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SENIOR MEDICINE RESIDENT ORIENTATION


 

 


 


 


 

   


Goals:
The overall goal of the Senior Medicine rotation is to prepare senior residents for the transition to an attending role while exposing them to the field of Hospitalist Medicine.  The focus of teaching is at the senior resident level.  The senior resident is primarily responsible for evaluating patients and developing and advancing their care plans.  Residents are given a high degree of autonomy and ownership of their patients.  Due to the streamlined team structure, residents are afforded the opportunity to interact more closely with their supervising attending than in traditional general medicine rotations.

Admissions and Patient Mix:
There are no strict guidelines as to the ‘type’ of patient that can be admitted to the Senior Medicine service.  However, generally speaking, these patients are more stable hemodynamically than General Medicine patients.  A senior physician assistant (PA) will take endorsement from the emergency department (ED) and decide if the patient is best suited for the senior medicine service.  If she decides this is the case, she will page the admitting senior resident with information about the case.  If the senior resident believes that patient is better suited for another service, he/she MUST first see and examine the patient in the ED, and then speak with his/her attending or the ED attending.  

Team Structure:
There are 2 senior medicine teams.  Each team consists of 2 attendings (either one  hospitalist and one non-hospitalist attending or two hospitalist attendings), 2 senior residents, and 2 physician assistants (when staffing allows).  There may also be a variable number of sub-interns (SI). One PA student from the Cornell PA School may also be a member of the team.   A psychiatry attending or a psychiatry fellow will usually be present on attending rounds and will be available to provide consultations on patients on the senior medicine service.

Call Structure:
Residents take long-call every 4 days and can accept 4-5 admissions (composed of new and/or night float patients) as outlined in the table below. After 4 pm, the long-call team can accept 2 patients if not already at the maximum admitting capacity. After 5 pm, the long call team can only accept 1 patient if not already at the maximum admitting capacity. On short call (also every fourth day) residents will receive 2 admissions worked up by the overnight doctor and up to 1 new admission from the ED for a total of 3 patients. The new admission from the ED will be given to the short-call team only before noon. 

Four overnight admissions performed by the overnight doctor will also be distributed to the senior medicine resident teams.  In general, the short-call team will receive 2 of these patients (as previously mentioned), the pre-call team will receive 1 patient and the post-call team will receive 1 patient.  However the ultimate distribution of the 4 overnight admissions will be determined by the senior medicine PA and will be based on each team’s overall census, call-cycle and other relevant factors.  The PA’s overall goal will be to balance the workload on the 4 senior medicine teams.  From time to time the senior medicine teams may also receive over-flow night-float admissions, which will typically be absorbed by the pre- or post-call team depending on the team’s censuses. The number of these admissions will be no more than three.

Long Call Admission Rubric

Night Float Patients

Available Admission Slots

0

4

1

3

2

3

3

2

4

1

Rounding/Work-flow Structure:
7:00AM – Senior PA arrives and distributes overnight admissions. Resident and SIs arrive when needed to pre-round on patients.
7:30AM – 7:45AM – Residents and SIs (and PAs, if available) hear overnight presentations from the overnight doctor.
8:00AM – 8:45AM – Residents attend morning report.
8:45AM – 9:00AM – Residents and PAs may continue work rounds.
9:00AM – 10:30AM - Attending Rounds. For many attendings this rounding time is flexible – if you would like a later start time to allow time to see overnight admissions, discuss with your attending at the beginning of the rotation.
10:30AM – 10:45AM – Multidisciplinary (multi-D) rounds on 7GS and 9GS with social workers, care coordinator, and charge nurse.  Residents and/or PAs attend these rounds. For patients followed by the SI, the resident MUST accompany the SI to multi-D rounds.

Sign Out:
The long call resident must stay in the hospital until 7 pm.  This is to ensure that there is a senior level physician available to the physician assistant at all times.

The senior medicine resident must be present when the SI signs out his or her patients. 

In general, when not on long call, the senior medicine resident will sign out to his/ her PA.  If there is no PA on the team (due to staffing reasons) then the senior medicine resident should sign out to the PA on the sister team (e.g. B to D, A to C).
When the senior medicine resident is paired with a SI instead of a PA AND the senior resident has clinic, the senior resident should sign out to the sister team’s PA in the presence of the SI. The PA and SI will continue management of the patient throughout the day.  The SI should notify the PA when he/she is leaving for the day.

Pagers:
PAs should be holding the team 1 pager, which will be the first pager paged by the RNs. Residents should have the team 2 pager forwarded to them as back-up. The designated provider order should be placed as follows:

Attending Name: Labella, Angelena;  Pager: Team 2 pager (carried by senior resident)
Resident/PA: name of person carrying pager;  Pager: Team 1 pager (carried by PA)

Guidelines for working with physician assistants:
Residents should develop a collegial, professional and effective working relationship with their physician assistants.  The success of the team will depend on the quality of this relationship. 

Residents are ultimately responsible for the care of the patients. 

Physician assistants are expected to assist the senior resident in almost all aspects of clinical care, including direct patient care, family interactions, interdisciplinary team mobilization, documentation, discharge summaries, etc.  Physician assistants are encouraged to take ownership of the patients to a great degree.  Management of patients will require constant communication between PA and resident.  The PA and resident should discuss the management plan for all patients.  Physician assistants will typically be the first ones paged about their patients, but are expected to recognize when the clinical situation requires involvement of the resident.  The resident is expected to be available and responsive to the PA.

Residents are expected to help the PAs broaden their knowledge base and improve their clinical skills.  Residents should encourage the PAs to think independently.  They should allow the PAs to communicate their patient care formulations prior to describing their own.

Physician Assistants will typically be present on attending rounds and are encouraged to participate actively.  On call days, depending on the work-flow, it might be more efficient for the PA to go to the ED to start evaluating new admissions. 
Physician Assistants are not expected to write admission notes or daily progress notes.  They are expected to assist with discharge/transfer summaries, hand-offs, and event notes. On the day of discharge, senior medicine residents are expected to co-sign the PA notes and write a daily progress note.

Physician Assistants should not be asked to do work for patients followed by the SI, as the expectation is that the SI  is able to perform all tasks (e.g. place orders, call consults, write discharge summaries) related to their patients.

Unfortunately there will be times when senior medicine residents will not have a PA on their team.  We will do our best to ensure that days without a PA are equally distributed among the senior medicine residents.  The senior medicine PA schedule is on amion (password: colhosp).  It is inappropriate for any resident to log on to the password protected hospitalist schedule on amion. 

Guidelines for working with medical student sub-interns:
The hospital medicine SI rotation provides training in the care of hospitalized patients and is the only general medicine SI available at Milstein Hospital.
By the end of the elective, the sub-intern will have:

  • Demonstrated patient management skills at the intern level, from diagnosis to treatment to discharge. 
  • Developed proficiency in obtaining a comprehensive H and P, interpreting routine labs, cxr, ekgs
  • Gained the knowledge necessary to formulate differential diagnoses for common medical presentations
  • Displayed the organization/efficiency necessary to be a successful intern.
  • Displayed the ability to search the medical literature to support appropriate EMB practices.
  • Displayed the ability to interact with multidisciplinary teams and coordinate the transition of care after discharge
  • Displayed the ability to communicate effectively with families.

Students will admit their own patients and assume primary responsibility for their complete care in the hospital.  This includes writing admission notes and daily progress notes, developing diagnostic/therapeutic plans, entering orders, answering pages, performing routine procedures, calling consults, coordinating hand-offs, and discharge planning.  Sub-interns will be expected to meet with the overnight cross-cover PA at 7AM for a face-to-face sign-out on their patients.  They should then pre-round and be prepared to discuss their patients during attending rounds and multidisciplinary rounds.  Students should follow at least 4 patients but no more than 5 patients, preferably cases that they admitted.  Residents and SIs rotate on the same call cycle staying until 7pm on long call.  They are expected to work on the weekend days that their senior medicine resident is working.  Residents will provide feedback to the residents and evaluate them formally at the end of the rotation.

Halfway through the senior medicine rotation, the SI and PA will switch to their respective sister team.  This will give the senior medicine resident initially assigned to the SI a chance to interact with a mid- level provider.

Didactics:
Each SI will give an Evidence-Based Medicine (EBM) presentation during the final week of the rotation.  The basis of this EBM presentation will be an interesting clinical question encountered during the care of patients on their service.  The student will conduct a literature search and identify the appropriate article, preferably a randomized controlled trial and present their conclusions along with a brief written document.   In addition to the EBM project, sub-interns are expected to give 3 informal presentations.  The psychiatry attending, the wound-care nurse, and the librarian may also give didactics during the rotation.  Attendance at these conferences is greatly encouraged. 

Documentation:
Residents are expected to write a comprehensive admission note using the “Milstein Hospitalist Resident Admission Structured Note” with a complete 9-point “review of systems.”  Residents are expected to write daily progress notes.  PAs and SIs will assist the resident by completing discharge summaries, event notes, transfer summaries, sign-outs, etc.