How Fellows Can Add Value to Their Internal Medicine Residency Program

Cyrus Khan, MD, and Zachariah DeFilipp, MD
Published: Sunday, Apr 15, 2012
As hematology/oncology fellows, we work with colleagues from multiple specialties. However, the majority of our interactions are with the internal medicine service, so here we will help you to maximize the quality of your interactions with internal medicine residents. In the following paragraphs, you will find many ideas that if followed will not just help you to “do your time” during fellowship, but contribute to the internal medicine residency program. And who knows, you just might inspire a resident to pursue oncology as a career!

Generally, fellows work with internal medicine residents on the consultation service and on the inpatient oncology service. Thus, I will focus on these settings. At the end, there are also some general considerations that can be applied throughout your fellowship.

The Consultation Service

The consultation service is the bread and butter of the hematology/oncology fellowship. As a future consultant, you are expected to develop the skills necessary to become an effective and efficient team player. Remember, you have been consulted for clinical guidance in answering a question, no matter how simple it may seem to you. The following is a list of points to consider:

Do not belittle a consult. Residents are not born hematologists/ oncologists—there is a reason why they are consulting you. Belittling a consult only creates tension between the consultant and primary team. Treat every consult as a learning and teaching opportunity.

Understand the questions being asked. It is imperative to know what questions the consulting team are asking. This is best clarified by speaking to the primary team directly. Oncology patients frequently have multiple problems. You do not want to write a detailed note regarding management of lung cancer when help is requested to evaluate thrombocytopenia.

Establish the urgency of the consult. Once again, this is best established by speaking directly to the consulting team. As 7fellows, we receive many consults of varying urgencies. Triage is of utmost importance. A 5 pm consult for thrombotic thrombocytopenic purpura is very different from a 5 pm consult for a mild chronic anemia.

Gather all patient-related information yourself. For an effective consult, every piece of clinically relevant data must be known. If this requires calling different offices and physicians, it is far more efficient to do it yourself than to delegate it to the primary team. We are often searching for specific information from a hematology/ oncology perspective, which the primary resident may not yet be qualified to address. Not only is this a fellow’s responsibility, but it also expedites the consult, preventing the patient and primary team from waiting in limbo.

Communicate recommendations. When you’re finished writing your note, it is best to call the resident on the consulting team and verbally communicate your recommendations. Most training programs require that consultants not place orders on patients and instead allow the primary team to write all orders. This prevents multiple orders on the same patient and also serves as an opportunity for resident teaching. Speaking with the residents also results in quicker implementation of your recommendations. If you are unsure about the specifics of a recommendation, check with your attending before writing them down.

Do not offer unsolicited advice. It is important to understand your role as a consulting fellow. It may seem natural to comment on issues like electrolyte disturbances, hypertension, and diabetes with recommendations on how to correct them. This is especially true for first-year fellows who are just coming out of residency and are used to managing every aspect of patient care. These comments are often not welcomed by the primary team or other consulting specialties. Thus, it is probably better to stick with making recommendations specific to your expertise, unless there is a glaring issue.

Provide educational material. Providing an article addressing the consulting topic improves patient care and resident education. Not only will this give credence to your recommendations, but it will serve as testament to your commitment to resident teaching. The extra effort to provide education today may even save you an extra consult on a busy day.

Provide appropriate follow-up. Your role as a consultant does not end with the initial consult. It is your professional responsibility to provide appropriate follow-up until the primary team is satisfied that their question has been answered. Consultation can conclude when the primary team feels comfortable managing the issue for which you were consulted.

The Inpatient Service

Many programs have inpatient oncology, hematology, or bone marrow transplant services with resident and fellow coverage. The fellow serves as the junior attending and is encouraged to make decisions regarding patient care, as well as to take an active teaching role. It is important to make these services worthwhile for residents so that instead of considering the rotation a burden, they see it as an exceptional educational experience.

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