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 gives interns extra support while giving upper-level residents 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 from 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.
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 so many that they 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, as well as some from surrounding states. The medical issues managed include common ailments such as pneumonia, COPD, UTIs, osteomyelitis, and encephalopathy, as well as rare diagnoses driven by our extensive patient population (including all solid-organ transplant recipients) and wide treatment area, with transfers 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 residents: 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, 7:00 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; 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 signs 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 the night float block by covering and admitting to the same service
- Residents work 6 nights in a row for three weeks during the 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 cared for predominantly digestive health patients on the fifth floor (patients with liver disease, gastrointestinal bleeding, inflammatory bowel disease, pancreatitis, etc.) and was staffed by General Medicine attendings. With the onset of the COVID-19 pandemic, this team became 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-to-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 is to give upper levels the opportunity to develop their skills managing a larger team by stepping 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 manage patients with malignant hematologic pathology, including leukemia, lymphoma, and stem-cell transplant patients, and is staffed by a hematologist. A separate Hematology-Oncology hospitalist service, staffed by a hospitalist and nurse practitioner, manages patient volume so resident education is not compromised.
2-day teams consisting of:
- One upper-level resident
- One intern (occasionally a team may have a second, off-service intern)
- 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 and is staffed by an oncology attending. A separate Hematology-Oncology Hospitalist service, staffed by a hospitalist and nurse practitioner, helps manage patient volume to support resident patient care and education. There are 2 residents on this service, and each can carry up to 8 patients. You will not rotate on this service as an intern but will have ample time to participate in this rotation as an upper-level resident. Interns are all scheduled for an outpatient oncology week to ensure exposure early in residency.
2-day teams consisting of:
- One upper-level and one intern
- 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.
Four-day teams consisting of:
- One upper-level resident
- One intern
- One cardiology attending and fellow
- One cardiology attending covers the AC ACS teams, and one cardiology attending covers the BD ACS teams
- General Cardiology Attending and Fellow (supervising general cardiology patients)
Q4 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 a 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 is 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 team admits some of the hospital’s most complex and critically ill patients. 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 in making management decisions and ensuring patient safety, with support from their fellow and ICU attending. Two separate advanced practice provider teams in the MICU 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-covers resident MICU teams and admits new patients from 7:00 PM to 7:00 AM
- Night float team presents overnight admissions directly to residents at 7:00 AM
- Night float team leaves by 8:30 AM
- Each team does 7 days of night float at a time
Elective Opportunities
There are also various 3-week inpatient elective opportunities for residents looking to gain exposure to available subspecialties. These include rotations in consult services such as infectious diseases (general and immunosuppressed), cardiology, pulmonology, gastroenterology (liver and luminal), hematology/oncology, endocrinology, toxicology, and more. 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.