Tulane Internal Medicine Residency, Program Information

The Friday School Curriculum

How We Arrived at the Friday School Concept

Tulane Internal Medicine Friday SchoolAs you look at different residency programs, ask yourself this, “Just how committed is each program to education?” This is the question I asked when I took over the residency program at Tulane, and here were some of my thoughts.

Tulane was already in compliance when the RRC instituted new duty-hours regulations years ago. But even so, I recognized that there were forces intrinsic to the standard residency system that limited education. The work-hours regulations didn’t cause it… it only heightened the tension. Consider the following in the standard residency program system: Noon conference occurs at noon. Ok, seems reasonable; everyone should be able to attend. However, in the ordinary program, the residents’ morning is devoted to morning report, work rounds, and attending rounds.

During these rounds, patient-care plans are made and refined. But here’s the problem: When does all of the work that was planned during morning rounds get done? The answer is that something has to give: either residents plow into the noon hour to get work done (so that they can get to clinic or get home at a reasonable hour to be under the work hours regulations), or residents attend noon conference and defer patient-related tasks until the afternoon. In the first scenario, ward service trumps education. In the second scenario, the resident has to sacrifice patient care for education. The bottom line is that no resident should have to choose between the two, and the current system makes the resident make that unfair choice.

Let’s say residents make it to noon conference. My experience was that residents were frequently late to noon conference, and this was no fault of their own. By the time the resident left the wards to get to noon conference, get lunch, and then get situated in the conference room, he or she had already lost 20 minutes of the conference. Of course the resident could leave attending rounds early to make it to noon conference on time, but then he or she had sacrificed 20 minutes of attending rounds. This, too, seemed to be an unfair choice to force upon the resident. And let’s say that the resident made it to noon conference on time. Still, the operations of the wards continued, and the nurses continued to page the resident during the conference. The flow of the conference was constantly disrupted by residents answering pages. Again, no fault of the resident; he or she was again placed in the unfair position of balancing patient care with education. And then, of course, there is clinic. Residents would have to leave noon conference early to get to clinic, and this further compromised resident education.

And finally, there was the educational format of a typical noon-conference schedule: didactic lectures with Powerpoint. Pain. The educational experts will tell you- at best, there is 20% retention of knowledge from a didactic lecture. And lectures rarely replicate the type of knowledge a resident needs. For example, when was the last time a patient presented with a chief complaint of “I have lupus nephritis. Please help me.” To the contrary, patients present with a problem (“There is swelling in my legs and I have a rash”) and the physician must work forward from the complaint to make the diagnosis and design the management; not backwards from the diagnosis to identify the symptoms.

So the bottom line is this: the old system of listening to didactics at noon puts the resident in an unfair position of compromise... some thing has to give. Or does it?

I thought this position of compromise was unfair, and to solve the problem, we went outside of the box to develop a new system of resident education. This system is FRIDAY SCHOOL, and here is how it works.

How Friday (and Monday) School Works:

Tulane Internal Medicine Friday School There is no longer a noon conference schedule. Monday to Friday, residents can devote the noon hour to whatever seems most appropriate: extending attending rounds into the noon hour for more attending rounds education, expediting patient care by acting on the plans set forth in attending and work rounds, or spending time teaching their ward team over lunch.

Fridays afternoons are protected time for the Interns, and Monday afternoons are protected time for the Residents. On each day the schedule works something like this...

The mornings work like any other day.... pre-rounds at 7:30 AM, followed by work rounds from 8 AM to 10 AM. Attendings rounds go from 10 AM to Noon, and the team has the noon hour to do what they please (continue rounds if the attending is in a "zone," get patient care completed, have lunch together, teach, etc).

At 1 PM on Mondays, the Attending takes the Resident's pager, and the Attending and Interns work together to provide patient care in the afternoon. While the resident is in Monday School, the intern has one-to-one time with the attending to receive individual feedback and coaching.

At 1 PM on Fridays, the Resident takes the Interns' pagers, and the Attending and Resident work together to provide patient care in the afternoon. While the interns are in Friday School, the resident has one-to-one time with the attending to receive individual feedback and coaching.


Resident School

From 1 PM to 5 PM, the residents convene for MONDAY SCHOOL. The Monday School is blocked into six segments:

1. The first 15 minutes is devoted to a high-yield, essential topic review of the previous week’s Monday School. See this as a quick review of the topic, with a focus on the “must-know” elements for the Boards. Coach Davies provides this fast-paced, high-yield review.

2.  At 1:15 PM, the competition begins! Each firm receives the mystery case as posted on the wiki. Each firm has its own chief resident that will facilitate the discussion (without giving the answer). Also on the wiki will be Tulane’s self-designed “lab machine,” in which the resident team enters the laboratory studies they need to solve the case. The lab machine provides the results for only those tests that the firm has ordered, and also provides an “expense report.”…. giving the firm some feedback as to their high-value cost-conscious care. (That’s right… even though its all the rage right now… Tulane has been teaching high-value cost-conscious care since 2004!) After the team-based discussion, and doing internet/pubmed research, the firm team discusses their findings and then reaches their final diagnosis. The firm that gets the correct answer at the lowest cost wins the competition.

3. At 2:15 PM, the residents have a chance to compare and contrast their clinical reasoning they used in solving the case by hearing from Coach Wiese, as he describes how he would have approached/worked through the clinical case. This allows the residents to hone their “intellectual knife,” so to speak…fulfilling Tulane’s commitment to training residents “how to think” as much as “what to think.” And along the way, you just might find those “unpublished” pearls and practical advice that only Coach Wiese can provide.  

4. From 2:45 to 3:00 PM, the resident teams identify five to ten “topics” that were “touched upon” as the firm worked through the mystery case. Perhaps the diagnoses that were considered along the way…. Perhaps the areas where there were knowledge gaps or points of confusion…. Either way, these become the topics that will be researched and taught by the residents, to the residents, the following week.

5. From 3:00 to 4:00 PM begins Active Learning and Teaching. It is one thing to learn something, it’s quite another to remember it. And if you can’t remember it down the road, well… you can’t use it. And what good was that? Achieving retention hinges on active learning, and during this time, the residents teach each other the topic they were assigned at last weeks Monday School (see above). In this way, one Monday School links to the next, consolidating the lessons such that retention is maximized. Plus… this is one more opportunity to hone your teaching skills, and practice the teaching techniques you acquired as part of the CAS curriculum with Dr. Wiese.

6. From 4:00 to 5 PM is time with an expert faculty. Instead of re-iterating all of the lessons learned in the resident peer teaching sessions, the faculty is freed up to take the talk to the highest level of detail and complexity on the disease, advancing resident knowledge to the forefront in the area.

The great part of Monday School is that teaches so much more than just the topic being addressed. It is the real-world approach to medical care… Monday school mimics what the residents will do every day in their practice. Unlike power-point lectures that start with a diagnosis (i.e, the lecture on lupus), Monday School cases begin with a patient problem (e.g., joint pain and fever) and work forward to the disease and its management (e.g., Lupus). The model emphasizes that clinical reasoning is important for effectively moving from the long list (i.e., all possible causes) to the short list (i.e., the five or so things that fit the case); great clinical reasoning is rewarded in the competition. Further, the model teaches that cost containment is all of our responsibility (i.e., negative points for spending too much on the labs). It models the behavior of the great physician: start with the differential diagnosis, then use all available resources (i.e., the internet, textbooks, colleagues) to learn more about the presentation and management of each disease on the differential.

Monday School also teaches teamwork: firms work together as teams as active learners instead of the individual, passive learner-model of powerpoint lectures. And it’s fun… the fun part of internal medicine was and is the detective-like deductive reasoning that went into solving mystery cases. Of course, the residents learn the board objectives for a topic (the intro session to each Monday School), but they also learn the most up-to-date information on each disease being considered. Because this is an exercise in comparing why one diagnosis fits better than others, residents also learn to compare and contrast diagnoses…. And in medicine, it is as important to know why it is not lupus as it is to know why it is sarcoid. Most importantly, each objective is addressed in a format that makes sense for not only the boards, but also for the wards. Of course, the added benefit is that each resident learns practice-based learning skills (i.e., how to use the internet, books, etc. to find the answers to questions derived as part of solving a mystery patient case) that will last a lifetime.

Finally, Monday School develops a virtue essential for greatness in medicine: we are our brother’s keeper… we are our sister’s keeper…. And by teaching and being taught by your peers, you advance the greatness of those around you.

Friday School

At 1 PM on Fridays, the Resident takes the Interns' pagers, and the Attending and Resident work together to provide patient care in the afternoon. 

From 1:30 PM to 4:30 PM, the interns have protected time… No pagers, no responsibilities. just protected time to participate in their Friday School Seminar. Intern Friday School works just like the Resident Monday School, except that the topics are focused at the level of the intern, both in complexity and in emphasis.

On-call interns return to the wards after Friday School. All other interns are off for the day, and pick up their pagers the following morning from their residents.

The Friday School Room

The important elements in any residency program, as with life, is not in the materialistic bling…. It’s in the virtues, principles and mission statement of the team. Beautiful hospital lobbies, for example, cannot substitute for what happens in the patient rooms. But there is something to be said for showing your commitment to residents’ needs, comfort and education.

When you see the Friday School room, you’ll palpably feel the commitment of Tulane to its resident team. The wall-to-wall whiteboards permit teaching at any possible moment… the leather chairs enable the comfort necessary for our three-hour Friday School sessions….

The coffee/sodas/food remove fatigue/thirst/hunger as distractions to the learning environment… the computers and textbooks enable the discovery of new knowledge that is the Tulane philosophy… and of course the one-of-a-kind, hand-carved Friday School tables (designed and created by Wiese) are representative of the unique character of Tulane’s Team, and Wiese’s commitment to this team. If you are interested, you can check out the Creation of the Friday School Tables, with a philosophical commentary by Wiese on how they represent for what Tulane stands.

The Uniqueness of Tulane’s Friday School

As you look about the country, you will find more and more programs gravitating to the “academic half day” (aka, “Friday School”) curricular format…. As they say, “imitation is the sincerest form of flattery.”  Tulane is proud to be the first to fully implement this curricular innovation, and you’ll prosper from our ten-year experience in running this type of interactive, team-based curriculum. Beware of imitations… changing a curricular platform is not as easy as “plug and play”… it takes experience. At Tulane, you’ll benefit from our years of experience in tweaking this innovation to make it as fully powerful as it is!