Rotation Schedule by Year – 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 consultations.
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 cardiac patients.
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.
- Approximate number of 2 day weekends free (all residents get at least 1 day off in 7):
Rounds, Conference and Social Events
Attending rounds for inpatient ward teams and the critical care units take place every morning. There is an emphasis on bedside rounds, integrating didactics with clinical skills.
Senior ward residents are expected to round with their interns prior to attending rounds to provide supervision and education to the interns, and to nurture clinical leadership. The clinical plan can be initiated when appropriate, and presented at attending rounds.
Signout happens in the residency room for ward teams, with interns and residents signing out to their respective night float residents. This insures that any potentially active patients overnight will be known to both the intern and resident night float.
Conferences are grouped into a themed week chosen from the recommended ACP curriculum. All morning reports, noon conferences, and high-value teaching sessions build on this theme. The week ends with a dedicated Board Review session which wraps up each week.
Morning reports occur Tuesdays and Thursdays. These are case presentations often presented by a resident, with a discussion lead by the chief resident. Journal club is also held during this time, which is an evidenced based discussion lead by a senior resident.
Noon conferences are held Tuesday, Wednesday, and Thursdays and are didactic lectures by subspecialty attendings or general internists with a focus on the latest guidelines, evidenced based medicine, and board preparation.
Radiology conference is held every Monday with review of common/interesting findings on imaging studies from patients on the wards teams, under the direction of the radiology department.
ECG conference is hosted once monthly by our staff electrophysiology attendings with an emphasis on reading and identifying key ECG findings.
Intern report occurs for the first 6 months of the year on Fridays. Senior residents cover the interns’ pagers during this time and the chief residents or a program director leads the session. Emphasis is on fundamental clinical skill development and core medical knowledge. Later in the year there are sessions on clinical teaching.
Grand rounds for the entire Division of Internal Medicine is Fridays from 7:30-8:30.
Visting professorships occur at least once per year. A nationally recognized physician is invited and presents at grand rounds, as well as smaller sessions specifically for the house staff. A dinner and luncheon also occur, allowing residents a less formal opportunity to talk with the physician.
This is held monthly. We also send 4 residents annually to participate in the ACP Medical Jeopardy Contest.
Simulation sessions occur weekly during continuity clinic. Emphasis is on procedural skills in a simulated environment. The education includes on-line didactics, faculty didactics and hands-on practice. Other sessions include patient scenarios to train clinical, leadership and communication skills. The Simulation Center at Lahey Hospital & Medical Center has several mannequins, including a heart/lung model, to enhance the experience.
The residents informally socialize outside of work. This is a result of the great camaraderie of our house staff. Formal events include a welcome cookout for incoming interns and a graduation celebration for all house staff and faculty in the spring.
Rotation Fact Sheet
- Teams consist of 2 interns, 1 resident, 1 attending (hospitalist or internist)
- At the start of the year, each intern is paired with 1 resident for their first rotation
- NO overnight call, night float rotation present
- Census up to 10 patients
- 4 week rotation in Jamaica Plains State Hospital
- Team of 4 interns from different hospitals, 1 Tufts PGY-3 resident, 1 attending
- Provide care to inmates and underserved populations of the city
- Combined resident subspecialty services
- Liver Team consists of 1 liver intern, 1 GI fellow, liver attending
- Oncology/Hematology Team consists of 1 intern, 1 senior resident and oncology/hematology attendings
- PGY-2 resident working one to one with hospitalist or GIM attending
- Allows resident to consolidate clinical knowledge and managerial skills
- Team consists of 2 interns, 2 residents, 1 Cardiology fellow, 1 Cardiology attending
- CCU unit + general cardiology floor
- NO overnight call, night float resident present
- Team consists of 2-3 interns, 2 residents, 1 PCCM fellow, 1 PCCM attending
- Closed ICU unit
- NO overnight call, night float rotation present
- Categorical residents rotate through all required
- Prelims can rotates as an elective
- Outpatient rotations in medical subspecialities including cardiology, pulmonary, endocrinology, gastroenterology, etc.
- Many electives available within Lahey consortium to be chosen by discussion with Chief Residents.
- Availability list with Ellen Cummings.
- Away electives can be arranged, including international electives (Bolivia)
- Elective rotation that is also designated as sick call. One day off a week.
- Categorical residents only
- Work together with a designated group of preceptor for duration of training every 5th week. Week also includes surgical subspecialty experiences., other experiences related to general medicine, quality improvement, half day per week that can be used for research, scholarship and QI and a simulation half day.
- 4 weeks for prelim interns and 2 weeks for categoricals (PGY2/PGY3) residents
- 6pm to 6am shift
- 2 intern night floats cross covers day teams inpatients
- 1 resident night floats admits overnight to housestaff teams
- Separate CCU/ICU night float to cover units
- Bedford VA Hospital and outpatients neurogeriatrics
- Inpatient and outpatient consult service, providing care in periop medicine
- Co-manage patients with surgical subspecialty services
- Outpatient neurology
- Work directly with various attendings who specialize in different fields (movement disorder, epilepsy, stroke, etc)