Overview of the Training Experience
Time is spent on the general medicine service, subspecialty
ward services (cardiology, oncology, hepatology and hematology) and in the
medical and cardiac critical units. The
cardiology ward and cardiology critical care (CCU) is a combined experience. Residents also spend time on night float for
both the wards and critical unit, and doing general medicine
In addition, early in the second year, residents spend 2-4
weeks caring for patients on their own with a supervising attending. This
provides them an opportunity to consolidate their clinical skills and medical
knowledge, prior to assuming responsibility as team leader/manager. To
transition into this role, PGY2 residents typically first work with just one
intern, before leading two interns.
All senior residents are encouraged to take charge of their team, directing
attending rounds, proposing care plans and teaching and supervising the
interns. The attending is always available for direct supervision and guidance
so the residents learn these skills in a safe environment that promotes quality
patient care and education.
Our ward attendings are a select group from either Hospital Medicine or General
Internal Medicine. Occasional subspecialty attendings also spend time as
general ward attending, including our chair of internal medicine. This person
is the attending of record for all of the patients on a service. This means
attending rounds and ongoing care is efficient. Ward attendings generally have
no other obligations, facilitating the direct observation of and feedback to
residents as they provide patient care. These physicians also champion learning
on the rotation – insuring that education supplements patient care at the
bedside, through presentations and the dissemination of relevant literature.
Attendings are encouraged to attend morning report as well.
There is a night float system for both interns and residents, eliminating
overnight call. There are also 2 nocturnal medicine attendings and an
intensivist every overnight to provide supervision.
PGY1 categorical residents spend time at the Lemuel Shattuck Hospital in
Boston, a premier public health hospital in Massachusetts. This provides
exposure to underserved populations, including prisoners, with a variety of
disease pathology, including HIV/AIDS.
Senior residents develop consultant skills working directly with the General
Medicine Consult hospitalist evaluating surgical and neurological patients who
require internal medicine care.
Intensive Care and
Coronary Care Units (ICU and CCU)
The ICU team includes 2 senior residents, 2 interns, a
pulmonary-critical care fellow and an intensivist. Housestaff develop the
clinical skills required in the care of critically ill patients. Simulation
training provides the foundation for procedural skills used frequently in the
ICU. There is no overnight call with coverage provided by an intern and senior
resident for both ICU and CCU patients. There is a critical care attending
in-house overnight, available for admissions and other issues.
The CCU team has the same housestaff staffing, and includes a cardiology fellow
and cardiology attending. The call schedule is the same as for the ICU. The
cardiology fellow assists with all admissions. The CCU team also cares for
cardiology patients on a general ward. This provides continuity for patients
transferred out of the CCU, and also augments exposure to less critically ill
Ambulatory and other experiences
At least one third of the residency experience is designed to
occur in ambulatory settings.
The foundation of this is the categorical resident continuity clinic experience
in our general internal medicine (GIM) practice on the Burlington campus. The
residents work closely with a designated group of attendings every 5 weeks when
this group of residents, labeled Firms A-E rotate throughout the 3 years. To
enhance continuity, residents are encouraged to assume primary responsibility
for patients they care for on the inpatient service who do not have primary
care physicians already. In addition, residents have the opportunity to care
for a subset of their continuity preceptor’s panel of patients. This provides
the chance to care for patients with chronic illness over time.
The residents rotate through required subspecialty ambulatory experiences. This
is a chance to spend 2 weeks concentrating in the various internal medicine
subspecialties. Intensive educational programs have been developed for each
rotation to insure robust learning. These rotations also provide residents the
chance to experience up close the sub-specialties as they ponder career
choices. The residents can also rotate through outpatient surgical
sub-specialties to enhance their skills as internists.
The categorical residents spend time in neurology and the emergency department.
They also spend time learning various aspects of geriatric medicine. This
experience includes time at a local VA, in palliative care, and with neurology
faculty learning about cognitive disorders and other issues that preferentially
affect elderly patients.
There is also elective and research/scholarship time over the course of the
training program. Residents can tailor this time to their interests and
educational needs. Elective options include radiology, psychiatry, transfusion
medicine, and anesthesia. There is a faculty research champion to help
facilitate scholarship. The resident’s mentor can foster introductions to
various attendings in a field of interest, and help the resident navigate the
numerous options for research and scholarship at Lahey Hospital & Medical Center.
There is funding to support resident travel should resident efforts lead to a
presentation at a national meeting.
Elective time can also be used to travel abroad as part of the Global Outreach
Program in which various Lahey faculty members participate. Typically each
year, 2 or 3 residents join the electrophysiology cardiology team for an annual
visit to Bolivia for Project Pacer. This group, for more than 25 years, has
been providing specialized cardiac care to patients in Bolivia, where Chagas
disease is endemic.
In order to make sure that residency training is as good as
it can be, we seek input from the residents on an ongoing basis through various
focus groups, elective class representative, and monthly business meetings (and
our doors are always open!). The
following changes have been made recently:
- A “4 + 1” schedule in which the residents are divided into 5 “firms” and spend every 5th week in resident continuity clinic
- A newly restructured primary care experience: with the change in the schedule we have also changed the location and structure of the primary care experience. The residents work in one section of our practice on a regular basis. In addition to patient continuity, the redesign is also helping continuity with preceptors, nursing and supportive staff. We are also integrating an expanded quality and patient safety experience into this week
- One fewer ward team has allowed for more outpatient time.
- Themed educational weeks in which AM reports, midday didactic conferences and board review are all centered around one specialty to help reinforce knowledge.
- Rightcare Action week began in 2015 and continues. It is an opportunity to join a nationwide conversation about the structure of healthcare and the need for reform.
- Work – life balance:
- Approximate number of 2 day weekends free (all residents get at least 1 day off in 7):
- Interns: 16 full weekends free
- Preliminary interns: 8 full weekends free during electives. Preliminary interns also do 4 weeks of ED where they have 2 days off each week. There is another 4 weeks of elective time when the intern may be pulled for sick coverage.
- PGY2: about 19 full weekends free
- PGY3: about 21 full weekends free
- “Connect and reflect” sessions with a Lahey psychologist with expertise running such groups (including for attendings in a number of departments at Lahey). These are monthly sessions for each PGY class and are run by an experienced clinician. She helps facilitate discussion with the goal of easing burnout and improving resilience. This is part of a broader Lahey initiative for residents and fellows this year to help prevent burnout and enhance provider well being.
- Sick call: because we and our families can get sick, we have found it important to have a mechanism to insure we can take time off when needed. Our sick call system is assigned to everyone so the residents all shoulder the burden of covering for colleagues. If there is an extended absence (eg maternity leave) this clinical time may need to be made up (either during training or by extending training) to insure a resident does not lose their eligibility for American Board of Internal Medicine (ABIM) certification. In addition, prolonged absences may also require “pay back” in to the sick call pool. This is necessary to insure fairness.
- Resident ombudsmen: several attendings from different specialties have made themselves available to residents if someone needs guidance from another person outside the program
- Mentor program: residents are matched with an attending who can help them navigate a variety of goals during training: personal challenges, professional goals, research interests, fellowship applications.