Tulane Internal Medicine Residency, Program Information


Tulane: Day-to-Day

The cardinal feature of any great physician is that he has the ability to make decisions with confidence, and every decision that he makes is done with prior thought as to the consequences (both good and bad) before the decision is made. And in no specialty is this skill as important as it is in internal medicine. Internal Medicine is not a game of checkers, where you merely respond to your opponent’s move. It is a game of chess… where every move must be made by thinking four, five, six moves down the game. Unlike the surgeon who can bovie his mistakes, the internist cannot take back the beta-blocker she injects into the IV.

The ability to quickly make decisions with confidence is what will define your excellence- that is for sure. And mastering that ability comes from only one road: continual practice in making decisions. Put another way: Do you remember how useless the “shadowing” of first year of medical school was? Merely following along, having orders barked at you without explanation left you feeling superfluous. Why continue that into residency? Tulane is a program built on autonomy, with residents routinely and consistently put into the position of making decisions. After two years of doing this, our third-year residents operate like faculty. And in any great residency program, this should be goal. Why follow along when you can be in the game?

The structure of the Tulane day has been built on this principle, but there’s two other important principles that guides the day. The Tulane system is built to avoid fragmentation…. that is, the waste in time and energy that comes with starting one task (i.e., seeing patients on rounds), and then having to leave that task to complete another (i.e., stopping rounds to go to morning report, noon conference or clinic). The Tulane day is also built to honor this essential principle… “Practice doesn’t make perfect…. Perfect practice makes perfect.” If you do not make the decisions, you’ll never be good at making the decisions. But even if you do make the decisions, and you’re not around to see/learn from the results of your actions, you can never become great… you’ll just become really good at doing the wrong thing over and over again.

The Tulane system is built to eliminate fragmentation, put you in the driver’s seat of making decisions, and to ensure that you are around after making those decisions to learn from your choices. This is how greatness is made… kind of sad that most programs leave this process to chance. Check out “The 4+1 System” to see how the Tulane Team’s newest innovation has augmented education, continuity, and efficiency of patient care.


YOUR DAY: NON-CALL & NON-POST-CALL DAYS

7:00 - 8:00 AM: Pre-rounds
The day starts with pre-rounds… which includes everything you do before you joining your team for work rounds. The purpose of pre-rounds is to gather the necessary information to make management decisions about your patients. It begins by taking sign-out from the Knightrider, and talking with the nurses who provided care for your patients overnight. Then there are the visits to each patient where a focused history of the events overnight is obtained, and focused physical examination is performed. But unlike most training programs, you will not be concerned about getting bogged down with the talkative patient. Why? Because your patients will know… this system is built such that there are multiple opportunities for you to return and talk with your patient. Gone will be the patient’s fear and anxiety (which drives the talkative patient) that, “this will be the only time that I’ll see my doctor… I better get everything out while I can?” Patients will be re-assured that you’ll be back multiple times during the day to spend more time with them, and that sets you up for not only efficient pre-rounds, but also for developing meaningful relationships with your patients. Remember… systems drive function… and this system is perfectly designed to put good people (you) in better positions!


8:00 - 10:00 AM: Resident Rounds
Resident rounds begin at 8 AM each day and include the entire team, except the attending physician, and are directed by the senior resident. All management decisions are made during resident rounds by the residents, and the resident leading the team will begin the discussion of each patient by asking you what you want to do for the patient. While it may seem intimidating at first, this is the first step towards becoming the master clinician. Soon your whole way of thinking will change to that of being in control… and responsible. This is the beginning of greatness. The expectation is that the team will have an assessment and plan on each patient prior to attending rounds. This will allow the attending to check your work, provide advice or modifications, and to spend most of his or her time teaching you about your patients. The nice part of Resident Rounds at Tulane is that there is very little in the way of time pressures to get things done.  In most residency programs, the morning is devoted to simply writing progress notes…. Why? Because someone on the team has to get to clinic in the afternoon. The Tulane “4+1” system enables moving the continuity clinics from the first 4 weeks of a block to the consolidated clinic week (week 5 of the block). This enables the team to stay focused on their inpatients (or the patients on their elective rotations), avoiding the fragmentation that wastes time and bleeds efficiency. In the Tulane system, there will be time in the afternoon to complete progress notes: the morning is devoted to actively engaging in the medical care of your patients (making decisions, writing orders, spending time with your patients, etc.)… not merely passively writing about it. The expectation for resident rounds is very clear: “Write Orders.” If you want to discharge a patient, then you write the order for the discharge during resident rounds. If you want to order a consult or a test, or change management, then you write that order during resident rounds to make it happen. If it is the wrong decision, then we’ll learn from it, and make the correction during attending rounds. But be at ease, remember… there is no yelling in the Tulane culture. If you make a mistake, so be it… actively engaging in making decisions is how you get to the point (a year or two down the line) where the mistakes come few and far between.

 

10:00 AM: Attending Rounds
Attending rounds begin at 10:00 AM at each hospital. The whole team walk-rounds to see each patient in person. Attendings do not write full notes while on rounds, but rather spend the time seeing patients with the team, and reviewing the decisions the team made during work-rounds. Teaching occurs at the bedside, just the way medicine was meant to be practiced.

 

12:00 Noon: No Noon Conference!
Wow, are you going to love this. There are no noon conferences at Tulane. I know… how can you live without a power-point lecture in the middle of the day, with pagers going off all around you… the crummy Chinese food that the Big-Pharma rep bought with your soul …. and the incessant snoring of your colleagues…. all the while wishing you were back on the wards because there is so much to do? For all of these reasons, we dispensed with noon conference. During the noon hour, you can finish attending rounds if your attending is in a teaching zone…. Or you can have lunch with your team… or you can finish some patient management issues (which will happen fast, since every other resident in the hospital is asleep at their noon conferences). Don’t worry about the curriculum, we’ll take care of that at FRIDAY SCHOOL…. Check it out! You are going to love this.

 

1:00 PM: Afternoon Teaching
While you are on the ward, elective or ICU blocks, YOU WILL NOT HAVE CLINIC! Using the “4+1” system, there is no clinic while you are on the wards, electives or the ICU. All of the clinics are rolled together in the “+1” week that ends each 5 week block. (Check out the “4+1” system to see how this actually improves continuity of care). The benefit on the wards is that neither you nor your resident will be in clinic in the afternoons, enabling resident-to-intern teaching each afternoon… a benefit that is almost non-existent in other residency programs where someone is lost to continuity clinic each day.

This is also the opportunity to advance patient care, do procedures, or teach your medical students. This will be a great opportunity to practice the “coaching skills” that Dr. Wiese will teach you during your CAS sessions. Remember, since the ward services are supervised by teaching hospitalists (who have not competing time commitments) you’ll have someone there throughout the day to help you with procedures, answer questions, or teach you.

Importantly, having the afternoon to complete patient care tasks and to engage in the fulfillment that comes with teaching (or being taught) greatly reduces the “intensity” of the day… a concept that has been missed by most residency programs as duty hours regulations have been put into effect. The upshot is that with lower intensity, a day on the wards at Tulane is going to feel a whole lot better and much more fulfilling than that at the standard training program.

 

3:00 PM: Afternoon Delight!
Based upon “The 4+1” system, Tulane has the luxury of moving the “morning report” to the afternoon… replacing “morning report” with “Afternoon Delight!” And why settle for the boring old “morning report” when you could have “afternoon delight?” Who doesn’t love afternoon delight?  Afternoon delight is a graduate–level discussion conference, focused upon honing the clinical reasoning abilities of the residents. It is not a lecture or a perfunctory report of a case admitted to the hospital the previous night. It is definitely not a census-like, run-down of each patient admitted to the hospital the previous night (useless). Morning report is an opportunity for one of the residents to present a fresh case (the variety and volume of patients admitted to the Tulane Hospitals permits this), and then to have the other residents actively exercise their clinical reasoning methods in diagnosing and designing appropriate management for the patient. Once again, medicine is learned by active participation, not passive listening. The diversity of residents in the Tulane Residency makes this a unique conference. By now you know that there is more than one way to approach the same symptom or disease. Having residents who have trained at over thirty-five different medical schools permits a discussion where multiple methods of approaching the case are shared. There is no dogma in Tulane’s Residency, because dogma is the death of free thought. And free thought is what enables the art of medicine (and what makes it fun). So the focus is on clinical reasoning, but picking up additional medical knowledge is not excluded. The following day, the chief resident finds and summarizes an article highlighting the salient features of the case discussion. Afternoon Delight then, is a nice marriage between honest problem-solving (and the fun of solving a non-canned, prefab case) and reviewing the evidence-based guidelines for treating the disease.

 

4:00 - 5:00 PM: Sign-out
Hey, when you are done, you are done. When patient management is completed, and you have done (or received) some teaching…. It’s time to leave. No one will think less of you for leaving earlier in the afternoon… time to enjoy New Orleans! Before you leave though, you’ll want to sign-out with the Knightrider.

The Tulane Residency uses the internally-designed, Phaedrus on-line sign-out system. This HIPAA-compliant, on-line system allows each firm to enter patients admitted to their service on the day of their call. As patients are discharged from the service, patients are removed from the system. Here’s the cool part: The information from all patients admitted by a firm member are downloaded to a database. This allows the resident, and the program director, to have a patient log of each patient seen by each resident (thereby guiding reading strategies to fill in the gaps of diseases not seen by the resident). The system is accessible by all Knightriders, allowing for strong continuity of care. It is also accessible by social workers and attending physicians, allowing at-home access to the firms activity and volume. And when you have a day off per week (as you will), it will be nice to log on to the internet from home and see how many of your patients have gone home prior to coming back into work the following day. The final benefit is that there is no more re-creating sign-out systems.

An important element of learning medicine is mastering the “transition-of-care.” See it as the metaphorical equivalent of a track relay team passing the baton…. You can run the best race of your life, but if you drop the baton, it is all for not. As part of the CAS curriculum, you’ll learn the cutting edge techniques of closed-loop communication, transitions-of-care essentials, and contingency planning. And as the signing-out intern, you’ll benefit from having upper-level residents receiving your sign-out. We believe that cross-coverage is so essential for patient safety, that we are unwilling to assign that task to a new intern just learning the ropes. All Knightrider duties are staffed by upper-level residents, which enable you to receive feedback in the moment from supervising residents as to the quality of your sign-out, and areas where you can improve.


MONDAYS & FRIDAYS
The daily schedule is modified a bit on Fridays to make room for Friday School . Check out this educational innovation under curriculum.