Overview

The goal of the ID clinical service is to be the best consult service in the Department of Medicine at both Duke University Medical Center (DUMC) and the Veterans Administration Medical Center (VA). This requires excellence in three areas:

Education of fellows, residents, and students
Patient care
Clinical research

Each area is vital to the success of the Division. This document is designed to outline our objectives and goals for the clinical service and to assist us when we annually review our performance.

The first month of the clinical year is used for intensive orientation for incoming fellows. A series of tutorials is presented by faculty on topics that are particularly relevant to the clinical services. These are tailored to meet fellow-level needs.

In summary, the clinical training year provides outstanding opportunities to study infectious disease at the bedside, through literature review, and in the microbiology laboratory. The fellows lead the consult team and organize the daily activities. They teach students and residents at the bedside. They benefit and learn from the experience and teaching of the attending physicians, each with varied backgrounds and interests in diverse areas of infectious diseases.

Education. The clinical service must emphasize education with every patient encounter. This will include a daily review of the clinical assessments and management decisions of our students and residents. Students should be given both a systematic approach to infectious diseases and an opportunity to study individual diseases in depth. In addition to the regular conferences held by the Division, students and residents should be encouraged to undertake a reading program that covers the principles of antimicrobial therapy and the diagnosis and management of common infectious diseases. All trainees are provided a reading list at the beginning of each rotation. IN addition, a month long series of tutorials covering a breadth of infectious disease topics are presented by faculty in a small group format. Students should have regular reading assignments. In addition, students will receive regular lectures from the fellows concerning antimicrobial therapy and common infectious diseases.

Education of fellows and residents as practical, efficient, and knowledgeable consultants will be a priority of each attending. Fellows are expected to organize and present at least two clinical cases per week at the Thursday clinical conference and include a scholarly discussion of the literature on appropriate cases. Second and third year fellows should function as discussants along with the attending staff.

Patient care. Fellows should provide written assessments of all ID consultations before they are presented to attendings. At a minimum, these assessments should include an impression, a discussion, and concrete recommendations. These comments should be reviewed by attendings (who may or may not add additional comments). Students should not write their impressions, discussion, and recommendations on consultation forms, but will be expected to know their cases in detail and to give a coherent, organized, oral presentation that includes their interpretation and impressions.

It is not desirable for consultants to recount exhaustively the laboratory results that are already in the medical record or to record a duplicate history; such repetitive data detracts from the effectiveness of consultation. The model the Division should use includes an abbreviated pertinent history, a discussion of the significance of pertinent diagnostic laboratory and clinical abnormalities, and then a diagnostic conclusion or discussion followed by concrete recommendations. All consultants should address the pertinent questions and provide useful assistance in management. Fellows are expected to communicate recommendations both in writing and in person to the ward team caring for individual patients. Writing a consult is not enough. Person-to-person communication is essential and expected. Attendings should judge the adequacy of each consultation and point out deficiencies when they occur. When disagreements over management occur, fellows and attendings are expected to attempt, personally, to reconcile these disparities with the ward team or consulting physician. Attendings should be involved in the follow-up management of critically ill patients. Fellows are primarily responsible for deciding which patients will be seen in follow-up, the frequency of follow-up, and the intensity of supervision needed. Residents and students will participate in day-to-day follow-up of these consultations, but all primary decisions concerning management will be made by fellows with the approval of attendings. At a minimum, fellows are expected to discuss follow-up decisions on a periodic basis with attendings.

Attendings are expected to make rounds every day and to be available to see critically ill patients promptly. Attendings are expected to be on time for rounds and to change their schedules so that other duties do not conflict with rounds (or provide suitable coverage from colleagues). On-service attendings will always be reachable by beeper.

Clinical research. Fellows should become actively involved in clinical research projects during their first year. The goal should be to develop the basis for one to two clinical papers while in the first year of clinical rotation. Their research may take a number of forms, including clinical case reports, a small case series, or a larger case series analysis. Fellows finishing their first year of clinical rotation without accumulating any clinical data suitable for eventual publication will be considered to be performing at a below average level.