PGY2-to-Be Retreat

*Due to a lack of available conference room space, the 2015 retreat will not be

at the Four Seasons Bora Bora, it will instead be on Tower 11. We will return to

Bora Bora in 2016.*

Overview4:00-4:30PM Snacks and informal discussion

4:30-6:00PM DidacticsGiving feedbackMilestonesStudent teaching - clerkship directors

6:00-7:00PM Dinner & Small GroupsHow to be a ward resident Q&A

7:00-9:00PM Administrative issues/changes for next year/chief residents New for next year: MICU, CICU, & Ambulatory changesElectivesJeopardyTransition datesTeam caps/duty hoursStaffing/new rolesCoverage/schedulesMoonlightingProfessionalism/conferencesIn-training examNight floatCodes

Changes for Next Year

• Interns will take overnight call in the MICU• Adoption of the MICU call structure in the CICU• Implementation of intern ambulatory blocks

(goodbye weekday resiterning!)• Friday Ambulatory Academic Half Day

UH MICU new for next year

Interns will take Q4 overnight call with their paired senior resident.

Last day of rotation their call day will end at 11PM.

Return to 2 attendings, 2 teams.

UH MICU• Overnight Call – Post Call – Helper Day – Pre Call• Senior residents get pre-call day off between Friday and Monday (interns

get helper day off during same days)• Five senior residents in the MICU (plus rotators)• Senior will be paired with intern. Senior “supervises” their intern, but

intern “staffs” new patients with the MICU fellow. • New: interns will take Q4 30 hour call with their residents (iCOMPARE

study). Last day of rotation they will leave by 11PM.• Helper day = supervise the post call intern (their senior will leave by 11am)

and help out on-call resident until at least 7 PM• Note: Our program is responsible for the care of a very sick MICU. Things

are always happening. Other than post-call residents/interns, no person should sign out before 4PM. Signing out early adds another thing to the on-call team’s plate.

UH MICU Nights• May have 2 weeks as MICU night resident (have Friday and Saturday

nights off that are covered by MICU moonlighter)• MICU night resident responsibilities

– Comes at 9 PM– Cross-covers unit at night– Alternates admissions with resident on call until 2 AM, then does all

admissions after 2 AM• Patients admitted by NF will be distributed by the MICU fellow in AM• NF residents sometimes stay to present patients on rounds (complex

patients)• Post-call resident will present and leave, sign out to the post call intern

and helper resident

UH CICU new next year

In response to feedback that:1. There were too many handoffs in the CICU2. There were too many cross-coverages in the CICU

Brainstorm: ideas regarding cause; possible remedies.

Intervention: trial run of the MICU call model in the CICU. The feedback from this pilot was that the residents preferred the new format (MICU call model) to the current CICU call model.

We will therefore adopt this change for next year.

Ambulatory Model 3.0

• Friday Morning Educational Half Day–8AM-Noon: Didactics, Journal Club, Workshops organized by system–Systems chosen by gaps in other parts of the program–No clinic or UCC requirements during Friday mornings

• No 8AM Conference, though VA clinics and UCC start at 8 (DMC start time TBD)

• Tues and Wed AM DMC Clinic. Decreasing wasted travel time between VA and UH.

• Challenges–Ambulatory blocks are fixed (cannot trade)–Clinic days are fixed throughout the year, allows improved scheduling

continuity

Ambulatory blocks for interns

• All categorical interns will have one primary care block and 2 ambulatory blocks with the senior residents.

• No Clinic on Wards/ICU! Resident no longer will have to cover interns in the afternoon who are in clinic (exception for Med/Peds)

Ambulatory Model 3.0

Example Schedules

Changes at the DMC

• Tuesday and Wed AM Clinics.

• Ongoing efforts to improve continuity

• New Attendings: Dr. Crystal Lantz and Dr. Babak Moini. 2 resident favorites back as outpatient teaching attendings!

Changes at the VA

• Clinic names changing, talk with your preceptor if you need to change your list

• Alerts

Electives

• PGY II: 8 weeks • PGY III: 12 weeks• Quality Chief will now be assisting Barb in keeping a running

list of what you are doing for elective• For ACGME requirements each resident must have a specified

activity and supervisor for each elective

Example Elective Tracking

Electives

• Research Electives:• Must have a mentor/PI for project• If doing two weeks (or more) of research elective, you are

required to present a poster at Medicine Research Day• If you present at a national meeting…travel money!

• Reading Electives:• Requires approval, KBA is designated supervisor• Required attendance at all UH noon conferences, UH

M+Ms, UH Grand Rounds, VA Grand Rounds

Elective Reminder

• Elective Professionalism & Jeopardy• Elective is not vacation• You are expected to be in town and available - if you need

to leave town, please let the Ambulatory chief know• Everyone on elective is back-up jep any given day, but we

will assign people on specific days to be the first called so you know when to have your pager with you. Look for the doodle poll email so you can choose your days.

• If you are on backup jep and do not answer your pager in 15 minutes, you will be assigned extra weekend coverage!

Jeopardy• Please carry your pager 24/7 Monday thru Friday• Failure to respond to pages within 15 minutes will result in extra

weekend coverage.• Use of jeopardy is tracked for training/support purposes• Those getting jepped from electives will be tracked as well

– Those jepped off elective multiple times will move down the list on future electives

– Makes the system more fair• KEY Points

– Jeopardy still remains for emergencies and significant illness– Unless there is excessive use of jeopardy (decided on a case by case basis),

you are not expected to pay back– When on the jep rotation, covering sick colleagues is the job. There is no pay-

back for this coverage.

Transition Dates

•PGY1 end date: 6/23•Block Zero: 6/24 – 6/30•Block One: 7/1 – start of your PGY2 year!

Team Caps

UH Wards: • 10 patients per intern for all services except Ratnoff & Weisman

which cap at 8 (with rolling cap for Long & Med call)• 2 Senior teams (Intern+AI or Intern/Intern): 12 patients; 10 patients for

Ratnoff & Weisman. • 1 Senior teams (Intern+AI or Intern/Intern): Same rules as per individual

intern caps; 10 patients for all wards except Ratnoff & Weisman (where cap is 8)

• Short call day caps at 8 (based on the number of patients you start the day with, not a rolling cap).

VA Wards: • 8 patients per intern• Intern+AI or Intern/Intern: 10 patients

Team Caps

Special circumstances:1. Hellerstein Short gets only 1 short admission.2. No Eckel short admissions.3. No weekend short admissions.4. AIs can get new admissions on short call.

Admissions• Long Call:

– 3 patients (4 if paired with AI) until 7 PM

– Max of 2 patients if after 5 PM

– Max of 1 patient if after 6 PM

– Anesthesia interns should leave by 9PM, work up admissions accordingly

• Medium Call:– 2 patients until 4 PM

– Can sign out at 7 PM

• Short Call:– 2 patients until 12 PM at UH (NF or ICU transfers)

– 2 patients until 1 PM at VA (NF or ICU transfers)

• Senior Resident: – Residents on call MUST stay until 8 PM when the NACR and NFs arrive.

– Weekdays: ward seniors staff any patient assigned before 4 PM.

– Weekend coverage seniors must stay and staff at least until 1 PM or longer depending on how busy the other seniors are

Staffing• UH wards will have double coverage the first 3 blocks, longer

for some services. There will be minimal orphan coverage in the first few blocks

• See and examine EVERY patient• No staffing note required for ICU transfers or inter-service

transfers• Focused notes by the senior resident with detailed plan• See PGY1 note for full H&P. Briefly, pt is a …

• Helpful to new interns: • Antibiotic doses• Description of imaging - With contrast? Without?• Medications to continue, medications to discontinue

• Daily AI notes: need a progress note for you, unless the attending is also writing a full daily progress note (Naff/Wearn)

Your New Role

Be a Manager:•Print out daily patient list for attending at UH•Enter team attendings in the EMR•Lead rounds•Review active medications and orders EVERY DAY!•Direct intern work flow•Help with discharge summaries!•Have teaching topics•Maintain a white board and saved list of patients•Review discharge profiles

Your New Role

Be a Teacher:•Great teachers are motivators, respectful, and treat their students as colleagues/equals•Take time to critically evaluate presentation skills•Find your own method of teaching

Your New RoleBe a Steward of Sign-outs:• What is important? What changes management?• What is not important?• Observe signouts early

Coverage and Schedule Switches

• All coverage arrangements and schedule switches must be approved by the Ambulatory chief so it can be noted in amion

• Switches must be arranged 2 weeks before rotation start date, ideally sooner

Professionalism: weekday swaps• Swapping weekday coverage of ward and ICU teams

will not be routinely permitted. • Where weekday absences would be needed for

events such as weddings, reunions, conferences, or interviews, residents should swap full blocks rather than weekday coverage.

• Exceptions may be granted for academic pursuits when only full block swaps cannot reasonably arranged

• Exceptions will need pre-approval by the ambulatory chief resident and will be on a case-by-case basis.

Moonlighting• FLEX – when your team is capped and a patient is in need

of your specific team. Senior residents should be open to flexing. It’s paid, it helps the nightfloat, and it keeps patients on the team that will provide the best care. A win-win-win.

• PRN SHD – admit 3 patients

• Early and Late SHD – admit 3 patients

• Admitting LHD – admit 6 patients from 6 PM – 6 AM

• Cross Cover LHD – cross covers hospitalist, NPs, and admit 1 patient (3 if overnight NP present), work from 8 PM – 8 AM

• MICU/CICU moonlighter – 9 pm – 9 am Fri/Sat. Responsible for alternating admissions with resident until 2am, then all admissions

• No moonlighting during wards or ICU

Professionalism: Attire• Men

• Shirts and ties• Women

• Professional• Keep white coats clean –

department pays for dry cleaning• Scrubs: long call, weekends, nights,

and ICUs• No denim• Closed toe shoes• No fleeces to morning report or on

rounds (unless under a white coat)

Professionalism: Absences

• If you have to call in sick > 1 day, you will need a doctor’s note from the Bolwell Family Practice clinic • You will be able to get a same-day appointment

• If you are sick for > 2 days and do not have a doctor’s note, you will be assigned extra weekend coverage and/or weekend jeopardy

• Call-offs: You must PAGE 31529 the Ambulatory Chief• DO NOT EMAIL• DO NOT TEXT PAGE• DO NOT CALL THE CELL PHONE OF THE CHIEF YOU KNOW

Professionalism: Reading Electives

• Residents on reading elective are expected to attend morning reports and journal clubs at the VA

• Must attend Grand Rounds and M&M at UH• Your pager is expected to be turned on and on you during

the entire two weeks of elective• All reading electives must be approved by KBA• For PGY2s it can only be used to study/take step 3• Please note that when you are on elective, you will be

assigned specific days of back up jeopardy – you must have your pager on these days. Failure to answer a page within 15 minutes when you are on jeopardy will result in extra weekend coverage.

Professionalism: Discharge Summaries

•If you put in the discharge order, you do the discharge summary

•Do them the day of discharge•This is a great way to lead your team by example and show your intern that you (1) care and (2) are not above helping with the scut work.

Professionalism: Conferences

•Be on time.

In-service Training Exam• In-service Exam Dates are in September – exam is

completely computerized this year• Includes all PGY2/3, PGY1’s?

• ITE during 2nd year is an important predictor of passing boards

• ITE remediation by percentile rank• >50% - no remediation, continue to study• 31-49% - turn in in 60 multiple choice questions every 4 weeks

to assigned APD for review; continue studying and attend board review sessions

• 16-30% - high risk for ABIM failure multiple choice questions as above with directed notes• If you are not already doing this PLEASE talk with us or your APD, ABIM

failure is no joke• 1-16% - more intense remediation, urgent intervention

required (we are here to help!)

VA Nightfloat Resident• Works from 8 PM to 8AM• Cover the VACR pager (medicine consults)• Run codes• Evaluate CARES Tower 6 patients

– If patient needs more evaluation then direct admission (DO NOT GO TO THE ED)

• VA chief will page you in the morning to distribute patients• Discuss Code status of patients• Change team assignment in CPRS (admission order: team)

The NIGHTFLOAT TEAM

NACR

Nightfloat ResidentRotating MSIII

Nightfloat Resident

Nightfloat InternRotating MSIII Nightfloat InternNightfloat Intern

UH Nightfloat Resident• Works from 8 PM to 8AM• Meets the NACR in the KACR• Admit patients overnight, works with the nightfloat intern to

help answer questions/manage ill patients.• NACR is always available if you need help• Two nightfloat residents, each resident either gets Saturday or

Sunday off (must have 1 nightfloat resident each night)• Must go to all Code Whites during the first 6 months with

intern

Running Codes

Code Whites (UH)

** 1ST six months – an upper level must go to all Code Whites with an intern**

•Sick or decompensating patients on the floor or Hanna House

• Initial response from ICU nurse, intern, and PGY2

•DACR/NACR for Level 2 code white• If you want to transfer to MICU, call MICU fellow

•Always write a Clinical Event Note!

Code Blues

• “Too many chefs spoil the soup”• One person leads the code• Make sure interns are involved: Never kick an intern out of the

room during a code, they will be running it next year!• Maintain a calm quiet atmosphere

• Keep the ACLS cards in your pocket

• CODE BLUE NOTE and notify family; DEATH NOTE if patient passes; notify attending

Running Codes• Rule #1: You are in charge

• If uncomfortable, defer to more senior resident

• Delegate, delegate, delegate – assign crowd control, chest compressions, airway, etc.

• Use the DACR/NACR if you need help

• Call the ICU nurses by their name, closed-ended communication

• Assign someone to call the family

• During a crisis, people want to feel like soldiers, not victims. Given them a job “please draw up 1mg of epinephrine” and things will fall into place.

Running CodesNotify attendings at night of any Code Blue

• Page the attending let them know the outcome (either of transfer to ICU or death)