1. Art of ID Consultation ID Fellowship Orientation Paul Pottinger, MD, DTM&H July 1, 2011

2. OBJECTIVES Nuts & Bolts for:Nuts & Bolts for: UW Inpatient Consult Services UW Inpatient Consult Services UW Outpatient ID Clinic UW Outpatient ID Clinic General principles for consultationGeneral principles for consultation

3. CAVEATS You already know this….You already know this…. You can do this…. You can do this…. Yes it’s fun (“It’s Good to be the Fellow”) Yes it’s fun (“It’s Good to be the Fellow”)

4. ID Fellowship: Mission To create successful physician scientists in academic infectious diseases Outstanding clinical training Unmatched research opportunities

5. ID Fellowship: Structure Year 1: Clinical ID Training –Inpatient consultations at 4 hospitals

6. Year 1: Clinical ID Training –Inpatient consultations at 4 hospitals University of Washington Medical Center –General infectious diseases –Solid organ transplant ID –Oncology and stem cell transplant ID –MEDCON ID telephone consults 2 weekends UWMC SCCA / FHCRC ID Fellowship: Structure

7. Year 1: Clinical ID Training –Inpatient consultations at 4 hospitals University of Washington Medical Center –General infectious diseases –Solid organ transplant ID –Oncology and stem cell transplant ID Harborview Medical Center

8. Jeannie Chan, PharmD HMC744-5854jdchan@uw.edu Rupali Jain, PharmD UWMC598-4416rupali@uw.edu Pharmacy Support

9. ID Fellowship: Structure Year 1: Clinical ID Training –Inpatient consultations at 4 hospitals University of Washington Medical Center –General infectious diseases –Solid organ transplant ID –Oncology and stem cell transplant ID Harborview Medical Center Puget Sound VA WWAMI

10. MEDCON Docs in WWAMI region can call you 24 / 7…. Free “educational” serviceFree “educational” service They greatly appreciate your help, and will manage pts as you recommendThey greatly appreciate your help, and will manage pts as you recommend Please be nice… even if they don’t deserve it!Please be nice… even if they don’t deserve it! Please keep database updated.Please keep database updated.

11. MEDCON Docs in WWAMI region can call you 24 / 7…. VA fellow takes these calls when on duty.VA fellow takes these calls when on duty. On days off, UW ID fellow takes over.On days off, UW ID fellow takes over. Please run cases by UW General ID attending by phone if ANY doubt whatsoever! Calls tend to fall off over year… but calling is encouraged!Please run cases by UW General ID attending by phone if ANY doubt whatsoever! Calls tend to fall off over year… but calling is encouraged!

12. Clinical Microbiology Lab

13. ID Fellowship: Structure Year 1: Clinical ID Training –Inpatient consultations at 4 hospitals University of Washington Medical Center –General infectious diseases –Solid organ transplant ID –Oncology and stem cell transplant ID Harborview Medical Center Puget Sound VA Seattle Children’s Hospital

14. ID Fellowship: Structure Year 1: Clinical ID Training –Inpatient consultations at 4 hospitals University of Washington Medical Center –General infectious diseases –Solid organ transplant ID –Oncology and stem cell transplant ID Harborview Medical Center Puget Sound VA Seattle Children’s Hospital –Outpatient continuity general ID clinics

15. ID Fellowship: Structure Year 1: Clinical ID Training –Inpatient consultations at 4 hospitals University of Washington Medical Center –General infectious diseases –Solid organ transplant ID –Oncology and stem cell transplant ID Harborview Medical Center Puget Sound VA Seattle Children’s Hospital –Outpatient continuity general ID clinic Years 2 & 3: –Continuity HIV clinic Additional Clinic Opportunities Hepatitis STD TB Hansen’s VA Travel Overseas HIV Additional Clinic Opportunities Hepatitis STD TB Hansen’s VA Travel Overseas HIV

16. ID Fellowship: Didactics Early July of first year: 2 week introduction to clinical infectious diseases, with hands on microbiology course. Late July of second year: Principles of STDs training course, with lectures on HIV and STDs, and focus on research practices. ID board review and lectures for fellows every Wednesday throughout the year.

17. Citywide ID Clinical Conference Weekly case conferences on Wednesday afternoons provide an opportunity for fellows to present interesting cases, practice presentation skills, and get input from other ID practitioners on management. Different ID services rotate presenting cases: UW general ID, UW SOT, SCCA (oncology), Harborview ID, VA ID, Children’s ID. Didactic sessions for fellows precede or follow the clinical conference.

18. ID Consultant’s Dual Roles Provide Care Teach Physicians

19. “Mandatory” Consults? HIV pts at HMC seen by HIV service Scary in micro rounds (Certain MDRO’s, multiple + BCx’s, etc. Review caseReview case If care or plan sketchy, contact team and strongly offer consultationIf care or plan sketchy, contact team and strongly offer consultation

20. Think Like a Consultant Whose Patient is this? Name, Rank, & Contact info for callerName, Rank, & Contact info for caller Attending & ServiceAttending & Service What is the question? Diagnosis?Diagnosis? Management?Management? Mediation?Mediation?

21. Think Like a Consultant Urgency? Often fine to give preliminary rec’s and staff following dayOften fine to give preliminary rec’s and staff following day “My attending wants this staffed right now:” Please let your attending know, regardless of time of day“My attending wants this staffed right now:” Please let your attending know, regardless of time of day

22. Think Like a Consultant Please Remind Caller: In order to see the pt, we need a written request in ORCA: “Consulting ID for assistance with management of X”In order to see the pt, we need a written request in ORCA: “Consulting ID for assistance with management of X”

23. Think Like a Consultant Curbside? Generally NOT recommended… but it happens anyhowGenerally NOT recommended… but it happens anyhow ALWAYS offer to see the patientALWAYS offer to see the patient If you have to ask > 2 questions, it’s probably best to strongly RECOMMEND a consultIf you have to ask > 2 questions, it’s probably best to strongly RECOMMEND a consult

24. Think Like a Consultant Is this patient infected? If so, does the infection explain the syndrome? What are the host & bug factors here?

25. This is Your Service! “It’s good to be the fellow” Use your own style for teaching Attending always there to back you up

26. Dx Recommendations Consider Implications of Testing Want a biopsy or BAL? Instead of demanding them, suggest consultation with performing service to get their input… if they say no, your attending will make a call.Want a biopsy or BAL? Instead of demanding them, suggest consultation with performing service to get their input… if they say no, your attending will make a call.

27. Dx Work Micro Labs extremely helpful Notify them of tough cases before micro rounds M/W/F 11-12Notify them of tough cases before micro rounds M/W/F 11-12 You also have access 24/7… use it!You also have access 24/7… use it! Seek Primary Data Radiology, Path, OR… go where the data are!Radiology, Path, OR… go where the data are!

28. Abx Recommendations Drug Name Generic pleaseGeneric please Route Route Acknowledge access issuesAcknowledge access issuesDose May vary by indicationMay vary by indication Renal or hepatic adjustmentsRenal or hepatic adjustments Drug interactionsDrug interactions Prolonged infusions may be helpfulProlonged infusions may be helpful

29. Abx Recommendations Duration Stop date / criteriaStop date / criteria Monitoring Labs Troughs, CBC, CMP, ESR, etc Troughs, CBC, CMP, ESR, etc Guidelines at www.uwantibiotics.com Guidelines at www.uwantibiotics.comFollowup IV abx: UW ID clinic within 2 weeks when possible IV abx: UW ID clinic within 2 weeks when possible

31. RN Support at UWMC ID Clinic Please notify them with home IV plans…. 598-8788or598-7750orid_clinic@uw.edu Jeanne Wolf, RN Josette Pierre-Antoine, RN

32. Orders for Inpatients Generally we do NOT write them. Exceptions: Direct request from primary team by phone (usually orthopedics)Direct request from primary team by phone (usually orthopedics) Exotic micro lab maneuversExotic micro lab maneuvers Outpatient IV abx for 4-S patientsOutpatient IV abx for 4-S patients

33. Communication Pearls: Notes Initial Consults: “We have been consulted by Dr. X of service Y to assist in the management of problem Z.”“We have been consulted by Dr. X of service Y to assist in the management of problem Z.” ORCA templates saves time.ORCA templates saves time.

34. Communication Pearls: Notes Initial Consults: MS may write, but must forward to you; only their PMH, SH, FH counts!MS may write, but must forward to you; only their PMH, SH, FH counts! MD (you or resident) must write note; please oh please include ROS: “all negative except as noted in HPI”MD (you or resident) must write note; please oh please include ROS: “all negative except as noted in HPI” All notes then forwarded to attending for signature (not just CC’d).All notes then forwarded to attending for signature (not just CC’d).

35. Communication Pearls: Notes Initial Consults: You may dictate new SOT consults, and new UWMC consults on busy days (e.g. clinic days).You may dictate new SOT consults, and new UWMC consults on busy days (e.g. clinic days). IF YOU DICTATE:IF YOU DICTATE: 1) Call in your recs, and 2) Write a summary of your rec’s

36. Communication Pearls: Notes Followup Notes: Please write notes whenever clinical issues arise or a change in recommendations are made.Please write notes whenever clinical issues arise or a change in recommendations are made. We are emphasizing time-based billing… please stay tuned!We are emphasizing time-based billing… please stay tuned! Please discuss note plan with attending each day (who needs a note?)Please discuss note plan with attending each day (who needs a note?)

37. Communication Pearls: MD’s Get notes done ASAP, but call with rec’s before writing If they don’t like your rec’s…. Acknowledge primary team’s expertiseAcknowledge primary team’s expertise Frame rec’s with evidence & likely odds of success or failureFrame rec’s with evidence & likely odds of success or failure Recognize ideal vs. practical approaches, and offer alternativesRecognize ideal vs. practical approaches, and offer alternatives

38. Communication Pearls: MD’s “Honey vs. Vinegar” A teaching opportunityA teaching opportunity Take the high road (even 4PM Friday)Take the high road (even 4PM Friday) No chart wars EVERNo chart wars EVER Engage the attendings (yours & theirs)Engage the attendings (yours & theirs) Keep “off topic” rec’s out of writing (but DO discuss verbally)

39. Communication Pearls: Pt’s You are here at request of Dr. X for assistance with problem Y.You are here at request of Dr. X for assistance with problem Y. Be honest, but defer to primary team (no splitting!)Be honest, but defer to primary team (no splitting!) Remember, your classmate will probably inherit this pt in f/u.Remember, your classmate will probably inherit this pt in f/u.

40. Communication Pearls: What have you liked working with fellows?What have you liked working with fellows? What has cheesed you off?What has cheesed you off?

41. The Obvious Never fake it.Never fake it. ID attendings want to hear from you early & often, especially early in the year, or any time with urgent issues.ID attendings want to hear from you early & often, especially early in the year, or any time with urgent issues. Think about what you did and did NOT like from consultants as the primary doc.Think about what you did and did NOT like from consultants as the primary doc.