How to Be a Junior Columbia University Medical Center Housestaff Training Program

How to Be a Junior
Columbia University Medical Center
Housestaff Training Program
2013 - 2014
Contents Introduction .............................................................................................................................. 3 Conferences……………………………………………………………………………………4 Structure of the Day ................................................................................................................. 7 Rounds ....................................................................................................................................... 7 OPD .......................................................................................................................................... 10 Clinic rules .............................................................................................................................. 10 How to Be a Night Resident ................................................................................................... 12 Emergency Room.................................................................................................................... 15 Elective..................................................................................................................................... 16 MICU ....................................................................................................................................... 16 CCU ......................................................................................................................................... 18 Arrests ..................................................................................................................................... 19 Telemetry................................................................................................................................. 19 Sick Pull ................................................................................................................................... 20 Trading Shifts ......................................................................................................................... 21 Jury Duty ................................................................................................................................. 23 Pager Policy: ........................................................................................................................... 23 Moonlighting ........................................................................................................................... 23 2
Introduction
The How to Be a Junior manual has been written to serve two purposes. While it provides
many helpful hints for working effectively as a second-year resident, it is also a guide to the
policies of the chief resident’s office regarding the operations of the medical house staff. We
hope that this guide helps you navigate some of the challenging and unfamiliar territory that
comes with the transition to becoming a junior resident.
As a junior resident you will be responsible for supervising interns and managing patients in
the following clinical settings: MICU, CCU, ID, and general medicine. You will also head
the inpatient oncology service, where you will work with PAs instead of interns. You will
admit patients overnight as the night resident in Milstein as well as at the Allen Pavilion. You
will also spend time seeing patients in the ER and the outpatient clinic. You will transition
from the intern who follows orders and focuses for the most part on only the details of each
patient’s presentation, to the team leader who is both charged with thinking broadly about
each patient as well as ensuring that your team is being educated on the basic skills and
approaches to internal medicine patients.
As a resident, you are now expected to take on the role of a supervisor and teacher in addition
to providing patient care. Early in the year, your interns will be particularly dependent on you
for guidance in almost every aspect of patient care on the wards and in the ICU’s. It is critical
that you pass on the good organizational skills that you learned during your internship year.
These skills include how to keep a useful patient list, tracking patient data and formulating a
sign-out list. For interns from other institutions you will need to show them where supplies
are kept, how to use eclipsys, webcis, and CROWN. You are also called on to provide
adequate supervision of all procedures. If you feel unsure of these procedures yourself (which
is to be expected since you have only been doing this for one year) please feel free to ask any
third year resident or any of the chiefs for help.
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Conferences
Conferences are an integral part of the residency training program. Attendance is taken and
reviewed by the KFAs and program director. Please make every effort to get your team to
conferences.
Morning Report
Morning Report will begin promptly at 8:00 am, please make every effort to arrive on time.
Morning Report is a mandatory daily conference for PYG-2 and PGY-3 residents during
which a resident presents a case to an attending. All residents on non-ICU and vacation
rotations are expected to attend daily. The day’s attending, with direction from the Chief
Resident, will lead a discussion based on the case that should be interactive, fun and include
all the residents in the room. This a great opportunity to learn from various experts and to get
your questions answered about relevant clinical management questions.
If you have a case that you would like to present at morning report, please email
[email protected] with the patient MRN and a few lines about the clinical history.
If you want to use path slides, echo videos, or need other technical support, please let the
chief’s office know at least one day in advance so we can make the appropriate arrangements.
Also, if you want to share an article relevant to the case, please drop it off in the chief’s office
and we will place it in the dropbox.
If you are consistently having difficulty attending morning report for any reason, please let
one of the chief residents know. The chiefs are committed to making it possible for every
resident to attend morning report on a daily basis.
Noon Conference
This is a one-hour lecture Tuesday, Thursday and Friday given by various attendings in the
institution for all residents. The lectures in the summer consist of the “Fundamentals of
Medicine” series and cover material directly relevant to patient care (e.g. management of
SVT, ACS, GI bleed, etc). These lectures are specifically geared to the new interns to taking
care of serious medical conditions on the medicine floors and every effort should be made by
the residents to both encourage and help their intern attend. It is our goal to make these
valuable lectures available online via podcasts so that all interns and residents may have the
opportunity to learn from them.
Starting in September, roughly every other Thursday will be dedicated to senior talks, and
intermittent Tuesdays will be a Clinicopathological Conference, Morbidity and Mortality
Conference, or Quality Assurance session run by Chief Residents.
Grand Rounds
Every Wednesday at noon (with the exception of a short summer break) the Department of
Medicine invites an faculty member from within Columbia or at a peer institution to discuss a
topic within his or her area of expertise. Grand Rounds represents a unique opportunity for
residents to learn the latest advances in a variety of subspecialties, ranging from basic science
to epidemiology. Residents are responsible for facilitating attendance by the whole team
including the interns. Attendance is taken by the program administrators.
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We hope to continue to increase the housestaff exposure to the grand round speakers by
inviting the speakers to attend rounds and conferences during the day, as well as dinners the
night before with selected residents and representatives of the host division. If you have a
suggestion for a grand rounds speaker please let one of the chief residents know.
Journal Club
This is a one-hour conference held on Monday afternoon (12-1pm). The conference is held in
the Cardiology Conference Room on 5GS (Room 411). Junior residents present a case and an
article from the literature. The primary objective of this conference is to learn how to
critically review an article from the literature and to develop expertise on the topic. First, you
will choose a paper 1-2 weeks prior to your scheduled date. Article selection should stem
from a clinical, patient management, or a scientific question that prompted a literature search.
The choice of paper should be made in conjunction with your firm chief resident to help avoid
repetition of papers and ensure a variety of topics. Then, you will send the article to Dr.
Palmas who will help you choose the stats/epi topic and incorporate it into your discussion
and analysis. Please schedule a meeting with Dr. Palmas one week prior to your presentation
to discuss the topic. Rudy will provide you with a journal club template to help structure your
talk. The chief residents are available to assist with the development of the presentations.
You are allotted one hour for the presentation.
Journal club is successful and worthwhile when people read the article and participate; please
make every attempt to do so. The article is emailed out in the “Weekly Calendar and
Announcements” on Fridays. Finally, please remember to take your interns’ beeper for the
hour so they can enjoy Intern Report.
The Milstein Wards: Structure of the Day
For Admitting Guidelines, please see the separate document “Admitting Guidelines”
Daily Schedule: GM1 (Long call à Post call à Short call à Precall)
7:00-8:00:
Housestaff walk rounds (residents, intern, medical student). From 7:30am the
resident also takes sign-out on new admissions from the ED.
8:00-8:45:
Morning Report. Mandatory for residents
8:45-9:00:
Multidisciplinary rounds with attending, resident, intern, SW, care coordinator.
9:00-10:30: Attending Rounds
10:30-12:00: Work time for housestaff
12:00-1:00
Noon Conference.
1:15
Intern briefly “regroups” with care coordinator
5pm
Post call, short call and precall teams signout to long call PA when work is
completed for the day
9pm
Long call team begins signout to overnight team
Daily Schedule: GM2 (Long call à Post call à Short call à Precall)
7:00-8:00
Housestaff walk rounds (resident, intern, medical student). From 7:30am the
resident also takes sign-out on new admissions.
8:00-8:45
Morning Report. Mandatory for residents
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8:30-8:45
8:45-9:30
9:30-10:30
12:00-1:00
1:15
5pm
9pm
Multidisciplinary rounds with intern, attending, SW, care coordinator.
Resident does not attend.
Liver rounds (all GM2 teams assemble in the morning report room)
GM2 Rounds **NF resident must leave by 10:00am
Noon Conference
Intern briefly “regroups” with care coordinator
Post call, short call and precall teams signout to long call PA when work is
completed for the day
Long call team begins signout to overnight team
Daily Schedule: Cardiology (Long call à Post call à Short call à Precall)
7:00-8:00
Housestaff Walk Rounds (intern, resident, medical student). From 7:30am the
resident also takes sign-out on new admissions.
8:00-8:45
Morning Report. Mandatory for residents. **Cardiology Chief of Service for
short and pre call teams on Fridays
8:45-9:30
CHF Rounds (combined, all four teams in the Morning Report Rooms)
9:30 – 10:30 General Cardiology Rounds **NF resident must leave by 10:00am
Daily Schedule: ID
Please see the ID orientation document posted on the www.columbiaresidents.org or
www.nypmed.com websites.
Daily Schedule: Malignant Hematology
Please see the Malignant Hematlogy orientation document posted on the
www.columbiaresidents.org or www.nypmed.com websites.
Daily Schedule: Oncology (Long call à Post call à Precall)
7:00-8:00
Walk Rounds with PA and medical students. From 7:30am the resident also
takes sign-out on new admissions.
8:00-8:45
Morning Report for resident. Work time for PA.
9:00-10:30
Oncology Ward Rounds
10:30-12:00 Work time for housestaff, Oncology multi-disciplinary rounds.
12:00-1:00
Noon Conference
Evening
Post call, short call and precall teams signout to long call PA or night ancillary
PA when work is completed for the day
9pm
Long call resident begins signout to overnight team
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Rounds
Work Rounds
Residents are expected to walk round with their intern to see the service’s patients. The
resident should generally see the majority, and preferably all, of the patients on the service
with the intern and medical students. The intern is freed from 8:00 – 8:45 to order studies,
call consults, place orders, etc while the resident attends morning report; hence, effective
work-rounding from 7-8am can facilitate efficiency, priority-setting for the day, and aid in the
intern’s organization. As this is often the opening act of the day for the team, it is crucial that
the time is well-spent as it can set the tone for the remainder of the day that follows.
Work rounds are fundamental to both patient care and education. From the patient care
perspective, work rounds allow evaluation of the patient’s progress, monitoring of changes in
exam findings, assessment of the patient’s readiness for discharge, discussion of management,
and formulation of a plan of care for the day.
We recommend the following structure for seeing patients during work rounds, although we
understand that resident-intern pairs will develop their own variations as well.
(1) Outside the patient’s room, the intern briefly states the patients name and reason for
admission, followed by the overnight events and vital signs.
(2) The team then sees the patient. The intern is to be the primary physician in this
setting, relating information, presenting findings, and discussing the day’s plans with
the patient. The intern will perform the primary exam, while the resident can focus on
the more dynamic, or educational, aspects of the exam.
(3) The intern then presents the plan of the day for the patient, including tasks that need to
be done, studies that need to be reviewed, and the patient’s disposition. The resident
uses this as a teaching opportunity for both intern and medical students, whether with
respect to physical exam, differential diagnosis, a discussion of the primary literature,
or management.
By the end of the month, the intern should be able to succinctly present a patient by citing
their admitting diagnosis, response to treatment, active issues and discharge plan. Time will
still be limited during work rounds, as the team may also have to hear presentations of private
admissions during this time, and because the team may also be taking sign-out on new
admissions. However, every attempt should be made to maximize the usefulness of work
rounds, both from a clinical care and an educational standpoint. Work rounds are an
opportunity for the resident to serve as teacher and team leader.
Also, during these work rounds, please consider the need for telemetry on your patients every
morning, and whether private patients could be transferred to the PA service (with private
attending approval).
Teaching (Attending) Rounds:
As the resident, you are responsible for leading rounds. The attendings expect you to direct
them. This is especially important when you are post-call and have a lot of admissions to get
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through. Do not be afraid to ask the attendings to move along to the next case in the interest of
time; they expect you to do this!
The main focus of these rounds should be on hearing new presentations, generally at the
bedside. You are also encouraged to include the patient’s nurse during bedside rounds. You
are encouraged to dedicate specific time during attending rounds to discuss literature and
participate in case-based teaching. You may also discuss interesting follow-ups during this
time. On Gen Med services, each Resident-Intern team will be paired with one attending in
order to help streamline patient management. The resident and intern will meet with his or
her attending after teaching rounds for management rounds, to go over all other follow-up
information for all of the other patients on their service. This is not meant in any way to take
away from the discussion by both attendings of patients at teaching rounds. You are also
expected to touch base with your attending toward the end of each on-call day to briefly
discuss the patients you are admitting as well as any management issues that have come up
throughout your call day.
GM2 teaching rounds have been organized to facilitate the integration of the liver transplant
service into general ward attending rounds, toimprove both patient care and resident
education. The “superteam” (or all 4 teams) will meet in the Morning Report room from
8:45-9:30am for combined liver transplant attending rounds.
Interdisciplinary Rounds
Multidisciplinary rounds occur at different times on different services (please see the daily
schedules above). During these rounds, housestaff briefly review patients’ status and
discharge planning. Be sure to enlist the social workers and care coordinators to help
navigate the pre-discharge bureaucracy. Important questions to ask: does this patient have
insurance? Do they have a stable home environment? Do they have services that need to be
reinstated? Addressing these questions early is crucial to a smooth discharge. Be sure to help
use these members of the medical teams to mobilize services for your patients, including
physical therapy and nutrition.
On GM1 and GM2, a dedicated care coordinator will be assigned to each team to act as a
liaison between the teams social work. They will be present during multidisciplinary rounds,
which takes place immediately before attending rounds on both services. Care coordinators
will touch base with the teams at various points throughout the day. There should be a
designated afternoon “re-group” between intern and care coordinator, generally at 1:15 pm.
Coordinators will serve to identify barriers to discharge and facilitate discharge planning.
Regardless of which service your patient is on, it is vital to work closely with the patient’s
nurses, social workers, and other non-physician members of the patient care team. By having
regular discussions with the patient care team about your patient’s progress and changes in
disposition, your patient will experience improved care, more efficient discharge planning,
and you will likely be paged less often as the patient’s nurses will be aware of why particular
orders were written or why a patient’s plan of care has changed. You or your intern are
expected to touch base with each member of your patient’s care team at least once a day.
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Sign Out Rounds
The resident, intern, medical student and PA should reconvene prior to leaving the hospital.
This time is best used to review check boxes for the day and generate a plan for the next day.
The handoff tab in eclipsys, including the patient summary and team to-do should be updated
daily. Please review the medication list and edit as needed. It is helpful to anticipate calls that
the coverage team may receive and list ‘FYIs’ in the coverage handoff tab. Please review the
actual sign out sheet (the front page of the list) that the intern gives his/he cross-covering
intern/PA -- particularly at the beginning of the year.
Intern’s signouts in Eclipsys should include the following information:
Patient’s name, unit number, and location
Working Diagnosis or impression
Chief complaint and short sentence or two on the patient
EF / Cr / DVT ppx / Code status
Attending’s name if private, “Ward” with the ward attending’s name
List if an IV is in place and necessary if it falls out
IV +/+ has one/needs one
IV+/- has one/don’t worry if it falls out
IV -/- doesn’t have or need one
What temperature you should panculture at: Cx temp >101
Code status: DNR or Full Code
NF/Cross-cover tasks and how to respond
For example:
Patient Summary
Impression: CHF exacerbation
62 M w/ HTN, DM, CHF, admitted w/ increased SOB and PVC on CXR. Responded to IV Lasix. Plan to
diurese to dry weight of 50kg. Etiology of exacerbation likely medication and diet non-compliance.
EF 35% l Cr 2 l Heparin SQ l Full Code
IV +/+
Notes/Comments
Private: Dr. X, Contact: Pager 11111
Emergency/Family Contact: Wife, X, 212-305-1111
Antibiotics
Levofloxacin 6/14 –
Primary Team To-Do List
[] Telemetry
[] TTE
[] Dry Weight
Coverage Team To-Do List
FYI – Patient may ask for trazadone at night. Okay to give this.
[] Private Note (Dr. X)
Schedule information is also available on the website www.medicineclinic.org, and on
www.amion.com as well. Please note that residents on OPD1 are responsible for NR coverage
on Sunday nights (though there are exceptions at the end of some blocks). Additionally OPD2
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and E2 residents will cover the occasional Friday night ID NR. Please check the day-to-day
schedule at the beginning of your OPD rotation to identify your weekend cross coverage
duties!
Rotation Description
Outpatient Rotation (OPD)
Juniors have OPD1 (4 weeks) and OPD2 (2.5 weeks).
OPD1 Juniors do Sunday night resident coverage. There is no clinic scheduled for Mondays.
One Monday per month there are intake rounds with the division chiefs in place of Morning
report. Junior residents will present one case from overnight to the division chiefs.
OPD2 residents do occasional ID night resident shifts on Friday night. They attend Harkness
Report (aka Blume Rounds) daily from 1pm-2pm in the AIM conference room in VC 205 and
psych rounds at 8am on Mondays. The schedule of case presentations for Blume rounds will
be assigned in advance (posted in VC 205). Please be sure you are aware of the presentation
schedule, and check it against your outpatient schedule, as last minute switches in clinic
timings can occasionally produce conflicts that could be addressed by switching presentation
days with your co-residents.
On mornings when there is no 8am conference, residents are expected to attend Morning
Report.
Clinic Rules and Scheduling
Clinics start at 1pm. Exceptions are in the Allen Wards, MICU, and AICU during which
clinic starts at 2pm. If clinic falls on the first day of a rotation for interns (except in the ICU),
it is cancelled. Residents will have clinic on the first day of a new rotation except during the
first block of the new academic year.
1. GM1, GM2, Cardiology:
a. Clinic 1pm Mon-Thurs post call for residents
b. Clinic 1pm Mon-Thurs pre-call for interns
2. Inpatient Oncology (PGY2): Clinic 2pm on pre-call days
3. Inpatient Malignant Heme (PGY2):
a. Clinic on Monday afternoons for PGY2
b. Clinic on Wednesday afternoons for interns
4. ID:
a. Continuity clinic on Wednesday afternoon and Monday morning of discharge clinic
week.
b. PGY 1 Team A: Friday PM clinic (wk 2), Thu PM (wk 3), Wednesday PM (wk 4)
c. PGY 1 Team B : Wed PM (wk 2), Tue PM (wk 3), Monday PM (wk 4)
5. CCU:
a. 1pm Mon-Wed pre-call for residents
b. 1pm Thurs-Fri pre-call for interns.
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6. MICU:
a. 1pm Mon-Wed pre-call for residents
b. 1pm Thurs-Fri pre-call for interns
7. OPD: OPD Block Schedule will be determined by the outpatient scheduling team and
e-mailed to you 1 week before block.
8. Senior elective: E1- Two morning continuity clinics/week. E2 – One clinic a week.
On E1/E2, rarely residents may be asked to swap one of their clinics for coverage of
walk-in clinic.
9. ER: One clinic session per week for a total of two sessions, Tuesday mornings for
PGY2s and Friday mornings for PGY3s.
10. Senior Medicine: 2-3 sessions per rotation on pre-call days
Please note that residents on Cards, ID, GM1, GM2, Onc should not be scheduled for clinic
on June 14th (the first day of the new academic year). Interns should not be scheduled for
clinic on the first day of each new intern ward block (Cards, ID, GM1, GM2, Allen)
Clinic Cancellations Policy:
To ensure our patients’ continuity of care, your best efforts should be made to avoid
unnecessary clinic cancellations. Cancellations of any outpatient clinics or conferences must
be approved in advance by the chief residents and Dr. Nancy Chang (Dr. Jin Choi at the
ACNC)
If you do need to cancel a session, please alert us as soon as possible; you will likely be asked
to provide an alternate date to make up any cancelled session.
For:
1. *Predictable cancellations* - (example: away electives, ACLS/BCLS training, USMLE
Step III, routine physician appointments, jury duty, conferences, “special” family events)
Please communicate this request to us at least 2 months in advance. Email instructions below.
2. *Unpredictable cancellations* - (example: last minute fellowship interviews, last minute
jury duty notices, personal/family illnesses) these must be communicated as soon as you are
aware of the dates.
3. Cancellations during the OPD blocks need to be approved in advance by Dr. Nancy Chang.
Coverage will be required for cancelled walk-in clinics (coverage may be required for last
minute (<1-2week) cancellations of preop/diabetes f/u).
4. Clinic will not be cancelled to accommodate personally arranged shift swaps and pay
back.
5. Fellowship/Job Interviews - Please email us as soon as you know the dates. Depending on
the number of sessions/pts cancelled, we may ask you to provide alternate clinic dates to
ensure patient care does not get compromised. During OPD blocks, coverage will be required
for any cancelled walk-in clinics. To help you plan your interview dates, feel free to email Dr.
Chang for an advance copy of the OPD block schedules.
All AIM Clinic cancellation emails should be addressed to all 3 of the following: Christina
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Collado ([email protected]), Chief Residents ([email protected]), and Dr. Nancy
Chang ([email protected]).
Oncology
Four teams each comprised of one resident and a PA; supervised by two attendings (one
hematologist, one oncologist). The residents provide continuity of care, thus it is important to
walk round with the PA in the morning as she may not have previously met the patients. The
long call PA will be present from 7am – 7:30pm. The short call and pre call PA from 7am to
5pm. The post call PA from 7am – 3pm. There is a night ancillary PA from 3pm – 9pm to
help with cross cover. You may find the PA schedule on amion.com, please ask the chiefs for
the password.
Clinic is on the pre-call day and starts at 1pm. While the precall resident is in clinic the post
call resident will answer questions that the precall PA may have.
Friday mornings from 8am – 8:45am there is a lecture series dedicated to topics in malignant
hematology. We will inform you when and where the lectures take place. Attendance is not
mandatory but we hope that the educational value will motivate you to attend!
The Night Resident:
Goals and Objectives
The goal of the Night Resident (NR) rotation is to further develop the junior resident’s clinical
and supervisory skills. Most importantly, as the night resident, you are the team leader for
your superteam, including being the supervising resident for the intern. You will be
responsible for issues pertinent to all patients on the team, not just those that you are
admitting. Over the course of the rotation, the Night Resident will:
• Teach and communicate knowledge to the interns and students on a nightly basis
• Supervise interns in the management of inpatients, from the rapid evaluation of
emergent issues to discharge planning
• Admit patients independently, generating diagnostic and therapeutic plans, which will
be presented and evaluated on attending rounds
Each superteam has a dedicated beeper used by the ER for admissions, overnight interns for
supervision and nursing staff to identify responsible MDs for patients:
Superteam
General Medicine 1
General Medicine 2
Cardiology
Oncology
ID
Allen
Pager
9071
9073
9077
9076
9078
9000
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Service beepers are passed along from the daytime admitting resident to the night resident at
sign-out rounds at 9:00 PM (with the exception of the Allen where the admitting pager is a
virtual pager signed out to your personal pager). In the morning, the beeper is handed off to
that day’s long call resident at 7:30 AM. The ER can start endorsing patients at 7:30 AM to
the long call resident, or if unavailable, the night resident.
Educational Responsibilities:
Teaching should be a top priority. Each night, time should be set aside for teaching sessions,
either at the bedside, in walk-rounds or at the white board. Educational goals for the interns
and students should be
• Review admissions with the on-call intern
• Teach emergent patient care to the long call interns
• Discussing the evaluation and management of topics in inpatient medicine, i.e. chest
pain, shortness of breath, change in mental status, supraventricular tachycardias, acute
renal failure, hyperkalemia, etc.
• Review procedures - appropriateness, technique and complications as well as issues
related to informed consent (www.columbiaresidents.org site)
Supervisory Responsibilities:
• You are responsible for the supervision of your corresponding night intern
• Walk-rounds should occur at a specified time with the night intern to identify at
risk patients, prioritize night work, and advance care.
• The professional development of the intern is always the resident’s responsibility.
Modeling organizational skills, time-management skills, professionalism and
humanism in medicine should always be a priority.
For your own supervision:
• Medicine Consult (b.86332) is your immediate back-up and the house doc
(moonlighting cross cover), ICU fellows and chief residents are also available at
any time during the night.
• Attendings, both private and ward, should be contacted with questions or
significant patient issues overnight including important changes in patient’s
clinical status, unexpected patient death, transfer to the unit, inter-service conflicts,
difficult family interactions and unresolved code status.
• Procedures must be supervised by a certified resident, chief resident, fellow or
attending, if you yourself are not certified for that procedure.
Clinical Responsibilities:
• For Admitting Rules, please see “Admitting Guidelines” on
columbiaresidents.org. Note the night time surge plan.
• For GM1 and 2: The most stable admission should go to the post call team. The
second most stable to the precall team. The most acute to the short call team. In the
Allen and on ID, the postcall team accepts one admission (the most stable). In
Milstein, and only on weekends, GM1, GM2, cardiology, and oncology can accept
one admission on the postcall day.
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•
•
•
Occasionally, the Night Resident admits overflow from other services and presents
these patients to the appropriate service’s rounds in the morning.
The night team assists the arrest resident with all cardiac arrests. The cardiology
night resident has a particularly important role. The Cardiology night resident is
expected, at an appropriate point during the arrest, to “take over” as arrest resident
so the CCU resident may return to the unit. If this hand-off occurs, the Cardiology
NF resident is expected to write an arrest note, communicate with nurses and
supervise any post-arrest arrangements. In the event that an ICU bed is not yet
available for a patient post-resuscitation, the Cardiology NR must stay and care for
the patient on the floor until they are able to be transferred to the ICU.
In the event that a second arrest is called, in general, the MICU resident should
respond. Given the problems of the overhead paging system, it may be necessary
to call the MICU to alert them.
Feedback and Evaluation
The NR should ask for and receive verbal feedback from the superteams’ attendings,
residents, interns and students. Additionally, rotation evaluation forms will be filled out by
your attendings, residents and interns and entered into your file.
Allen Night Float:
In general, the long call resident (carrying the 9000 pager) and the Hospitalist Service
Coordinator (carrying the 4558 beeper) communicate closely throughout the admitting day.
The Hospitalist will triage the majority of your admissions. If you hear about an admission
through an alternate route (i.e. from the ED, Milstein), please notify the Hospitalist about the
admission. In addition to keeping the Hospitalist up to date about your census, this frequent
check-in allows them to serve as an effective advocate for you, by confirming that a patient
actually needs to be on service.
Only ward patients may be admitted to the Medicine Service, unless the private attending is
the ward attending.
Regarding nursing home patients: Some of the admissions to the Allen are patients that
normally reside in nursing homes. Each nursing home has an Allen admitting attending
assigned to it (there's a master list in the 9000 binder). Specific nursing home patients always
go to the PA service (i.e. Manhattanville, Fort Tryon). Nursing home patients without a
private doctor may be on service (as ward patients). All patients admitted from a nursing
home with a designated individual private attending should be admitted to the PA service.
Ventilator dependent patients must be on-service, on a Hospitalist or medicine team.
As the Allen Night Float, you are the night arrest resident and carry the arrest pager. Each unit
as well as radiology has its own defibrillator and arrest cart. You may use a unit’s
defibrillator for arrests that occur outside of these patient care areas. The AICU may need
assistance in running arrests and activate the arrest pager.
Additional pearls about admitting at the AP:
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1. All patients being transferred from the Milstein ER to the Allen Pavilion must be approved
by the Hospitalist attending at the Allen Pavilion.
2. AICU triage is done by the overnight Hospitalist attending. Medical consults are taken by
the Hospitalist attending.
What happens in the morning?
The Allen morning schedule will begin at 8:30 AM to allow the night resident the opportunity
to present directly to the accepting teams. In the morning before attending rounds it is
expected that you will touch base with the post call resident to review the patients that you
admitted overnight. At 8:30 AM you will present your admissions to the appropriate teams
(as above). You should be leaving the hospital no later than 9:30 AM.
ID/Oncology
The ID/Oncology night resident’s schedule runs Saturday through Thursday, with Friday
night off. On Friday night, the ID/Onc NR will be covered by an OPD2 or E2 junior resident.
The ID/onc night resident admits up to 3 patients until 5:00 am, one of which should be done
with the ID night intern (an infectious disease case) and one of which should be done with the
Onc night intern (an oncologic case). Until 3 am, The NR may only admit a maximum of 2
ID or 2 oncology patients each night. At 3 am, a third oncology or ID patient may be
accepted.
The ID/Onc NR resident will present cases not admitted with the interns first, but afterwards
should attend either ID rounds or oncology rounds to hear the interns’ presentations. The
night resident and night interns must leave the hospital by 10:00am.
The ID/Onc NR may admit up to one Gen Med or Private overflow patient per night, but this
is not to be done with the intern. The night resident admits up to 3 patients until 5:00 am.
After 3:00 am, the night resident may accept no more than 2 new patients, and after 4:00 am
no more than 1 new patient.
The patients formally worked up by the night ID teams will be distributed the next morning to
either the post call team or long call team. The post call team will accept one NF admission if
they are below cap.
Transfers from other services:
As with other services, the ID long call team can accept a pre-arranged service transfer from
another service if approved by the chief residents.
Emergency Room
Please see How to be an ED rotator for details
Resident shifts will be 12 hours long; rotating on a staggered basis to include 8AM-8PM,
12N-12M, and 9PM-9AM shifts. The ER attendings are aware that you must leave at the end
of your shift even if sign-out rounds have not been completed. You should make sure you
sign out the patients you cared for during your shift to the resident who is taking your place,
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but must not stay past the end of your shift. If the attending will not allow you to leave at the
end of your shift, please remind them of this policy and let the Chief Residents know if this
becomes an issue. Conferences will include a daily (M-F) noon conference (located in the ER
resident’s rooms in the Garden Café of the P&S building) and Wednesday didactics from 8
AM to 1 PM (which will take place either at Columbia or Cornell on an alternating weekly
schedule). Medicine housestaff who are in the ER during these conferences will be released
from their clinical duties. Attendance to didactic sessions is mandatory – otherwise, you
should be in the ER.
Medicine residents on ER rotations will work an average of 5-6 shifts in 7 days (60 hours a
week), as will the residents rotating in the ER from other services. In addition, you will have
clinic on two mornings, generally Tuesdays, during the rotation. For schedule requests,
please email the EM Chiefs at [email protected] at least 2 or 3 months in
advance. The EM Chiefs will attempt to honor requests, especially earlier requests, but they
cannot guarantee it.
Elective
Each resident has a total of 10 weeks of elective, usually broken up into one 5 week block of
E1 (or two 2.5 week blocks of E1) and two 2.5 week blocks of E2 elective time. This time
may be spent for either research or clinical experience on a consult service. An elective
proposal form. These forms should outline your elective plans and must include the signature
of the attending physician who will serve as your advisor.
Inquiries about away electives are considered on an individual basis. Any elective outside of
Columbia is considered an away elective, such as an elective at the Department of Health.
Those who wish to do away electives must contact the Chiefs and submit a formal proposal
AT LEAST TWO MONTHS IN ADVANCE of their elective date if they wish to be
considered.
Residents on E1 are responsible for providing sick pull coverage (see below). One week prior
to starting the rotation, the residents obtain a “sick pull block form” from the Chief’s Office
and then create and submit a mutually agreed upon schedule detailing the sick pull order for
the block. This schedule should also include as many forms of contact information as
possible (home #, cellular phone #, etc).
The schedules this year are additionally arranged such that OPD usually immediately
precedes the CCU block (although there are some exceptions). During the last week of OPD,
you will be required to attend an afternoon session as part of a newly instituted Code
Curriculum to assist in preparing you to be the arrest resident in the CCU. You will receive
notification at the start of your elective regarding the date and time of the session. Individuals
who have CCU or night float cardiology in the first two months of the will have their session
during the resident retreat.
During one of your E2 electives you will be required to attend a 5 day Health Systems course
which is intended to provide a background of knowledge of key components of the US health
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care system. The course will be taught by Professors from the Mailman School of Public
Health and is an excellent opportunity to learn more about our health care system. Attendance
is mandatory and you are expected to be present for all sessions unless you have previously
been excused by a Chief Resident.
MICU
A team of one attending, one fellow, four junior residents, and four interns runs the MICU.
The call schedule is as follows: Long à Post à Pre/Clinic à Short. If your pre-call day
falls on a Monday through Wednesday, you will be expected to round in the unit in the
morning then have a regular clinic session (starting at 1PM). On these days, it is expected
that the precall resident will assist with prerounding by seeing two patients. If your pre-call
day falls on Thursday through Sunday this will be your day off and you will not have clinic.
The structure of the day is as follows: All residents will have work rounds together from 7:30
to 8 AM. Interns are expected to have completed pre-rounds by 8 AM. Resident rounds
should focus on follow-up patients and their overnight events rather than presenting new
admissions to one another. New admissions should be left for attending rounds unless time
permits otherwise. Attending rounds begin at 8 AM, and end by 10:30 AM. The post call
resident leaves by 10:30 AM after they have presented the new cases, even if rounds have not
yet been concluded. The precall resident has clinic at 1pm.
Short call residents will start admitting at 6 AM and accept up to 2 admissions before 1 PM.
The short call resident will admit with the long call intern until 1:00 pm, or until two
admissions have been completed. Subsequent admissions will be done by the long call intern
under the supervision of the long call resident. Other notable short call duties include 1)
second arrest resident until 5 PM 2) generating the scut list and line placement list on rounds
and performing procedures with the short call intern, 3) reviewing AM EKGs (point out any
outstanding findings to the long call resident holding the board). Short call is expected to stay
to help with work/intern supervision until at least 5 PM.
The long call day starts at 7:30 AM and ends at 10:30 AM the next day. The long call
resident “carries the board” in the ICU. The board is intended to track patient data for the
day, outline treatment plans, and changes in treatment or patient status. The long call resident
should remain on rounds at all times (while the other residents/interns deal with emergencies
or other issues that arise during rounds). After rounds, the long call resident should check labs
and act on abnormal/changing values, and update the scut list if indicated (the initial list is
generated by the short call resident on rounds).
In the early evening (~7 pm), the resident should walk round with the ICU fellow and the logn
call MICU intern to review the day’s events, plans of care, and possible evening/nighttime
transfers out of the unit. Other facts and data should be checked as well, including Is & Os,
vitals, consult/attending notes, vent settings, etc. During early morning, walk rounds should
be repeated and a new board sheet should be generated/updated for the oncoming team.
Remember to write update/event notes for significant events or changes that occur during
your call.
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The long call resident starts taking admissions with the long call intern after 1 PM (or after the
short call resident has taken two admissions). The long call intern should generally stop
admitting around 7 pm, in order to leave sufficient time to complete notes and leave by 9:30
pm. The long call intern must absolutely leave no later than 9:30 pm. The long call intern
will help with the evaluation and management of patients arriving between 7 pm and 9:30pm,
but these will be the primary admissions of the night intern, who arrives at 9:30 pm.
Similarly, the night intern should stop admitting at 6am, although may assist with the
management of patients that arrive between 6 am – 7 am, when the long call intern arrives.
However, if patients are held for the short call resident, they must have an initial evaluation
by the long call resident, holding orders written, and emergent needs addressed (including
placement of appropriate lines) before the short call team arrives.
Although the MICU resident is in charge of the ICU and responsible for many patient care
decisions, the resident always has backup. REMEMBER – YOU ARE NEVER ALONE IN
EITHER UNIT. CALLING FOR HELP IS NOT A SIGN OF WEAKNESS. IT IS A SIGN
OF SOUND JUDGMENT. Nighttime resources available to the long call team include the
ICU fellow and attendings as well as the Med Consult senior resident (whose duties will
include accepting and observing patients sent from the ICU to the floor overnight, and who
already likely knows a brief story on every ICU patient). Similarly, during codes on the floor,
the MICU resident is nominally in charge of the CCU intern and should check in on him/her
to ensure that no emergencies require immediate assistance.
In the MICU, you will care for all patients, both ward and private patients. The MICU
attendings are the attending of record for all patients but privates should still be notified of
any changes in their patient’s status. There are no official rules governing which types of
lines residents are allowed to place; however, as always, someone experienced/certified for
the procedure/line placement must be present.
There will be didactics at lunch time, led primarily by the fellows. All residents are required
to attend, except those admitting a new patient or managing an unstable patient.
CCU
The call schedule and short/long call duties in the CCU are the same as that in the MICU (see
above). The structure of the morning is different. The long call resident arrives at 8am. All
residents and interns have walk rounds together from 8:00 to 9:30 AM each day. Interns are
expected to have done pre-rounds prior to 8:00 AM. Attending rounds begin at 9:30 and end
by 12 noon. The post call resident leaves by 11 AM, after new cases and follow ups have
been presented. If you completed presenting your new admissions prior to 11 AM, you
should still stay for rounds until 11AM.
You will care for ward and private patients in the CCU. All patients should be rounded on
during attending rounds; however, private attendings are the attending of record for their own
patients and remain active in directing care. Privates should be involved in all management
decisions and notified of any changes in their patient’s clinical status. Residents are permitted
to place femoral central venous catheters and arterial catheters. All neck lines (PA catheters
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and jugular/subclavian central venous catheters) must be placed under the supervision of the
CCU fellow.
The team will round with a PA who will assist in pre-rounding and patient care duties during
daytime hours. As of now, 12 beds in the CCU are the primary responsibility of the CCU
team, and at night of the CCU long call resident and night intern.
There will be didactics on certain days of the week at lunch time led primarily by the fellows.
All residents are required to attend, except those admitting a new patient or managing an
unstable patient.
Although the CCU resident is in charge of the unit and responsible for many patient care
decisions, the resident always has backup. Night-time resources available to the long call
team include the CCU fellow and attendings as well as the Med Consult senior resident.
Arrests:
The CCU residents act as the primary arrest resident. In general these duties are covered by
the short call resident until 5 PM, then by the long call resident. During the day, the
Cardiology long call resident is expected, at an appropriate point during the arrest, to “take
over” as arrest resident so the CCU resident may return to the unit. Overnight, the Cardiology
NF resident fulfills this role. If this hand-off occurs, the long call/NF cards resident is
expected to write an arrest note, communicate with nurses and supervise any post-arrest
arrangements.
In the event that a second arrest is called, in general, the MICU resident should respond.
Given the problems of the overhead paging system, it may be necessary to call the MICU to
alert them.
The short call resident in the CCU is responsible for changing the battery in the arrest box at
the start of each day (i.e. as you walk in the door in the morning do not get coffee before
changing the battery).
Telemetry:
See Housestaff Manual for up to date details
There are 2 telemetry orders at Milstein. One labeled as “Milstein Telemetry-Cardiac Floors”
and the other as “Milstein Telemetry-Non cardiac Floors.” It is MANDATORY that
providers use the “non-cardiac floors” order for all patients on non-cardiac floors (all hospital
floors except for 5GN, 5GS, 5HN, 7HN). This order will automatically expire after 72hrs. In
the near future, approval will have to be obtained in order to extend telemetry beyond 72
hours.
Days off and Clinic:
ID:
Please see separate ID orientation for details. During the two weeks of ID days, residents will
be assigned to the same team and admitting on a q2 cycle. Days off are post call Friday and
long call Sunday. On the Monday after your long call Sunday off, please see new admissions
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before rounds and get signout from the admitting resident. There will be no continuity clinic
during ID days.
GM1 and GM2:
The resident day off is pre-call and short call Saturday, Sunday and hospital holidays. The
clinic day is post-call.
Solid Oncology:
Please see separate solid oncology orientation fo details. Resident day off is pre-call Saturday
– Monday and 1 post call Saturday (For the resident who has two post call Saturdays, you
have the last one off).
Malignant Hematology:
Please see separate malignant heme orientation for details. Days off are the first post-call
Saturday of the block and Sundays.
Allen Night Float:
The resident night off is Sunday.
MICU/CCU
The resident day off is Pre-call, Thursday – Sunday. The Clinic day is Pre-call Monday –
Wednesday. Clinic starts at 1pm.
Notes
The intern writes the definitive admission note. A resident’s note should focus on only the
most pertinent portions of the H&P. In addition, the assessment and plan should be a higher
level discussion of what is going on with the patient, and the major aspects of your plan for
their hospitalization. Residents should attempt to include citations of the literature in their
notes. Essentially, the resident note is as much an academic exercise as it is a practical
contribution to the patient’s medical chart.
Residents write notes on all admissions except night float admissions. For night float
admissions, both the resident and the intern must interview, examine, and formulate an
assessment and plan for the patient but only the intern needs to write the accept note. On the
weekends your team is responsible for writing progress notes on all cross-covered patients. If
possible the intern should round on these patients and write their cross coverage notes, but
when the cross-cover list is long or if your intern does not have enough time you are expected
to help and see cross-cover patients and write their progress notes.
A note must be written on every patient seven days a week. The admission note counts as the
patient’s note on the day of admission and the attending’s admit note counts on the new
admission’s post call day. It is your responsibility to ensure that every patient has notes
written in Eclipsys each day of the week.
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Evaluations
During each rotation, you will be given oral feedback by each of your attendings. They are
aware that they should evaluate you during and at the end of each rotation, so if this is not
occurring, please ask the attendings for concrete feedback as well as areas for improvement.
Additionally, these attendings will submit an evaluation to the program director commenting
on your performance in each of the 6 core competencies. You will find your evaluations on
E-value where they can be reviewed at any time. In addition, you will also review your
evaluations with your Key Faculty Advisor at your biannual review. If you receive a negative
evaluation, you have the right to appeal to the program director before it is placed in your file.
You will also be evaluating the interns that you work with. It is important to give frequent
and constructive feedback to your interns. You should give the feedback within the first week
or so of working with them so they will be able to improve on areas of weakness during the
rotation.
Work Hours
ACGME and IPRO work hour regulations have impacted the architecture of our admitting
days as well as service capacities. These rules include a work hour limitation of 80 hours per
week, preferably 10 hours off between shifts (8 hours minimum), a maximum of 24 hour
shifts with 3 hours allowable for transfer of care, and an average of one day off in seven. It is
the job of the resident to help ensure that interns leave the hospital at the appropriate time.
Current ACGME guidelines do not allow interns to work in excess of 16 hours in a single
shift. It is critically important in the current regulatory climate that we adhere to these
guidelines, and we ask that residents do everything they can to make this happen.
Sick Pull
General Rules for Sick Call:
1) Be reasonable: Don’t work while requiring IV hydration, but don’t call in sick for allergic
rhinitis.
2) If you do plan to call in sick, call as soon as possible before your shift starts to allow
adequate time to arrange coverage.
3) Notify the Chief onCall if you are sick on a clinic day so he or she can cancel your clinic.
All AIM Clinic cancellation emails should be addressed to all 3 of the following:
Christina Collado ([email protected]), Chief Residents ([email protected])
and Nancy Chang ([email protected]).
4) You must speak to the chief by direct phone conversation or in person- i.e. e-mail, text
pages, and/or messages on the chiefs’ answering machine are NOT acceptable
alternatives. PLEASE CONTACT THE CHIEFS AS EARLY AS POSSIBLE if you
know (or even suspect) that you will be unable to make it to work. All absences, even
those not requiring coverage, must be reported to the Chief Resident on call.
5) If you call in sick for three consecutive days, you are required to see a doctor and obtain a
note. If you do not have a MD, you can be seen in Occupational Health. Residents with
more than 5 absences from work due to illness over a 12-month period are also required to
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have a letter from a treating physician on the first day of any subsequent illness that
requires an absence from work.
6) If you are absent from work due to illness you should be reachable to provide information
that may be needed about patients.
7) For non-emergent absences you must arrange for coverage of your clinical
responsibilities. This includes jury duty. If you are absent for reasons other than illness
and require someone to be pulled, you will be scheduled to pay back twice the number of
hours worked by the person pulled. Please submit coverage schedules in advance to the
Chiefs by emailing [email protected] .
8) You are allowed 3 days off without payback from June 2012 – June 2013, but if you call
in sick more than 3 times, you will owe an equivalent shift to the fourth person pulled.
Additional Rules for Sick Pull
1) If you are on elective E1 you may be pulled to cover sick or absent colleagues. The list of
pull order should be submitted to the Chief’s Office prior to the start of each new block.
The list may be handed in person to one of the chiefs or e-mailed to
[email protected] Any changes to this list must be given to the chiefs.
2) If you are on sick pull, you are expected to be available by beeper or phone at all times,
and must be able to reach the hospital within one hour in the event that you are pulled. If
you are called by the Chiefs, you must work unless you yourself are sick.
3) If someone on the pull list is unreachable for their pull, the next person down the list will
be pulled and the unavailable person will owe the person who works double payback.
4) In the unlikely event that the sick pull list has been exhausted (i.e. everyone has been
pulled), residents on OPD or E2 will be called at the chief’s discretion. Hopefully this
will not be necessary, but if called by the Chief, you must work unless you yourself are
sick.
5) If you are on the sick pull list and are working someone else’s shift by previous
arrangement (i.e. a trade or pay-back which has been approved by the chiefs), we strongly
recommend that you are as far down on the pull schedule as possible. If you are working
for someone else while you are on the pull schedule, we recommend that you identify
someone else who will be able to perform your sick pull duties should you be called into
work.
6) Sick pull coverage may also be arranged in the event of family emergencies such as a
death or serious illness. As these matters are of a highly personal nature, we do not feel it
is necessary or possible to create a comprehensive policy that specifically outlines which
emergencies will and will not be covered. In general, our policy will be to discuss each
case on an individual basis with the person involved. For reasons of confidentiality you
may not be told exactly why you are being pulled.
Emergency Jeopardy
In the unlikely event that the sick pull list has been exhausted (i.e. everyone has been pulled),
the residents on E2 and OPD2 and OPD1 will be called at the Chiefs’ discretion. Hopefully
this will never be necessary, but if called by the Chiefs, you must work unless you yourself
are sick. Payback policies apply in such instances as well.
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Trading Shifts
Residents may trade equivalent shifts or calls with other residents. All changes to your
previously assigned clinical responsibilities must be approved by the chief residents. The
most appropriate means of switching is to e-mail [email protected] and all
involved residents. It is unacceptable to trade shifts without involving the Chief Resident’s
Office.
Jury Duty
Residents will be called upon by New York State to perform jury duty. You should postpone
your duty if it falls at a time when you have inpatient clinical responsibilities and re-schedule
it for your elective or outpatient blocks. The state will often allow multiple postponements of
jury duty. If you are unable to postpone jury duty to a non-ward month, you will be asked to
present your papers showing that you have not been allowed to further defer jury duty and
that you had attempted to schedule it for a non-inpatient month. Otherwise, you will be asked
to find coverage for yourself, or you will be required to pay the sick-pull resident back twofold. When re-scheduling jury duty, keep in mind that even if you are not selected for a jury,
you will spend 2 days at jury duty for the selection process.
Pager Policy
Pagers are to be kept on at all times while on service or when on call (i.e. OPD AIM
telephone coverage). Residents and interns on vacation or night rotations should sign their
pager “out of hospital, unavailable” when unavailable. Interns and Senior Medicine Residents
should always have their pager signed over to the in-hospital doctor covering their
hospitalized patients.
Moonlighting
In order to be eligible for moonlighting, you must have no pending discharge summaries and
be up to date on evaluations and duty hour log in. Juniors and seniors may qualify for
moonlighting privileges for the hospitalist service after having received their medical license
(and thus having passed Step 3) and after having completed at least one month of ICU time as
a junior resident. Juniors and seniors do not need a license to qualify for moonlighting on the
heme/onc services, the general medicine PA shift, or the Allen shift. Juniors are currently
permitted to moonlight if they have no other clinical responsibilities and only if they are on
vacation, outpatient, or elective. Moonlighting which results in working for greater than 24
hours (overnight shifts between on service days) is also prohibited, as is moonlighting that
leads to more than 80 hours of work during a week or less than 10 hours between shifts of
duty or duties. Splitting of shifts to avoid this is acceptable. Moonlighting during the evening
and nighttime hours while on elective is permissible but arrangements for sick pull must be
made in advance. Moonlighting privileges will be revoked if a resident violates any of these
restrictions. Nightime moonlighting is prohibited during the weekday daytime hours except
while on vacation and is prohibited during all inpatient rotations. Moonlighting while
simultaneously assuming other clinical responsibilities (“double dipping”) is strictly
prohibited.
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