Cambridge Hospital Ward Medicine Rotation

Revised June 7, 2012

Rotation Director:
Priyank Jain, MD
pjain@challiance.org

 

Description of rotation

Two four-person teams comprised of one resident and three interns provide care to hospitalized internal medicine patients on two general medical wards (4W and 6N). Resident service patients are primarily located on 4W per our geographic rounding policy. All resident care of patients is supervised by hospitalist attending physicians and primary care physicians from affiliated primary care clinics.  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 and objectives for the inpatient rotation are listed below and organized within the six core competencies identified by the ACGME.

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
• Access and critically evaluate current medical information and scientific evidence relevant to patient care
• Build basic fund of knowledge related to clinical diagnosis and management of common and “cannot miss” diagnoses, see Appendix A.

 

PGY 1 Learning Objectives	PGY 2 Learning Objectives	PGY 3 Learning Objectives
o   Build cognitive schemas to facilitate approaches to common symptoms and syndromes o   Demonstrate independent critical thinking in patient evaluation and management	o   Consolidate basic fund of knowledge related to evaluation and management of common and cannot miss diagnoses o   Apply clinical guidelines and principles of evidence-based medicine to patient evaluation and management	o   Review core knowledge base related to common and cannot miss diagnoses o   Develop more detailed knowledge of selected topics within inpatient internal medicine o   Critically appraise data from recent literature and evidence behind clinical guidelines

 

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

 

PGY 1 Learning Objectives	PGY 2 Learning Objectives	PGY 3 Learning Objectives
o   Gather essential and accurate information about patients through history, physical exam, and review of secondary data o   Identify and prioritize patient’s medical problems and develop rational plans for evaluation and management o   Work effectively with nurses and allied health professionals in daily activities of patient care o   Attend to patient needs and provide patient-centered care	o        Supervise interns in their work of gathering, interpreting, and managing information for patient care o   Apply scientific evidence to the work of patient evaluation and management and assist interns in formulating plans of care o   Triage patients to appropriate levels of care and ensure appropriate communication with colleagues and attending physicians o   Manage inpatient medical emergencies o   Work effectively with multidisciplinary team in planning patient discharge o   Assist interns as necessary in completing daily tasks of patient care to facilitate the primary care-giving relationship between the patient and intern	o   Supervise interns in their work of gathering, interpreting, and managing information for patient care o   Apply scientific evidence to the work of patient evaluation and management and assist interns in formulating plans of care o   Triage patients to appropriate levels of care and ensure appropriate communication with colleagues and attending physicians o   Manage inpatient medical emergencies o   Work effectively with multidisciplinary team in planning patient discharge o   Assist interns as necessary in completing daily tasks of patient care to facilitate the primary care-giving relationship between the patient and intern

 

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

 

PGY 1 Learning Objectives	PGY 2 Learning Objectives	PGY 3 Learning Objectives
o   Complete comprehensive and concise written documentation for patient care including admission H&Ps, daily progress notes, and discharge summaries and other discharge paperwork. o   Orally present patients effectively in a variety of patient care settings including work rounds, signout rounds, and in requesting consultation. o   Build effective therapeutic alliances with patients o   Teach medical students effectively and provide peer teaching on discrete clinical topics o   Cultivate respectful relationships with coworkers	o   Review and provide feedback to interns on written documentation; complete a resident addendum note on all new admissions. o   Teach effectively in informal settings in the context of shared work and in formal settings such as morning report and visit rounds. o   Provide effective team leadership including setting expectations, reinforcing productive behaviors, providing feedback o   Facilitate interdisciplinary team meetings with patients and families o   Assist interns in negotiating conflictual relationships and managing difficult patients	o   Review and provide feedback to interns on written documentation; complete a resident addendum note on all new admissions. o    Teach effectively in informal settings in the context of shared work and in formal settings such as morning report and visit rounds. o    Provide effective team leadership including setting expectations, reinforcing productive behaviors, providing feedback o    Facilitate interdisciplinary team meetings with patients and families o    Assist interns in negotiating conflictual relationships and managing difficult patients

 

Professionalism

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

 

PGY 1 Learning Objectives	PGY 2 Learning Objectives	PGY 3 Learning Objectives
o   Work with mindfulness of duty hours restrictions o   Identify personal limitations and seek help as needed to facilitate optimal patient care and optimal self care o   Demonstrate a commitment to excellence including careful follow through and attention to detail o   Demonstrate principles of ethical practice including altruism and honesty o   Demonstrate compassion in relationships with patients and families	o   Supervise work of interns and ensure compliance with duty hours restrictions o   Facilitate the personal and professional development of the interns o   Model self reflection and self care o   Demonstrate a commitment to excellence in oversight of the overall work of the team o   Demonstrate principles of ethical practice including altruism and honesty o   Demonstrate compassion in relationships with patients and families	o   Supervise work of interns and ensure compliance with duty hours restrictions o   Facilitate the personal and professional development of the interns o   Model self reflection and self care o   Demonstrate a commitment to excellence in oversight of the overall work of the team o   Demonstrate principles of ethical practice including altruism and honesty o   Demonstrate compassion in relationships with patients and families

 

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

 

PGY 1 Learning Objectives	PGY 2 Learning Objectives	PGY 3 Learning Objectives
o    Set personal learning goals in each of the six core competencies for the rotation o    Endeavor to learn something from the care of each patient o    Develop familiarity with a range of information resources	o    Set personal learning goals in each of the six core competencies for the rotation o    Practice generating effective clinical questions for personal learning o    Use information resources effectively for answering clinical questions	o    Set personal learning goals in each of the six core competencies for the rotation o    Develop greater sophistication in generating effective clinical questions for personal learning and meaningful teaching with attention to learner needs o   Expand repertoire of information technology resources for teaching and learning

 

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

 

PGY 1 Learning Objectives	PGY 2 Learning Objectives	PGY 3 Learning Objectives
o    Understand from a patient perspective challenges imposed by dysfunctions in the health care system including post-discharge contacts with hospitalized patients o    Develop basic knowledge of costs of care in the inpatient environment o    Identify opportunities for improvement in systems of patient care o    Reflect on the rotation and offer constructive suggestions for improving the rotation	o   Develop familiarity with the multidisciplinary resources necessary for effective in-hospital and post-discharge patient care o   Review available data on quality of care and patient satisfaction in the inpatient environment o   Consider costs of care intentionally in making patient care plans o   Propose strategies for improvement in systems of patient care o        Reflect on the rotation and offer constructive suggestions for improving the rotation	o   Advocate effectively for patients within the complex multidisciplinary environment of the health care system o   Review available data on quality of care and patient satisfaction in the inpatient environment o   Provide cost-conscious guidance to interns in making patient care plans o   Participate in patient care quality improvement initiatives o        Reflect on the rotation and offer constructive suggestions for improving the rotation

 

Clinical encounters and learning venues

During the rotation, residents will learn through participation in:

• Initial evaluation of new admissions from the ED, from clinic, and accepted in transfer from other services, 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
• Daily review of radiologic studies with a radiologist
• Formal teaching sessions including Monday case conference, Tuesday School programming, and Grand Rounds
• Morning and afternoon patient management rounds with the hospitalist attending physician

 

Principal resources

On-line databases including UptoDate and Dynamed

Primary and secondary medical literature accessible through full-text searching using PubMed

Textbooks of internal medicine including Harrison’s, Washington Manual, Wachter’s Hospital Medicine

Consultation with generalist primary care and hospitalist physicians and subspecialists

 

Daily Schedule

7:45 am Nurse – Resident Huddle

The inpatient ward residents meet with their team nurses at the 4West nurses station to review any urgent patient issues before the start of rounds. This is meant to address patient critical patient needs, aid in the development of plans and prevent disruptions
during morning rounds.

8-9am Morning Report

Members of the short call team and the night intern and resident join together every morning in this conference facilitated by the chief resident and the team’s attending. Transfer of care for patients admitted by the night team takes place in this venue which includes, whenever possible, examination and interview of patients at the bedside. Residents generate clinical questions that emerge from patient care and share in the responsibility for teaching one another.

8-9am Department of Medicine Grand Rounds (Wednesday morning only)

Weekly teaching conference for the Department of Medicine from September to June addressing a broad range of topics in internal medicine – ambulatory and inpatient foci; general and subspecialty medicine; biomedical, clinical, and social sciences.   All house officers are expected to attend.  Morning report takes place from 7:15-8am on Wednesday mornings in Macht 414 during these months.

8:15-8:45 am Radiology Rounds

House officers on the long call team meet a radiologist to review all inpatient radiological studies performed in the last 48 hours and obtain radiological consultation on patient care.


9-10:30 am Morning Work Rounds

The physician team (interns, resident, and attending hospitalist) join to round on their team’s inpatients and make diagnostic and therapeutic plans for patient care.  A clinical pharmacist joins the team on the long call day. Use of the rounding template (Appendix E) is encouraged. Patient white boards are updated each morning accordingly during bedside rounding. Efficient day begins with efficient and effective work rounds and suggestions for planning these are in Appendix F.


10:30-11:15am Multidisciplinary Rounds

Team resident meets with all allied health providers including care managers, nutritionists, physical and respiratory therapists, social workers and nurses to coordinate multidisciplinary patient care and make appropriate discharge plans. MDR rounds are facilitated by case management and occur on 4W nurses’ station by the white board.


12-1pm Resident Case Conference (Mondays)

PGY2/3s and chief residents facilitate a case conference for both ward teams and all available House Staff.  The format for these conferences is a typical morning report / chalk talk format with the goal to be an exercise in clinical problem solving and review of evidence based approach to the clinical presentation and diagnosis. Residents are assigned 1-2 conferences each year and chief resident facilitates the conference. A senior clinician is present to guide the participants in problem solving exercise.  Location is 4W resident room.


12-1pm MGH Cardiology Rounds (Mondays)

A case is presented for discussion by an assigned junior resident following their month long MGH Cardiology experience. The session is facilitated by a visiting cardiologist from MGH and attendance is mandatory for all housestaff. Location is Learning center.


Tuesday 12-4pm Tuesday School

All interns and residents participate in a four-hour didactic conference designed to cover core internal medicine curricular topics identified by the Federated Council for Internal Medicine.  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 three trimesters.  The first term (Blocks 1-2) is devoted to fundamentals in each subspecialty discipline and topics are repeated every year. The second term (Blocks 3-12) is organized into discipline-specific blocks; topics are repeated on a two year repeat cycle. The third term (Block 13) has predominantly complex cases requiring the application of multi-disciplinary perspectives and board review.  Tuesday School sessions are interactive and case-based whenever possible.  Three cross cutting themes are woven into the biomedical curriculum – evidence based medicine, interpersonal skills and communication, systems-based practice.


Thursday, 12-1:30pm 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 for all interns and residents on the healer’s art entitled “Food for the Soul”
• 3rd Thursday: House officer union meetings
• 4th (and 5th) Thursday: Resident led journal clubs

3-4 pm Afternoon Rounds

Each ward team convenes with their hospitalist for a review of their tasks, to strategize the remainder of the day and to discuss any changes in patient status. Team members teach one another from their reading on previously identified clinical questions. This time also serves as a venue to discuss team dynamics and identify strategies for improvement.


5-5:30pm  Short Call Sign Out

Short call team signs out to long call team resident and leaves the hospital by 5:30pm


7-7:30pm  Long Call Sign Out

From 7-7:15pm, the long call team signs out to the night team and leaves the hospital no later than 8:30pm 

From 7:15-7:30pm, the long call team resident team joins with the night resident and night intern, the night hospitalist, and the bed coordinator to review respective patient lists, clarify team assignments for any pending admissions, and review critically ill patients in what is known as the “change of shift huddle”.

Evaluation

Resident Evaluation

Interns and residents will work with two hospitalist attending physicians during each ward month who work on alternating weeks.  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 each week, the hospitalist will sign out to the other hospitalist to give a ‘learner signout’ about the four members and their goals and progress. Additionally, during the third week, the hospitalist will meet with the four members of his or her house officer team and provide mid rotation feedback.  This information will be shared with the second hospitalist who will then continue with the learning plan identified in feedback sessions, and be responsible for filling out the 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 and 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.