See the following review on Hypertriglyceridemic Pancreatitis:

• American Journal of Gastroenterology VOLUME 104 | APRIL 2009

Set the tone of the team:

• establish goals with each team member
• determine responsibilities – daily and overall
• establish limits
• make decisions based on substance, not style

Team manager:

• keep track of time during rounds – there should be some teaching but it isn’t time for a 20 minute discussion on a subject
• help your interns prioritize their scut list
• give tasks to the medical students

Patient care: oversee the process, try not to micromanage unless it’s called for

• keep your own scut list
• flag new orders, new results, new anything really so you always know what’s going on with each patient
• check d/c summaries and med recs
• make yourself available, especially at the start of the year with new interns
• try to let the interns put in all the orders – if you do order something, remember to let the intern know! it’s their patient, too.
• remember to establish with each attending whether you or they will be alerting PCPs to new admissions
• remember: in the end, it’s your responsibility!

Teaching:

• contribute your expertise without letting a perspective dominate
• pick a few 2-minute teaching points for rounds each day
• ask clinical questions during rounds, even if you don’t know the answer – look it up or send a good review or study later
  • assign the med students things to look up for the next day
• look through EKGs and CXRs on rounds – have someone different read them each day

Feedback:

• give timely feedback – in the moment even – don’t wait until the end of the rotation
• give specific feedback with action plans for improvement

Key teaching points:

• Protease inhibitors and NNRTIs can cause transaminitis, or worsen existing hepatitis
• Acute CMV can present in many ways,  including as a hepatitis. It differs from EBV and MAI, which can also present with hepatitis, in that it does not necessarily present with lymphadenopathy as EBV and MAI would.
• Treatment with ganciclovir is only indicated in severe disease with hemodynamic compromise or CNS (including retina/eye) involvement
• Counsel patients on transmission via bodily fluids and potential for congenital defects (hearing loss most commonly, but can be severe with multi-organ involvement) with maternal transmission of primary or existing infection trans-placenta or via breast feeding
• Think about reactivation of existing infections as well as acute primary infections in patients with advanced AIDS who are started on ART causing an immune reconstitution inflammatory syndrome (IRIS). Always try to continue ART through IRIS, although this may not be possible in life-threatening infections or complications of drug therapy.

Here is a nice review of drug allergy/hypersensitivity reactions.

Kikuchi’s disease is a rare disorder characterized by fever and lymphadenopathy and diagnosed by lymph node biopsy showing necrosis and histiocyte invasion. It is self-limiting. It has been associated with EBV, although no definitive causality has been established.

Education – A very frightening thing for new juniors. Also known as, “How can I teach when I don’t know anything?”

• Safe environment for learners – empower people to ask questions and to be wrong
• Be practical – teach EBM in small spurts – for example, 2 minute presentation on rounds rather than 15 minute lecture
• Make handouts – include small, digestible pieces of information for interns
• Email resources to your team – email appropriate amount – don’t send 10 papers at a time to your team
• Teachable moments – not every patient is a case report, but there are things to learn from the mundane problems
• Teach to your interns’ interest – if you have someone who loves GI, give them more GI cases or have them do small presentation on interesting GI case
• Consultants – set up times to meet with consult team and have them teach you
• Encouragement – don’t be afraid to let people know they are doing a good job, especially on a tough day

Manager – One critical role as a resident is managing your team effectively

• Set a good example by conducting yourself professionally. Model good behaviors for your team, as they are all looking up to you.
• Managing Up – setting expectations with your attending about how you want to manage your team (times for work rounds, PM rounds, attending rounds, etc.)
• Managing Down – setting clear expectations with your interns about their responsibilities.  What should they manage on their own? What should they call you about?
• Workflow – teaching your interns how to get stuff done in the safest, most efficient way possible. The system is complex, so don’t short-shift this one!
• Accessibility – be accessible to your interns, especially early in the year. Some recommended working in close proximity to one another. If not, at the very least be responsive in answering pages
• Students – Be very explicit about what you want from them, as they know very little about medicine and how things work. If things are overwhelming between interns and students, ask your attending or the chief residents for help! And please remember to send them home when the work is done.
• Be Supportive – Don’t hang your interns out to dry if they are being annihilated by a consultant or someone else

Thanks to everyone who participated. There were tons of good ideas brought up by all of you. Get ready to expand on those ideas on Friday in small groups sessions. And one week from today, get ready for “How to Be a Bad Resident”, alternatively titled, “Airing of the Grievances”.

Subclavian Stenosis Epidemiology paper in JACC - http://content.onlinejacc.org/cgi/content/full/44/3/618

36 year old Haitian F with pmhx signficant for pseudotumor cerebri, R thyroid nodule who presented with fevers x 3 weeks and bilateral cervical lymphadenopathy.  Exam notable for bilateral enlarged cervical & supraclavicular nodes (largest 3 x 5 cm) with labs notable for normal WBC count with lymphocyte predominance and elevated ldh.  Full infectious workup including HIV & Tb studies negative as well as connective tissue disease workup which was negative.  Eventually, CT c/a/p performed notable for diffuse lymphadenopathy leading to a bone marrow biopsy which ultimately revealed acute lymphoblastic T cell leukemia with 53% blasts confirmed by excisional biopsy.  She was treated based on the ECOG2993 protocol but ultimately never achieved complete remission and passed awy.  Teaching objectives included fever of unknown origin and acute lymphoblastic leukemia.

Fever of Unknown Origin: http://www.ncbi.nlm.nih.gov/pubmed?term=9284789

Acute lymphoblastic leukemia (t-cell): http://www.ncbi.nlm.nih.gov/pubmed/19828704