Each medicine team has a resident and three interns, a designated hospitalist attending, and a care coordinator. Teams care for a fascinating and diverse panel of patients. 24-hour interpreter services, excellent social work staff, engaged consult liaison psychiatrists, comprehensive outpatient services for special populations - immigrants, the frail elderly, the homeless, the chronically mentally ill, those struggling with addictions - make it possible to provide high quality comprehensive care for a socially complex group of patients. The breadth and depth of medical pathology provides an inexhaustibly rich environment for learning. Patient care teams are geographically staffed such that all resident team patients are on one ward. This enables closer collaboration between nurses, doctors and care-coordinators.
Daily schedule of work
At 8am, the chief resident and a hospitalist attending join the on-call day team in morning report to listen to the night team tell the stories of the patients admitted overnight. Whenever possible, we go to the bedside together to engage the patients in the transfer of care process and learn pearls in history taking and the physical exam. On their non-admit day, teams go to radiology rounds at 8:15 to meet with a radiologist and review films of the last 24 hours.
From 9 - 10:30, both teams do bedside patient care work rounds with their team's hospitalist attending. At 10:30, team residents lead multidisciplinary rounds with the care coordinator, social worker, therapists, and nutritionists.
At 3 pm, the ward team meets again for afternoon rounds with the attending to review the patient care plan for the current day and prioritizing task list for remainder of the day. This is also an opportunity for ‘bring-backs’. Clinical questions come up during routine care of patients during work rounds and are assigned to team members. Emphasis is placed on learning to manage common and “cannot miss” diagnosis, learning to generate clinical questions and applying available evidence to patient care decisions. Case discussions may also focus on issues related to cultural competence, ethics, health systems, and population health sciences.
Monday and Thursday have noon conferences. On Monday, this occurs on 4West workroom and is case based resident led exercise in clinical reasoning and diagnostic decision making. On Thursday the conference is in Learning center C/D and is a different activity each week of the month. Sometimes it's a house officer meeting with the program directors or a meeting of the house officer union (CIR); sometimes it's a resident-led journal club or case presentation; sometimes it's a reflective session on the art of medicine - CHA's unique Food for the Soul series.
On Tuesdays, residents sign out their clinical work to the hospitalist service at 11:45am and make their way to the Learning Center for Tuesday School Program a four-hour block of protected time for teaching and learning the core curriculum in inpatient medicine.
Manageable hours of work
Long before the ACGME mandated 80 hour work weeks, our residents were working manageable hours. We know that exhausted residents can't learn and can't take good care of others. The whole team is on call together, every other day. When a team is on call, start admitting new admissions from 12 pm that day. At 7pm, they sign out to the night team. In the morning, the team takes sign-out from the night team and continues admitting till 12 noon, when the other team starts its 24 hour call cycle. Having shorter days and longer days makes it possible to balance hard work with life outside the hospital. The night team works Sunday through Thursday night. Interns on the ward rotation take turns covering the Friday and Saturday overnight shift, but hours of work are adjusted so that no intern works any shift longer than 16 hours on a ward rotation.
We share the work of caring for hospitalized patients with a non-teaching hospitalist service. Triage of patients to the teaching service is organized to optimize the volume and pace and case mix of admissions to the teaching service.
One intern and resident pair work together on the wards to look after the patients on the resident teams; another intern and resident pair work together in the medical intensive care unit. The administrative hustle and bustle of the day quiets down and residents focus on managing emergent medical problems and admitting new patients. An overnight hospitalist is available in the hospital for consultation on patient care and the intensivist is only a phone call away. Nevertheless, night rotations are a chance for residents to test their own wings and make more independent clinical decisions.
At morning report, the night team presents new patients to the day team, the chief resident, and the accepting day team hospitalist. Whenever possible, we present patients at the bedside to facilitate high quality transfer of care and point-of-care teaching and learning. Often the night team will choose a focus case for more in-depth analysis and group problem solving. The group identifies clinical questions from the case; one person assumes responsibility for reviewing the literature and bringing the evidence back to the group the following day. The format ensures safe patient-centered care and engages a group of clinicians and learners to think together and to make evidence-based medicine practical.
One resident and three interns work together with critical care nurses, respiratory therapists and a pulmonary-critical care intensivist to provide care to critically ill patients in a 10-bed ICU. In this setting, residents develop expertise in managing sepsis, respiratory failure, toxic overdoses and doing invasive procedures, and also in caring for families in crisis and negotiating goals of care in ethically and medically complex situations. Because there are no critical care fellows, residents assume a significant amount of autonomy in the care of patients and work directly with the attending physician to make decisions and execute plans of care.
The day begins at 8 am with signout from the night ICU team to the day ICU team. Work rounds are led by the intensivist and begin at 9 am. The overnight team, consisting of one resident and one intern, is responsible for preparing updated assessments and plans and for presenting each patient on morning rounds. The night team signs out and leaves at 10 am. At the conclusion of rounds, the tasks of patient care are undertaken by the day team, including any procedures, consults, transfers, and new admissions. The day team consists of one resident and two interns. Depending on the demands of patient care, time each afternoon is carved out for dedicated resident teaching, led by the intensivist. Signout is given to the night team at 8 pm each evening.
Our Cambridge Hospital campus has a busy emergency department with over 30,000 visits annually, or 80 visits/day. Under the direct supervision of ED attending physicians, residents diagnose, treat, and care for men and women from adolescence to old age with acute, sub-acute, and chronic medical, surgical, orthopedic, and ob/gyn problems. House officers have first-hand, first-contact experience with undifferentiated, unselected health problems, including life-threatening emergencies. The ED rotation also offers important opportunities for internal medicine residents to develop greater understanding of the hospital system.
The curriculum in the ED is case-based and hands-on. The supervising attending provides direct bedside teaching on all patients. He or she guides residents in performing interventional procedures and running codes and leads conversations to debrief every code.
Residents rotate through the emergency department in the PGY1, PGY2, and PGY3 year. Like other ED staff, house officers work shifts. All residents have three day shifts in ED and during the remaining week have two night shifts in the ICU to relieve the night float team.
Most interns and residents say they actually like working in the hospital overnight. Night rotations are a chance for residents to test their own wings and make independent clinical decisions. One intern and resident pair work together on the wards to look after the patients on the two day teams; another intern and resident pair work together in the ICU. The administrative hustle and bustle of the day quiets down and residents focus on managing emergent medical problems and admitting new patients. There is an in-house hospitalist attending available to supervision all night and the ICU attending is only a phone call away.
At morning report, the night team presents new patients to the day team including the hospitalist attending. Every morning, the night team chooses a focus case for more in-depth analysis and group problem solving. The group identifies clinical questions from the case; one person assumes responsibility for reviewing the literature and bringing the evidence back to the group the following day. The format ensures safe and complete transfers of care from the night to the day team and engages a group of clinicians and learners to think together and to make evidence-based medicine practical.