Hepatology Rotation Outline

  1. The team will always have 1 resident, intermittently 1 intern or 4th year medical student may be on the rotation as well
  2. The rotation is still formally defined as a consult rotation
    1. As such, the residents are eligible for an MROC during this rotation (attempts will be made to have mostly Friday and Saturday MROCs in order to prevent many absences during the week).
  3. A resident should follow up to 6 patients, an intern should follow up to 3 patients
    1. Goal is for the resident is to cultivate skills as a “junior fellow” or co-manager with the hospitalist service for patients admitted to the inpatient hepatology service
      1. The resident is NOT the primary provider for the patients. They continue to function in the consultant role, and the hospitalists continue to function in the primary provider role.
        1. Residents should NOT be placing orders in Epic unless this has been discussed with the hospitalist team first
      2. Residents are expected to perform all procedures (e.g. paracenteses) on their patients with the supervision of the hospitalist attending or the procedure attending
      3. Inpatients and consults will be delegated to the resident in the order that they come, but some effort can be made by the fellow (if the volume is high enough) to give more inpatients than consults to the resident.
      4. Also, the fellow should attempt to evenly distribute straightforward inpatient admissions (e.g. s/p TACE/RFA monitoring) to residents, interns, and themselves in order to keep the work-loads and educational opportunities balanced amongst the different members of the team
      5. If the resident is given consults, the fellow can make some effort to preference ICU consults over floor consults if possible.
      6. Ideal ratio is 4-5 inpatients + 1-2 ICU consults = 6 patients total
    2. Goal for intern/medical student is cultivate skills as a consultant
      1. The fellow should make some effort to delegate floor and ICU consults before inpatients to the interns/students
      2. Ideal ratio is 2-3 consults + 0-1 inpatients = 3 patients total
    3. A resident/intern cannot be assigned more than 3 patients in one day in order to promote conference attendanc
  4. It is expected that the residents are the main point of contact on the hepatology team for those inpatients being co-managed with the hospitalist
    1. Update the paging contact in Epic to reflect your name and pager number associated with the Liver team so the hospitalists know to contact the resident
    2. The resident is expected to discuss overnight events and plan of action for the day with the hospitalist each morning prior to the start of multidisciplinary rounds
  5. Multi-disciplinary rounds will begin at 11:00 AM if the attending has an afternoon clinic and at 1:15 PM if the attending has a morning clinic or does not have clinic
    1. Will be located in the hepatology/transplant unit on 4NE and 4NW in Mitchell
    2. Resident, Intern/Student, Fellow, Hepatology Attending, Hospitalist, nursing, transplant coordinator, transplant social worker, transplant pharmacist, and sometimes transplant surgery will all be present
    3. Will only round on inpatients being co-managed by the hospitalist service during multi-disciplinary rounds (consult rounds will occur separately)
    4. Will occur at the patients’ bedsides in order to involve floor nursing
    5. The resident/intern/student will be expected to formally present a one sentence assessment of the patient and the problem-based plan for the patient
      1. The presentation should be focused, but thorough; the goal of the presentation is to effectively communicate the plan for the entire medical team to ensure all members have been updated.
      2. Vital signs, laboratory data, etc. does not need to be included in this presentation unless it is critical to the plan
      3. The intention is to focus on all major medical problems, not just hepatology related issues during this presentation
        1. For example, if a patient needs his/her hypertension to be better controlled, the resident is expected to discuss a plan of action with the hospitalists and then present this plan on multi-disciplinary rounds
        2. If the resident has suggestions for management of a significant general medicine problem that has not been discussed previously, they are expected to propose these before or during rounds to the hospitalists
      4. The goal is that the resident will have full ownership of the patient’s plan when presenting to the multidisciplinary team
  6. Resident/s, Fellow, Hepatology Attending will also separately round on the consult service patients either before or after multi-disciplinary rounds
  7. It is expected that the residents work on the sign-outs for their patients with the fellow on Friday afternoons (prior to the start of the weekend)
  8. It is expected that there is a formal sign-out of patients between the incoming resident and/or intern and the outgoing resident and/or intern at the end of each 2 week block
  9. Example of workflow each day:
    1. Attending has morning clinic
      1. Arrive at 7-8 AM, resident will evaluate any inpatients who were admitted overnight and will pre-round on old patients
      2. 10:30 – 11:30 PM – Round on inpatients with just the hepatology team
      3. 11:30 – 1:10 PM – Morning Report and Lunch Conference
      4. 1:15 – 2:00 PM – Multi-Disciplinary Rounds
      5. 2:00 – 3:00 PM – Round on consult service patients
      6. 3:00 – 3:30 – Didactic session reviewing one of the core topics (below)
      7. 3:30 – 5:00 – Finish up notes and evaluate any afternoon admissions
    2. Attending has afternoon clinic
      1. Arrive at 7 AM, resident will evaluate any inpatients who were admitted overnight and will pre-round on old patients
      2. 9:00 – 10:00 – Round on Inpatients and Consult patients
      3. 11:00- 11:30 – Multi-Disciplinary Rounds
      4. 11:30 – 1:10 PM – Morning Report and Lunch Conference
      5. 1:10 PM – 5:00 PM – Finishing notes and evaluating late morning or afternoon admissions/consults
      6. 5:00 PM – 6:00 PM – Finish any rounding that has not been completed after rounds
    3. Residents will be expected to attend the Clinical Case Conference on Mondays at 5 PM, Hepatology Journal Club on Tuesdays at 4 PM, the Inpatient Management Conference/Radiology Conference on Thursdays at 3 PM, and the Multi-disciplinary meeting for transplant candidacy on Thursdays at 4 PM
  10. Didactic Sessions – Led by attending, can be a formal powerpoint presentation or wipe-board presentation, should be around 20-30 minutes in length, will focus on the following topics:
    1. Patterns of Liver Injury
    2. Outpatient Management of Hepatitis B and C
    3. HCC
    4. Drug Induced Liver Injury (DILI), NASH, NAFLD, OLT
    5. Wilson’s disease, Autoimmune hepatitis, Hemochromatosis
  11. Medical Student Rotation – Will plan to implement once the resident rotation is functioning smoothly. Offer a 2-week (or 4 week if the student desires) rotation on the blocks where there is no intern. The student will follow a maximum of 3 patients, which can be consults or inpatients. The student will also rotate in 2-3 of the clinics of the attending that is on service (if possible) in order to promote continuity in both the inpatient and outpatient setting.