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 one more important principle 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). 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- 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 nightfloat, and talking
with the nurses who provided care for your patients overnight. Then there
are quick visits to each patient where a focused history of the events
overnight is obtained, and focused physical examination is performed. Patients
are re-assured that you’ll be back in less than an hour to spend
more time with them. The goal of pre-rounds is to collect all of
the information you need to make decisions for your patient- that will
be the expectation on work rounds.
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 work 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.
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 your soul with…. 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 clinic is 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. 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.
2:00 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.
3 to 5 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 nightfloat intern. The Tulane Residency uses
the internally-designed, Iatrodesign on-line sign-out system. This HIPPA-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 night-float interns, 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.
FRIDAYS
The daily schedule is modified a bit on Fridays to make room for Friday
School . Check out this educational innovation under curriculum.