House Staff Manual and Policies:
Introduction
We would like to take this opportunity to welcome you to the Department of Medicine at Lincoln Medical and Mental Health Center. We believe that Lincoln will provide you with an exciting and challenging environment in which to learn Internal Medicine. We are convinced that the faculty in the Department of Medicine will help you develop the knowledge, skills, and attitude requisite for the practice of Medicine. This manual has been developed to help you during your stay at Lincoln. Please review the manual and refer to it when the need for information arises. We have made every effort to include all the information that is needed by a resident regarding the program into this handbook. We hope that you find it helpful throughout your training.
Welcome to the Department of Medicine and wish you success in your career.
Sincerely,
Anita Soni, MD., FACP.,
Chairperson Dept. of Medicine, Associate
Clinical Preofessor of Medicine Weill
Medical College/Cornell University |
Vihren Dimitrov, MD.,
Program Director, Dept of Medicine,
Assistant Clinical Professor of Medicine
Weill Medical College/Cornell University
|
Program Goals and Objectives:
The goal of the program is to ensure that the residents develop skills and attitudes necessary to function well independently by the end of the training and to establish the foundations for life-long learning. A resident is expected to acquire competencies in the following areas.
Patient Care: The residents are expected to provide patient care that is compassionate, appropriate and effective for the promotion of health, prevention of illness, treatment of diseases and at the end of life.
Medical Knowledge: Residents are expected to demonstrate knowledge of established and evolving biomedical, clinical and social sciences, and the application of their knowledge to patient care and education of other.
Practice Based Learning: Residents are expected to be able to use scientific evidence and methods to investigate, evaluate and improve patient care practices.
Interpersonal and Communications Skills: The residents are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationship with patients, families and other members of health care teams.
Professionalism: Residents are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, profession and society.
System-Based Practice: Residents are expected to demonstrate both and an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care.
Resident and Attending Responsibilities
General Medicine In-patient Service
Team Complement:
Two PGY-Is
One PGY-II
One Attending Physician
PGY-I
Patient Care Role
The PGY-I is the primary physician for each patient on the service. Responsibilities of the PGY-I include:
- Initial work up on the patients admitted to the service. This work up is to include: detailed history, physical examination, review of the laboratory test and formulation of a management plan. If the patient has a previous record at this institution, the record must be reviewed and a summary included in the admitting H/P.
- Discuss the findings, differential diagnosis and proposed work up and management plan with the senior house officer.
- Present new cases to the ward attending.
- If the patient has a primary care provider, he/she must be informed of the admission
- Examination of the patients daily.
- Discharge planning. A notice of discharge must be given to the patient 24 hours prior to the anticipated discharge. If the patient has a Primary Care Provider (PCP), he/she must be referred back to the PCP. In the absence of a PCP, PGY-I is responsible for providing follow up in the clinic.
Charting Responsibilities
All notes are entered using an Electronic Medical Record (EMR). PGY-I is responsible for the notes which are to be typed daily (six day/week) on each patient. The notes are to be written in the specified problem oriented format and must address every active and new problem, updated medication list, assessment and investigations requested. The notes must be focused and must include an acknowledgment of the relevant consultant's and ancillary notes (rehab, dietitian, etc). In addition, documentation of the patient education and Care plan must be made using the appropriate fields of the EMR. Patients must receive a 24 hour discharge notice and a discharge note is to be written which must include:
- Summary of chief complaint, diagnostics impression and hospital course.
- Condition on discharge and disposition
- Treatment on discharge- medications, dietary instructions.
- Follow- up, including date of next appointment.
Educational Role:
The PGY-I may be assigned a third year medical student. The PGY-I is to review all of the student's cases and notes on a daily basis and sign them. PGY-I will teach the students round the problems of the patient. In terms of their own education, the PGY-I is expected to seek information through literature regarding the issues involved in the patient's disease state with emphasis on pathophysiology. During the attending rounds, the PGY-I is expected to take an active part in discussions. PGY-I is required to attend all conferences except when assigned to the Emergency Department and Medical or Cardiac Care Units. Specific learning objectives are further outlined in the Core Curriculum.
PGY-II
Patient Care Role
PGY-II performs in a supervisory role in the management of patients on the service. The responsibilities of PGY-II include:
- Perform a history and physical examination on all patients admitted to the service.
- Review the H/P performed by the PGY-I, check accuracy of the findings.
- Discuss the diagnosis and management plan with the PGY-I.
- In the event that the number of patients admitted to the PGY-I exceeds 5, the PGY-II assumes primary responsibility for the new admissions and writes a detailed H/P, progress notes, management decisions, consultations, investigations etc.
Educational Role
The PGY-II is responsible for teaching the PGY-Is during work rounds, while admitting new patients, and on other occasions as they arise, for example, if the PGY-II, decides to do some tests, the reason for doing so must be explained to the PGY-I. We believe that given the variety of problems that the patients at Lincoln present with, a lot can be taught during the work rounds alone.
Attending Physician
Patient Care Role
The ultimate responsibility for the care of every patient lies with the attending. The role of the attending physician, then, is to seek the optimal balance of house staff autonomy with appropriate supervision, with the goal of the best possible care provided to the patient. All new patients must be examined by the attending of record within 24 hours of admission. The attending is responsible for reviewing the admitting H/P completed by the PGY-I and PGY-II. All management decisions are reviewed with the attending, including all investigations planned, consultations from medical subspecialties and other services, medications and discharge planning.
Charting Responsibility
The supervision provided by the attending must be documented in the medical record. The documentation includes:
- Admission note within 24 hours of admission.
- Review and acceptance of the PGY's admitting H/P within 24 hours of admission.
- Daily progress notes.
- Review of resident's progress notes with countersignature.
- Review and signature on the discharge summary.
- Ensuring documentation in the Patient Education and Interdisciplinary Patient Care forms.
Educational Role:
Attending rounds are scheduled 6 days/week, from 8.30 to 11.30am. On daily basis, all patients on the service are seen and discussed by the team. New admissions are presented by the PGY-I in detail on alternate days. History, physical exam, diagnostic/management plan are reviewed and discussed. Many of the learning objectives are covered during these rounds. On alternate days, teaching rounds are scheduled from 10 to 11.30am. Teaching rounds must be made at least three days per week. During these rounds, specific issues are discussed which include general principles of pathophysiology, diagnostic strategies, clinical decision making, ethical dilemmas and social and economic aspects of health care. Issues which may have arisen during the management rounds are also discussed. Attending rounds include bed-side teaching, residents skills are evaluated periodically using Mini-CEX format.
Saturday Schedule:
All residents on the floor, who are not on-call on Sunday, must come to work on Saturday at 8.30am. After completion of work rounds, attending rounds and patient progress notes, residents who are not on-call may sign out at noon. The Saturday on call team has a 24 hours duty.
Sunday Schedule
The Sunday on call residents begin at 7.30 am, at which time Saturday post-call residents my sign-out. Resident on-call on Sunday signs out to Night Float at 9:00 pm.
Discharges:
Discharge planning starts on admission. Each patient is to be evaluated with respect to the possible need for services after discharge. Patient should be informed as to approximate day of discharge. A discharge notice must be given 24 hours prior to the discharge. All paper work including discharge summary, prescription and other instructions must be completed on the evening prior to discharge. The following morning, these patients must be seen by the team to ensure that the patient is indeed stable for discharge. This must be done before rounding on new and other patients. A discharge order is to be written before 9 am. The above does not apply to short stay admissions.
Patient must be sent back to his/her Primary Care Provider to ensure continuity of care. If patient does not have a PCP, the PGYI taking care of the patient during admission will follow the patient in his/her RMC.
Resident and Attending Responsibilities
Intensive Care Units
Orientation:
Residents are assigned to the MICU and CCU on a monthly basis. Prior to the assignment, they are provided a copy of the manual for the ICU that contains a description of the procedures frequently performed in the ICU, and relevant articles on critical illnesses. Residents are expected to review the material before starting their rotation in the ICU. On the first day of the rotation, the team undergoes an orientation with the Head Nurses and the attending staff. Orientation includes policies and procedures, physical plant, format for daily notes, procedure notes for the various procedures performed in ICU.
Schedule
Sign out rounds, the transfer of the care of patients between the daytime MICU/CCU and Unit Float or weekend on-call teams, takes place at 7.30am. Evening sign out rounds take place Monday through Sunday at 7.30 pm, Except Friday when the sign out is at 4.30pm and.
Responsibilities of Junior Resident (PGY-I or PGY-II) in ICU:
- Complete the initial history and physical examination on each patient. This note is to include relevant data base, diagnosis and management plan.
- Write daily progress notes on all patients.
- Write summary notes when patients are transferred to and from the ICU. The transfer note must include a summary of all important events during patient's stay in ICU, follow up recommendations.
- Note any significant events such as a decrease in the blood pressure, change in respiratory status etc., and take appropriate action in consultation with the senior house officer and the attending physician.
- Order and follow up indicated blood work and other investigations.
- Perform procedures including insertion of central venous lines, arterial lines, pulmonary artery catheterization under supervision of the attending physician and senior house officer.
Responsibilities of the Senior Resident in the ICU
The PGY-III is responsible for the care of all patients admitted to his/her service. He/she is often called upon to evaluate patients on the medical wards, and other services for possible admission to the MICU. He/she ensures that the patient accepted to ICU meet the admission criteria. The PGY-III supervises the junior house officers in their daily activities including invasive procedures, weaning of patients from mechanical ventilator and interpretation of bedside hemodynamic monitoring.
The PGY-III carries the Rapid Response Team (RTT) beeper, answers all calls that activate the RRT and participates in all codes on the medical floors.
Responsibilities of the Attending in the ICU
The attending physician is responsible for the care of all patients admitted to his/her service. All admissions to the ICU must be approved by the attending. He/she makes rounds on all patients daily. During rounds, patients are examined by the attending, cases are discussed in depth and management planned. Academic discussions pertinent to the patients= problems (Teaching Rounds) are held five days per week. The goal of Teaching Rounds is to educate the house officers in the pathophysiology, pathogenesis and management of various critical illnesses. Attending supervises the invasive procedures performed by the residents. Attendings also participate in the Performance Improvement activities.
Responsibilities of the On-Call Attending
During off hours, one attending is available on site for the critically ill patients and another for patients on the medical wards. The ICU attending is a trained intensivist with certification/ eligibility in the American Board of Critical Care Medicine. This attending is responsible for all the patients in medical and cardiac care unit. He/she approves all admissions, examines the patients, discusses management with the residents and supervises the procedures. Additional responsibilities of this attending include providing consultation for acute problems in patients on the non medical services. The ward attending is responsible for the patients admitted to the regular medical wards. He/she examines all patients and writes a brief coverage note. The ward attending is also responsible for all acute events in the patients previously admitted. It is imperative that the on call attending be informed about the problematic cases by the primary attending.
Resident and Attending Responsibilities
Consultation Services
Medical Consultation
Resident Responsibility
All Internal Medicine problems on the adolescent and adult patients on non medical services throughout Lincoln Hospital are referred to the Medical Consultation resident during business hours. Consultation is performed by a resident assigned to the service for the given month. The role of consulting resident is to evaluate the patient and to develop a plan for recommendation under the supervision of attending physician in Internal Medicine. Although the consulting service does not assume primary responsibility for the patient, the resident is expected to follow the patient until the acute medical problem may be managed under the care of the primary service to which the patient is assigned. In the event that the consulting service deems that transfer of the patient to medical service is indicated, it is the responsibility of the Medical Consultation resident to discuss transfer arrangements with the Medical Admitting Resident.
Attending Responsibility:
The attending physician is ultimately responsible for all recommendations provided on patients seen by the Medical Consultation Service. During business hours, the consultations are done under supervision of an attending in Internal Medicine who has experience in consultative medicine. During off hours, consultations are done under supervision of the on site attending on medical service. This attending is Board certified / eligible in Critical Care Medicine.
Medical Subspecialty Consultation:
Resident Responsibility
Internal Medicine residents have the opportunity to rotate through various subspecialties during the second and third year of the training. For each elective rotation, the resident is provided with a curriculum that has been developed by the chief of the division in consultation with the Program Director, Associate Program Director and the Chief Medical Residents. The curriculum specifies the educational goals and objectives of the elective. The resident first evaluates the patient, formulates a plan of recommendation for management. The case is then presented to the subspecialty attending assigned to do consultations in that specialty for the month. The consulting team discusses the patient and plan as a group. The resident then communicates the recommendations to the primary physicians. Follow up is provided under the supervision of the attending physician on as needed basis.
Attending Responsibility
The attending on the consultation service is ultimately responsible for the quality of the consultation provided. The attending is also responsible for ensuring that the educational goals of the elective rotation are met. This is accomplished by discussing the pathophysiology of the problems encountered, and reviewing the current literature pertinent to the patient's problems with the resident. The attending is strongly encouraged to conduct mini exam at the end of the month.
Emergency Department
Internal Medicine Resident Responsibility
In the Emergency Department, the internal medicine residents work under the supervision of ED attendings. Here, the residents see patients on first contact basis prior to the physician triage. On each patient, the resident performs initial history, physical examination, formulates a diagnosis and investigation and treatment plan. The resident then reviews the case and management plan with the supervising ED attending who makes the final decision. After review of the case with attending physician the resident is responsible for care of the patient till final disposition. If the patient is to be admitted, the resident is responsible for presenting the case to the Medical Admitting Resident and for caring for the patient till patient is admitted to the medical service. If the patient is to be discharged, the resident is responsible for making all appropriate follow up arrangements, including instructions to the patient, prescriptions and follow up in clinic. If the patient is awaiting final disposition at the end of the shift, the resident is responsible for providing sign out information to the incoming resident.
Attending Physician:
The ultimate responsibility for care of every patient lies with the attending physician. The role of the attending physician, then, is to seek an optimum balance of house staff autonomy with appropriate supervision with the goal of best care provided to the patient. All important management decisions must have the attending's input. The final disposition of every patient, whether it is an admission, discharge or further evaluation is made in conjunction with the attending physician.
Medical Admitting Resident (MAR) Responsibilities
Definitions/Overall Responsibilities
Every third year resident has an opportunity to be a Medical Admitting Resident for a month or two during the year. Responsibilities of the MAR are to,
- assess all patients referred for admission to medicine (the Emergency Department physician has the authority to admit the patient to any service. The MAR's role in assessment is only to ensure that assignment to the medical team is done appropriately, i.e., patients with multiple problems are equally distributed to all teams).
- assign floor team and recommend bed placement of all patients admitted to medicine.
- determine potential and actual discharges from the medical service.
- disseminate information regarding pending/actual admissions and discharges to medicine teams and Admitting.
- provide emergency medical consultations for patients on non medical services during off hours (from 5pm to 9am next morning on week nights and on Saturday and Sunday)
- communicate with the MICU/CCU attending regarding potential admissions to the MICU/CCU service.
Admission Procedure to Floor Teams
The Emergency Department physician has the final responsibility and authority to admit patients to the medical service. The MAR has the authority and responsibility to choose which clinical area within the Medical Service is most appropriate for the care of the patient.
On notification by the ED physician, the MAR must respond immediately and go to assess the patient. If the MAR is unable to do so within 15 minutes, a bed must be assigned on the phone. Otherwise the MAR must examine the patient and review the available data. The MAR then may decide that the patient should be assigned to a floor team or intensive care unit team or that more information is needed before an assignment can be made. When the Emergency Department physician and the MAR agree that the patient has been stabilized and a reasonable amount of work-up completed (sufficient to determine the need for hospitalization and the area of the hospital to which the patient should be sent), the MAR accepts the patient and initials the Emergency Department sheet, noting the date and time of acceptance and the name of the attending to whose team the patient is assigned.
The MAR then takes the following steps:
- Notifies the appropriate second year resident.
- Notifies the Admitting Office of the admission and the suggested disposition so that the bed may be assigned by the Admitting Office.
- In the case of proposed intensive care unit admissions contacts the CCU or MICU attending.
Patients are assigned to the teams on a rotation basis. The assignment however does take into account the complexities of the cases. Every effort is made to ensure that great disparity does not occur between the teams as far as workload is concerned. When there are no beds available on the medical floor, patient is assigned a bed on a surgical floor. The medical team is responsible for the care of the patient. Patient is transferred to the medical floor as soon as a bed is available.
Procedure for Admission by the MAR of patients to Critical Care Unit
When the MAR deems that a patient presented for admission requires admission to an intensive care unit, the MAR discusses the case with the appropriate attending i.e., MICU or CCU attending and admits the patient to the MICU or CCU team. If the patient is accepted for admission to the unit but no bed is available, the patient is cared for in the Critical Care Room in the ED, by the physicians from MICU or CCU until such time as a bed is ready.
Procedures for Resolving Differing Opinions Regarding Admissions
The ED physician has the authority to admit patients to any service within the hospital. Where to admit the patient in Medicine, i.e., on a regular ward or critical care unit, is at the discretion of the MAR. If the MAR decides to admit the patient to the regular ward but the ED physician believes that the patient should be admitted to the ICU, the case must be discussed with the on site attending.
Admissions of Patients from the Clinics:
When a patient seen in the clinic requires admission to the hospital, the patient should preferably be admitted directly, bypassing the Emergency Department. Attendings in the medical clinics or residents whose patients require admission with approval by the preceptors must page the MAR directly to arrange for admission. In the case of patients identified for admission during the last half hour of an afternoon session or evening session, the MAR may decide to transfer the patient to Emergency Department pending further work up and disposition, however this should not be done only to obtain routine tests that would not change the decision to admit. In case of unstable patients, the MAR may transfer the patient directly to the Emergency Department.
Numbers of patients assigned to the Medical Service:
In keeping with the credentialing requirements of the Residency Review Committee of the ACGME, first year residents should not admit more than 5 new patients and two transfers during a call and not more than 8 patients per 24 hour period and should not manage more 12 patients at any time. In the event that these limits are exceeded, the second year resident assumes primary responsibility for the care of these patients.
Medical Consultation/Transfer to Medicine from other Services
After 5 pm, the MAR is responsible for evaluation of any emergency medical consult requests. The supervision of the MAR for consultation is provided by the onsite attending. If in the opinion of the MAR and the attending, and emergency consultation is not warranted, a brief note is written with formal consultation to be requested the following morning. If the patient requires transfer to the medical service, the MAR makes all arrangements for transfer.
Responsibilities of Internal Medicine Residents to Medical Students
Introduction:
Lincoln Medical & Mental Health Center is a teaching institution, affiliated with Weill Medical College of Cornell University. The Department of Medicine has been selected as a site for their Internal Medicine Clerkship, Physical Diagnosis course and Introductory Clerkship. In addition, the fourth year residents are offered electives in various subspecialties of Internal Medicine. The goal and objective of the General Medicine clerkship is to provide the student with practical clinical experience of working with adult patients. The clerkship is intended to augment and strengthen the students skills in developing a comprehensive database with regard to a wide variety of common medical problems in General Internal Medicine.
In addition, Lincoln Medical Center is used for the clerckship training of medical students from two offshore medical schools.
Responsibilities of Resident Supervisor (PGYI and PGYII)
- Provide clinical instruction and supervision for students on the medical wards. Review H & P and countersign each note prior to being placed in the chart.
- Orient students to appropriate patient problems, differential diagnosis and procedures.
- Direct the students to specific assignment, data collection responsibilities and diagnostic and therapeutic procedures to be performed.
Assignment of Patients on the Medical Service
The primary objective in determination of patient load carried by each house officer is to enable detailed analysis and effective management of each patient, while ensuring that the house officers are challenged with diverse and complex problems.
dmissions
First year residents assigned to the medical ward are on call every fourth night. PGY-Is are responsible for no more than five new admissions and two transfers per admitting day (transfers are defined as any patient transfered from another service in the hospital,including MICU/CCU). During the winter months the number of admissions usually increases and each team admits more than five admissions. In that event the supervising PGYII is responsible for the next patient. The MAR assigns all patients, new as well as transfers to the medical service, thus ensuring that the guidelines are adhered to.
Ongoing Patient Care
Each patient on the inpatient units in medicine is assigned to a PGY-I as a primary physician. Two PGY-Is, one PGY-II and an attending constitute one team. PGY-III is shared between two teams. The average patient number of patients assigned to one PGY-I is below 12. In case the patient load exceeds this number, the PGY-II assumes responsibility for the patients above the limit.
MICU/CCU
Lincoln Medical and Mental Health Center has a 25 bed Medical Intensive Care Unit. At this time, out of these, 20 are operational. In addition, there is a four bed Step Down Unit for patients who are not stable enough to be admitted to the medical ward but do not fulfill the criteria for admission to the ICU. The patients in the Step Down Beds are also under the care of staff assigned to the ICU. The team in Medical Intensive Care Unit consists of three PGY-Is, one PGY-II and one PGYIII. Two attendings supervise the care. The team in Cardiac Care Unit consists of two PGY-Is and one PGYIII and one cardiologist. PGYI is responsible for the ongoing care of no more than five patients and is responsible for the work up of no more than 2 new patients on a given call day. The PGYII admits and becomes the primary physician for any patient who exceeds the PGY-I limit.
Reporting Time and other essential items
Inpatient units
When assigned to medical ward, residents report for work at 7.30 Sign out rounds go on for about an hour after which attending rounds begin at 8.30am.
Floor Float Schedule
Night Float team starts at 8:00 pm Sunday to Friday until next morning. The R1 presents new admissions to the attending physician at 8.30 and the R2 and R3 attend the Morning Report. New cases are presented by the R2 to the Chief and Program Director. All medical consults on patients on other services are performed by the Night Float R3. The Floor Float team is off on Saturday night.
Unit Float Schedule
Unit float starts at 7.30pm Monday through Sunday, except for Friday when the teams report to duty at 4:30. Residents who are assigned to the unit float team are off on Friday and Saturday.
Absences
As per ACGME and ABIM, to receive credit for their training, residents must spend 33 months in a post-graduate training program. In order to comply with this requirement and to provide equal amopunt of training to all residents, the program has developed a process that allows all residents to complete the necessary amount of training. In case of unusual circumstances the resident's contract may be extended with the permission of the office of Graduate Medical Education (GME). Administrative Chief Medical Resident must be informed before the start of the day in case you are not reporting to work.
Unpaid Leave of Absence
A leave of absence without compensation is intended for those residents who need an extended period of time away from their training program but have no vacation balance and do not qualify for or have expended their sick leave. An unpaid leave of absence must be requested and granted for compelling personal reasons. Requests for leave must be submitted in writing, to the program director or designee for his/her consideration.
Effect of Leave of Absence on Board eligibility
To meet the training requirements of the American Board of Internal Medicine, i.e. the resident must complete 33 months of meaningful clinical responsibility, the resident may be required to spend additional time in training to make up training time lost while on a prolonged leave of absence.
Beepers/ Home Phone numbers
All internal medicine residents are issued beepers for the duration of their training. It is each resident's responsibility to keep the Department of Medicine up-to-date with their beeper, home telephone numbers and cell phones.
House Staff meetings
House staff meetings are held monthly. A number of importance announcements are made at these meetings and attendance is mandatory. Residents are encouraged to bring their issues/concerns for discussion at these meetings in advance. To facilitate the process, residents may use one of the following methods - talk to the program director or send an e-mail, discuss the issue with the CMR or one of the housestaff union representatives, use the mail boxes to leave an anonymous message. All anonymous messages are reviewed by resident representatives and the summary o f the suggestions/problems are presented to the program director.
Visa status
It is the responsibility of each individual resident to ensure that their visa status is up-to-date. Specifically for those residents who are on J-1 visa, it is their responsibility to update the IAP-66 before it expires.
Moonlighting
The Department of Medicine expects that all responsibilities required of the residents in its training program will be met and that the performance level of residents at all times will be of the highest caliber. Further, since medicine is a profession that requires independent study even outside of the formal workplace, it is expected that significant time will be devoted to studious pursuits such as regular reading of the current medical literature, subject reviews, and preparation for the Board Examination in Internal Medicine. The Department of Medicine also understands and respects the need for personal leisure and development of outside interests that are important to the maintenance of physical and mental health.
Only to the extent that any additional employment would not compromise any of the above principles, does the Department of Medicine accept moonlighting activities on the part of resident staff. Approval from the Program Director must be obtained prior to the moonlighting. The Program Director is to ensure that the total number of hours worked does not exclude 80 as mandated by Bell Commission.
Dress Code
Residents are expected to be neat, clean and orderly at all times during performance of training program activities. Residents are expected to dress according to the generally expected professional standards appropriate for the resident's particular program. Where safely is a factor, residents should use common sense in choosing clothing and shoes for training activities. Jewelry, clothes and hairstyle should be appropriate for the performance of duties in the hospitals. Photo identification tags must be worn at all times while on the premises.
Consultations
Any request made for the evaluation of patients with acute or life threatening problem must be answered within one hour. Emergent and urgent consults can not be placed on line without contucting the respective service and informing themof the nature of the consult . The name of the responding physician must be noted in the request.
Urgent
Consult must be answered within 6-8 hours.
Routine
Any non-emergency consult shall be answered within one full working day.
Contents
Each consultation request must include the following:
- Present illness and pertinent past medical history.
- Pertinent physical exam and lab findings.
- Specific problem to be addressed by the consultant- i.e., specific diagnostic question you want the consultant to answer.
- Status i.e. routine, urgent or emergent must be checked.
Location
- Urology consultations must be brought to second floor, room 2-A.
- Ophthalmology- 2-A.
- Psychiatry- 7A.
Performance Improvement
House officers in the Department of Medicine are expected to engage in professional quality improvement activities. Resident, attending, noon conference and Grand Round evaluations all form part of the Departmental Performance Improvement.
Monthly Peer Chart Review
To maintain the quality of documentation and patient care, charts from the medical wards and MICU are reviewed by the members of Peer Review Committee which consists of hospitalists. Each attending physician reviews a sample of charts belonging to another one. The house officers assigned to the attending participate in the review process. Specific areas assessed include completeness of the PGY-I admitting note, quality of assessment and plan, and adherence to the Problem Oriented Medical Record format, compliance with management guidelines such as for community acquired pneumonia, congestive heart failure, myocardial infarction, stroke, bronchial asthma, diabetes mellitus. When a deviation from standard of care is found, the concerned physicians are counseled. Tracking and trending is done in case of major deficiencies.
Monthly Performance Improvement meetings
The Administrative Chief Medical Residents attend the monthly meetings of the department of medicine. Issues that arise out of PI projects and Mortality Review are communicated to the house officers.
Monthly House Staff meetings
The Program Director meets with all house officers on monthly basis. QI issues that arise out of the internal review or those referred from external sources are discussed at these meetings extensively.
Procedure Credentialing
The American Board of Internal Medicine requires a credentialing process for approval of procedures performed. All house officers are provided with a list of procedures in which they are expected to acquire skills during residency training. Each house officer is required to document in a procedure note the procedures taht they perform.
Procedures must be performed under direct supervision of a physician privileged to do the procedure until certified as clinically competent to perform them under general supervision. Associate Program Director meets with the house officers regularly to review the Log Sheet and document procedure proficiency in the house officer's permanent record.
Curriculum for Internal Medicine Residents
Educational Purpose
Internal Medicine program seeks to ensure that the house officers develop skills, knowledge and attitude necessary for a career in Internal Medicine. On graduation the house officer is expected to possess detailed knowledge and practical skills to pursue successful careers as general internists.
Principal teaching methods and settings
The principal teaching methods in Internal Medicine education involve a combination of individual patient based encounters, case discussions and a series of didactic conferences. In each individual patient encounter, there is a detailed discussion with an attending physician. The didactic conferences similarly utilize a patient based approach to integrate the basic sciences of pathophysiology with clinical presentations and an evidence-based approach to diagnosis and management. It is our strong belief that this patient-based approach utilizing both individual and group teaching maximizes our educational efficacy.
Patient Encounter
The settings include the General Medicine Clinic, Emergency Department, the Medical and Cardiac Intensive Care Units and the Medical wards. In each environment, the PGY-I acts in the role of the primary care physician under close supervision by a senior resident and attending physicians. The PGY-I is expected to obtain his/her own medical history, perform a physical examination, interpret available laboratory data and develop an initial diagnostic/management plan on each patient. The case is discussed in detail with the senior resident and attending physician, facilitating immediate feedback and evaluation in all cases.
Teaching Rounds
On the inpatient service, teaching rounds are scheduled from 8.30 to 11.30am on Anon admitting@ day three days/week. During teaching rounds a limited number of patient issues are discussed by the team with focus on such points as pathophysiology, differential diagnosis, interpretation of clinical data, appropriate utilization of technology, appropriate diagnostic strategies, ethical issues, pain management, and end of life care. In the outpatient setting teaching is directed to preventive guidelines, and is centered around the problems of patients seen by the resident. In the ICUs, teaching rounds are held daily in the morning. Bedside teaching is done in the later part of the morning and afternoon.
Core Curriculum
Conferences are held every day from mid-July through mid-June, Monday through Thursday and are mandatory for all except, residents who are assigned to vacation, night float, Emergency Department. House officers assigned to the ICUs are encouraged to attend. The Core Curriculum includes topics from all subspecialties in Internal Medicine, Morbidity and Mortality Conferences, Radiology Conferences, Journal Clubs and, topics in office gynecology, psychiatry, ophthalmology, urology, ENT, adolescent medicine and dermatology. A minimum of 60% attendance at the Core Curriculum is required. The attendance records are kept for each resident and included as part of the permanent record.
Medical Grand Rounds
Medical Grand Rounds are held weekly by prominent guest speakers, covering a wide range of important topics in Internal Medicine and its subspecialties.
Journal Club
The ability to critically appraise medical literature and apply it to patient care in a systematic fashion is essential for effective performance as an internist. These skills are taught at the monthly Journal Clubs which all residents are required to attend. At these sessions, a PGYII or PGYIII selects a topic based on a patient problem, performs an on-line literature search, and critically appraises the evidence obtained, using the format of the Evidence -Based Medicine Group published as AUsers= Guides@ in JAMA. The Program Director and/or a designee review important concepts in clinical epidemiology and biostatistics at these conferences.
Morbidity and Mortality Conferences
This conference is held monthly to discuss deaths and problematic cases, identified by the ACMR, attending staff, or through the CQI process. The cases are presented by the PGYII or PGYIII who was not involved in the care of the particular patient in order to ensure and in depth and objective discussions of the issues identified. The conference is attended by the medical house staff, medical attendings staff, the Program Director and Chief of Service. The ACMR is responsible for moderation of the case discussion.
Morning Report
The Morning Report starts at 8.30am and is conducted by the Chief of Medicine and the Program Director. Several attendings and house officers on electives attend this one hour long educational session. The MAR selects cases for presentation. The cases are presented by the PGYII who admitted the patient. Discussion is moderated by the ACMR. Attendance by various attendings provides for an exciting discussion.
Morbidity and Mortality Morning Report
Every thursday interns present patients that have expired for which they have provided care. The purpose of this report is to analyse the hospital course and to train the resident to be able to objectively analyze whether the standadrd of care was met, to identify areas of improvement, to research the relevant literature and to improve his/her communication skills.
Tumor Board
This is a combined medical-surgical conference held every other week in which surgical, medical and radiologic management of cancers is reviewed.
Educational Content
The educational objectives of the Core Curriculum are outlined by subspecialty in the pages that follow. Essential requirement for all the PGY-I's are as follows: the ability to obtain a comprehensive history, perform a thorough physical examination, analyze the case and arrive at a reasonable differential diagnosis and management plan. Effective synthesis and communication of this information is imperative, and is a requirement for promotion to a PGY-II level. Similar sets of learning objectives have also been developed for all elective rotations during the PGYII and PGYIII years. Written curricula are given to all residents assigned to an elective and the Critical Care Units.
Ancillary Materials
PGY-I's are expected to meet the learning objectives which follow, through the course of daily conferences, participation in work, management and teaching rounds on all rotations, and supplemental reading. There is a Health Sciences Library located on the second floor and an Internal Medicine Reading Room which is accessible on a 24 hour basis. In addition there is a 24 hour access to the National Library of Medicine database which allows residents to explore the most recent medical knowledge available. Specific textbooks recommended to the house officers include Harrison's, Cecil's textbooks of medicine.
Research/ Scholarly Activity
All Internal Medicine residents must complete a research project or demonstrate scholarly activity prior to graduation. This requirement is met through one of the following mechanisms:
All third year residents are required to present a Chief Medical Conference. During this conference the resident presents a case illustrating a clinical topic of particular interest and leads the discussion on diagnostic approach, prognostic outlook, and/or therapeutic/management strategies to the clinical problem, using principles of Evidence-Based Medicine. In preparation for this conference, the third year resident must perform an in-depth search of the medical literature, and analyze the literature utilizing critical appraisal skills and concepts of clinical epidemiology/biostatistics. The search strategy and requisite analytical skills are to be discussed explicitly and are an integral part of the presentation. Details of the presentation are kept on file by the ACMR.
Other forums in which potential topics for resident research are discussed on a regular basis include Morning Report. Cases discussed in Morning Report are reviewed by the Program Director and Chief of Medicine for research interest. The Chief of Medicine and Program Director also provide attending coverage in the MICU and medical ward respectively. This provides a unique opportunity to suggest research topics to the residents, based on cases seen.
All residents are strongly encouraged to become Associates of the American College of Physicians and to actively participate in Associate's Competition. Every year, a large number of abstracts are submitted to both Regional and National meetings of the American College of Physicians.
Death Pronouncement/Family Notification/ Autopsy Consent
I. Death Pronouncement
When called to pronounce a patient's death, the following steps should be followed:
- Identify the patient (examine hospital ID tag on the patient's wrist)
- Examine patient for;
1.
Response to verbal or tactile stimuli (none)
2.
Spontaneous respiration (none)
3.
Heart sounds and pulse (absent)
4.
Pupillary response (pupils fixed and dilated)
5.
Asystole on EKG
- Document the time the patient was pronounced dead (legal time of death)
- Notify supervising resident and attending physician.
- Document findings in patient's chart.
e.g. ACalled by charge nurse to evaluate Mr. John Smith. Patient examined. Unresponsive to verbal or tactile stimuli, no spontaneous respiration noted, heart sounds not audible, pulses absent, pupils fixed and dilated. Asystole on EKG. Patient pronounced dead at 2330hr. Attending notified. Next of kin to be contacted by (name of supervising resident).
II. Family Notification
PGYII and PGY-III's are to notify the next of kin in the event of a patient's death. The steps are as follows:
- Familiarize yourself with the patient's medical history and mode of death.
- Identify yourself to the family in a humble and caring manner and ask them to come to the hospital. If death had been expected and the next of kin had been informed earlier of the possibility, you may tell them that the patient has expired. Inform them of the time the patient was pronounced dead and always try to comfort them that their relative died peacefully.
- sk the next of kin if the family will be coming to the hospital to view the body before it is transported to the hospital morgue. Notify the charge nurse of their decision.
- lthough it is preferable for the patient's family to be notified in person, the family may be informed over the telephone if they are unable to come to the hospital in a timely fashion.
III. Notification of the Organ Donor Network
Organ Donor Network must be called within one hour of all deaths. In case of Brain death ODN is to be notified before Brain death is declared by the neurologist or intensivist.
IV. Autopsy
Autopsy must be requested for all patient deaths. Ask in a respectful manner whether the next of kin will consent to an autopsy. You may inform them that autopsy results help future patients. Many families are unaware of the option to perform limited autopsies. Keep in mind that the request must be made in a respectful manner.
Be sure to include the beeper number of the patient's primary PGY-II on the autopsy form. This will allow the Pathology Department to notify the primary team about the time of autopsy and organ review. You must make every effort to attend the autopsy yourself.
In an estimated 30% of autopsies performed, major unanticipated clinical findings are discovered. Performance of autopsies represents an essential component of the educational process, and is essential even when there is a belief that the cause of death is Astraight forward@. Residents are required to request an autopsy for all deaths on the medical service. For unexplained deaths, the New York Medical Examiner must be called as well
Evaluations
Formative Evaluation
- Performance of residents is evaluated throughout the training. The evaluation includes six domains of clinical competence (patient care, medical knowledge, practice based learning and improvement and interpersonal and communications skills).
- Structured clinical evaluations are conducted both on inpatient rotation and electives. Called Mini-CEX this is done as part of the routine work and immediate feedback is given to the resident.
- Medical records are reviewed for quality of data entry, accuracy of assessment, appropriateness of assessment and plan, and legibility during each rotation. The review of medical records is included in the evaluation.
- Residents are evaluated in writing and their performance reviewed with them verbally. Residents are required to review the written evaluation and sign it.
- Residents are evaluated in the writing and their performance in continuity clinic reviewed with them verbally on at least a semi-annual basis.
- A formal evaluation of knowledge, skills and professional growth of residents and required counseling by the program director or designee occurs semi-annually.
- Permanent records of the evaluations and counseling sessions for each resident are maintained in the resident's file.
- An evaluation of each resident is conducted by the Administrative Chief Medical Resident which includes feedback from peers, nursing and patient, on semi-annual basis.
Summative Evaluation
- The program director prepares an evaluation of the clinical competence of each resident annually and at the conclusion of the resident's period of training in the program.
- The summative evaluation must stipulate the degree to which the resident has achieved the level of performance expected in each competency (i.e. patient care, medical knowledge, practice based learning and improvement, interpersonal and communication skills, professionalism, and systems- based practice).
- A record of summative evaluation is maintained in the resident's file.
- In the event of an adverse evaluation, a resident is offered an opportunity to address a judgment of academic deficiencies before Clinical Competence Committee.
Resident evaluation of the faculty members and the program
- The residents are asked to evaluate the attending physician confidentially, at the end of each rotation. The evaluations are reviewed by the program director and used for faculty member counseling and for selecting faculty members for specific teaching assignments. Please be honest in your evaluations. Without accurate feedback from you the programmatic changes cannot be made.
- The residents must evaluate the program at least annually. Specifically the quality of the curriculum and the extent to which goals and objectives have been achieved must be assessed. Please feel free to offer suggestions for improving the training, and new ideas for curriculum.
Combined Fellowships – Change to “Fellowships”
At present there is one combined fellowship – Hematology/Oncology. Throughout the year, a fellow from Montefiore-Einstein Hematology/Oncology Fellowship Training Program is assigned to our Cancer Center. The head of the Hematology/Oncology department at Lincoln is part of the committee selecting the fellows for the training program.
Fellowship Placement for our Recent Graduates:
| Class of 2007 |
Hematology/Oncology
Pulmonary/Critical Care
Geriatrics |
2
2
2 |
| Class of 2006 |
Hematology/Oncology
Infectious Diseases
Geriatrics
|
1
2
2 |
|
Residency Program 
