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Inpatient rotations take place in a wide variety of hospitals:
The University Hospital (UH)
The Ross Heart Hospital (RHH)
The Arthur James Comprehensive CancerCenter (JCC)
The Ohio State University East Hospital (OSUE)
UH, RHH and AJCC are all located on the campus of the Ohio State University; the OSUE hospital is located approximately 6 miles away in downtown Columbus. These four hospitals provide a terrific spectrum of patient acuity and disease states. At the end of three years, our residents are proficient in caring for inpatients and ICU patients in both community and referral settings.
Ohio State University is one of the few residency programs to offer an inpatient subspecialty ward system. During their three years of residency (or four for Med Peds!), residents rotate through a variety of general internal medicine and subspecialty inpatient services (see table below). Each rotation is staffed by a specialist in that field—only cardiologists attend on the cardiology service, only general internists attend on the internal medicine services, etc. Thus, residents learn to care for patients from experts in their field. Our residents are passionate about this service structure. They find that it is easier to learn when your clinical and educational experiences are concentrated in a given field for a month at a time.
Residents are the team leaders and have a significant amount of autonomy in the daily evaluation and management of patients. We strongly believe in resident led work rounds where the initial patient assessment and management plan is developed then presented to the attending for advice and approval during attending rounds. The attending physicians participate with residents, interns and medical students on daily teaching rounds and have been repeatedly recognized for their support and dedication.
MICU
Our MICU rotation is one of the most popular rotations for all of our residents, even those not planning a care in critical care medicine. Our 25 bed ICU is manned with four resident and intern teams. In this busy environment, the residents care for the sickest of the sick under the guidance of fellow and faculty physicians who consistently win teaching awards. All residents are coached in proper procedural technique and get many opportunities to insert venous and arterial lines, manage airways and insert endotracheal tubes. By the end of their internship, all residents have been judged competent to independently place central lines in at least one location and insert radial and femoral arterial lines.
Team Structure
During the 2009-2010 academic year, our service structure is going through some changes. Historically, most of our teams consisted of one faculty member, one intern and one supervisory resident, along with several students. Though a few teams will remain with this structure, we are introducing new service models for most of our services. These changes have occured for a variety of reasons, but we believe will give the residents a wider range of practice structures to learn in and develop their decision making and leadership skills. No matter what the resident/intern structure is, all teams will include an attending physician and several third and fourth year medical students.
- One resident with One Intern covering up to 10 patients, which has proven quite managable given our team design. The one resident and one intern team allows close relationships to develop between our residents. Every patient on the team belongs to the entire team. Residents and interns share note writing and care planning responsibilities. Both interns and residents admit and staff patients with the faculty attending and thus get the opportunity to get direct teaching and feedback about their clinical diagnostic skills.
- Two Residents covering up to 16 patients. In this structure the residents will have an opportunity to mature their decision making skills and efficiency without the responsibility of overseeing an intern. The residents will still have teaching responsibilities with the medical students on the service. In this model, the residents will work closely with the attending physicians and be able to include practice management education specific to the advanced level the residents are practicing.
- One resident and Two Interns covering up to 16 patients. In this model, the residents take on a more supervisory role while allowing the interns to develop relationships with their own patients. This structure allows interns to develop clinical decision making and a sense of autonomy early on. The resident and attending provide a strong support network for the interns as they develop these skills.
Call Structure
Our call structure is designed to provide outstanding patient care and give residents the rest they need to stay sharp and focused on their important work and to continue to read about their patients. For all services other than MICU and Cardiology, residents and interns sign out their patients to a night team at 6 pm, taking overnight call only on weekends (approximately 2-3 times/month). Because the presence of higher acuity patients makes signing out to a night team more challenging, the MICU residents and interns and Cardiology interns take q 4 night overnight call and leave the next day before 1 pm to insure compliance with the ACGME work hour restrictions. This hybrid call model allows our residents to learn both how to manage a service overnight as well as how to appropriately transition care to another colleague for coverage purposes.
Current Innovations in Inpatient Care and Education
Sign Out Coaching:
Our residents believe that appropriate transitions of care are going to be the cornerstone of effective medicine in the future. To that end, the chief residents lead seminars on and also observe real time sign outs to insure that the appropriate information (not too much and not too little!) is being transmitted between day and night teams.
Mixed Inpatient and Outpatient Rotations:
The division of Hematology and Oncology identified that a month of inpatient oncology, with its focus on oncology complications and end of life care was a poor representation of the domain of Hematology/Oncology. To improve the resident’s exposure to the typical practice of an Oncologist, the division implemented a split rotation strategy. Each month, 2 interns are assigned to oncology. They each do 2 weeks of inpatient oncology and 2 weeks of outpatient oncology. This allows them to be involved with the entire spectrum of cancer patients from those with newly diagnosed malignancies, patients living successfully with cancer, people who have been cured of cancer to those whose cancer is advancing, all during the same month.
Educational Innovations Project and Inpatient and Critical Care Medicine:
Under the supervision of Dr. David Wininger, resident and faculty task forces are working to construct and implement strategies to allow residents to:
a. Explicitly assess their skills in diagnostic test interpretation and decide on future educational activities in skills for which they desire a higher level of competency. Tools to help residents move beyond basic competency in EKG reading and and other diagnostic tests are being considered for pilot.
b. Plan and study different strategies for the appropriate transition of patients from:
1. Day to night
2. Inpatient to outpatient
3. Month to month
Mechanisms to improve communication between doctors and nurses that can enhance patient care and patient satisfaction are currently being piloted.
Dr. Maria Lucarelli heads our educational innovations project planning for the critical care environments. In these realms, resident and faculty teams are planning for more sophisticated procedural training using the simulation center and specific training on leading and participating in high stakes teams. Our goal is to train all our residents to be expert (not just competent) in the procedures they need for their career. Selected residents will be able to pursue training to become certified procedural trainers.
Please also visit our web page on the Educational Innovations Project. |
