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Inpatient Medicine Curriculum

Internal Medicine Ward Rotation Curriculum

Revised May 21, 2013

Rotation Director:

Priyank Jain, MD

pjain@challiance.org

(pager) 617-546-1682

(phone) 650-336-4873

 

Description of rotation

Two teams comprised of one resident and 2-3 interns provide care to hospitalized internal medicine patients on two general medical wards (4W and 6N). 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 and primary care physicians from affiliated primary care clinics. 

 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 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

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

Weekly 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 Harvard e-commons

Textbooks of internal medicine including Harrison’s, Washington Manual

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 7-8am on Wednesday mornings in Macht 414 during these months.

 

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.

 

10:45 -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 resident work room.

 

12-1pm Resident Case Conference (Mondays)

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 work room.

 

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 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.

 

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 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”.

 

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.

 

 

Cambridge Hospital Inpatient Ward Rotation

 

The Intern Role

 

  • Patient Care

Interns perform a full history and physical on all new patients and write a complete admission note for the chart.  Interns pre-round on patients including visit to patient and relevant portions of the physical exam, review of vital sign records, medical charts, medication administration records and conversation with overnight nurses.  Given constraints of time, interns will often have to make choices and prioritize their pre-rounding activities giving preference to sicker, more active patients and patients that are new to the service.

Interns are responsible, with the assistance of their residents, for activities of patient care including procedures, consults, review of laboratory results and radiologic studies, communication with patients and their families.  Interns write daily progress notes on all patients using the S-C-O-A-P format (Subjective, Patient Concern, Objective findings, Assessment and Plan).  Notes should include a current problem list and active medication list.  Best practice is to complete the note by the end of work rounds.

On the last day of an intern’s ward rotation, he or she is expected to write expanded patient progress notes that serve as “off service notes” and provide a brief summary of the hospital course to date with an outline of active problems and plans.

At the time of discharge, interns are responsible for patient education, prescriptions, and referral paperwork for accepting sub-acute care facilities and/or visiting nurses.  Interns should complete discharge summaries at the time of discharge on all patients. 

Interns are responsible for writing all orders on their patients, but may on some occasions choose to delegate that responsibility to their residents.

Interns, with the assistance of their residents, are responsible for communicating daily with the attending of record for each patient and for making contact with the patient’s primary care physicians on admission and discharge.

To facilitate transfers of care, interns are responsible with their residents for maintaining and updating electronic medical record with relevant patient information.

 

  • Intern roles, admitting cycle, and hours of work

 

Interns are expected to begin pre-rounding on patients no earlier than 7am except on Wednesdays.

 

Teams admit patients every day on an alternating short call/ long call cycle.  The short call team accepts patients admitted overnight, admits new patients and accepts admissions until 3pm. The long call team admits new patients from 8am until signs out to the night team from 7-7:30pm.  The night team (a resident and an intern) admit from 7pm to 8am and present patients to the short admit team at 8am in morning report.  Overnight admissions are assigned in alternating fashion to the day interns on the on-call team to a morning maximum of four new patients per intern or eight new patients per team. The 24 hour cap for new admissions per intern is five new admits + 2 transferred patients; the 48 hour cap for new admissions per intern is 8 new admits + 2 transferred patients. 

 

Interns are encouraged as a matter of professionalism to monitor their own work hours by regularly logging their hours of work and seeking assistance in complying with work-hours restrictions when necessary from peers, residents, chief residents, and attending physicians.

 

On weekend days, one team has a resident (+one intern for first 3 blocks) and the other team has two interns. The hospitalist on the intern-only team assumes the role of resident-attending for the day to allow for adequate supervision. (Please refer to Lone Intern Policy). All interns stay until at least 7pm. All three interns are expected to leave no later than 9pm.

 

Every intern has one weekend day off each week. On days when interns are off, the patients will be covered by remaining team members (intern, resident and if necessary attending). The team resident distributes the patients.

  

 

  • Teaching and Learning

 

Our patients provide the focus for the clinical education in medicine. Thus, interactions between house officers and attendings should optimize patient management and everyone's education. The nature of these interactions will change over the year and vary with the specific personalities involved. To facilitate the learning and house staff autonomy, house staff are encouraged to: 

Formulate specific questions before seeking consultation.

Commit themselves to a most probable diagnosis and plan before asking for advice and feedback.

Ask for advice and feedback.

Ask residents and attendings to observe their skills and give feedback as much as possible.

Explore beneath the surface, search for patho-physiologic explanations of all observed symptoms and signs of illness. 

Prepare for your rotation by completing the learning goals worksheet (Appendix D) and setting your own educational priorities.

Intern attendance is expected at morning report for members of the on-call team.

Intern attendance is always expected at Tuesday School, Thursday noon conferences, Medical Grand Rounds, and weekly case conferences except when prohibited by clinic and/or unusual exigencies of patient care.

 

  • Evaluation and Feedback

During a ward month, interns should expect mid-rotation formative feedback and an end-of-rotation summative evaluation on a standard evaluation form available on New Innovations.  Interns will complete a learning goals worksheet to be discussed with the block’s first hospitalist who will provide the intern with formative feedback at the end of the second week. Formative feedback will be shared with the second hospitalist, who will be responsible for completing the summative evaluation form at the end of the block. You can see the aspects that are evaluated at the end of rotation here End of rotation evaluations

 

In addition, the intern will receive targeted feedback through the one on one session with the attending, including direct observation of history taking and physical exam skills, review of written notes, or completion of the chart stimulated review exercise.  Interns are encouraged to take initiative in seeking targeted feedback if not initiated by the hospitalist.

 


Cambridge Hospital Inpatient Ward Rotation

 

The Resident Role

 

  • Patient Care

Residents are responsible for supervising interns in all work of patient care, taking on direct patient care tasks as negotiated with their team of interns.

In admission of a new patient, residents conduct a full history and physical, discussing the case with intern, reviewing intern documentation and orders, writing a resident addendum to the intern admission note.

At the time of a new admission (from the ED, from clinic, or accepted in transfer from another inpatient), residents are expected to staff the patient with the appropriate attending of record by telephone or in person.  Residents are responsible for ensuring daily conversation with the attending of record, and ensuring contact with the patient’s primary care doctor on admission and discharge.

Residents are expected to see all patients on their team every day, confirming relevant aspects of the evolving history and physical exam and providing patient and family education as necessary; labs and imaging on all patients should be reviewed critically every day.

Residents assume responsibility for ensuring that necessary patient care procedures are performed in a safe and timely manner by a credentialed provider.

Residents participate daily in multidisciplinary rounds on 4W to coordinate patient care among nurses, therapists, and social workers and to facilitate discharge planning.

At the time of discharge, residents are responsible for reviewing discharge medications, referral paperwork, and follow-up care plans completed by the intern and may assist in facilitating patient discharges by dictating discharge summaries and/or making additional post-hospital care arrangements.

Residents should write orders on patients only in consultation with their interns and should ensure proper signing of verbal and telephone orders.

To facilitate transfers of care, interns are responsible with their residents for maintaining and updating a daily sign-out with relevant patient information. Residents are responsible for team signoff to the night float team on long call day, and to the long call team resident on the short call day.

 

  •  Management and Supervision

The two ward residents share responsibility for all patients cared for by the Teaching medical service.  Each resident should be available to supervise all six interns but has primary supervisory responsibility for the three interns on his or her team.

Team assignment of new admissions is facilitated by the Triage Hospitalist, who assigns patients to house officer teams according to a set of triage rules, which are described in the Triage Guidelines attachment.

Residents are responsible for understanding and ensuring compliance with policies outlined in the house officer policy manual including intern and team caps as follows:

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.

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. 

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.

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.

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, and on rare occasions admissions to another team

Residents are responsible for orienting interns to the ward rotation, helping the intern set learning goals and objectives, providing support to the intern in accomplishing goals and objectives, offering feedback on performance, and facilitating reflection on learning.

The resident serves as first call for any problems encountered by the intern in clinical care, program or hospital administrative concerns, interpersonal conflict and is responsible for seeking guidance to solve problems that he or she cannot adequately address alone.

The resident is responsible for planning and leading work rounds daily and making a daily patient care plan incorporating as appropriate: 1) conversations with nurses and other allied health professionals; 2)  bedside patient visits as necessary, 3) generating a prioritized “to-do” list including writing orders and calling consults efficiently; 4) identifying clinical questions and assuming responsibility for focused teaching; 5) incorporating anticipatory trouble-shooting and “contingency”-based thinking into medical decision-making.

As the team leader, the resident is expected to make independent clinical judgments and formulate specific questions before engaging attending physicians and/or consultants.

The resident is responsible for managing time effectively; starting punctually; adjusting the pace and structure of rounds to respond to daily exigencies; defining discrete time frames for interns to accomplish tasks to facilitate work flow.

The resident is expected to lead team review of any errors or adverse events in patient care, inviting multidisciplinary and attending physician participation as appropriate.

 

  • Hours of Work

The resident day begins at 7:30am to review overnight events with the night resident. At 7:45am, the residents each meet with their team nurses at the 4West nurses station to review any urgent patient care issues prior to the start of morning rounds. The Short Call Team Resident attends morning report with his or her team at 8am. 

 

Ward residents have one weekend day off (either Saturday or Sunday on days when their assigned team is post-call). A single ward team resident supervises three interns (drawn from both teams) on Saturday and Sunday but preferentially admits to their own team (please refer to lone inter weekend supervision policy). Residents are expected to ensure that team interns are compliant with work hours restrictions and entering work hours data into the New Innovations program

 

  • Teaching and Learning

Prepare for your rotation by completing the learning goals worksheet and setting your own educational priorities.  Be assertive in identifying your learning goals to the attending physicians with whom you are working.

Residents partner with the hospitalist to clarify teaching and leadership responsibilities on morning and afternoon work rounds including assignment of discrete clinical questions for discussion by all team members.

Residents are expected to understand the rationale for all diagnostic and therapeutic initiatives in the care of patients on the team and should seek to understand the evidence for those initiatives whenever possible.

Residents should model self-directed learning for their teams; should use evidence-based methods to make clinical decisions and should know and access relevant clinical practice guidelines.

Residents are expected to attend all scheduled inpatient conferences – morning report, Grand Rounds, noon conferences, and Tuesday School.

 

  • Evaluation and Feedback

Residents should meet with the hospitalist in the beginning of a ward month to discuss goals and expectations for the rotation and identify ways of sharing teaching responsibilities.  Residents should seek and receive direct feedback from the hospitalist on any formal teaching sessions they deliver during attending rounds.

Learning goals will be reviewed by the first hospitalist each block; the first hospitalist is expected to provide mid-rotation feedback at the end of the second week. Summative evaluation will be provided on a standard evaluation form by the second hospitalist of the block. You can see the aspects that are evaluated at the end of rotation here End of rotation evaluations

 

Residents are expected to give formal and informal feedback to their interns in real time immediately following clinical encounters and at the end of the month.

 


Cambridge Hospital Inpatient Ward Rotations

 

The Medical Student Role

 

Twelve third year medical students from Harvard Medical School are participating in the Cambridge Integrated Clerkship.  Though rarely assigned to a house officer team for any significant period of time, residents have the opportunity to interact with medical students every week.  In the beginning of the medical students’ academic year, each participates in a week-long “immersion experience” in the inpatient environment.  In the next interval of time, medical students take call on a regular basis, starting in the emergency department and participating with the night team and rounding with the day team in the morning.   In the final interval of time, medical students’ experience in the inpatient medical environment is organized in “bursts,” in which they take call and then join the team for a three-day period. Throughout the year, medical students follow inpatients who are members of their longitudinal cohorts. When medical students have an admitted inpatient, they are expected to follow their patient on a daily basis and write daily progress notes.  They are eager to participate in meaningful aspects of the patient’s care – procedures, family meetings, examinations by subspecialty consultants.  They are deeply appreciative of resident efforts to engage with them and their inpatient internal medicine learning.

 

Strategies for engaging students:

 

Read student notes and give feedback (by e-mail, by page, in writing on the note in the chart, and in person)

Exchange pager numbers with students and invite them to be in contact with you during the day; page them during the day with important developments in the care of their patients.

When the student is available to join the team for work rounds, round (if possible) on the student’s patient first and allow the student to present the patient and formulate the first oral draft of the plan

Identify discrete ways in which the student can participate in furthering patient care – soliciting additional items of history from the patient, reviewing the old medical record, contacting family members, researching a specific question that will facilitate patient care, getting information on the patient’s post-hospital course

Make time to review with them the clinical decisions made in the care of their patients; review whenever possible physical exam findings, laboratory values, radiologic tests, decision-making processes, evidence from the literature

Whenever possible, interview and examine patients together; allow the student to lead the discussion and direct the physical exam; provide feedback

Allow the student to present the patient to you and help the student formulate a differential diagnosis and an evaluation and management plan.

Include the students’ name in the signout and mention the student’s involvement with the patient to the day team

Include students, if possible, in signout conversations with the day team

Help students identify clinical questions and prioritize his or her own reading

Whenever possible, guide the student in preparing a brief teaching topics for your team.

 

 

Ward teams may include other acting interns and/or observers who are directly responsible to team residents.

Observers are not legally permitted to provide patient care; they are permitted to interview patients with the patients’ permission but may not examine a patient.  Residents should give observers responsibility for following one or two patients closely.  Observers are accountable to the ward visit, who may ask them to write shadow notes on patients that are not filed in the medical chart.  Observers do participate on rounds and in didactic teaching sessions; residents should feel free to assign teaching and learning tasks to observers.  Residents will be asked to evaluate observers.

Acting interns should be treated as interns, though all orders and notes must be co-signed by the resident.  Residents should assign one or two patients to an acting intern initially and increase the number and acuity of patients as appropriate relative to the acting intern’s competence.  The resident assumes final responsibility for dictating all discharge summaries on patients cared for by acting interns.  The specific roles and responsibilities of the acting intern are characterized fully in the curricular documents for the acting internship.

 


Cambridge Hospital Inpatient Ward Rotation

 

The Teaching Hospitalist

 

  • Patient Care

The teaching hospitalist will serve as the attending of record for all hospitalist patients on his or her resident team. In that capacity, the teaching hospitalist is expected to see and evaluate his or her patients within 24 hours of admission and every subsequent day of the hospitalization.  An admission H&P and daily progress notes are expected in the patient chart.

On discharge, the teaching hospitalist is expected to review discharge plans with the house officer team and cosign the discharge summary.  Direct contact with the patient’s primary care attending on discharge (via e-mail or telephone) is encouraged.

Clinical responsibilities are scheduled in 2 week stints, in 10 hour shifts (8am to 6pm).

The teaching hospitalist provides clinical supervision to residents for any invasive procedures to be performed on patients on his or her service.  Residents may solicit supervision for invasive procedures to be performed on patients on the resident service who have primary care attendings; if the primary care attending is unable or unavailable to provide supervision for invasive procedures, the primary care attending consults the teaching hospitalist for assistance

The teaching hospitalist may be called upon to care for patients on the non-teaching service depending on the tan team census.

The two teaching hospitalists share responsibility for carrying the triage from 9-5 pm.

The academic half day takes place on Tuesdays from 12-4.  During the academic half day, the teaching hospitalist covers all patients on the resident service without resident support and advances the care of patients as necessary.  Admissions and transfers to the teaching team during Tuesday school are managed, with necessary documentation and orders completed by the teaching attending. In effect, attending works as the ‘float’ covering the residents while they are away for Tuesday school.

Like other DOM attending physicians and non-teaching hospitalists, teaching hospitalists are expected to submit daily billing for patient care and complete all requirements for timely completion of medical records.

 

  • Teaching and learning

The teaching hospitalist participates in combined teaching/ management rounds daily from 8-10:30am.  Work rounds include bedside visit to all new patients admitted overnight and preferably to all other patients on the team. The resident retains responsibility for planning and leading work rounds despite the presence of the hospitalist attending.  Clinical questions should be generated during work rounds every morning and assigned for discussion during afternoon rounds.

The two teaching hospitalists support the chief resident who facilitates case conference teaching session on Monday at noon.

During each 4-week rotation, residents will work with two different teaching hospitalists, who will share the responsibility of providing evaluation.  The teaching hospitalist on service in the first two weeks will provide formative feedback to the house officers.  The teaching hospitalist on service in the second half will be responsible for completing a formal evaluation form and meeting with each house officer to review his or her performance.

During each block, the teaching hospitalist is expected to meet with each of three interns and one resident at least once (for approximately 30 minutes) for some one on one teaching and feedback around a clinical case.  That teaching may include any one of the following: direct observation of history taking or physical exam, review of a note or discharge summary, or a chart-stimulated recall exercise.

On the first day of the resident block rotation during 3pm rounds, the hospitalist is expected to review curricular documents and outline goals and expectations for resident performance during the rotation. 

 

  • Evaluation of hospitalists

Teaching service hospitalists will be evaluated by residents after every block rotation. Evaluations from residents, participation in resident teaching in other venues, and faculty development activities determine the hospitalist staffing on teaching teams.