Resident's Handbook: 3A Psychiatry
Ralph H. Johnson VAMC
Version 1.9 6/01/2008
Robert P. Albanese, Jr., MD Director
I.
II.
Introduction. Through all of my years of clinical practice, I have had the
privilege of caring for veterans. Serving these heroes who have been prepared
to make "the ultimate sacrifice" for our great nation, for the freedom of all
people, has given great meaning to my life. Not only are veterans among the
most courageous Americans, but the clinical problems encountered in veterans
hospitals are challenging and demanding of your utmost clinical acumen and
skill. I hope that you too will find your work at the Ralph H. Johnson VA
Medical Center fascinating, rewarding and enjoyable. You will be a better
physician for the time you have served here. Welcome, and may the spirit of
Hippocrates be with you!
Unit 3A Psychiatry
a. Access to the Unit. The inpatient psychiatry unit is a secure, locked unit.
Patients may not leave the unit unaccompanied, and leaving the unit with
staff only occurs when the patient must have a procedure or a consultation
or when the patient goes to Charleston County Probate Court. Inpatient
psychiatry at our VA is also a non-smoking unit, so nicotine patches or
gum are commonly prescribed for patients who smoke. Staff may enter
the unit by picking up the phone outside the door and requesting entry;
nurses will unlock the door remotely. In the past, residents and medical
students have had access to keys to open the door on the unit, but for the
foreseeable future keys to the door of 3A will not be available to people
other than ward attending physicians and nurses. This measure has been
taken in the name of the security of the unit; a number of keys have been
distributed to residents over the years and they are still "out there." As of
this writing residents and medical students may still acquire CM1 keys,
which open doors in the clinic area and also the workrooms on 3A.
Students get their keys from the university, and residents get keys from
Erica Smith.
When you leave the unit, please make sure that the door closes behind
you. Our elopements have generally happened when residents or medical
students walk through the door and continue down the hallway without
making sure that no one has darted out behind their backs.
b. Clinical Character of the Unit. Our inpatient psychiatry unit is designed to
care for adults with serious mental illnesses. We consider 3A to be a
psychiatric intensive care unit. Most of our patients are of course male,
but we also care for female veterans. Typical clinical categories include:
i. Schizophrenia exacerbations.
ii. Addictions and detoxifications.
iii. Major depression.
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iv. Bipolar mania.
v. Bipolar depression.
vi. Posttraumatic stress disorder.
vii. Borderline personality disorder.
viii. Adjustment disorders
There are psychiatric conditions that we do not generally treat on 3A.
These include:
i. Dementia (all admissions for demented individuals must be
approved by Dr. Albanese or Dr. Myrick).
ii. delirium
iii. dissociative disorders
iv. impulse control disorders
v. amnestic disorders
vi. eating disorders
vii. anxiety disorders other than PTSD.
viii. factitious disorders.
ix. somatoform disorders
x. paraphilias
xi. simple sleep disorders
xii. cocaine detoxification
We occasionally make exceptions to the rule on these diagnoses.
Examples of exceptions we may make include early delirium in alcohol
withdrawal or brief hospitalizations for patients with dementia where there
is a great deal of social support.
c. General Medical Issues. We make a great effort to take comprehensive
care of our patients. When your attending is myself or Dr. Haren, you will
manage general medical issues under our supervision; therefore you will
not be consulting the Internal Medicine service (you will continue to
consult specialists). General medical issues you will handle on 3A
include, but are not limited to:
i. Hypertension
ii. Diabetes
iii. Hyperlipidemia
iv. Urinary tract infections
v. Respiratory infections
vi. Seborrhea
vii. Tension headache
viii. Constipation
ix. Diarrhea
x. Orthostatic hypotension
xi. Angina
xii. COPD
When your supervisor is not a dual-boarded physician, you should follow
your attending psychiatrist's directions as to when to treat general medical
issues and when to obtain a consultation. Please feel free to contact me or
Dr. Haren at any time if you wish to discuss a case.
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d. Census. As of this writing, the capacity for patients on our unit is 14
patients. As of November 1, 2007, we have returned to a one-team
inpatient unit on 3A for most of the year. More specifically for eight
months there will be one attending psychiatrist and that we be me, Dr.
Albanese. For the other four months, such as when I am on Medicine
Service, there may be two psychiatrists and two separate teams. Other
psychiatrists who may be in the rotation include Drs. Huber, Haren,
Wright and Cusack.
e. Patient Care.
i. Respect. Interactions with patients should always be characterized
as respectful. That means that the resident and the medical student
should be courteous and professional in their appearance.
Residents and medical students should avoid dress that is too
casual or revealing (anything that encourages the patient to see
them as anything other than professionals). The resident and the
medical student should never refer to the patient by his or her first
name, even if the patient requests it.
ii. Pre-rounding. The resident must see every patient before rounds if
at all possible. Sometimes the patient is not on the unit because of
ECT or imaging; otherwise the resident must see the patient prior
to attending rounds. If the resident is working with a capable
student, the student may see the patient before rounds but the
responsibility is on the resident to be certain that the student is
diligent and that the student's report is accurate.
iii. Attending rounds. Rounds with the attending psychiatrist begin at
8:30 every morning except Tuesday, when rounds start at 09:00.
On Fridays we have Morning Report, which begins at 8:00 and
goes to 08:30-9:00.
f. Documentation. There are numerous issues surrounding documentation
that are of paramount importance during your tour on 3A.
i. General documentation. Medical students and residents must take
great care that their notes not convey a negative attitude toward the
patient or his or her family members. It is sometimes necessary to
document evidence for malingering or for an occult addiction or a
negative family dynamic but this kind of notation can always be
done in a clinical and professional manner. Also, our
documentation must NOT use lay terms or familiar language
unless we are quoting the patient. A serious attitude toward patient
care must be reflected in our documentation. The tone of our
progress notes should always reflect compassion and respect.
ii. "Cut and paste" is not permitted on any service in the VA as it
reflects an unprofessional attitude toward documentation. The
purpose of note writing is to document one's thought processes on
patient care, and cutting and pasting from previous notes or
imaging studies fills the chart with repetitious and eventually
irrelevant information. Rather than cutting and pasting the results
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of a head CT into the progress note, it makes more sense to
describe in the note how the imaging study is relevant to the
patient's diagnosis or treatment. In particular, do not cut and paste
the assessment and plan. I have seen this done throughout a
patient's hospitalization, and it does not reflect good care.
iii. Progress Notes. There is only one approved progress note
template for notes on 3A. It is called "Mental Health Resident
Note." This note template includes documentation of attending
involvement, which is necessary for Joint Commission
requirements. There are certain abbreviations that are not
permissible in any documentation; these abbreviations include are
posted on the inpatient unit. See below:
DO NOT USE Abbreviations
Abbreviation
Correction
U
Write “unit”
IU
Write “international unit”
Q.D.
Write “daily”
Q.O.D.
Write “every other day”
Zero after decimal point (1.0 mg)
Do not use terminal zeros for doses expressed in whole
numbers
No zero before decimal dose
(.5mg)
Always use zero before a decimal when the dose is less
than a whole unit.
MS
Write “morphine sulfate or magnesium sulfate”
MSO4
MgSO4
iv. History and physical examinations.
1. The H & P should be completed within 12 hours of
admission, and it should be completed by rounds the next
morning if at all possible. The exception is if the patient
was admitted in the early morning, say 0600 and there has
not been sufficient time to finish it; by definition an
unusual situation.
2. There is only one approved version of the history and
physical examination; it is the History and Physical
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Psychiatry found under progress notes in the computerized
VA medical record. This is a templated note and all of the
sections must be completed. Please do not omit any of the
information in the history and physical examination
template.
3. You must identify the co-signer of the note when you write
it; please take care to identify the appropriate attending
psychiatrist. Identifying a co-signer who is not attending
on the ward may delay the signature of a supervising
attending physician.
4. The history and physical examination is normally
performed by the inpatient residents if the patient arrives on
the unit by 4:30. If the patient arrives between 4:30 and
5:00 PM, the inpatient resident enters the admission orders
and the on-call team does the history and physical
examination.
5. Transfer Accept Notes and readmission notes.
Traditionally it has not been necessary to compose an entire
history and physical examination when patients are
accepted in transfer from other units, or when they are
readmitted after a brief period (less than 30 days).
Documentation requirements have evolved, however, such
that among the necessary elements of any such note are
medication reconciliation (which must be done in two
parts) and MHICM screen. If the resident wishes to try his
or her luck at composing a transfer accept note from
medicine or surgery or a readmission note, we are willing
to consider it as long as those elements are included. It
may be a better idea to use a history and physical from the
template and abbreviate sections of it, such as the physical
examination.
v. Progress Notes.
1. Patients on 3A must have a note written by a physician
every day. Medical student notes do not meet this
requirement. Medical students should write notes
frequently, but there still must be a separate MD progress
note. An addendum to a student note also does not satisfy
this requirement.
2. There is an approved progress note template for residents
on 3A; it is called "Mental Health Resident Note." This
note identifies the attending psychiatrist and also the degree
of attending involvement, documentation of which is
required.
3. When I am on the inpatient unit I generally write all of the
regular progress notes except Thursdays (I have Action
Team Meeting) or when something else intervenes; other
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attending psychiatrists will ask the residents to write the
notes daily. If the attending has written a note, it is not
usually necessary for the resident to write a note. If the
attending psychiatrist has written a progress note and there
has been a development in the patient's case that merits a
significant change in the treatment plan, a brief note by the
resident is warranted. This kind of note does not require
the use of the templated note, as attending involvement is
documented in the attending psychiatrist's note.
vi. Orders
1. Diet. Please note that our patients are generally obese,
diabetic and hypertensive and they quite often have
coronary artery disease. Our patients quite frequently ask
for double portions and snacks, and our residents typically
ordered these dietary supplements in the past. Complying
with these requests is bad care, and not infrequently our
patients gain a significant amount of weight while they are
on the unit. Please order "3A NCS" on the majority of 3A
patients. If they are diabetic, please strongly consider no
more than 2000 kcal per day. If the patient requests
additional snacks or extra portions, please get a nutrition
consult. Remember that for most hospitalized patients, the
basal energy expenditure is 1500-1700 kcal per day, so
even with a diet of 2000 kcal per day the patient may gain
weight.
vii. Treatment Plans. Our service line policy is that a Multidisciplinary
Treatment Plan must be completed within 72 hours of admission.
The requirement for residents, however, is that the
Multidisciplinary Treatment Plan note be done within 24 hours of
admission. In other words, after the first morning rounds with
nursing after admission, the resident must write the Treatment Plan
note. The note should not be written before the first morning
rounds with nursing, as such a note would not reflect a
multidisciplinary note. When you are doing the initial treatment
plan, try to resist the urge to identify all appropriate interventions.
We can really only realistically make 2-3 interventions during a
typical hospitalization. Please note that the resident will be
required to determine on the treatment plan whether the admission
was precipitated by a suicide attempt or potentially lethal gesture.
Answering in the affirmative necessitates a "psychological
autopsy" performed by the attending; you may want to clarify with
your attending psychiatrist whether or not a parasuicidal behavior
meets criteria for suicide attempt or potentially lethal gesture
before you make a definitive assessment on the treatment plan.
viii. Notification of Case Manager. As soon as you have assessed your
patient on 3A, please make certain that the case manager is aware
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that his or her patient has been admitted to 3A. We would like for
our case managers to come and see the patient and write a note if
possible while the patient is hospitalized. If the admission was
initiated by the case manager, it would not be necessary; if the
patient is from Atlanta or Columbia a courtesy call to the patient's
provider is still desirable. If you have difficulty determining who
is the patient's case manager, ask your attending psychiatrist for
help.
ix. Discharge Summaries. Discharge summaries must be completed
within 3 working days of discharge. Failure to complete the
discharge summary in the allotted time could result in suspension
of clinical privileges for your attending physician; sparkling
evaluations usually do not follow this scenario. Please DO NOT
use any abbreviations in the diagnosis section of the discharge
summary, in other words, state "bipolar disorder" instead of BPAD
and "posttraumatic stress disorder" not PTSD. Please identify the
patient’s case manager as co-signer of the discharge summary, and
the patient’s outpatient attending psychiatrist should also be so
identified.
x. Discharge Instructions. On the day prior to discharge, you will
write discharge instructions for the patient and also write orders for
discharge medications. The orders for discharge medications will
not be acted upon by pharmacy until the discharge instructions for
the patient have been completed. There must be no discrepancy
between the discharge instruction and the discharge medications;
the two medications lists must be the same. Please identify the
patient’s case manager as co-signer of the discharge instructions,
and the patient’s outpatient attending psychiatrist should also be so
identified.
xi. Pre-Discharge Progress Notes and Appointments. In order to
create a predictable supply of beds, we have instituted a couple of
a measure related to discharge. The first is the Discharge
Appointment. This appointment is NOT the same as a FOLLOW
UP APPOINTMENT. A Discharge Appointment is a prearranged
time at which the patient must leave the unit. We are given an
hour before and an hour after the specified time to get the patient
off of the unit. The day before discharge, the resident or the
attending must write a "Pre Discharge Note" detailing the
discharge medications and the TIME of discharge (discharge
appointment time). The resident needs to get discharge
instructions done the day before discharge as well, and the
discharge medications need to be ordered the day before discharge.
We are asked to try to do the following:
1. make sure all patients have a pre discharge note written the
day before discharge.
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2. make sure all patients are discharged before noon to the
utmost extent possible.
3. make sure all patients have a discharge appointment time.
Obviously it will not be possible to be 100% on all of these
requirements; some patients leave AMA for example, but we
nonetheless strive for 100%.
xii. Follow-up. Patients who are admitted to 3A expressing suicidality
must be seen in follow-up by a psychiatrist and case manager.
This is not a flexible policy, so please make certain that the
suicidal patient does not leave without a scheduled appointment,
and it should ideally be within two weeks of discharge if the
patient has not already been identified as chronically suicidal.
Patients who have made a suicide attempt prior to admission must
be seen by a physician or nurse practitioner in a scheduled followup appointment within one week of discharge.
Patients who are not suicidal at the time of admission should
generally be followed up in the Mental Health Clinic within 3-4
weeks. Please call the case manager to schedule the follow up
appointment. If the patient has not previously been followed in our
Mental Health Clinic but will need to be followed there after
discharge, call Erica Smith, the administrative coordinator for
outpatient, to assign the patient a case manager.
Please note that only patients who have been assigned to our
Primary Care Clinic are eligible for outpatient follow-up in Mental
Health. If you need to have the patient assigned a Primary Care
provider (PCP), please call Louise Smalls (x. 7854) in Primary
Care. If the patient cannot be assigned a PCP (for example the
patient is ineligible), please consult with your attending
psychiatrist.
Another problem that frequently arises surrounding discharge is
that the resident waits to assign to the patient a case manager until
the day before discharge. When a patient admitted to 3A is going
to require follow up in our clinic and they do not already have a
case manager in our clinic, please call to get a case manager
assigned at the time of admission, not at the time of discharge.
Doing so makes it possible for the case manager to meet their new
patient prior to discharge.
We frequently care for patients from Columbia VA. Making
follow-up appointments for those patients requires calling Rachel
Dillahunt at extension 7183 or Dinah Hall at 7184 and 7037
(that’s at the Columbia VA). For patients not previously followed
in Columbia but who live in the Columbia catchment area, please
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III.
call Mary Maxwell at 7689. The number to the Dorn VAMC is
(803) 776-4000.
xiii. Psychological autopsy. When a patient is admitted to 3A after a
suicide attempt or a potentially dangerous gesture, the treating
attending must complete a psychological autopsy (Suicide
Assessment). This undertaking helps the treatment team to focus
on risk factors for suicide in the patient and also in other suicidal
patients. There should be resident input on the psychological
autopsy. The assessment is a progress note the attending
completes by interviewing the patient; it must be completed within
72 hours of admission. Feel free to pressure your attending to
complete the note if he or she is "taking their time." Blame it on
me!
xiv. Consultations
1. SATC (Substance Abuse Treatment Clinic) consultations.
Many of our patients on 3A are admitted with substance
use disorders. The Addictions Team should be consulted
with any such patient who expresses an interest in
treatment for these disorders. The psychiatry inpatient
resident should call the SATC resident for the month, and if
the inpatient resident does not know who the SATC
resident is, they should call Dr. Cluver (14490). There is
no need to enter an electronic consultation for SATC
2. Medicine and Surgery Consultations. For these consults, it
is necessary to enter the consultation electronically in
CPRS and also to call the consulting resident (or fellow)
for that service. As previously noted, when your attending
physician is dual-boarded, you will not likely request
general medicine consults but you will get surgical and
subspecialty consults. Special note to med-psych residents:
When your attending psychiatrist would like a general
medical consult, do not resist. If you are concerned about a
loss of prestige with the medicine service, perform the
consult yourself and report to the consulting attending
internist, making certain that the consulting internist cosigns your consultation.
Resident Staffing of 3A and CL (our Consultation Service). The inpatient
psychiatry and CL rotations are combined during this rotation. Since the
inpatient service is relatively small and we generally get no more than three
consults per week from the other services, the workload is generally
considered to be very manageable. Nevertheless we require that there be at
least two residents on service at any given time; we cannot run our clinical
operation for more than a few hours at a time with fewer. Staffing must be
considered when residents are contemplating vacations. Please note that we
only ask residents to do consults on General Medical and Surgical Services
when we are sufficiently staffed with residents. CL is a teaching service
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IV.
V.
staffed by two physicians board-certified in psychosomatic medicine
(Albanese and Haren) so the emphasis is on education to a greater degree that
service (or "scut").
a. Holiday Coverage
i. When it is a Federal Holiday but not a State Holiday, one of the
residents on the 3A/Emergency Psych rotation will be designated
to cover 3A and round with the attending. The resident will be
available throughout the daytime hours for order writing and
admissions.
ii. When it is a State Holiday but not a Federal Holiday, the on-call
team will provide resident coverage for admissions and orders;
rounding in the morning will be provided by one of the residents
on the service that month. When a resident works on a State
Holiday that is not a Federal Holiday, it has been the policy to
grant that resident a "Comp Day."
iii. When the first of the month is a holiday that falls on a Monday, an
admittedly rare situation that usually involves New Year's Day, a
resident from the previous month will round with the on-call
attending. That resident should be designated at the beginning of
the month.
b. Vacations. Vacation requests are required to be handed to me (Dr.
Albanese) in writing thirty days prior to the effective date, but this is a rule
we are very willing to bend when ever possible. The only potential
problem for late vacation requests is that, as previously noted, we have to
have two residents on service at any given time, and they are granted on a
"first come, first serve" basis. If there are only three residents on service
and two have requested vacation at the same time, the one who requested
leave first will be granted the leave.
PAC (Psychiatric Access). Until recently, PAC was a resident rotation, but
our supply of residents was not sufficiently predictable to keep this service
running that way. Then we incorporated PAC into the 3A rotation along with
C/L, but staffing continued to be an issue. Recently we hired a nurse
practitioner (Susan Beylotte) to run what we now call PAC/ACA. PAC =
Psychiatric Access Clinic and ACA = Advanced Clinic Access. Ms. Beylotte
sees psychiatric emergencies and some routine, same-day patients. The
reason it is important for residents to know about PAC is that Ms. Beylotte
may be admitting patients to 3A and she may call the resident to give a
description of the patient and a rationale for admission. Ms. Beylotte works
under my supervision, so she uses the same algorithms I use for evaluation
and admission.
Issues for Being on Call.
a. Admissions. Patients under consideration for admission must pass two
tests:
i. They must be eligible for admission. This is an administrative
assessment that must be determined by Bed Central during the day
and by the AOD (the Hospital Administrator) at night. In general,
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patients are eligible for admission if they are veterans of the US
Military. On rare occasions we have admitted patients who say
they are veterans but a review demonstrates that they are not. For
example a patient may have been in the Army for only a couple of
weeks; in that case the individual is not a veteran and he is not
eligible for care. There have also been cases where the patient
identifies himself as someone else, in other words an ineligible
patient claims to be another person who is eligible. Even when
patients have been in the military, however, they may not be
eligible for care. Examples include veterans who have been
dishonorably discharged and those who have been banned from
VA facilities because of behavioral problems. Also, patients with
pending charges or outstanding warrants are not eligible for
admission. These kinds of determinations cannot be made by a
resident, and if the administrator or bed central say that the patient
cannot be admitted, another psychiatric unit will have to be found.
Please note that on very rare occasions, we have knowingly
admitted non-veterans because it is a psychiatric emergency and
we are employing compassionate justification. Such cases should
be discussed with the attending on call and preferably Dr.
Albanese.
ii. They must meet clinical criteria for admission. We use Interqual
Criteria for admission to 3A. In general, that means the patient
must be suicidal, homicidal or acutely psychotic in order to merit
admission to 3A. Also, patients should be admitted for
detoxification only if medical detoxification is necessary to prevent
complicated withdrawal. We also use the same criteria the courts
use to find a patient eligible for hospitalization against his or her
will, that is, imminently dangerous to self, imminently dangerous to
others, or substantially unable to care for self by virtue of a
mental illness. Please note that with rare exceptions, demented
patients are not to be admitted to 3A, and they should not be
admitted without prior approval of Dr. Albanese or Dr. Myrick.
To a reasonable extent, we employ a "sliding scale" of clinical
necessity for admission. The best example of such is that if a
patient has been detoxified from alcohol within the last three
weeks, readmission for detoxification is generally not indicated. If
we have a lot of empty beds and the patient is not a "frequent
flyer," readmission is not unreasonable. Our competing goals are
to keep our inpatient unit at capacity but also not being enablers, as
it were.
b. Transfers. Transfers from inpatient units, whether MUSC or any other
facility, must be approved during business hours. If you are on call and
you are asked to evaluate a patient for transfer, check CPRS to see if there
is a note from myself, Susan Beylotte or a psychiatry attending specifically
approving the patient for transfer. If no such note can be found in the
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medical record, the patient is not approved for transfer and the patient
must remain at the facility of origin until the next day. Please note that
this rule does not apply to patients who are in emergency rooms, it only
applies to those who are on inpatient units.
c. Admissions from Outside ERs. It is very common to have calls after
hours from emergency rooms around the state asking for beds in our
inpatient unit. These are often emergency rooms in the Columbia (Dorn)
VA catchment area, as their inpatient unit does not have the capacity to
meet their demand. Remember that the patient is not to be considered for
admission to our unit unless the Administrator on Duty (AOD) has
researched the patient's eligibility and deemed that the patient is eligible
for care. Once the patient is cleared administratively, clinical
considerations come into play. It is paramount to remember that the way a
patient is presented to you from an outside ER is often very different from
what you see when the patient arrives. The concept of Medical Clearance,
for example, varies widely between locations. Our policy is that before
we accept the patient from an outside ER, we must have:
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
Vital signs
A benign physical examination
CBC
Chemistries
Liver Function Tests (aminotransferases)
UA
UDS (don't use your judgment just order it)
Levels of any drug that requires monitoring (for example lithium
level, valproate level, PT/PTT INR).
ix. Radiographic examinations where appropriate (for example in a
patient who has had a head injury).
Also, please make sure that the physician with whom you speak (there
must be physician-to-physician contact) has seen the patient. Quite often
the day shift physician signs the patient out to the evening shift MD and
the latter has not seen the patient. There can be a considerable clinical
evolution in just a few hours.
It is also important to make sure you have a good idea of the patient's
functional status. In general the patient must be ambulatory and capable
of performing ADLs. We do not accept delirious patients, and we do not
accept patients with IVs. Patients on home O2 or who use CPAP can be
managed on 3A.
We do not accept "pink papers," that is to say that we do not do
involuntary treatment for addictions at this VA.
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VI.
Civil Commitment. When patients arrive on 3A, they are rarely committed.
They are often under an Order of Emergency Involuntary Hospitalization,
however, and it is not a trivial distinction. Committed patients may be
discharged out our discretion, in general, but patients under an OEIH cannot
be discharged unless we petition the court to drop the order. Otherwise
patients under an OEIH must wait until they see the Probate Judge. It can take
between several days and two weeks for the patient to have a commitment
hearing in Probate.
With respect to Civil Commitment, we deal with three different jurisdictions:
Berkley County, Dorchester County and Charleston County. Patients who do
not fall under one of those counties are assigned to one of those three counties
anyway for the purposes of the hearing. Dorchester and Berkley Counties
send judges and attorneys to our unit; Charleston County usually requires that
we send the patient downtown.
Residents must submit DE (Designated Examiner) to the court with our
recommendations before a hearing is scheduled. Lavinia Mitchell on 3A is
very helpful getting the hearings scheduled; when she is not at work Pat
Hyman or one of the other nurses can usually be of assistance. Remember
that commitment criteria in South Carolina are 1. Imminently dangerous to
self; 2. Imminently dangerous to others; 3. Substantially unable to care for self
due to a mental illness.
VII.
Conclusion. We are justifiably proud of our inpatient and CL services; we
consistent get rave reviews for our teaching and patient care. We hope you
will have a great month when you rotate with us, and if there is any way we
can improve your experience, please let me know (Dr. Albanese).
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