Consult Services

The ID consult service at Duke and the VA provides specialist consultations for patients on all inpatient units. The patient population is therefore diverse. This diversity of patients, services, and clinical questions provides an excellent opportunity for trainees at all levels to learn infectious diseases. Duke enjoys a strong reputation for quality care, so our referral base is broad, providing numerous opportunities for teaching and patient care.

 

The consult service is organized to achieve the following goals:

The consult service is the heart of the clinical training year of the fellowship program. The service consists of four teams, typically staffed by an attending physician, a fellow, a senior resident from the Department of Medicine, and one or two fourth-year medical students. There are three consult teams at Duke Hospital and one at the VA Hospital. Two Duke-based services cover general infectious diseases and the third service sees patients who have had solid-organ or stem cell transplants exclusively. Each team usually sees several new patients per day and these patients are then presented to an attending on daily rounds. The attending staff rotate monthly, assuring the fellows a varied exposure to different teaching styles. The fellows work in 3-month blocks (consecutive months), yielding three-fourths Duke and one-fourth VA hospital rotations.

 

The fellow will be responsible for the day-to-day operation of the consult service and thus will take responsibility for the initial and continuing advice on infectious diseases diagnostic and management issues that arise. He or she will be expected to see the patients as soon as possible, to formulate a treatment plan, write a consultation note, and consult with the primary service regarding any actions or procedures indicated for the patient. The fellow will be responsible for coordinating with the attending physician any additional patient care issues. The fellow, with the residents and students, will make daily work rounds on all patients. All new consults should be seen by the attending physician within twenty-four hours.

 

On a typical day the fellow will see follow-ups and new consults in the morning. At 1:15 p.m. "plate rounds" begin in the clinical microbiology laboratory at Duke. The emphasis for this teaching exercise is to correlate findings from microbiology specimens with the clinical findings on respective patients. The consult team then has attending rounds covering the new patients and pertinent follow-ups. On the average, there are two new consults per day for each Duke rounding team and one to two consults per day for the VA Hospital rounding team. This allows the fellow time for in-depth study and literature review on selected cases. Night and weekend calls alternate between the fellows and senior residents (roughly 1 of 4 nights but when a resident is on call, one of the fellows serves as his backup at all times).

 

This organization places the fellow in a pivotal role in teaching and patient care, with support in each from the attending physician. The fellow assumes significant responsibility for patient care, which optimizes a fellow's learning opportunities. Attendings offer guidance in assisting each fellow's leadership of the consult service and carry the final responsibility for the service recommendations. The fellow will have a great deal of responsibility for the patients. The attending will have ultimate control of management decisions but will not act unilaterally without consulting with the fellow and housestaff.

 

Bedside teaching is emphasized. The fellows assume teaching responsibilities in the context of work rounds. A list of learning objectives has been developed, encompassing the major areas with which the trainee should be conversant by the conclusion of the rotation.

 

Learning objectives. At the conclusion of training, the trainee should be able to accomplish the following steps in a manner appropriate to the infectious disease in question:

The major conditions to be covered under the above objectives are:

Other objectives are as follows: The trainee should learn the elements of hospital epidemiology and infection control, as well as learning about the prevention of infections by immunization and by antimicrobials. Each first year fellow may attend the meeting of the Infection Control Committee, either at Duke or the VA. Specific projects may be identified in which the fellow will participate. If desirable, the fellow may elect to pursue a research track in infection control or hospital epidemiology in the second and third years.

 

Service teaching conferences will be led in most cases by the fellow. These conferences will be held in the morning prior to work rounds. Usually, the management of a current patient will lead to the choice of a topic for discussion. The fellow will be responsible for choosing the patient/subject. He or she will discuss the patient's problem in general terms and then focus on the management of the specific patient presented. Rationale for treatment decisions will be discussed. The fellow might also assist the housestaff and students by providing copies of pertinent journal articles. The fellow will be responsible for assuring that the teaching objectives are met and that the residents and students have the opportunity to accumulate the appropriate knowledge base before leaving the service.

 

Attending physicians will maintain ultimate responsibility for the ID Consult Service. They will make daily contact with the fellow to review the progress of the patients and to give their advice or thoughts on decisions affecting patient care. It is expected that the fellow would be allowed an increasing level of autonomy as his or her experience increases and expanding competency is demonstrated.

 

The clinical service is a demanding rotation, so there is little opportunity for trainees to participate in other activities while on this rotation. Potential problems for the trainees include the adjustments needed to cope with different situations and attending physicians throughout the hospital. The wide dispersal of patients throughout the hospital may cause logistic problems. Absences from the service can be very disruptive, so vacations should not be scheduled during heavy clinical rotations. All fellows are required to abide by the 80 hour work week.