We transitioned to the 4+1 schedule starting in July of 2016. Our rotations consist of 4 weeks of an inpatient wards or consult service followed by a 1 week period of dedicated outpatient experience. During the +1 week, our categorical residents rotate between their continuity clinic and outpatient specialty rotations. They are able to focus their time on their own primary clinic patients in addition to improving their skills in the outpatient setting. The residents will be assigned to “cohorts”, groups of PGY1, PGY2, and PGY3s which will rotate through the continuity clinic together.
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 cohort that will help to cover your patients for you.
Didactics: During the clinic week, the cohorts have dedicated academic half-days on Wednesday afternoons. They are excused from clinical duties for journal club, outpatient didactics, and board review.
Golden Weekends: The schedule guarantees a golden weekend in every 5. Residents will still have 1 day off in 7 days averaged over the other 4 week rotations for their RRC days.
Example of 4+1 Schedule
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)
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 and nephrology.
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 the S&W emergency medicine departments throughout the year. 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. Residents will also rotate through outpatient VA clinics in Cardiology, Gastroenterology, Anesthesia, Rheumatology, Gynecology, Orthopedics, Neurology, and Dermatology in order to improve outpatient diagnostic skills as well as outpatient procedures.
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.
Electives: The elective rotations allow for additional experience in medicine subspecialties. Additionally, opportunities for dedicated research time are available and many of our residents utilize this time for case presentation write-ups as well as IRB-approved research proposals.
Ambulatory Medicine: The PGY2 outpatient weeks are similar to the intern experience with combination of continuity clinic with outpatient specialties.
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: PGY3s have a dedicated month on the neurology consult service rotating directly with neurology attendings and residents. They will get focused practice with diagnosis of neurological disorders as well as the neuro examination from a neurologist perspective.
Hospitalist: PGY3s will have a dedicated 2-4 weeks (depending on chosen schedule) on a dedicated upper level hospitalist ward service at S&W. Just like the Teaching Team A&B, the hospitalist service is geo-localized meaning the team (Team C) has all of its patient located on the teaching floor on 7 North. This experience is designed to be as close to a true hospitalist experience as it can be, allowing hospitalist-minded residents the opportunity to experiment with their rounding styles as well as providing significant autonomy prior to graduation.
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.