Inpatient Service: Each hospital is unique regarding having an inpatient service, having a consulting service, or both. As a fellow, you should expect to be the primary provider for your service’s patients and to coordinate the patient care activities of the team (rounds, returning pages, consulting with other teams, etc.). Your clinical time will be your opportunity to focus on learning infectious disease diagnoses and treatments – take advantage of it! Also, become familiar with the microbiology lab and find out about how your lab functions. Keep in mind that some institutions have one year of clinical service followed by two years of research, while others divide clinical time over the three years. Take this into account when considering your goals in fellowship to make sure you are able to pursue your desired research, additional degrees, or specific clinical training.
Clinic: Most outpatient clinics see a mix of hospital follow-ups, new outpatient consults, and HIV infected or exposed children. Some clinics also have a focus on international adoption and/or travel medicine. Get a sense of the make-up of your division’s clinics. If there is a disease process you are particularly interested in but is seen in another clinic (i.e., a city-run tuberculosis clinic or a separate HIV clinic), discuss with your fellowship program director about incorporating these experiences into your training so you feel competent by the end of fellowship.
Calling your Attending with Questions: You should never feel badly about calling your attending, even late at night. Especially at the beginning of the year, it is much better to talk through a case when you are uncertain about next steps. Besides making good decisions for patients, talking through your thought process is an important part of your education. Your attendings fully expect to be called often, if not always, with questions in the beginning of the year.
Phone Calls and Curbside Consults: You will receive many questions from both inpatient and outpatient providers who do not request a formal consult. Managing these questions is challenging and requires a different skill set than being a front-line clinician. Rely on your attendings to help develop this skill. Do not hesitate to tell providers that you will discuss their question with your attending and call them back. Most providers are happy to hear that you are taking their question seriously and will not mind waiting.
Additionally, it is important to realize the limitations of telephone medicine. It is not uncommon to receive incomplete or inaccurate information, as there is likely more complexity to the patient than can be conveyed by phone. This can make providing a recommendation difficult and even unsafe. It is usually okay to answer general questions, but when the questions become patient-specific or very involved, it is often better to do a formal consult. Check with your attendings to see how much information they are comfortable giving over the phone. If the question is too complex, suggest that you do a formal consult. For patients outside of your institution, this may require referral to your clinic or the emergency room or having them transferred to your hospital.
Residents and Medical Students: Most hospitals have several learners involved in service – residents, medical students, and observers, to name a few. Learn early what role these members should take on (and can take on, by legal standards at your institution). Can medical students write notes? Can observers examine patients? Finding out early will save you confusion down the line. Even if you assign patients to the other learners, make sure you know what is going on with your patients. Don’t just rely on the other learners during rounds.
Billing: Frequently, trainees are removed from the billing process. However, many of our actions do affect how divisions can bill for services. Ask your attendings or co-fellows what practices need to be followed so that your hard work also keeps your division in business! It’s not a bad idea to learn the billing process during fellowship either. You will be in charge as soon as you graduate, so learning early could be of great benefit.
Health Records: Become proficient in your institution’s health record system early on. Many other trainees likely have tips and tricks for the system – don’t be shy about asking to spend a few minutes with someone to maximize your efficiency so that paperwork doesn’t distract you too much from taking care of patients.
Duty Hour Restrictions: Fellows must abide by ACGME duty hour restrictions just like residents. Your schedule should be designed to make sure you have the proper days off per month – if it’s not, work with your program to prevent duty hour violations. Duty hour requirements are included in the ACGME revised common program requirements.
Electives: Each institution offers elective time in different ways, both to complement your training and to fulfill certain ACGME requirements. Some elective rotations may include Infection Prevention & Control, Antimicrobial Stewardship, and/or a Microbiology Laboratory experience. Find out early on what your responsibilities are so that you can make sure your electives are scheduled accordingly to balance clinical service and research responsibilities.
Education: Any teaching hospital will have an array of educational talks for you to choose from. Prioritize any ID specific talks – case management, journal club, microbiology rounds, and learning directed towards fellows. Also seek out the other talks that interest you – grand rounds, immunology conferences, conferences with adult ID physicians, or research talks that will keep you connected to your research interests during clinical time. You can’t attend everything, but ensuring you prioritize those that fit with your training goals is important.
Feedback: Giving and receiving feedback is an important component of your training. Be sure to set aside time for feedback with your service attending, as this will be your main opportunity to get feedback on your clinical skills. We all are so focused on taking care of the patients that it is easy to forget about this! Your attendings are also required to provide an evaluation of your progression through clinical and professional milestones, similar to residency.
All programs should use the ACGME “Milestones” as part of your evaluation, which follow development over time. You should review these with your program director during your semi-annual review throughout fellowship. Keep in mind that milestones track growth. You should not really excel at anything as a first-year fellow, but rather should improve over the three-year program. Additionally, when you have residents and medical students rotating with you learn how to give them feedback on their performance during the rotation.
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