Resident Responsibilities

All Residents 

Rounds

• The chief will text the team the details for where and when to round the night prior by 8 PM

• In the morning, the whole team rounds together.

• There is no physical pre-rounding (except at chief's discretion for medical students). 

  • However, reviewing the chart and preparing the notes is encouraged.

  • It may also be necessary to call the nurse for an overnight sign-out and review any missing drain outputs or other concerning information in the chart

• The number of inpatients ranges from 0-10 - we do not keep any formal patient lists on paper

  • However, it is common for the junior resident to print a copy of the list for the team members

  • All primary service patients must be seen as a group, consults will be checked up on as needed

• Usually we start sometimes between 0700 and 0730 depending on the number of patients and schedule

• Residents who are operating should be down in pre-op by 0715 to complete the pre-op H&P, etc. by 0730

• After rounds, all patients should be verbally discussed with their respective staff as soon as possible

  • If there is a junior resident working with that attending, he/she will be the primary resident to review the pt with the attending and get whatever needs to be done, done

• At the end of the day, we also make evening rounds

  • Usually this can be done by whoever is done earliest - sometimes as a group

  • Evening rounds are a good time to get anticipated discharges teed up (complete the discharge paperwork, meds, etc.) to make things faster in the morning

  • Whoever rounds at the end of the day should check out with the chief resident in the OR and also the on-call person for sign-out

• In addition, if possible round with either the attending in the OR (if they are done), or the on-call attending, or the primary attending whose pts are hospitalized to co-sign our daily notes

Call

• Call at Oakland covers Oakland, Richmond, and the Vallejo call center (advice RN)

• Everyone shares call equally over their 5 years here

• The call schedule is made by the chief resident 3 months at a time

• Junior residents not on research (protected months) and not at Fremont/SF take Oakland call - so, yes, you take Oakland call when you are at outside rotations as an R2

• R4s at Oakland who are not on research and R5s at Oakland also take regular Oakland call

• The R5 will back up the R1s at all time and the R2s for the first 2 months until they are comfortable

• At any time, if a junior resident feels uncomfortable calling an attending (or has a hard time finding one) - please call a senior - we are all happy to help and have all been there before

• Call is from home

• Call runs from 5 PM to 8 AM the next da

• Over the weekend, call is taken as a cluster (Friday 5 PM to Monday 8 AM) so that you are free the other three weekends

• Weekend call does mean physically pre-rounding on in-house patients alone (although again the R5 may come and help newer residents as needed); The attending will then round with you in person 

• On the weekends, all pts (especially Dr. Gurushanthaiah's) should be seen by 9 am. Most attendings will want to review the patient's anticipated care of the weekend on Friday afternoon and also expect a call to update as needed over the weekend

• During off hours, we are NOT allowed to use the clinic for any patient care

• Richmond is a more limited facility so please be cognizant of this and consider transferring to Oakland for further care as appropriate

• Please take responsibility for the patients you are called on.  Sometimes you can ask others to help out, but in general you should see that patient through their care

• Call during the daytime goes through the on-call pager: 510-805-0089

  • The residents in clinic (typically juniors R1-3) should share this fairly

  • Ideally this should be held by someone who is more available (i.e. - not in procedure clinic)

  • The R1 or R2 should not have to carry this all the time either

  • If you see a patient as work-in from another clinic, please ask them to send an eConsult also to HNS (this our access time)

  • All inpatient consults should be reviewed with the chief resident the day of consult

• On Sunday evening by 8 PM, the resident on call should contact the chief to sign-out and determine the rounding plan for Monday morning

• The resident on call may also need to contact other residents as needed to make Monday morning run smoothly

Equipment

• Flexible scopes can be obtained either from clinic (will also need to bring heavy light source) or from the HNS equipment room next to OR1 (has portable/attachable light source)

• When using scopes from clinic, you will have to label them with a sticker containing the patient's name and MRN

• Flexible scopes in Richmond can be obtained in our HNS clinic

• When returning the scope, be sure to complete the paper log in the soiled utility room and leave a patient MRN sticker on the scope itself 

• Each resident is issued a spray bottle for scope use outside the clinic

  • Please be sure your spray bottle has your name on it

  • Remember to make sure the spray is not expired (change every 30 days)

• Spray bottles from the clinic rooms are not to be taken upstairs, but if they are, they need to be promptly returned

• Common HNS items such as merocel packs, instruments, trach tubes (preferably, use the ones stored on the floors or have material management bring one up to bedside for inpatients) can be found in the clinic storage closet

• Special sutures can be found either in the OR or clinic procedure room

• Again, return reusable instruments from clinic back to the clinic sink as we have a separate sterilization process

• 4% cocaine for use in nasal decongestion/anesthesia can be picked up from the inpatient Rx (next to elevators in hospital lobby) by an RN or MD

• We have a separate storage container for HNS use at the Rx - bring the MRN of the patient

Staffing

• All consults should be reviewed with a staff physician

• For daytime consults seen in clinic, this usually can be done by finding the P-phone attending for the day

• For inpatient consults, this should be addressed to the attending on call

• For overnight consults, the attending must be present for operative cases and should be apprised of any admissions (if in the middle of the night - call your attending and let them know)

• In terms of consults, the rules are technically that all pts should be reviewed with a staff member - and most of the time this can be done without issue

• If you are in doubt, its better to run it by a senior or attg just to make sure. Remember, we are here to learn and our attgs understand that

Pages

• All residents on service should respond promptly to pages. 

• While on call, be sure your pager is on with battery life. 

• During call hours, pages go directly to the resident on call. 

• During the day, team pages go to the team pager

Medical Records

• All operative reports should be written up after the case is over (there is a set amount of minutes after the case where at least a brief op note needs to be present - but aim to complete your op note immediately after the case as this is usually possible)

• All discharge summaries should be completed within 24 hrs (assigned to the person's signature that is on the discharge instruction sheets)

• Ideally junior residents who are most familiar with the patient should complete this

• All consult notes should be started immediately upon receiving the consult request and finished as quickly as possible after seeing and staffing the patient 

Procedure room

• The R2s and R3s have a once weekly procedure clinic - which is an opportunity to work on skills doing minor procedures such as skin/cyst excisions, earlobe repairs, etc

• Simple consults such as otitis externa, cerumen impaction, etc may also be routed into your clinic which will give you some experience with autonomy

• If at anytime you feel uncomfortable with what you have been asked to do (and trust us - all of us have) - do not hesitate to involve your attending of the month or the triage MD

• The R3s should proctor the R2s until they are comfortable

• We are working out details to help us “take back” some of these proc room appts so that we can schedule our follow ups or delayed closures on separate days without having to wait the current two month wait

Miscellaneous Clinics

• Every month (nearly) we have a variety of craniofacial clinics (regional panel, intake clinic, neurofibromatosis clinic, etc.)

• If there is a resident with the assigned staff, he or she goes along

• Otherwise, the most junior resident (or two) needs to cover the clinic and should make necessary arrangements

R1 responsibilities

• • Hold the pager and phone

  • Keep team updated on patient status, consults, discharges, etc.

R2 responsibilities

• • • Take ownership over steps of each surgery

      • Primary source, HNS preferences, videos, chatting with attg about steps, 3X surgical training

    • Take responsibility for clinic and procedure room patients, including follow up care

    • Manage PGY1: rounding, note accuracy, consults, teaching clinical and procedural care of patients

      • Could be main contact for most days but when PGY2 in OR then consider other options - next senior, P-phone attending, on-call attending

      • Two week training period

      • Refer to email for consult management

    • Sign in sheet

    • Prep notes

• • Competency with procedure room, and appropriate level cases (T&A, tubes, septum, turbs, trach, max antrostomy/ethmoidectomy, raise the ear and take a graft, MDL, pedi bronch)

  • Learn appropriate clinical management of common H&N disease processes.

R3 responsibilities

Overview:

As a PGY-3, you now have the experience of being on call by yourself for the later half of you PGY-3 year and are starting to get quite comfortably with most bread and butter consults from the ED and in the inpatient setting. This will serve you well because you will be on-call at roughly the same frequency as your PGY-2 year at other Kaiser sites. In addition, you will take on a bigger role for daytime consults since all consults will be filtered through you and it is up to you what you feel comfortable doing on your own. In addition, as a PGY-3, you will be expected to take on a primary surgeon role for a more diverse set of cases. It is your chance to work with new attendings who you have not worked yet with in order to both show off your skills as well as to see areas where you are still deficient. These attending MDs primarily work with us during this year so they will have a good gauge of where you should be at this level. Finally, this is the year where you really start to think hard about whether or not you want to do a fellowship and to start setting things in motion (research, contacts, case experience, etc...) should you confirm your desire to pursue fellowship as a PGY-4.

Clinical Responsibilities

• • Oversee PGY1s-2s for consults. See with them if questions.

  • Hold phone/pager if needed

  • If no higher level around, lead rounds when possible

  • Start intentionally directing your own learning

  • At other sites

    • See patients on your own

    • Know when to ask for help

    • Be a good ambassador of the program (on and off the field) - i.e. communicating pre and post rotation

  • If not on service, help set up education room (load computer, chairs, etc)

Technical Skills

• • Becomes competent at certain level appropriate cases

  • Some cases off the PGY-3 from 2016-2017 can recall but refer to ACGME for PGY3 level cases

  • Septums, trachs, FESS, microDL, certain steps of neck dissection (incision, skin flaps, LN dissection, in flaps (harvest skin graft, close donor site), mastoidectomy, cochlear implant, tympanoplasties

R4 responsibilities

Weekly education email

• On Saturday of the preceding week, send the education email to all residents and attendings

• Include GR, journal club, T-bone and any other resident education event 

Tuesday lunch hour education - "Case of the week"

• Each week, choose one resident to present a "case" - either a surgical case or a clinic problem

• For surgical cases, the resident chooses any case that he / she is preparing for that week

• The resident either creates or adds to a surgical case in our existing wiki 

• During the lunch hour, the resident presents what he / she has learned to the group and receives feedback  

Thursday morning education

• Organize and schedule all educational sessions taking place Thursday mornings, 7-9 AM

• We currently use a schedule called "Basic Science Review" - see Google Doc

• For COCLIA, just go here http://portal.entnet.org/aaohns_Portal/Education/COCLIA/portal/coclia/onlineguide/cocliamain.aspx and you can find the questions and photos

• For temporal bone teaching, discuss with Dr. Rasgon since Dr. Byl is no longer local

• Pretty much the attendings never come to BSR on the business meetings, which is every second Thursday

• Neurorads has had some fluctuations in their schedule; Contact them a few weeks in advance to confirm

• For path, I emailed Balram to be included on the email for the path schedule, which is always very consistent

  • We complied to review certain path topics is really good and will help focus the path sessions next year

• For the attending lectures, in the beginning of the year, review the topics with each of the attendings and come up with a list of talks they were willing to give

  • Talk with Tyler re talks about BPPV and TORP/PORPs, but I would give him a couple of months to prepare the talks

Organize inservice review

• Organize questions according to category 

• Edit questions, eliminate duplicates

• Divi up questions so that each resident has questions in all categories 

• Historically, the number of questions per resident varied by your seniority, so the seniors did the least and the juniors did more questions

How do you go about splitting the admin responsibility?

• Whoever is on service or split every 3 months or split into a 6 month straight block

Organize M&M&M

• • M&M&M is going to continue to take place during GR

  • Please make sure all residents are present during M&M&M 

  • Be sure to complete on time 

Plan the resident retreat

• Confirm the budget with PD and GME

• Pick the venue 

• Schedule with GME

• Send save the date and invitation 

Plan graduation

• Traditionally the 4th years plan graduation, 4th year roast, invites, coordinating venue, cake and food, collecting money, etc...with the help of Dr. Cruz and the GME office

• Be sure to get budgets from them prior to planning anything definitively

• Pick the venue 

• Schedule with GME

• Send save the date and invitation 

R5 responsibilities

Grand Rounds

• March/April of 4th year

  • Finalize GR dates for the entire academic year with Jalie/Deepak, which in general are 2nd Friday of Jan, April, July, Oct

  • Ask Joel/Antoinette (GME) to book conference rooms ASAP!

  • Ask if the WebEx can be setup in order to record video/audio

• May of 4th year

  • check with Cruz re: alternate GR, for example this year we had a visiting professor day and the year before it was Hilsinger's retirement

  • start contacting attendings and picking topics with them

  • once topics are decided, contact residents to have them sign up for talks (the more time to prep for the talk, the better)

• One month before GR

  • Finalize agenda and have Joel send out email

• In a stepwise fashion

  • • Things to make sure to do for planning. 

  • 1. Pick general topic for Grand Rounds

  • 2. Pick an attending who will co-host for Grand Rounds (they'll have to fill out some paperwork in order for GR to count as CME).

  • 3. Pick attending/resident speakers.

  • 4. Let Antoinette who the speakers are so she can sent them paperwork for CME.

  • 5. Confirm w Antoinette to get the webcast set up beforehand.

  • 6. Confirm w Jalie/Antoinette that a conference room has been setup. Make sure it's up to 1:30. Make sure to account for M&M&M.

  • 7. Confirm that speakers/mics are available.

  • 8. Send out emails to all northern california attendings (ask Antoinette to do this) regarding GR as the time approaches.

  • 9. If you have guest speakers, make sure to get them parking passes.

Resident Rotation Schedule

• March/April of 4th year

  • • Start planning next years rotation schedule with the program director and GME

• May of 4th year

  • • Finalize next years rotation schedule with the program director and GME

Call Schedule

• • May of 4th year - send out email to PGY2s to divide up holiday call

    • July 4

    • Labor Day

    • Thanksgiving

    • Christmas

    • New Years

    • MLK

    • Presidents' Day

    • Resident Retreat

    • Memorial Day

    • Graduation (I am adding this because it was an issue for us this year)

  • 2 months before start of block - send out email to residents for call schedule / vacation requests

  • 1 month before start of block - give Jun call schedule

  • We made one google calendar with call for the entire year to allow for vacation requests and PGY2 holiday call to be put on ahead of time.

  • Physically print out 2 copies of the 3 month google calendar and 1) highlighted those on call and handed it to Jun, 2) highlighted vacation/time off and handed it to Jalie

Resident Clinics

• • 1 month before start of block - touch base with Jalie re: resident clinics and divi up senior resident clinic

  • All residents should directly contact Jalie and the attending (in addition to making sure the chief / team are aware and the google calendar is updated) they are working with re: vacations, medical appointments, other time off, conferences, etc. 

Weekly Schedule

• • Saturday AM of the week before - send out DRAFT schedule for the week so that residents can approve / modify as needed 

  • Saturday PM of the week before - send out FINAL schedule for the week to all residents and attendings / PAs

Rounds

• • If possible by 8 PM night before - send out group text with rounding time and location for the next morning

Rotating medical students/Sub-Is

• Prior to the start of the rotation

  • • Email the medical student an orientation to the team that clarifies expectations and responsibilities as well as learning goals

    • Here is an example email that you may wish to use as a template

      • I'm ***, the chief resident here at the Kaiser HNS residency. 

        • We are looking forward to having you ***-***. 

        • This is my personal email address, ***. 

        • My cell is ***. 

        • Please text me your contact info. 

        • On Monday, expect to finish whatever paperwork and logistical things you need to take care of (parking, security, etc.). 

        • Once you are all set, head to the resident office, where you can find ***, our 4th year resident who will be in clinic. You can hang out in clinic for the day. When clinic is done, you can either head to the OR to meet me or round with our team and head home. *** will be in charge of rounding that day. 

        • Starting Tuesday, you and I will decide what you will do each day - either clinic or OR or both. 

        • Please email me what you are interested in and what you hope to get out of your time with us. 

        • My expectations are that you: 

        • - Have a good time

        • - Round with the team in AM and PM

        • - Take on some responsibility and ownership over patients - at least one patient to "pre-round" on each rounds

        • - Give one 20 minute talk during your last week on service during our Th AM education time - Alex or Lucas will coordinate this with you 

        • We tend to communicate via group text throughout the day to update each other re patient care, etc. 

        • Please let me know if you have any questions, 

• • Ask the medical students to get involved with picking cases they are interested in and making sure they are keeping track of the attendings they have worked with so they get well-distributed exposure to clinics/ORs

  • Specifically, if an attending is going to be on vacation, make sure they get time with them before/after they are away

  • Goals with rotation: The medical student should 

    • Attend all rounds

      • Prep the note for at least one patient during each rounds 

      • Be prepared by having supplies for patient care during rounds 

    • Operate with each attending at least once

    • Attend clinic with each attending at least once

    • Participate in specialty clinics, when possible