2. Dr. Bosl’s Rules
1. It’s not cancer until it’s proven to be cancer.
2. The disease is curable until proven otherwise.
3. The disease is treatable until proven otherwise.
4. The patient is ALWAYS treatable!
Note: If you are at MSKCC during Professor’s Rounds with Dr. Bosl he will ask you his rules
3. Year at a Glance
• Inpatient Medicine (including night float)
• Outpatient Medicine
• Surgery
• Emergency Medicine (Cornell)
• Elective
• Vacation
5. MSKCC: A Comprehensive Cancer Center
• Urgent Care Center
– Our “ED”, for established patients
6. MSKCC: Services by Floor
• 5th: Genitourinary (GU)
• 10th: Breast
• 11th: ICU
• 12th: Leukemia/Lymphoma
• 16th: Gastrointestinal (GI)
• 17th: Telemetry
• 18th: Telemetry, Gen Med
7. Structure of Medicine Service at MSKCC
• Medicine Housestaff Services:
– Gastrointestinal (GI)
– Breast
– Genitourinary (GU)
– Leukemia
– Lymphoma Green
– General Medicine
• Medicine Nurse Practitioner Services:
– Thoracic Oncology
– Bone Marrow Transplant
– Head/Neck, Melanoma, Sarcoma (HMS)
– Gynecologic Oncology
– Lymphoma Red (Multiple Myeloma)
10. • Day starts at 7am
▫ Admissions are listed on the board
▫ Interns pick up signout from night float on their
patients
▫ This includes admissions from previous day
▫ Residents pick up signout from nocturnalists on
overnight admissions
▫ All patients must have a
service care provider
assigned to them!
Starting your day: AM Signout
12. Inpatient – Mornings:
• Pre-Rounds: 7am–8am
▫ Interns see their patients
▫ Run your list with your resident
▫ See sick patients together
▫ Residents will see nocturnalist overnight
admissions to present on rounds
• Attending/Work Rounds: ~8am–11am
• Meet with case manager/disposition (early is better)
• On Wednesdays: 11am Intern Morning Report
13. • Afternoon Conference with lunch (1pm)
– Thursday– TY Core Curriculum
• Work (2pm-5pm)
– Usually PM Attending Rounds
• Sign-out to NF (starting at 5:30pm)
– Don’t forget to forward your pager
Inpatient – Afternoons
14. Being “On Call”
• Approximately every 4days
• On-call team admits anytime until 7:30pm
• Interns never admit alone, always paired with a
supervising resident (buddy team)
• All residents MUST stay until “buddy” intern signs out
• You must be out of the hospital by 11PM
• You may sign-out your list/new admits earliest 7:30PM
• Anyone on call is on the code team
• Required to be in-house until 7:30pm to staff the
CODE TEAM until hospitalists take over
15. On Call “Buddy” teams
• “Buddy” teams:
• Leukemia A + Leukemia B + Lymphoma Green
• GI A +GI B
• GU + Breast + General Medicine
• All intern admissions supervised by a resident
• Residents must fully evaluate all admissions
themselves and review the note with the intern
• Residents must also assist their “buddy”
intern with floor patients
16. • 7am – 3:30pm: admissions are paged to both residents
on the service, to be done by any member of the team
– decided by the two residents
– ALL admissions done by intern, supervised by the resident
• 3:30pm – 7:30pm: admissions are done by the
on-call team members
• If a service is particularly busy, other teams may be
asked to admit for them
Admissions Policy
17. • Our services admit patients post-procedurally:
▫ Hepatic artery embolization
▫ Radiofrequency ablation (RFA)
of lung or liver lesions
▫ Cryoablation of
kidney or bone lesions
▫ Portal vein embolization
▫ Catheter placement
IR – admissions
18. Sign-Out
• You must go over hand-offs with your resident
prior to sign-out
• Your resident must be present to supervise
your verbal sign-out
• Residents and interns should leave the
hospital together
– every intern needs to have a back-up resident
in house (and should have their contact info)
19. A note on signing out
new admissions
• Daytime admissions presented and discussed with
primary attending can be added to the sign-out list
• Admissions not yet staffed by an attending should be
signed out in full
– We require a full copy of the admission note at sign-out
20. – Nightfloat coverage:
– Mon-Fri: 5:30pm – 7am
– Sat-Sun: 7pm – 7am
– Pagers:
– NF 1 (p 9132) SOLIDS:
GI, GU, Breast
– NF 2 (p 9133) LIQUIDS:
Leuk, Lymphoma Red/Green, Gen Med
Night Float
21. Weekend schedule
• Everyone works 6 days per week
– Either Sat or Sun off
– On weekends: you will be “on call” or “rounding”
• If “on call” – you take admissions from 7am-7:30pm
• If “rounding” – no admissions (usually**)
• You may sign out to the “on call” person on your team
when your work is finished (earliest 2:30pm)
• gen med signs out Leukemia intern on call, earliest 5pm
**if it is very busy you may be asked to admit as well
24. General Medicine
• The gen med team has 2-3 TYs with an
attending (no resident)
• The Breast/GU Resident acts as back-up if the
attending is not immediately available
– (If the Breast/GU resident is not available, the
code leader acts as back-up)
25. Codes
• Call team is paged with all
codes (7:00a – 7:30p)
• Please respond promptly!
• Identify yourself and check
with code leader/chief resident
regarding your role
• Pediatric codes (M9) are run by
medicine for adult sized
patients – we attend all codes!
26. TY Conferences
• TY Core Curriculum: Thursdays at 1pm
– Summer boot camp Series (+ Tues at 1PM)
– Gen Med Curriculum
• EBM:
– Once a month
– Organized by Dr. Koo
– Led by you!
27. Patient Death Debriefing Sessions
• Goal: to focus on emotional reactions of
house-staff to a patient’s death
• Led by inpatient service attending or resident
– Please remind your attending if needed
• Can also use this time to discuss complicated
end-of-life issues
• Please see chiefs for a green pocket card reminder,
also see LibGuide for reference
28. Medical Students
• MS3s:
– Paired with intern, take call together,
q4 (includes weekends)
– You still must write notes
• Sub-intern:
– Paired with resident, take call together,
q4 (includes weekends)
– Resident must write notes
• All medical students present
their patients on rounds
29. You are a team
• Both residents will know all patients and
supervise both interns
• Entire group works as a complete team.
• You will need to
cross cover your
co-intern’s list
on weekends
30. • Be friendly, respectful, willing to help
• Respond in a timely manner to pages
• Conferences are arranged for YOU
– Attend and participate!
General expectations
31. • Wear a white coat and MSKCC ID badge
• Business casual, though men must wear a tie
• Proper footwear (no open shoes as per OSHA)
• On call days you can wear scrubs:
• Gray scrubs are provided
• Other colors are allowed
• Except green (reserved for OR)
Dress to impress
32. Patients with Limited English
• All patients with Limited English Proficiency
(LEP) should be spoken to in their native
language at least once daily
– Remote interpreters: video cart,
phone (by Vocera or bedside phone)
– In person: interpreters@mskcc.org
33. • Do not send Protected Health Information (PHI) over
a personal email account: gmail, yahoo, etc
• You may use your secure, institutional email account
(chpnet, downstate.edu, etc) when necessary
• Avoid work-related postings on social networking
sites, no matter how seemingly benign
• Keep all PHI onsite at MSKCC; do not bring it home,
store to thumb drive, etc
HIPPA
34. Documentation
• Select note template: type “Medicine Inpatient Progress Note”
– Title your notes with your service (e.g. Breast Progress Note)
– Sign your note with your pager number, date, and time
• You should write an event note for any acute events for your patients
(such as RRTs, ACS, and Codes). End-of-life discussions should also be
documented.
• You do not need to write a discharge summary but pts MUST have at
least brief progress note on day of discharge
• Do NOT copy notes daily, especially from attendings/consults (the
attendings WILL read them)
35. Paging
• Tag your message with contact info:
– Ex: call back number x6733 & your pager p9132
tag your page with “6733*9132”
Hey Teddy, Do you want to grab some popcorn?
Please let me know. Thanks, Sarah 6733*1030
36. Paging
• Vocera: if you get a page from 4646*####,
a nurse is trying to get in touch with you:
Call 4646 and follow the instructions (enter ####)
38. Feedback/Evaluations
• Praise/Concern cards are available on paper in
the Medicine Library
• Completely anonymous (you can slip them
underneath our door)
• We are available anytime for feedback
• Faculty evaluations will be sent to your MSKCC
e-mail accounts
40. Jeopardy
• If you cannot work:
• Please contact us ASAP (chief on call pager p1030)
• If you are on Jeopardy:
– You are expected to have your pager and cell phone
with you at all times
– If paged/called, you are expected to call back
within 15 minutes and be at the hospital
within 1 hour (ready to work!)
41. Schedule Changes
• NO SWITCHES CAN BE MADE UNLESS
APPROVED BY CHIEFS
• ALL REQUESTS MUST BE MADE BY
EMAIL: BEDRESIDENT@MSKCC.ORG
• THE EARLIER THE REQUESTS, THE
MORE LIKELY WE CAN ACCOMODATE
42. Finding Information
• All orientation materials,
can be found on the “LibGuide”
– Accessible internally and externally
– Also contains educational resources:
• Selected articles and powerpoints
• NEJM videos for procedures
• Commonly used calculators
• Feedback forms (praise/concern cards)
