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Inpatient Medicine Curriculum

Rotation Director: Priyank Jain

Description of rotation
Two teams, each comprising of one resident and 2-3 interns, provide care to hospitalized internal medicine patients on general medical wards. For the first 3 block of academic year, the teams have 3 interns each, for remaining 10 blocks the teams have 2 interns each. All resident care of patients is supervised by hospitalist attending physicians.

Resident service patients are primarily located on 4W per our geographic rounding policy. Residents receive a broad introduction to the evaluation and management of a wide variety of problems in general internal medicine. The patient population is diverse with approximately 50% of patients speaking primary languages other than English. In addition to the routine case mix for general internal medicine wards at a community hospital, the rotation provides a unique opportunity for residents to consider the complex relationships between health status and poverty including in-depth clinical experiences with substance abuse, co-morbid medical and psychiatric disease, geriatrics, HIV/ AIDS, homelessness, international and immigrant health.

The inpatient service functions on the premise of shared responsibility between house officers and attending staff. Interns (and acting-interns) will admit and manage patients, calling upon the resident and attending staff for guidance as needed. House officers enter all orders. The attending physicians have legal responsibility for patient care. Residents, as trainees, and attendings, as teachers, will collaborate to guarantee their patients the best medical care, the best learning experience, and the most collegial and satisfying work environment possible.

Goals and objectives
Broad goals for the inpatient rotation are listed below.

Medical knowledge
During the inpatient rotation, interns and residents should:
Expand understanding of the basic, clinical, and social sciences underlying the care of medical inpatients
Build basic fund of knowledge related to clinical diagnosis and management of common and “cannot miss” diagnoses, see Appendix A.

Patient Care
During the inpatient rotation, interns and residents should improve their ability to:
Interview and examine patients
Define and prioritize patients’ medical problems
Generate and prioritize differential diagnoses
Develop rational, evidence-based management strategies
Understand the role of the hospital and the acute phase in the overall illness episode and develop effective patient care plans for post-hospital care
Perform basic clinical procedures and interpret common radiology studies
Manage common inpatient medical emergencies

Interpersonal skills and communication
During the inpatient rotation, interns and residents should improve their ability to:
Communicate effectively with patients and families
Communicate effectively with physician colleagues at all levels
Communicate effectively with all members of the health care team
Present patient information concisely and clearly, verbally and in writing
Teach colleagues effectively

During the inpatient rotation, interns and residents should:
Develop greater self understanding
Practice self care
Behave respectfully with colleagues including effective conflict resolution, reliability, honesty, punctuality
Demonstrate a commitment to standards for lifelong excellence
Cultivate compassionate relationships with patients and family
Reflect on physician responsibilities to society

Practice-based learning and improvement
During the inpatient rotation, interns and residents should:
Demonstrate curiosity
Develop capacity to ask relevant clinical questions
Complete a learning goals worksheet with personal learning objectives for the rotation
Identify knowledge gaps in personal knowledge and skills in the care of hospitalized patients
Develop and implement strategies for filling gaps in knowledge and skills

Systems-based practice
During the inpatient rotation, interns and residents should improve their ability to:
Understand and utilize the multidisciplinary resources necessary to care optimally for hospitalized patients
Manage transitions of care effectively
Use evidence-based, cost-conscious strategies in the care of hospitalized patients.
Participate in improving systems of care
Participate in improving the inpatient ward rotation as a resident clinical learning experience

Clinical learning venue and schedule
During the rotation, residents will learn through participation in:

  • Initial evaluation of new admissions, daily evaluation and management of inpatients, and multidisciplinary discharge planning; all patient care activities will take place under the supervision of an attending physician
  • Procedures including abdominal paracentesis, ABG, lumbar puncture, NG tube placement, thoracentesis, central line placement, EKG analysis
  • Monthly review of radiologic studies with a radiologist and daily as needed
  • Formal teaching sessions including Tuesday School and Grand Rounds
  • Morning and afternoon patient management rounds with the hospitalist attending physician

6 - 7:30 a.m.: Day interns arrive, get signout on old patients, pre-round on old patients, read new patient H&Ps.

7:30 - 8 a.m.: Day interns and residents get signout on new patients from day team (7:30 for short call, 7:45 for long call).

8:30 -.10:30 a.m. Morning Work Rounds

The interns and resident join attending to round on patients and finalize management plan for the day. Interns are expected to present preliminary plan for their patients in rounds, residents are expected to determine sequence of patients and identify learning opportunities, attendings are expected to support the team and resident in their learning and patient care decisions. Use of the rounding template (Appendix E) is encouraged. Efficient day begins with efficient and effective work rounds and suggestions for planning these are in Appendix F.

10:45 -11:15 a.m. Multidisciplinary Rounds
Team resident meets with allied health providers including case managers, nutritionists, physical and respiratory therapists, social workers and nurses to coordinate care and make discharge plans. MDR rounds are facilitated by case management and occur near 4W nurses station.

2 p.m. Short-call team takes its last admission

3 - 4 p.m. Afternoon Rounds
Each ward team convenes with their attending to review the patients' progress, discuss new patients. Thereafter, team members share their answers to previously identified clinical questions. This time also serves as a venue to discuss team dynamics and identify strategies for improvement.

6 p.m. Handoff to the night team

Short call team can signout to long call resident earlier than 6 p.m. if their work is done.

Caps: Team assignment of new admissions is facilitated by the triage hospitalist. Residents are responsible for understanding and ensuring compliance with policies outlined in the house officer policy manual including intern and team caps as follows:

  1. .Each intern may accept a total of 5 new patients and 2 transfers in a 24 hour period; each intern may accept a total of 8 new + 2 transfer patients in a 48-hour period. When an intern “caps” before the team meets cap, the resident is responsible for doing a “res-intern” work up and note.
  2. The team may accept a total of 10 new + 4 transfer patients in a 24-hour period up to a team cap of 16 patients.
  3. Transfers from other services within the hospital, including the ICU will be treated as admissions in the flow of patients. Residents should work collaboratively to ensure relative balance in patient load between the two teams and between interns on each team.
  4. Patients readmitted within 7 days of discharge will be readmitted to the intern who previously cared for the patients. If the patient is admitted at a time when this intern is not taking admissions, the patient will be worked up by the admitting team and then transferred to the previous intern on the following day.
  5. After meeting team caps, residents will not admit additional new patients to their own team, but are available to assist in care of other patients including cross-coverage, procedures

Didactic learning venue and schedule

Tuesday 12 - 4 p.m. Tuesday School
All interns and residents participate in a four-hour didactic conference designed to cover core internal medicine curricular topics identified by ACP. The sessions are facilitated largely by internal medicine subspecialists from infectious disease, nephrology, rheumatology, pulmonology, cardiology, hematology, gastroenterology, geriatrics, psychiatry, palliative care, endocrinology, and neurology. The year is divided into two terms. The first term (Blocks A-B) is devoted to fundamentals in each subspecialty discipline and topics are repeated every year. The second term (Blocks C-M) is organized into discipline-specific blocks; topics are repeated on a two year repeat cycle. Location is Learning center A/B and Lunch is provided.

Wednesday 8 - 9 a.m. Department of Medicine Grand Rounds
Weekly teaching conference for the Department of Medicine from September to June addressing a broad range of topics in internal medicine – ambulatory and inpatient; general and subspecialty medicine; biomedical, clinical, and social sciences. All house officers are expected to attend.

Thursday, 12 - 1:30 p.m. Noon conference
Every Thursday, all interns and residents gather for teaching, reflection, or a program-related meeting. Scheduled during this block of time are the following:

  • 1st Thursday: House officer meetings with program directors
  • 2nd Thursday: Reflections on the healer’s art entitled “Food for the Soul”
  • 3rd Thursday: House officer union meetings
  • 4th (and 5th) Thursday: Resident led journal clubs

Feedback and Evaluation

Resident Evaluation
Interns and residents will work with two hospitalist attending physicians during each ward month who work in 2 week blocks. The first hospitalist will assume responsibility for orienting his or her team to the rotation and facilitating a conversation with each house officer about his or her learning goals for the rotation. At the end of the two weeks, the hospitalist will meet with house-staff for mid-rotation feedback and then sign out to the other hospitalist to give a ‘learner signout’ about their progress. The second hospitalist who will continue with the learning plan identified in feedback sessions, and be responsible for filling out the end of rotation evaluation form.

During each ward rotation, each intern and resident is expected to have at least one one-on-one session with a hospitalist. Suitable times for such sessions are Thursday or Friday afternoon sessions. The intern or resident and hospitalist choose from a variety of activities during that one on one time: review of written documentation; direct observation of a patient interaction; a chart stimulated recall.

Attending Evaluation
Interns and residents are expected to complete an online evaluation form on both of the attending hospitalist physicians with whom they work during the rotation.

Program Evaluation
Interns and residents are expected to complete an online evaluation form of the rotation. Additional comments, questions, concerns, and suggestions for improvement are always welcome.