Inpatient Training
Inpatient Team Structure
A unique feature of our program is a 1:1 pairing of resident to intern on most of our inpatient services throughout the three years. This affords interns extra support, while providing upper level residents the opportunity for more one-on-one teaching including bedside, evidence-based and chalk talks. 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 strictly followed. 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. Some of these details have been modified throughout the COVID-19 pandemic to address the unique needs created by this virus throughout the health system.
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 four to five 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 an extensive patient population (including all solid-organ transplant recipients) and wide treatment area, transferred in from many of our community hospitals throughout Virginia.
Six geographic day teams consisting of:
- One upper level resident
- One intern (occasionally a team may have a second, off-service intern)
- Five Attending physicians (four have one resident:intern pair per attending; one has two resident:intern pairs)
Night float structure consisting of:
- Two upper level residents
- Three interns
- Two in-house night hospitalists (divide supervision of overnight admissions and resident support)
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 4:00-5:00 pm, then go home
Day Call (Long Call Day Q4 days, 7:00AM – 8:00PM)
- 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; the rest are admitted by a swing hospitalist
- Receive sign-out at 4:00-5:00 pm from two 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
- Interns and residents present hold-overs to the day teams at 7:00 am
- NF team leaves by 07:30-8:00 am every day
- Interns work 6 nights in a row for three weeks during night float block by covering and admitting to the same service
- Residents work 6 nights in a row for three weeks during night float block. Each week they cover a different set of general medicine teams.
This rotation consists of General Medicine teams operating on our fifth floor. Historically, this team had predominantly digestive health patients on the fifth floor (patients with liver disease, gastrointestinal bleeding, inflammatory bowel disease, pancreatitis, etc) staffed with General Medicine attendings. With the onset of the COVID-19 pandemic, this team has become more flexible in geography, and GI patients are now evenly distributed across all general medicine teams. However, the unique team structure has remained the same, as outlined below.
This is one of two services 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.
Two day teams consisting of:
- One upper level resident
- Two interns
- General Medicine attending physician
Q4 day call cycle
- Structure of call day cycle and night float are identical to the other general medicine teams as discussed above
Our inpatient Hematology service gives residents the opportunity to be involved in the management of patients with malignant hematology pathology including leukemia, lymphoma and stem-cell transplant patients who they staff with a hematologist. There is a separate Hematology-Oncology hospitalist service staffed by a hospitalist and nurse practitioner to manage the patient volume in order to not compromise resident education. This is one of our two services that function with a 2:1 intern:resident ratio, with a hard cap per resident team of 14 patients (7 per intern).
2 day teams consisting of:
- One upper level resident
- Two interns
- Hematology Attending and Fellow (supervising malignant hematology and bone marrow transplant patients)
One night float team consisting of:
- One intern and one resident who cover both Hematology and Oncology patients
Q4 day call cycle
Non-Call
- Drip system, can admit Hematology patients until 2:00 pm on weekdays and 11:00 am on weekends
Call
- Will admit with either a Hematology or Oncology resident until 8:00 pm (admissions after 4:00 pm can be either Hematology or Oncology)
Night Float
- One intern and one resident
- Team admits new patients from 8:00 pm to 7:00 am
- Team cross-covers on patients overnight
- Intern presents holdovers to the non-call day teams at 7:00 am
- NF team leaves by 8:00 am
- Interns work 6 nights in a row for three weeks; weeks can be GM, Hematology/Oncology or blended
Our inpatient Oncology service gives residents experience with patients with solid tumors who they staff with an oncology attending. There is a separate Hematology-Oncology Hospitalist service staffed by a hospitalist and nurse practitioner as above who helps to manage the patient volume in order to help with the balance of patient care and education for residents. There are 2 residents on this service that can carry up to 8 patients each. You will not rotate on this service as an intern but will have ample time to participate in this rotation as an upper level. Interns are all scheduled for an outpatient oncology week to ensure exposure early in residency.
2 day teams consisting of:
- One upper level resident each
- Oncology Attending (supervising solid tumor patients)
One night float team consisting of:
- Same as above
Q4 day call cycle
Non-Call
- Drip system, can admit Oncology patients until 2:00 pm on weekdays and 11:00 am on weekends
Call
- Will admit with a Hematology intern until 8:00 pm
Night Float
- One intern and one resident as above
- Team admits new patients from 8:00 pm to 7:00 am
- Team cross-covers on patients overnight
- Intern presents holdovers to the non-call day teams at 7:00 am
- NF team leaves by 8:00 am
- Interns work 6 nights in a row for three weeks; weeks can be GM, Hematology/Oncology or blended
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.
Three 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)
Q3 day call cycle
Day Call
- Non-call teams receive “holdover” patients at 7:00 am (patients admitted overnight by the ACS NF resident)
- Non-call teams sign-out to the on-call team at 4:00-5:00 pm
- On call team admits from 7:00 am to 8:00 pm and then signs out to ACS NF resident
Night Float
- One resident and intern team cross covers ACS teams and admits acute cardiology patients overnight from 8:00 pm to 7:00 am
- Intern presents holdovers at 7:00 am and leaves by 8:00 am
- Resident is on for 7 day block and then rotates to elective
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 24 hours a day), 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 cardiology fellow
Q2 day call cycle
Day Call
- Team admits new patients from 7:00 am to 8:00 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 8:00 pm (when NF team arrives)
Night Float
- Night float resident admits patients to CCU from 8:00 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 8:00 am
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 patient safety, with support from their fellow and ICU attending. There are two separate, advanced practice provider teams in the MICU which help offload resident teams and maintain team caps when the ICU census is high, while still maintaining excellent exposure for residents.
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
- One fellow
Q4 day call cycle
Day Call
- Team admits new patients from 7:00 am to 7:00 pm
- Non-call team sign-out to the on-call team at 4:00 pm
- On-call team remains in-house for admissions and cross-cover until 7:00 pm (when NF team arrives)
Night Float
- Night float intern/resident team cross cover resident MICU teams and admit new patients 7:00 pm to 7:00 am
- Night float team present overnight admissions directly to residents at 7:00 am
- Night float team leaves by 8:30 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 |
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| 07:30-08:45 Resident and Intern Bedside Rounds and Work Rounds |
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| 09:00-10:30 Attending Rounds with Team - Residents, Interns, Students |
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| 12:00-13:30 Acute Care Series (Jul-Sep) Morning Report (Jul-Nov) CMC/CPC Conference (Nov-Feb) Board Review Series (Feb-Jun) | 12:00-13:30 Acute Care Series (Jul-Sep) Morning Report (2 cases or a 1 case and didactic session) | 12:00-13:00 Work-up Wednesdays (fresh case discussion) | 12:00-13:30 Acute Care Series (Jul-Sep) ICU Morning Report (Jul-Nov) CMC/CPC Conference (Nov-Feb) Board Review Series (Feb-Jun) | 11:30-13:00 Medicine Grand Rounds and IM Residency Program Weekly Meeting |
| 14:00-15:00 Afternoon Teaching including Intern Report and Subspecialty Service Lectures |
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Elective Opportunities
There are also various inpatient 3-week elective opportunities for residents looking to gain exposure to the available subspecialties. These include rotation on the consult services such as infectious diseases (general and immunosuppressed), cardiology, pulmonology, gastroenterology (liver and luminal), hematology/oncology, endocrinology, toxicology, among many others. There are also several non-consult service opportunities such as cardiac imaging, procedures, vascular access (focused on CVL placement), ventilators, and research blocks for residents hoping to complete projects for publication.