The Department of Medicine at Steward® St. Elizabeth's Medical Center offers ACGME accredited training in two categories: Internal Medicine Categorical and Internal Medicine Preliminary.
The internship year is similar for both Categorical and Preliminary interns. Preliminary interns do not have a scheduled week outpatient continuity clinic. They may also use their elective and ambulatory time to pursue rotations relevant to the field they will enter in the PGY-2 year (e.g. anesthesia, dermatology, neurology, etc). During the last three years preliminary interns have continued on in residencies in anesthesia, dermatology, emergency medicine, neurology, ophthalmology, radiology and rehabilitation medicine.
The ward teams are set up geographically. There are two large medical teams covering the two medical floors and one team covering the cardiology floor. Each medical team consists of one PGY-3, three PGY-2s, four PGY-1s and one or two medical students from Tufts University School of Medicine. The cardiology team consists of one PGY-3 with one PGY-2s and two PGY-1s. Each team is assigned to a particular medical floor. The average number of patients carried by each of the three major teams is 20 to 25. Each of the major teams is further divided in sub-teams consisting of a resident and an intern to follow an assigned group of patients. One of the medical teams is involved in the care of inpatients on the general medicine service. The second team involved in the care of predominantly patients on hematology/oncology service and general medical patients on outlying floors. The cardiology service and cardiology step-down unit is followed by the cardiology team. Interns and residents on the wards are ensured at least one full day off every week (either Saturday or Sunday).
The geographical distribution of care involves a drip system of admission with each team admitting patients every day. One resident and one intern on each team are required to remain in the hospital till 7 p.m. every fourth day, considered the long call. There is no overnight call for interns or residents on the ward rotations. There is a night float system in place for the interns where one of the four interns on each team work six nights at a stretch in a month, from 7 p.m. to 7 a.m. Intern night floats provide cross coverage for patients on the medical and cardiology ward services. For all ward teams the number of admissions and transfers are strictly capped.
While on the wards house staff work closely with faculty from the hospital medicine service, cardiology division (telemetry floors and intermediate cardiac care unit) and a dedicated group of primary care physicians (most located on campus or nearby).
The RICU/CCU team is a combined team with two third-year residents, two second-year residents, four interns and fourth-year medical-students. Call is every fourth night with the second- or third-year residents leaving by 11 a.m. the next day. There is a night float system for the interns who work from 7 p.m. to 7 a.m. for three to four nights at a stretch. The CCU patients are rounded on by the cardiology team and RICU patients by the pulmonary and critical care team. At nights, cardiology and pulmonary fellows are assigned directly to the ICU and help coordinate care in their respective teams. We have recently established an electronic ICU (eICU) program where from 7 p.m. to 7 a.m., an ICU attending continuously monitors the status of all the patients during the night and can live chat with the residents, nurses, and patients to give suggestions for enhanced patient care. Our new 25-bed multidisciplinary ICU opened in December 2013.
This rotation consists of two PGY-2 residents who admit patients overnight and two PGY-1 interns who provide coverage for the day teams' patients. This rotation provides a unique opportunity for near absolute autonomy in admitting and managing patients overnight. If necessary, the interns can ask the overnight residents for support and there is always a hospitalist on-call who can assist with any questions or issues. The night float shift begins at 7 p.m. and ends at 7 a.m. The residents work for two weeks at a time with each Friday off, and the interns work for one week at a time during their wards block with Sunday off.
House officers rotate for a three-week block in the emergency room during their intern (PGY1) year and again as a senior resident (PGY3). The emergency room is staffed by one or two board-certified emergency physicians 24 hours a day. Each emergency medicine rotation consists of approximately eighteen 10-hour shifts over the course of three weeks. During the emergency medicine rotation, medical house officers play an active role in the triage and management of a diverse number of patients with varying levels of acuity so the resident is exposed to a large number of undifferentiated medical problems.
PGY-3 residents spend three weeks rotating on the neurology service. Mornings are spent seeing patients on the inpatient neurology consultation service while afternoons are devoted to work on the neurology consultation service. During this period they are encouraged to attend all neurology noon-time conferences and morning reports.
Through our new 3+1 block system, one week of every four weeks will be spent in an ambulatory setting without any conflict of inpatient responsibilities.
During the clinic week, house officers spend four half days in their continuity clinic conducted in a general medicine setting. Each resident is assigned to one general internist (preceptor) and works closely with that attending physician for three years. The focus is on managing a panel of patients with a broad array of illnesses over time and develop long term relationship with patients. The ambulatory program utilizes the Yale University Primary Care Curriculum (a comprehensive set of cases) to supplement the outpatient experience. Most continuity clinics are on campus or within easy walking distance. For the two sites that require a commute, the program provides reimbursement for a taxi to those venues.
During the same week, house officers spend an additional five half days in various specialty and subspecialty ambulatory areas. Clinical experiences are available in allergy, cardiology, dermatology, endocrinology, gastroenterology, hematology/oncology, infectious disease, nephrology, non-operative orthopedics and sports medicine, non-operative otorhinolaryngology, pain management, occupational medicine, gynecology, ophthalmology, pulmonary, and rheumatology.
For elective rotations, residents spend time on medicine subspecialty consultation services. When rotating on the cardiology, endocrinology, gastroenterology, hematology/oncology, infectious diseases, nephrology and pulmonary services, interns and residents work closely with sub-specialty attendings, fellows and fourth-year medical students. Additional elective rotations are available in anesthesia, geriatrics, pathology and radiology. Residents with a well-conceived plan can perform other electives as approved by the program director and may also do one elective off-site with approval of the program. There is also an opportunity for participating in an elective to Uganda (click this link to view information about the program - www.omnimed.org). Please note that some off-site electives may be limited depending on visa status. Residents on the elective rotation get weekends and holidays off. PGY-2 and PGY-3 residents with a well-conceived research plan and a designated faculty mentor can use one elective block to pursue a research project instead of their away elective.