The Inpatient Residents' Service
There are six general Internal Medicine Residents' Service teams comprised of a teaching attending physician, a G2 resident, a G1 resident and 1 or 2 medical students. Each team cares for patients in both critical and non-critical care units to provide optimum continuity of care. Approximately 10 percent of the patients on the teaching service are in critical care units.
A separate critical care unit rotation occurs in the G1 and G3 year, which does not involve night or weekend call. The team cares for approximately six critical care unit patients at any one time under the direct supervision of board certified intensivists.
Attending Teaching Rounds
All of the Residents' Service patients are the direct responsibility of full time faculty physicians. Subspecialty physicians are consultants for these patients. Faculty attending physicians give residents primary responsibility for patient care. Faculty and residents maintain routine communication through progress notes, not through daily joint work rounds, although residents and supervising faculty are often at the bedside together. The availability of the computerized medical record has strongly facilitated resident/faculty communication.
Each resident team has separate daily teaching rounds with its teaching attending to provide optimal learning for the residents. Our system maintains an ideal balance between the need for resident responsibility and autonomy and the need for appropriate supervision and education by experienced, knowledgeable clinicians.
Attending Rounds Technology
The online availability of the computerized medical record and the radiology system has improved the quality of attending rounds tremendously. In addition, Promethean ActivStudio computerized white board technology in all of the resident attending round rooms, offers an on-the-fly look into our online radiology system and complete patient chart during attending rounds. In addition, it allows the attending to access any online resources to answer questions, or to access our audiovisual database of items such as physical exam findings, peripheral smears, ECGs, etc.
Call, Admissions and Workload
G1 and G2 residents are on long call every sixth night while on inpatient general medicine Residents' Service rotations although the G1 residents are finished and leave the hospital by midnight. There is no night call responsibility during non-ward rotations, and G1s and G2s have one weekend day off per week during ward rotations. During a 24-hour long call, a G1/G2 team admits a maximum of six new patients.
Besides one long call day in each six-day cycle, each team has two short call days. Thus, each team admits new patients every other day. On a short call day, teams admit a maximum of three new patients who must be in the hospital by 3 p.m.
An average Residents' Service team admits nine new patients per week and has a census of 8 patients, one of whom will be in a critical care bed.
Night Float System
The night float system provides additional nighttime coverage for the patients on the Residents' Service. One resident covers from 4 PM to 2 AM and provides cross coverage for all patients on the Residents' Service. Another in-house moonlighting resident is available for cross coverage from 2 AM to 5 AM and then an off ward resident takes calls until 8 AM. This allows the long call team to concentrate on new patient evaluations. This system of coverage allows the long call team to work on admissions and obtain uninterrupted sleep when they are finished with their work. Night float G1s are helped and supervised by the long call G2 resident and half-hour attending rounds occur from 4:00-4:30 p.m. each afternoon for the G1 float resident. Our night float system does not shift workload to other parts of the residents' schedule and maintains continuity of patient care through the long call G2 resident. Our admission limits ensure that G2 residents also receive adequate sleep on long call nights.
