New Curriculum Changes

We will be transitioning to the 4+1 block scheduling system beginning in July 2016.  The 4+1 system allows for a 4 week rotation (wards, ICU, subspecialty consults, etc.) followed by a 1 week rotation focused specifically on ambulatory medicine. Residents are placed into firms consisting of equal numbers of PGY3, PGY2, and PGY1 residents.  We believe that this will allow for a smooth transition between the inpatient and outpatient portions of internal medicine and thus result in a greater focus on each. The ambulatory week will consist of continuity clinics, subspecialty clinics, emergency medicine, and ambulatory didactics.

Why is this changing?

This is a change that we have been investigating for several years and after resident feedback the decision was made to incorporate the new curriculum next year. This is a change that will allow for a broader and more comprehensive experience in the outpatient clinic. It also removes the added stress of having a half day of clinic while on inpatient rotations.

Advantages:

  • Exclusive Outpatient Staff: Greater continuity in the outpatient clinic as each firm will have 2 outpatient physicians assigned solely to their group of residents for the entirety of residency.

  • Continuity Clinic: No continuity clinic during 4 week rotations allows for full resident focus on that specific rotation. It will also give residents more freedom in scheduling patients. You will no longer be limited to your one half day a week and thus patients will find it easier to schedule with you on any day while you are on your ambulatory block. If you have a patient that needs an urgent appointment and you are not in clinic for several weeks, there are sub-groups within each firm that will help to cover your patients for you.

  • Didactics: Firms will function as journal club, quality improvement groups, board review, and have their own exclusive outpatient morning reports.

  • Golden Weekends: The schedule will have a guaranteed golden weekend in every 5. Residents will still have 1 day off in 7 days averaged over the 4 week rotations.

 

Example of 4+1 Schedule

4+1 Example


 

New Curriculum:

The new three year curriculum is focused on giving residents a broad medicine base during the first year and to increase autonomy through the three years. The goal is for the PGY3 resident to feel comfortable and competent practicing independently in the inpatient and outpatient setting.

Personalized Scheduling: As opposed to offering specific tracks, we favor flexible personalized scheduling that increases elective time as residents progress each year to allow for specific training and education in the resident’s chosen focus. For example, if you are pursuing a career in ambulatory care you have the options to rotate through clinic electives, orthopedics, dermatology and psychiatry.

Geographic Localization: Scott & White also has transitioned to “geo-local” which takes advantage of bunching patient teams in specific geographic area.  This allows for the physicians, APPs, nurses, social workers, pharmacists, and case managers to work as an interdisciplinary team and improve patient dispositions, length of stays, patient satisfaction and ultimately lead to better outcomes. This means that patients with certain diagnoses (primary cardiac, stroke, etc.) are placed on a floor with nurses who have specialized training in that area. We have taken advantage of this by placing our teaching teams in these areas in order to care for and learn from these patients.

3 Year Curriculum (Weeks)

 

3 Year Curriculum (Weeks)

Chart

 


Intern Year

The PGY1 curriculum encompasses a general introduction to internal medicine with a majority of the year spent on medicine wards and ICU.  Subspecialty experience is gained in cardiology, nephrology, and neurology.

Night Float: Interns rotate through VA cross cover/admits, S&W cross cover, S&W admits, and MICU; there is a PGY2 upper level in-house at both the VA and S&W for back up and assistance, but this rotation allows for good autonomy with managing patients on the general wards. There is 1 intern on call at the VA with 1 upper level to assist with admissions. At S&W, there are 3 interns splitting work between the ICU and floor at night.

General Medicine Wards: These weeks will be spent at either the VA or S&W. There are 3 teams at the VA. At S&W, 2 teams (Medicine A and B) cover 7 North (29 beds between the 2 teams). Resident teams will cover only patients on this floor that allows for closer relationships with the nurses, techs, social workers, and case managers. These teams have 2-3 interns per team with 1 upper level resident and core medicine staff. There are also medical and pharmacy students.

Cardiology Medicine Wards: This is a new rotation that has one of our general medicine teams working in the newly developed CCU. All patients on this floor are medicine patients with a primary cardiac diagnosis. The team will work closely with the cardiology consult team in managing patients. There are exclusive didactics in reading ECGs, heart failure, ACS and arrhythmias with the core cardiology faculty. This team has medical students, 2-3 interns, 1 upper level, and 1 internal medicine hospitalist staff.

Emergency Medicine: Interns will have the opportunity to work at both the S&W and VA emergency medicine departments during parts of the ambulatory clinic weeks. In the S&W ED, interns will have 12 hour shifts covering a pod of 15 patients that is shared between the intern and an upper level ED resident.

Ambulatory Medicine: The intern year ambulatory week consist of continuity clinic with your own exclusive cohort of patients that are passed down from outgoing PGY3 residents. Interns will also rotate through the S&W ED, VA ED, VA orthopedic clinic, and VA dermatology clinic. The orthopedic clinic allows for experience with joint injections that can then be performed in the continuity clinic.

 

 

PGY1 Curriculum

 

PGY1 Ambulatory Block

PGY1 Ambulatory Block

 


 

PGY2 Year

The PGY2 curriculum increases resident autonomy as PGY2s become upper level residents on night float and wards. Subspecialty experience is gained in gastroenterology, infectious disease, and oncology. The ambulatory block incorporates endocrinology and nephrology clinics.

Night Float: The PGY2s are upper levels at the VA and S&W ICUs. They cross cover and admit with the assistance of interns. PGY2s are expected to manage critically ill patients and run all codes in the hospital. There is assistance when needed from an in-house ICU fellow at S&W and home call ICU fellow at the VA.

General Medicine Wards: PGY2s begin as upper levels on VA ward teams and transition to upper levels at S&W in the latter half of the year.

Oncology Medicine Wards: Patients on active chemotherapy or with acute oncologic/hematologic emergencies are admitted to this service. PGY2s work with oncology fellows and staff to run this service. There are typically 2 PGY2 residents, 1 oncology fellow, and 1 core oncology staff.

Medicine Consults: PGY2s work with teaching hospitalist to cover all general medicine consults. They also assist in managing the orthopedic co-management team and gain experience in perioperative medicine. This functions as the procedure team allowing for residents to gain additional experience in paracentesis, thoracentesis, lumbar punctures, central lines, PICC lines, and IV guided peripheral lines. Most residents gain enough numbers to satisfy residency requirements for performing independent procedures as interns, but those that don’t are able to use these weeks to increase their numbers.

Selective: The selective rotations allow for additional experience in medicine subspecialties. Rotations are chosen based on scores from the annual In-Training Exam taken by all residents. Residents are allowed to choose rotations from their lowest scoring areas in order to increase exposure to these areas. As a reward for outstanding performances, residents that obtain greater than 75% correct may treat a portion of their selective as an elective.

 Ambulatory Medicine: The PGY2 ambulatory block is focused mostly on continuity clinic with additional nephrology and endocrinology clinics.

 

 

PGY2 Curriculum

 

 

PGY2 Ambulatory Block

PGY2 Clinic


 

PGY3 Year

The PGY3 curriculum gives increased flexibility to residents to gear their education toward their chosen focus (ambulatory, hospitalist, academic, subspecialty, etc.). Subspecialty rotations are provided in pulmonology and palliative care with ambulatory blocks focused on rheumatology and hematology.

Neurology Medicine Wards: This rotation is for PGY3s to experience hospitalist medicine with a neurology focus. They will work independently with a teaching hospitalist caring for patients on  4 North (neurology floor).

Palliative Care: Residents work with the palliative care/hospice staff on the consult service as well as in the palliative clinic.

Night Medicine: PGY3s assist interns in admitting overnight to the S&W 7 North teams. Residents are available at evening check out and then will oversee admissions overnight. The PGY3 is not required to take in-house call for this and is allowed to return home once admissions are complete. They are excused from daily conference and are encouraged to use the week for board preparation.

Ambulatory Medicine: PGY3 residents are responsible for continuity clinic and helping to manage the firm. They will coordinate ambulatory didactics, journal club, and QI. This week also provides experience in rheumatology and hematology.

 

 

PGY3 Curriculum

 

 

PGY3 Ambulatory Block

PGY3 Clinic