history and physical examination data; use a prioritized problem list to select tests; apply principles of sensitivity, specificity, and pre/post-test predictive probabilities.

3. Record findings of an initial history and physical examination and prepare oral presentations of new and follow-up cases.

4. Interpret common tests utilized in internal medicine and proper use of sensitivity, specificity, and pretest probability.

5. Assess risk, benefits, and costs of treatment options; involve patients in decision making, select drugs within classes, design basic treatment plans, and use critical pathways when appropriate.

6. Plan, prioritize, and function efficiently in a hospital-practice setting by establishing rapport with patients and working effectively with house staff, faculty, nurses, and others.

7. Demonstrate expertise in researching problems by identifying key information sources and increase familiarity with information management by utilizing the electronic medical record.

8. Exhibit knowledge of basic procedures in hospitalized internal medicine patients.

9. Demonstrate an understanding of the principles of bioethics of care including professional ethical principles, advanced directives, informed consent, and patient needs vs. society as evidenced in their everyday interactions that are carried out in the practice setting.

10. See patients as fellow human beings that are in need -- although they are sometimes scared or angry -- of practitioners' concern and understanding. This understanding includes sensitivities to patients' racial, cultural, or religious diversities.

11. Apply the principles of preventive medicine.

Student Assignments (Wards Only)

Students will be assigned to an inpatient ward team. Each team will be supervised by a full time Hospitalist. Each team is usually composed of an intern, a resident, and an attending.  Each student will be assigned to patients under the care of that team. Each student will be responsible for four new patient work-ups per week, no more than two in a 24-hour period.  Students will be expected to take call with their team on admitting days. Unless patient loads dictate otherwise, students will be released from call coverage at or around 9:00 pm.

Weekly Work

Medical students are expected to work for no more than 80 hours a week. This includes the call days as well.  Please refer to the daily schedule for more details. The 10-hour rule as pertains to residents also applies to students.

Students will assist the house staff with direct patient care including daily rounding, documenting physical findings and response to treatment, and tracking ancillary test results.  Students will be expected to write daily notes on patients using the standard SOAP format.  Students will enter orders electronically on their patients which will then need to be co-signed by the resident or the attending. Students must inform the co-signers that orders are pending.

Teaching Sessions

Students will receive afternoon teaching sessions scheduled at the beginning of their clerkship conducted by the Hospitalists and Sub-Specialists. It is a great opportunity for you to have a one-to-one session with a Medical Sub-Specialist or Hospitalist. The sessions are held Monday through Friday from 2:30 pm to 3:30 pm in Building 143, Conference Room 3J-147, unless otherwise notified. The teaching session schedule is posted on the bulletin board in Room 147.

Lectures

Morning Report (11:00 am - 11:45 am) and Noon Lectures (12:00 Noon - 1:00 pm) are held Monday through Thursday for both residents and students in Building 143, Conference Room 3J-147. The Noon Lecture schedule is posted on the bulletin board in Room 147.

Medicine Grand Rounds are held every Friday in the Director's Conference Room in Building 74-Room 232 and start promptly at 7:45 am. Grand Rounds on the fourth Friday of the month is designated as an inter-disciplinary case conference. Students are expected to take advantage of these lectures and conferences.

Computer Access

The Salem VA Medical Center utilizes an electronic patient record system called CPRS (Computerized Patient Record System). This will require all incoming personnel to have computer access. You will receive computer training by an Information Technology Specialist and be issued computer access codes. The issuance of computer access and codes are contingent upon the completion of all required mandatory training and facility in-processing. It is imperative that you keep these codes confidential and observe VA information systems regulations.

USB Devices

Using or charging personal/unauthorized USB devices on the VA network is prohibited. Per VA Handbook 6500, USB devices include but are not limited to: thumb drives, external hard drives, game systems, digital cameras, IPods, MP3 players, etc. No personal laptops are permitted to be connected to the VA network. Unauthorized programs and devices that connect to the VA network create a potential entry for viruses and a way to get protected information out the door. This exposes our veterans to identity theft and other forms of abuse. If required for your job, VA authorized encrypted thumb drives can be requested through Information Management Security. Contact your supervisor or ADPAC for request procedures.

Pagers

You will be issued a pager for use in carrying out your assigned duties during your rotation at this facility. You will be responsible for carrying the pager with you at all times. This pager is the property of the VA Medical Center, Salem, VA and use of this pager is restricted to official purposes only. You are responsible for the proper use and care of the pager while it is assigned to you. Malfunctioning pagers should be turned in to the Residency Program Coordinator. If available, a spare pager will be issued until your pager is repaired. Damage by willful or gross negligence as defined in VA Handbook 7125 (5101-14) will result in a bill of collection for the cost of the pager. Replacement batteries can be obtained from the Residency Program Coordinator or the hospital operator. Pagers must be returned to the Residency Program Coordinator on the last day of your rotation at the VA.

Keys

Each student will be issued a T1 and D31 key - these keys open conference rooms, work rooms, and staff restrooms. These keys are your responsibility during your time here at the Salem VA. If you misplace or damage a key, you will be charged $10 per key for the cost of replacing the keys. This must be paid before a new key is given. Keys must be returned to the Residency Program Coordinator on the last day of your rotation at the VA.

Library

The Salem VA Medical Center maintains a Medical Library located in Building 77. All major journals and recent textbooks are available for study. The Library is open for general use from 8:00 am to 4:00 pm. However, access to the Library for after hours use and study can be arranged by contacting the Administrative Duty Officer in the Admitting Office. The house staff is available to assist with this if needed.

Living Quarters

UVA medical students will be housed in the dormitory on the second floor of Building 77. Students will be assigned living quarters and receive room keys through the Program Coordinator. This is a secure area, accessible by keyed elevator service. The Salem VA Medical Center Housekeeping staff maintains the living quarters. The living area offers kitchen and refrigeration facilities for food preparation and storage. A television lounge is provided which includes WI-FI installed by UVA for use by UVA students. Medicine students will share the living quarters with other students rotating on surgery and psychiatry. All dormitory residents are expected to keep living spaces clean, neat, and conduct themselves with respect for others' privacy and sleep time.

Meal Service

Students will be authorized a credit in the hospital canteen in the amount of $5.00 for breakfast, and $5.00 for the noon meal. Any amount purchased over the allotted $5.00 must be paid by the student at the time of purchase. You are not allowed to carryover meal amounts, e.g., if breakfast is not eaten, you cannot carry that $5.00 over to lunch.

You must be wearing your VA ID badge at the time of purchase. The Canteen Chief requests that you enter the Canteen on the Canteen side and that you sign the paperwork by printing your name and the amount of purchase legibly.

Weekday evening dinner meals are provided for medical students assigned to Internal Medicine wards. A box plate can be picked up in the Nutrition and Food Service Kitchen, Building 4, 1^st Floor between the hours of 5:00 pm and 6:50 pm. You must sign for your own box plate. You will not be permitted to pick up several for others who could not make it.

Students on Medicine Teams will be reimbursed for weekend designated calls as follows: Friday = $5; Saturday = $15; Sunday = $10. Reimbursement checks can be picked up at the Cashier window (Ground Floor of Building 143) the Wednesday after weekend call.

Urgent/Emergent Medical Care

If you become ill during the rotation or need to seek medical services during your rotation, you may do so through the Salem VA Medical Center Occupational Health Program located in Building 12, 1^st Floor.

Wellness/Fitness Center

A modern, well-equipped fitness center and gym are located on the ground floor of Building 77. This facility is open to students, residents, and staff. It provides a variety of aerobic exercise and health club equipment. An orientation to the Fitness Center must be attended prior to using the facility. Orientations and registrations will be scheduled on a regular basis and will be announced in the Daily Bulletin. Please be sure to adhere to all rules and regulations involving the Fitness Center. A copy of the rules and guidelines is included in your student packet.

Orientation

All students will receive an orientation tour of the facility given by the Residency Program Coordinator. Members of the Medical Service Line office will handle additional orientation issues.  Students will be required to have a briefing on infection.

End of Rotation Check Out and Debrief

At the end of the rotation, you will be expected to complete a critique of the rotation and meet with a preceptor to discuss the experience.

You must check with Neysa Luckado (Transcription Coordinator) to verify that all notes, discharge summaries, etc. entered into CPRS have been completed and signed.

You will also be responsible for returning your pager, keys, and ID badge to the Residency Program Coordinator.

The Education Department has requested that all students complete the "Voice of the Learner" survey during their rotation. A flyer is included in your packet that provides more information regarding the survey as well as the website address for accessing the survey. You must access this survey from a VA computer.

Conduct on the Wards

Promoting the Patient's Welfare

People surrender some of their autonomy and control when they become ill and enter the hospital. Hospitalized patients are in a position of forced dependency, unable to avoid situations which they find unpleasant or frightening. They often are so ill and feel so helpless that they are unable to speak out against situations or practices, which offend them in some way.

It is vital to your effectiveness as a physician that you appreciate your patient's predicament and seek to avoid any conduct that might be regarded by your patient as threatening, demeaning, or otherwise unprofessional. Attention to the details of propriety and good taste in both conduct and appearance is essential. Some behaviors that would be perfectly acceptable outside the hospital may seriously damage the patient-physician relationship in the hospital. 

While in the hospital all students must wear white jackets and official name tags.  Men must wear neckties and no one should wear jeans. 

Displaying potentially controversial opinions on clothing or backpacks, (e.g. buttons or badges), is not advisable.

Eating on rounds or in front of patients is prohibited.

The Salem VA Medical Center is a non-smoking facility.  Designated smoking areas are provided outside the building.

Your patients and their families must know who you are. You may have to introduce yourself several times to patients who are confused, disoriented, cognitively impaired or just overwhelmed by the number of new people they are meeting.

You should introduce yourself as a medical student, not as "Dr. ______."

Showing courtesy and respect to patients is very important. You must notify your patients in advance if they are to be visited by a group of physicians or presented in person at a conference to a group of physicians. Patient's objections should be respected. Knock before taking anyone into a patient's room, and introduce the patient and the visitor. Exercise caution in bedside conversations and avoid any language or behavior that might be stressful for the patient.

Do not address patients by their first names unless they have invited you to do so.

You should devote an appropriate amount of time to talking with members of the family about the patient's condition and progress. If you have any questions regarding issues to be discussed with the family, review them beforehand with members of the staff. Conflicting reports to the patient or family from different members of the health care team can cause undue anxiety; such problems can be avoided if the team is organized and communicating well.

Some patients will come to regard you as their primary physician. You may be the person who spends the most time with the patient and who has explained the most to the patient regarding their illness and management. Still, some medical information is best communicated to the patient by more experienced members of the team.  Initial discussion of a serious or life threatening diagnosis (e.g., AIDS, malignancy), a confrontational suspicion (e.g., malingering, self-induced illness, psychosomatic disease), or a diagnosis with legal implications (e.g., job associated, limiting future employability), is a challenge even for seasoned clinicians. Such patient interactions should be conducted only with members of the house staff or the attending physician present.

You must exercise great care regarding your conversations in public areas of the medical center (i.e., corridors, elevators, lobbies, and dining rooms).

IMPORTANT PATIENT SAFETY ITEM:

Please ensure that doors in designated locked treatment areas are securely locked/re-locked when entering/exiting the unit.