Program Structure

RUMC Internal Medicine Residency Program is the largest residency program within the Hospital, which offers other residency training in Surgery, Pediatrics, Obstetrics and Gynecology, Radiology, and Psychiatry and Podiatry. The number of IM residents totals about 69, and includes about 15 Preliminary and 54 Categorical positions in all 3 years.

A regular workday

The morning starts at precisely at 7 am with daily educational activities. These activities enable residents two hours of protected learning time that includes presentations, discussions and lectures. Approximately half an hour is dedicated to cases from over the night. This is presented by one of interns/residents. An assigned intern/resident presents a topic based on current clinical cases supported by published literature.  The daily core curriculum lecture follows; this is organized according to subspecialty blocks. Sign out from the Night Float (NF) team to the Day team takes place at 9 am.

Then, residents depart to the wards or to the ambulatory clinic as per schedule. Full-time Internal Medicine faculty supervises the residents on the wards and clinic. In some afternoons there are more educational activities and meetings.

By 5pm all day teams are encouraged to endorse their patients to the long-day (LD) teams, who carry patient care until 9pm. At 9 pm long-day teams endorse all patients to the Night Float teams, who will oversee patient care until 9 am the next morning.

Daily attendance is required for the educational activities from 7 to 9 am for all residents including day teams, clinics, and Night Float residents.

Daily schedule from 7 am to 5 pm is called Regular Day (RD).

Daily schedule from 7 am to 9pm is called Long Day (LD).

Night Float (NF) runs from 8 pm to 9 am.  Note that the RUMC Internal Medicine program does not have a call system.

 At the end of the work day, every floor team (intern and resident)  sign out/endorse together in a collaborative effort. The pair will sign out their complete patient list to the incoming long-day team, emphasizing critical aspects of each patient status and plan of care. Endorsement lists are computerized and should be stored daily on the computer floor and should not be deleted from the computer. Unstable patients during the day are especially important to note during endorsement as they may deteriorate during the night. These patients are highlighted as ‘HAWK’ patients. Senior residents are required to write a note on these patients. ALL residents MUST PAY EXTREME ATTENTION to these critical patients.

Ambulatory Clinic

Throughout the three years of residency, residents experience ambulatory care by participating as primary care physicians to patients in the continuity clinic located at the RUMC site, or working with physicians in the community. Residents have an opportunity to build a patient roster mostly based on patients they cared for during hospitalization and follow them through three years, learning how to build rapport and manage chronic conditions. Residents are encouraged and expected to contact and exchange information with the resident provider of any patient admitted from the Ambulatory Clinic to the inpatient service to ensure seamless care.

Richmond University Medical Center is currently implementing the Patient Centered Medical Home PCMH Module to service our expanding ambulatory care services on Staten Island. The Ambulatory clinic is expected to move to our 800 Castleton Location in 2014, and a number of improvements are underway. The clinic became EMR compliant and is using e-Clinical Works (eCW) and ancillary and nursing assistance has improved greatly. The number of full time attendings in the clinic has also increased.

Using the EMR definitely improved patient follow up on test results; referrals, medication refill, remotely and during office visit, and also provide secure, legible and comprehensive information accessible to all caregivers.

Residents are a key player in this module, as they participate as primary care physicians to patients in the community throughout their three years of residency.  Residents spend a whole week every five weeks in the ambulatory area setting, rotating daily between the primary care adult medicine clinics and the different Subspecialty clinics and also attending multiple academic sessions related to ambulatory care topics and participating in Research activities. General medicine topics are reviewed regularly.

In the primary care setting, residents are divided into groups of 2-4 resident, each group supervised by an attending physician, who is involved in the teaching process from history taking, physical exam until formulating the treatment plan according to the recent guidelines. Each clinic session has two regular general internal medicine faculty supervisors and each clinic attending has no more than 5 residents at a time.

Sub-specialty clinics include Cardiology, Pulmonology, Hematology /Oncology, Endocrinology, Infectious Diseases and HIV, Neurology, Gastro-Enterology, and other non-internal medicine specialties, such as Gynecology, Orthopedics, Ophthalmology, Dermatology and Podiatry, which are essential for primary care internists. Residents are responsible for checking which specialty clinic they are assigned to and show up in the right location and the right time.

The Ambulatory Clinic medical staff includes:

Approximate work load per level and service

Work exposure for PGY1, PGY2 and PGY3 include medical floors, ICU, research, Board study, subspecialty/elective rotations, and vacation. An approximation of the work distribution, measured in  4-week blocks, per level is below.

Schedules

Block schedule and Scheduling is intended to provide a well-rounded Internal Medicine experience with flexibility to meet individual residents training goals.

Each academic year consists of thirteen 4-week blocks. Residents are randomly and fairly assigned to all services the hospital has to offer.

Vacation is taken in 2-week blocks approximately 6 months apart. Vacation is offered all year long except during the busiest months of the year, such as every July. Residents are encouraged to take the vacation slots available as soon as possible as there is no possibility of rearranging the schedule without incurring in overloading of other residents and compromising work and training.

The ambulatory clinic is scheduled as a “4-week ward 1-week clinic” cycle. The schedule is done through AmIon. Chief residents usually prepare all schedules and make necessary adjustments.

Residents should abide to the schedule. Any change in one portion of the schedule, reflects to the other components of that schedule. Residents proposing/accepting swaps are responsible to carry out all the attached responsibilities of that schedule, which may incur in extra-work.  Schedule swaps are discouraged as they impact resident duty hours. Chief residents are not responsible to find coverage for swaps. All changes and swaps MUST be official and approved before hand by the Chief Resident. .

Categorical residents will complete a subspecialty rotation in all seven of the following subspecialties: Infectious Diseases, Neurology, Cardiology, Pulmonology, Nephrology, Hematology/Oncology, and Gastroenterology. Each rotation should be a full 4-week experience to maximize contact with fellows and attendings, patient care and learning. Rotations are fairly distributed over the 3 years of training. For fellowship-bound residents an outside elective in the specialty of choice is allowed either on the 2^nd or 3^rd year of residency. Residents on elective are also on jeopardy. Chief residents will assign the activities for these days as they see needed.

Medical consultations to other specialties are done by PGY2 and PGY3 residents only.

Consultations in Dermatology, Endocrinology and Rheumatology are done by the floor PGY2/3 and discussed with the attending on service. Consults on weekends in any specialty are done by the residents (PGY2/3) on service and discussed with the attending of the month.

Primary care residents follow the categorical residents’ schedule and in addition are required to complete Cardiology and Hematology/Oncology outpatient clinic rotations to expand their primary care exposure.

Preliminary residents experience subspecialty core rotations as categorical residents do. Preliminary residents do not get outside elective time.

PGY3 residents will have elective activity in ED, Ambulatory Medicine and Geriatrics. Ambulatory Medicine rotation for PGY3 includes ENT, Ophthalmology and Dermatology rotations at specialists’ community based offices.

Research elective is now coupled with the Ambulatory Clinic schedule. During the Medical Clinic week, each resident must be present for his/her clinics and report to the research office for the free periods in order to complete an 8h work day daily. The medical clinic is closed on weekends. Chief residents may pull a resident from research if there is shortage of residents.

Weekly/Daily Floor Resident Work Schedule (For ALL residents including on Consults and Electives)

The program does not support 24h calls. We have Short-Days (SD) and Long-Days (LD). Residents on SD work from 7a-5p daily and residents on LD work from 7a-8p daily. LD takes place approximately once a week. The Program has a Night Float system (NF). NF ranges from 8p to 9a.

**Working Interns (WI) work either Saturday or Sunday with one day completely free of clinical activities

Weekly Ambulatory Continuity Clinic Schedule (under review)

All residents are mandated to comply with Ambulatory Clinic which lasts the entire residency. This allows continuity of care of patient roster and teaches the resident about care of ambulatory patients. The roster is mostly built on patients discharged from the hospital. This schedule is under review!

NF schedule Call schedule weekly PLUS weekend (under review)

* Weekend call on either Sat or Sunday, followed by free post call day

Supervision

Supervision is an important part of the medical training as it implies patient safety as well reimbursement opportunities. Supervision is both normative and formative. Supervision can be direct or indirect and can be provided by different members of the health team, dependent of the activity being supervised.

Objectives of supervision are:

1. promoting professional development,
2. ensuring patient safety and effective care,
3. Certifying each resident’s development of skills, knowledge, and attitudes required to enter the unsupervised practice of medicine, and
4. Establishing a foundation for continued professional growth.

Supervision is crucial during times of uncertainty, when a resident feels uncertain about what to do. At any time a resident feels uncertain supervision should be sought. This can be done in a hierarchical manner or directly to the attending.

Uncertainty can be conceptual (e.g. how to decide that a patient needs upgrading?), technical (e.g. how to perform a procedure?) or personal (e.g. what are the patient’s decisions in his/her care?).

Most res Residents should be aware of their uncertainties, work to solve them and never be ashamed to call in for supervision. Unresolved and refuted uncertainties jeopardize patient safety.

Residents, however, display tremendous growth during the 3 years in all areas discussed above. 

RUMC is implementing a policy of supervision that is based on documentation of resident interactions with the other members of the health team. The resident has the responsibility to have his supervisory forms appropriately checked and signed by the appropriate supervisor.

Evaluations

Core competencies are one way to evaluate residents and each resident needs to achieve satisfactory level of performance to successfully complete the residency program. The core competencies are listed below.

• 1-Medical knowledge
• 2-Patient Care
• 3-Practice Based learning
• 4-Interpersonal and communication skills
• 5-Professionalism
• 6-Systems based practice

For more information visit ACGME core competencies. All residents are evaluated by a Clinical Competency Committee at least 2x a year and these evaluations are shared with ACGME.

All evaluations are now done through New Innovations. Use of New Innovations is also a measure of resident compliance with the rules of the program. In addition residents are evaluated by their peers, the nursing staff, and by the patients. Residents will regularly evaluate their attendings, colleagues and chiefs, which complete a 360˚ evaluation process.

Evaluations are part of the residents file and are used to congratulate residents, place residents on probation, tailor improvement plans etc. They are also very useful to base recommendations letters for promotion and fellowship, recommendations to sit in the ABIM exams or for future employment.

Letters of recommendation are important tools in the application for a job. Job applications usually require the program director to report the applicant performance in areas such as clinical competence, patient care, participation on staff and committee activities, relationship with patients, ability to work with others, professional attitude, emotional stability, personal character, disciplinary actions of any type, quality and timeliness of medical records. The character of the recommendation letter depends on the resident’s behavior, performance, professionalism and compliance during residency.

Information and Technology

RUMC is transitioning to a fully integrated electronic medical recording system. Meditech is in use for all aspects of nursing and ancillary services and laboratory diagnostics. Residents write progress notes and discharge notes electronically.  Computerized Physician Electronic order Entry (CPOE) is available for most orders.

Dictated consultations and reports of diagnostics are electronic as well. MRI and CT scans, XR and ultrasound examinations are available in PACS. Electrocardiograms  are stored and available in MUSE. To integrate Evidence Based Medicine and approved protocols into residents’ daily prescription the hospital continues to implement order sets.
The Emergency Room uses EDIM.  Initial H&P and specialty consultations are still handwritten.

Use of New Innovations for duty hours, case logs and evaluations is mandatory for all residents. These reports are due every block and should be completed with 1-2 weeks after each rotation. Lack of duty-hours input will not jeopardize resident promotion to the next level.

Schedules and conferences will also be available in AmIon

Electronic communication regarding hospital, residency and work matters must be done through the hospital MS Outlook system. All schedules will be published in the Intranet, in Outlook Calendar and in New Innovations and AmIon . Residents must check their emails, schedules and lectures calendar on a daily basis. To find out the lecture schedule please log in to your work email, check the folders tab in the left bottom side, choose public folders, and click on the IM lecture schedule. Topic and speaker will be available to help the resident prepare for the upcoming lectures

Laptops and/or tablets are available for resident use, to overcome the shortage of desktop computers. If using personal items they have to be cleared by IT.

RUMC still uses the beeper system. However communication between providers and residents is gradually transitioning to Practice Unite, which is a HIPPA compliant system to communicate clinical information. Make sure you are connected!

[1] 4^th Tuesday – Reward and Recognition

[2] 3^rd Wednesday – Heme/Onc Journal Club

[3] 1^st Friday – Near Miss, 2^nd Friday ID Journal Club

[4] 3^rd Tuesday – CPC, 4^th Tuesday – Business Meeting