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July 3rd, 2013

First Year ID Fellows — What Do They Learn, and What Do They Hate?

In the weird calendar of academic medical centers, July 1 is the “official” first day of school.

In our ID program, however, we shifted it to July 5 a few years ago to avoid the interruption of the July 4 holiday at the beginning of the year. On July 3 — today — our incoming first-year fellows round with our ID fellows who have completed 363 days, acting as observers.

If ever you wanted tangible evidence that the first-year learning curve has a very large area under it, this is the day. Because the soon-to-be second years know a ton, the newbies … well, let’s just say there’s a reason they do an ID fellowship, and it’s to learn clinical ID!

In addition, fellows who have spent a year doing ID consults nearly every day also have learned a few things that they truly hate.

Here’s one: A late afternoon consult.

(That was easy.)

But rather than my providing the list, I would love to hear from you — two targeted questions:

  1. What do first-year fellows learn?
  2. What do they learn to hate?

Responses — anonymous and otherwise — welcome! And here’s a video:

7 Responses to “First Year ID Fellows — What Do They Learn, and What Do They Hate?”

  1. Emily says:

    Things I learned during my first year of ID fellowship
    1. Respect Staphylococcus aureus – after seeing it destroy normal heart valves, joints, vertebrae, lungs, and stick to any plastic we place in people, I have learned to really respect S. aureus for the virulent pathogen that it is.
    2. The indication, duration, dosing, and side effects (sometimes the hard way) of antimicrobials (and, thus, I gained further appreciation for my PharmD colleagues during the year).
    3. How to understand and truly interpret diagnostic studies in the clinical context. I learned that negative tests don’t always exclude disease (“Yes, I know his PPD is negative but I still think that he has TB”) and positive tests don’t always confirm disease (“Yes, I know his CMV IgG is positive, but I don’t think that explains his current febrile illness”).
    4. I have learned to value actually talking with the patient. While being able to quickly and thoroughly biopsy a medical chart is an important skill, it can never replace the information that comes straight from the patient’s mouth – especially when the patient answers the ever important question, “what do you like to do for fun?”
    5. (the corollary of #4) The danger of the curbside consult

    Things I learned to hate
    1. Reading “Consult ID” in the chart when ID had already been following the patient
    2. Incorrect information that is continuously copied/pasted in the electronic medical chart (i.e. “chart rumors”)
    3. Surgeons or interventional radiologists that fail to send cultures during a procedure
    4. “STAT” ID consults for home antibiotics in patients that have been in the hospital for weeks (especially late on a Friday afternoon)
    5. Missed opportunities for HIV screening (“… if only someone had done an HIV test 5 years ago…”)

  2. Paul Sax says:

    Emily,
    Superb list. One of my oft-repeated “jokes” is that first-year ID fellows are really doing a Staph aureus Fellowship. (Ha.) And the “Consult ID” in a note on a patient we’re actively following still rankles after more than 20 years in this business!
    Paul

  3. Krispin Hajkowicz says:

    Hi Paul,

    In Australia, in our first year we learned the 28 golden rules of Infectious Diseases of the late, and great, Allen Yung, a selection of which follows:

    1. Recurrent rigors are most likely to be caused by bacterial infections
    2. Severe muscle pain may be a symptom of sepsis, even in the absence of fever
    6. When a patient has a fever post-operatively, it is usually related to the surgical procedure (Petersdorf’s rule)
    12. Staphylococcus aureus in the urine means staphylococcal bacteraemia until proven otherwise
    19. Think of vertebral osteomyelitis and an epidural abscess in a patient with fever and back pain
    21. Specific IgM antibodies are an unreliable marker of primary infections in pregnancy

    More on Allen Yung’s golden rules: http://www.asid.net.au/downloads/goldenrulesofid.pdf

  4. brianne says:

    Paul,
    what a great way to share from learned experiences. Always thinking outside the box!

  5. Tim says:

    Having just completed my first year, I would argue that the most important thing that a first year ID fellow learns is not a specific fact or well-defined lesson, but instead it is a subtle attitude shift, the result of the cumulative experience of all of those consults, (hundreds of histories taken, patients examined, differential diagnoses considered) that seems to seep into our pores somewhere along the way, and transform us from unsure newcomers to more confident (and competent) ID doctors.

  6. CanadianTrainee says:

    I’m not sure I have a lot to add to Emily & Krispin but here’s what I learned in my first year:

    1.I also feel like our service could be renamed the Staph service. I actually wish my hospital had a mandatory Staph aureus bacteremia = ID consult policy, even thought that would mean a lot more vanco levels for me to manage.
    2. Due to #1 I’m getting pretty good at getting vanco levels from 15-20 in a jiffy. Our service could also be renamed the vanco-dosing team.
    3. Always correlate the culture with the gram stain. No neuts is usually no infection.
    4. Always correlate the urinalysis with the culture. I didn’t truly realize how many people were walking around with colonized bladders until I started my clinics this year.
    5. love this quote from the newest IDSA guideline: “the lab needs a specimen, not a swab of a specimen”. If only we got consulted before the surgery occurs and the swabs (or nothing) are taken – from this I learned to implement a quality improvement project in my city!
    6. ID consultants have the best patients. It’s because we take the best histories. Even if your exposure history ends up being non-contributory to the medical presentation, your patient may turn out to be a lot more interesting than you think and interesting conversations ensue! I always ask about travel, sex, drugs, pets & other animals, jail/prison etc. even if it’s just another Staph aureus bacteremia consult.
    7. If the patient is in the building, always always insist on doing a full consult instead of just a phone consult. The story is usually more involved than one was first led to believe.
    8. How to fill out OPAT forms efficiently.
    9. Make sure to clearly address the question you were asked in the referral. Often there’s so much to comment on the actual reason the patient got referred can be lost.
    10. Always look at the temperature trend. A temp of 36.9C may actually be a fever in a hemodialysis patient who lives at 35C (sorry I’m Canadian, I don’t do Fahrenheit).
    11. people with staph bacteremia (and sometimes other bacteremia) get thoracic back pain even with no epidural abscess.
    12. LOVE your ID pharmacist.
    13. Always ask the patient why THEY think they are in your clinic. Often it’s different from what your referral letter says. Address both issues.
    14. You are now the consulting team, not the admitting team. Don’t step on toes. You were asked to see the patient because the admitting team needs help, not criticism.
    15. It isn’t sufficient to say, “this isn’t infectious” and walk away. You are still an internist. A great one (see #6) Come up with at least one helpful thing to add even if it’s definitely not an infection. Finding the non-infectious etiology is even more satisfying than coming up with the infectious one.
    16. For patients who have been admitted for more than a month I’ve learned to start each consult with flipping through the chart to make sure we haven’t already been consulted and left a nice note before starting fresh.
    17. De-foley/central line as many people as you can.
    18. You will be watched – don and doff your PPE properly and wash your hands. If we can’t do it who do you think will!

  7. Cheryll says:

    Thing I have lerned to love in my first year as an ID fellow:
    1. ID Phrm Ds are great, take them every where and keep them on speed dial.
    2. HIV patients are not as concerned about their disease as I am.
    3. You must explain every decision to change, start, stop an antibiotic in your note that no one ever read.
    4. My job is mostly about d/c antibiotics rather than starting them.
    5. Yes, respect staph aureus.

    Things I learn to dislike:
    1. The call ” ID did not leave final recs” on the chart. Can you tell me what the team wanted from 2 weeks ago?
    2. The chart that says discussed with ID fellow when no call was made.
    3. “I have a quick curbside questions”. Usually takes an hour and you still do not get the full story.
    4. The outside records were requested, but never were.
    5. The midnight call “I need Meropenem, for a PCN allergy”. Next am the pt had a rash like 20 years ago.
    6. C.Diff diarrhea, but there is no sink to wash hands anywhere near the room.

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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