Consult Services/Outpatient Clinics
The ID clinical service aims to be the best consult service in the Department of Medicine at both Duke University Medical Center (DUMC) and the Veterans Administration Medical Center (VA). This requires excellence in three areas:
- Education of fellows, residents and students
- Patient care
- Clinical research
During the first month of the clinical year clinical fellows receive an intensive orientation. Faculty present tutorials on relevant topics tailored to meet fellows’ educational needs.
The clinical training year provides outstanding opportunities to study infectious disease at the bedside, through literature review and in the microbiology laboratory. The fellows lead the consult team and organize the daily activities. They teach students and residents at the bedside. They benefit and learn from the experience and teaching of the attending physicians, each with varied backgrounds and interests in diverse areas of infectious diseases.
Education of Fellows, Residents and Students
The clinical service must emphasize education with every patient encounter. This will include a daily review of the clinical assessments and management decisions of our students and residents. Students should be given both a systematic approach to infectious diseases and an opportunity to study individual diseases in depth. In addition to the regular conferences held by the Division, students and residents should undertake a reading program that covers the principles of antimicrobial therapy and the diagnosis and management of common infectious diseases.
All trainees are provided a reading list at the beginning of each rotation. In addition, faculty present a month-long series of tutorials covering a breadth of infectious disease topics in a small group format. Students should have regular reading assignments. In addition, students will receive regular lectures from the fellows concerning antimicrobial therapy and common infectious diseases.
Education of fellows and residents as practical, efficient and knowledgeable consultants will be a priority of each attending. Fellows should organize and present at least two clinical cases per week at the Thursday clinical conference and include a scholarly discussion of the literature on appropriate cases. Second- and third-year fellows should function should participate along with the attending staff.
Fellows should provide written assessments of all ID consultations before they are presented to attendings. At a minimum, these assessments should include an impression, a discussion and concrete recommendations. These comments should be reviewed by attendings, who may add additional comments. Students should not write their impressions, discussion and recommendations on consultation forms, but will be expected to know their cases in detail and to give a coherent, organized, oral presentation that includes their interpretation and impressions.
Consultants do not have to exhaustively recount the laboratory results that are already in the medical record or record a duplicate history; such repetitive data detracts from the effectiveness of consultation. An alternative model includes an abbreviated pertinent history, a discussion of the significance of pertinent diagnostic laboratory and clinical abnormalities, and then a diagnostic conclusion or discussion followed by concrete recommendations. All consultants should address the pertinent questions and provide useful assistance in management.
Fellows should communicate recommendations both in writing and in person to the ward team caring for individual patients. Writing a consult is not enough; person-to-person communication is essential and expected. Attendings should judge the adequacy of each consultation and point out deficiencies when they occur. When disagreements over management occur, fellows and attendings should personally attempt to reconcile these disparities with the ward team or consulting physician. Attendings should be involved in the follow-up management of critically ill patients.
Fellows are primarily responsible for deciding which patients will be seen in follow-up, the frequency of follow-up, and the intensity of supervision needed. Residents and students will participate in day-to-day follow-up of these consultations, but all primary decisions concerning management will be made by fellows with the approval of attendings. At a minimum, fellows should discuss follow-up decisions on a periodic basis with attendings. On-service attendings will always be reachable by beeper.
Fellows should become actively involved in clinical research projects during their first year. The goal should be to develop the basis for one to two clinical papers while in the first year of clinical rotation. Their research may include clinical case reports, a small case series, or a larger case-series analysis. Fellows finishing their first year of clinical rotation without accumulating any clinical data suitable for eventual publication will be considered to be performing at a below-average level.
Duke Requirements for ACGME Certification of Training
To fulfill the requirements for the Accreditation Council for Graduate Medical Education (ACGME) for training in infectious diseases and to maintain satisfactory accreditation of the training program, this Division expects the following specific elements of each trainee in the Duke program:
1) Completion of one year of clinical subspecialty rotations, with documentation by attending faculty that the trainee has developed competence in each of the objectives of the rotation. Satisfactory completion of supervised experience in:
- Inpatient consults
- Outpatient clinics
- Infection control and health care epidemiology
- Antibiotic use
2) Attendance and active participation in a majority of scheduled conferences:
- Interdisciplinary Infectious Diseases Conference
- Department and Division research conferences
- Journal Club
- Infectious Diseases Weekly Case Conference
3) Completion of an approved research project, with presentation of the results at a Division, Departmental or national meeting. Trainees are encouraged to submit requests for extramural funding from the NIH, CDC, VA and private foundations for support of their fellowships and for all fellows in the clinical year receive monthly evaluations, and all fellows in the research years receive twice-yearly reviews by both their research mentors and by the Program Director/Division Chief.