Inpatient Training

Inpatient Team Structure

C3A unique feature of our program is a 1:1 pairing of resident to intern on most of our inpatient services (with one exception) throughout the three years. This affords interns the support needed for caring for very ill patients, while providing upper level residents the opportunity for more one-on-one teaching, including bedside, evidence-based and on-the-fly teaching. Throughout the year the intern will gradually be expected to function more autonomously, while still receiving valuable teaching and guidance provided by an upper level resident.

Each service has a slightly different structure in terms of the number of teams, attendings, and the presence of fellows, as outlined below, with patient caps closely monitored by the chief residents and program leadership. We pride ourselves on being a resident-run program that highly values the input of our trainees. For this reason, the different services are constantly being reassessed and, over time, undergo design changes with resident and chief resident input to optimize the quality of the training experience.

General Medicine (3rd Floor)

The General Medicine service is the core of any internal medicine experience. We have six general medicine teaching services staffed by residents and interns and three inpatient hospitalist services to maintain reasonable censuses for the residents. The goal is for residents to have enough patients to ensure a robust training experience, but not too many to sacrifice learning for the sake of service. Residents and interns work closely together to care for patients with a myriad of medical issues and comorbidities, with a diverse patient population from a catchment area that extends to the furthest corners of the state and some from surrounding states. The medical issues managed include common ailments such as pneumonia, COPD, UTIs, osteomyelitis, encephalopathy, to the rare diagnoses offered by such a diverse patient population and wide treatment area, transferred in from many of our surrounding community hospitals throughout Virginia.

Six geographic day teams consisting of:

  • One upper level resident
  • One intern
  • Five Attending physicians (four have one resident:intern pair per attending; one has two resident:intern pairs)

Three night float teams consisting of:

  • One upper level resident per team
  • One intern per team
  • In-house night hospitalist (supervising all three teams)

Q4 day call cycle

Non-Call

  • Non-call teams accept “holdovers” at 7:00 am, i.e., patients admitted overnight by the night teams
  • Non-call teams accept patients transferring out of the Medical ICU until noon
  • Non-call teams sign their patients out to the long-call team at 5:00 pm, then go home

Day Call (Long Call Day Q4 days, 7:00 am – 8:00 pm)

  • Long call team admits new patients throughout the day from 7:00 am to 7:00 pm
  • No admissions in the last hour, to protect residents from having to stay long beyond end of shift. Any stable admissions in this hour wait for the night team
  • Receive sign-out at 5:00 pm from the non-call teams to cross-cover their patients for the rest of the call day
  • On-call team remains in-house for admissions and cross-cover until 8:00 pm (when NF team arrives) then sign-out their patients to the night team

Night Float

  • Team admits new patients from 8:00 pm to 7:00 am
  • Team cross-covers unit based general medicine service overnight
  • Residents present hold-overs to the day teams at 7:00 am
  • NF team leaves by 8:00-08:30 am every day
  • Interns works 6 nights in a row for 3 three weeks during night float block by covering and admitting to the same service
  • Resident works 6 nights in a row for 3 weeks during night float block. Each week they cover a different set of general medicine teams.

Digestive Health Focused General Medicine (5th Floor)

This rotation consists of general medicine teams operating on our Digestive Health floor. The teams are staffed with General Medicine attendings but have predominantly digestive health patients (patients with liver disease, gastrointestinal bleeding, inflammatory bowel disease, pancreatitis, etc). These teams work closely with our gastrointestinal consultants with daily discussion of patients with consulting teams and twice weekly dedicated teaching sessions by the gastrointestinal fellows. Patients are focused on the 5th floor for the benefit of receiving care from nurses with experience treating patients with digestive health issues.

This is our only service with a 2:1 intern:resident ratio, designed to give our upper level residents experience carrying a larger patient census (typically 14 patients, up to a maximum of 16, split between two interns). The goal of this is to allow upper levels the opportunity to develop their skills managing a larger team, by taking a small step back from the details of executing care, and focusing more on the bigger clinical picture, teaching the larger team, and allowing the interns even more autonomy to implement the daily care plan.

This service was a new change this last year, and we are constantly soliciting feedback from residents on way to optimize the quality of the experience.

Two day teams consisting of:

  • One upper level resident
  • Two interns
  • General Medicine attending physician
  • Active teaching role from GI consult fellows and attendings

Day Call

  • Each resident team has a short-call day and a long-call day in a 4 day cycle
  • Long call team admits new patients from 7:00 am to 7:00 pm
  • Short-call team admits new patients from 7:00 am to 4:00 pm
  • A separate swing resident admits new patients from 4:00 pm to 8:00 pm on short-call days
  • Long call team remains in-house for admissions and cross-cover until 8:00 pm (when NF team arrives)

Hematology-Oncology Service

Our inpatient Hematology-Oncology service gives residents the opportunity to be involved in the management of patients with various forms of malignancy. Residents carry oncology patients with solid tumors and staff with an oncology attending. They also carry malignant hematology patients including leukemia, lymphoma, and stem-cell patients, staffed with a hematologist.

Four day teams consisting of:

  • One upper level resident
  • One intern
  • Hematology Attending and Fellow (supervising malignant hematology and bone marrow transplant patients)
  • Oncology Attending (supervising solid tumor patients)

One night float team consisting of:

  • One intern
  • A moonlighter, typically an Internal Medicine resident or subspecialty fellow

Q4 day call cycle

Non-Call

  • Non-call teams receive “holdovers” at 7:00 am, i.e., patients admitted overnight by the night team

Day Call

  • On call teams admits new patients from 7:00 am to 7:00 pm
  • Non-call teams sign-out to the on-call team at 5:00 pm
  • On-call team remains in-house for admissions & cross-cover until 8:00 pm (when NF team arrives)

Night Float

  • One intern and supervising moonlighter
  • Team admits new patients from 7:00 pm to 7:00 am
  • Team cross-covers on each patient overnight
  • Intern presents holdovers to non-call teams at 7:00 am
  • NF team leaves by 8:00 am
  • Interns works 6 nights in a row for 3 three weeks during night float block by covering and admitting to the same service

Acute Cardiology Service

Our inpatient Acute Cardiology service gives residents experience in the management of a multitude of cardiac issues including acute coronary syndrome, arrhythmias including atrial fibrillation/flutter, heart block, and decompensated heart failure. Residents work with both a general cardiology attending and an advanced heart failure attending to maximize their exposure to expert clinical management, enhanced by daily teaching sessions provided by the attending and fellow on service.

Four day teams consisting of:

  • One upper level resident
  • One intern
  • General Cardiology Attending and Fellow (supervising general cardiology patients)
  • Heart Failure Attending (supervising advanced heart failure patients)

Q4 day call cycle – resident overnight

Day Call

  • Non-call teams receive “holdover” patients at 7:00 am (patients admitted overnight by the CCU team)
  • Non-call teams sign-out to the on-call team at 5:00 pm
  • Team admits from 7:00 am to 9:00 pm
  • Intern leaves by 10:00 pm
  • On-call resident remains in-house for cross-cover on acute cardiology service
  • Overnight admissions provided by CCU resident and intern
  • CCU intern and resident present holdovers to the day team at 7:00 am
  • Post-call intern and resident round following holdovers with post-call resident leaving by 10:00 am and post-call intern signs out to on call team at 5:00 pm

Coronary Care Unit

Our Coronary Care Unit cares for critically ill patients admitted for cardiac issues. With a general cardiology attending and a heart failure attending, and the guidance of a fellow (in-house overnight), residents will care for patients with cardiogenic shock, patients with mechanical cardiac support, STEMIs, and fatal ventricular arrhythmias, to name a few.

Two day teams consisting of:

  • One upper level resident
  • One intern
  • One CCU Fellow
  • General Cardiology Attending (supervising general CCU patients)
  • Heart Failure Attending (supervising advanced heart failure patients)

One night float team consisting of:

  • One upper level resident
  • One intern

Q2 day call cycle

Day Call (Sunday-Friday)

  • Team admits new patients from 7:00 am to 9:00 pm
  • Non-call team sign-out to the on-call team as soon as work completed (approximately 2:00 pm)
  • On-call team remains in-house for admissions and cross-cover until 9:00 pm (when NF team arrives)

Night Float (Sunday-Friday)

  • Night float resident/intern team admit patients to both ACS floor and CCU, 9:00 pm to 7:00 am
  • Night float team presents holdovers to Acute Cardiology and CCU day teams starting at 7:00 am
  • Night float team leaves by 10:00 am

Medical Intensive Care Unit

The Medical ICU is one of our residents’ most challenging and rewarding services. Working with a critical care attending and fellow, the teams admit some of the most complex and critically ill patients in the hospital. Patients have a variety of medical problems including multimodal shock, multiple organ failure and/or ARDS. Residents learn to triage and stabilize critically ill patients with a fine balance of autonomy to make management decisions and safety in support from their fellow and ICU attending.

Four day teams consisting of:

  • One upper level resident
  • One intern
  • Two Attending physicians and two Fellows (each supervising two resident teams)

One night float team consisting of:

  • One upper level resident
  • One intern

Q4 day call cycle (overnight for resident but not day call intern)

Day Call

  • Team admits new patients from 7:00 am to 8:00 pm
  • Non-call team sign-out to the on-call team at 5:00 pm
  • On-call resident remains in-house to cross-cover overnight
  • On-call intern leaves by 10:00 pm
  • All teams round at 8:00 am the next day and post-call resident leaves by 10:00 am
  • Post call intern signs out to on call team at 5:00 pm

Night Float (Continuous)

  • Night float intern/resident team admit new patients 8:00 pm to 7:00 am
  • Night float intern is responsible for cross cover with the help of the overnight call resident
  • Night float team present overnight admissions on morning rounds
  • Night float team leave by 10:00 am
  • Each team does 5 days of night float at a time

Typical Weekly Schedule

Monday

Tuesday

Wednesday

Thursday

Friday

07:00-07:30

Holdover Rounds presented to the Day Teams by the Night Float Team

07:30-08:45

Resident and Intern Bedside Rounds and Work Rounds

09:00-10:30

Attending Rounds with Team – Residents, Interns, Students

11:30-12:30

Morning Report (Jul-Nov)
CMC/CPC Conference (Nov-Feb)
Board Review Series (Feb-Jun)

Morning Report (2 cases or a 1 case and didactic session)

Work-up Wednesdays (fresh case discussion)

ICU Morning Report (Jul-Nov)
CMC/CPC Conference (Nov-Feb)
Board Review Series (Feb-Jun)

Medicine Grand Rounds and IM Residency Program Weekly Meeting

14:00-15:00

Afternoon Teaching including Intern Report and Subspecialty Service Lectures

Elective Opportunities

There are also various inpatient 3-week elective opportunities for residents looking to gain some exposure to the available subspecialties. These include rotation on the consult services such as infectious diseases (general and immunosuppressed), cardiology, gastroenterology (liver and luminal), hematology/oncology, toxicology, among many others. There are also several non-consult service opportunities such as cardiac imaging, procedures, ventilators, and research blocks for residents hoping to complete projects for publication.