Curriculum Areas
Hospitalist Medicine
Location:
- UT Medical Center, Various Floors and Emergency Department
Faculty:
- Trey La Charité, MD, Course Director, UTH
- Jano Janoyan, DO
- Sammeh Naguib, MD
Rotation Outline and Schedule:
The Resident and their UTH Attending will function as a closely knit team for a two week rotation. The Resident will gain the perspective and experience of autonomy by independently developing care plans for a prescribed number of patients each shift. The UTH Attending will ensure best practices are maintained at all times by daily review of the Resident’s patient care plans in the form of daily afternoon managing/teaching rounds after the Resident has had time to formulate his/her care plans in the morning. A two week rotation with UTH would consist of the following template:
Day 1: Orientation with their UTH Attending for the rotation. The UTH Attending will discuss expectations of the Resident for the rotation and give a primer on inpatient billing and documentation to be utilized by the Resident during patient care blocks. The first day of the rotation will be an A Day. This will be day call.
Day 2: B Day (rounding only)
Day 3: C Day (rounding only)
Day 4: D Day (rounding only)
Day 5: E Day (rounding only)
Day 6: Off
Day 7: I Day (Float)
Day 8: G Day (Night)
Day 9: Off
Days 10 – 14: repeat Days 1- 5 schedule
Patient Care Block Shifts & Schedule:
| A |
B |
C |
D |
E |
F |
G |
H |
0730-1930 |
0730-1930 |
0730-1930 |
0730-1930 |
0730-1930 |
0730-1930 |
0730-1930 |
1930-0730 |
New Admits and Consults |
No New Admits or Consults |
No New Admits or Consults |
No New Admits or Consults |
No New Admits or Consults |
Rounds and New Consults |
New Admits and Consults Only - No Rounding |
New Admits and Consults Only - No Rounding |
The Resident will be required to be in-house for the duration of all “A,” “I,” and “G” days. While the Resident is responsible for their patients until 1930 on each rounding day (Days “B” through “F”), the Resident is not required to stay in-house on these rounding days once their patient care goals for that day are completed. However, they must be available by pager and are fully responsible for all needs of the patients in their care until the rounding shift ends at 1930. This includes the unlikely but potential scenario of having to return to the hospital from home should a significant problem arise. All will end at their scheduled times with minimal exception. The Resident will be expected to arrive at 6 AM on the day their Ambulatory Care Clinic (ACC) is scheduled to allow time to complete all rounds prior to 1300. The Resident should report to the UHS Attending when the ACC is finished and assist with patient care until 1800.
A typical rounding day (Days “B” through “F”) will begin with UTH morning check-out in the UTH office @ 0730. The Resident will then attend the Department of Internal Medicine’s Morning Report at 0800. After MR, the Resident will see the patients in their care, develop care plans, write notes, etc., and be done in time to attend Noon Conference. After Noon Conference, the Resident will meet with their UTH Attending for patient rounds. The Resident’s rounding shift ends at 1930 and after all work is completed for the patients in the Resident’s care. The “I” shift will begin @ 0730 but start times may change as the UTH schedule evolves.
Accommodating Resident Ambulatory Continuity Clinic:
The Resident will begin the rotation with an A shift on the first calendar day unless the Resident’s ACC occurs on this day. If this occurs, the Resident will assist the Attending in the care of the previously established patients and start the A Day the following day. If the Resident’s ACC occurs on a day in which the Resident would normally be working the “I” shift, the Resident will participate in their usual clinic and then report to their UTH Attending to resume their “I” shift responsibilities when their clinic responsibilities are concluded. If the Resident’s ACC occurs on a day in which the Resident would normally be rounding (Days “B” through “F”), the Resident will be required to see their patients earlier in the day so that rounds with their UTH Attending can occur at 1000 instead of the usual 1300. If the Resident is scheduled to give a lecture to the medical students at 1300, they should arrange to meet earlier with the Attending for patient rounds. The Resident is expected to participate in their regularly scheduled ACC when scheduled for a G Day as these duties begin at 1930 and end the following morning at 0730.
Rotating Resident Guidelines and Expectations:
- The Resident will be in the UTH office every morning no later than 0730 for UTH morning check-out from the night-time UTH physician. The Resident’s UTH Attending will then divide the UTH Attending's patient load for that day between the UTH Attending and the Resident.
- The Resident will be responsible for no more than one-half (or one-half plus one for an odd number of patients) of their UTH Attending’s patient load on any given rounding day. The Resident will be responsible for a minimum of 5 and a maximum of 10 patient contacts per rounding day. The estimated average number of patients for which the Resident will be responsible is 8 to 9 patients per day on rounding shifts.
- The Resident will perform daily face-to-face patient check-out to the UTH physician on-call before they leave the hospital for the day after completion of all of their daily patient care responsibilities.
- The Resident will carry both UTH on-call pagers (#6049 for the ED and #6050 for the floors) while they are on the “A” and “G” shiftsThe #6050 pager will be given to the “I” physician when that physician has completed their rounds.Their responsibilities will include coordination of all ER admission requests, all UTMCK consult requests, all UTMCK UTH outside transfer requests, all direct admission requests from UT affiliated primary care physicians, and all UTMCK UTH Service patient cross-cover calls. The UTH Attending will be immediately available for all requested assistance by the Resident and will be “conference called” for all outside hospital transfers and direct admissions to the UTH service at UTMCK.
- The Resident will carry the UTH floor call pager (#6050) only while they are on the “I” shift coordinating all UTMCK UTH outside transfer requests, all UTMCK inpatient consult requests, all direct admission requests from UT affiliated primary care physicians, and all UTMCK UTH Service patient cross-cover calls. The UTH Attending will be immediately available for all requested assistance by the Resident and will be “conference called” for all outside hospital transfers and direct admissions to the UTH service at UTMCK. Assistance from the Resident in handling excessive ER admission volumes may occasionally be requested (must not exceed total contact caps) by the UTH physician carrying the #6049 pager.
- All outside physician/facility requests for transfer to UTH at UTMCK and all direct admission requests from UT affiliated primary care physicians to UTH at UTMCK will be coordinated by the Resident and their UTH Attending when they are on “A”, “I”, and “G” shifts. The UTH Attending will be “conference called” at the time of these requests in order to assist the Resident in learning this valuable skill and to ensure safe acceptance/transport of the patient to UTMCK.
- The Resident will attend all Morning Reports and Noon Conferences Monday through Friday throughout the rotation.
- The Resident will attend all additional conferences required by the Department of Internal Medicine such as Grand Rounds, M&M, journal clubs, etc. that occur during their Hospitalist rotation.
- The Resident will attend UTMCK’s Performance Improvement Committee monthly meeting on the first Tuesday of each month @ 0700 if they are rotating at a time when this meeting occurs.
- The Resident will attend their regularly scheduled ACC.
UTH Attending Guidelines and Expectations:
- The Resident’s UTH Attending will work the same shifts that the Resident works during the rotation. The Resident will then begin with a second UTH Attending to complete the rotation.
- The UTH Attending will give no more than one-half (or one-half plus one for an odd number of patients) of their assigned patient load to the Resident at any time.
- The maximum number of patients that the Resident can be responsible for on any given rounding shift may not exceed 10.
- The UTH Attending will attend the Department of Internal Medicine’s morning report with the Resident from 0800 to 0900 Monday, Wednesday, Thursday, and Friday. Attendance at Grand Rounds and other educational conferences is strongly encouraged.
- The UTH Attending will see his/her half of the UTH Attending patient load during the morning hours so that they are available for rounds with the rotating resident promptly at 1300.
- The UTH Attending will be immediately available for all requested assistance by the Resident at all times during the rotation.
- The UTH Attending will discuss at length with the Resident the care and coordination of care required by each new admission, consultation, or transfer.
- The UTH Attending will be “conference called” with the Resident for all outside physician/facility transfer requests to UTH at UTMCK and for all direct admissions to UTH at UTMCK at the time these requests are made. This is to ensure that the Resident gains this valuable experience of care coordination and to ensure safe acceptance/transport of the patient by a UTH Attending at UTMCK.
- The UTH Attending will not expect the Resident to participate or perform in the care of the UTH Attending’s daily patient load. Obviously, the Resident should assist in patient care in emergent situations if needed.
Other notes:
- Non-teaching UTH physicians not involved in the rotation will check-out to both the Resident and his/her UTH Attending when the Resident and their UTH Attending are working the “A”, “I”, and “G” shifts.
- Residents will not be allowed to schedule vacation time during their Hospitalist rotation.
Related Conferences/Venues:
- Residents should attend Morning Report, Grand Rounds, Morbidity and Mortality Conference and Noon Conference. They will attend their usual Ambulatory Care Clinic.
Primary Goals:
Patient Care:
a. Learn to coordinate hospitalized patient care among various consultants from different specialties, primary care physicians, extended care facilities, and patient’s families.
b. Prepare detailed patient care plans to maximize opportunities for reductions in hospital resource utilization.
c. Gain experience with pre-operative evaluations, surgical co-management, and peri-operative care.
d. Learn to prevent iatrogenic complications and proactively reduce the risks inherent to inpatient hospitalizations.
e. Gain experience with the development, implementation, and evaluation of practice guidelines and care pathways as part of an interdisciplinary quality improvement initiative
Medical Knowledge:
a. Formulate age and disease specific safety practices pertinent to fall risk, decubitus ulcers, delirium, DVT/PE, hospital acquired infections, and medication adverse events.
b.
Gain experience with the delineation of disease processes that require inpatient evaluation and treatment against those processes which can be effectively addressed on an outpatient basis.
c.
Understand and implement national disease treatment guidelines and best medical practices.
Practice-Based Learning and Improvement:
a. Design evaluation methods and resources to define problems and recommend interventions.
b. Gain experience using hospital consultants, clinical journals, and online databanks as inpatient knowledge resources.
Interpersonal and Communication skills:
a. Learn to gather, record, and transfer patient information utilizing timely, accurate, and confidential mechanisms.
b. Gain experience with patient handoffs from physician-to-physician, patient transfers from facility-to-facility and direct admissions from primary care physician offices to the inpatient setting.
c. Learn appropriate inpatient documentation techniques for medical record charting.
d. Learn to effectively communicate inpatient care results and goals with patients, their families, hospital consultants, primary care physicians, and extended care facilities.
Professionalism:
a. Develop a sense of personal responsibility and accountability for the patients under their care.
b. Develop conflict management and negotiation skills as it pertains to inpatient management.
c. Develop leadership skills necessary to effectively guide patients through the entire course of their inpatient hospitalizations.
System-Based Practice:
a. Summarize methods of system and process evaluation for patient safety.
b. Familiarity with the “just culture” and its ramifications for patient care.
c. Develop an understanding that best medical practices for patient care can be effectively combined with host facility operational initiatives.
d. Understand the risk management issues of patient safety initiatives.
e. Develop an understanding of how hospital systems effectively reduce the frequency of medication and medical errors.
Additionally, the Resident will likely be exposed to the following clinical conditions which have been identified as Core Competencies by the Society of Hospital Medicine (SHM):
Clinical Conditions:
- Acute Coronary Syndrome
- Acute Renal Failure
- Asthma
- Cardiac Arrhythmia
- Cellulitis
- COPD
- Community Acquired Pneumonia
- Congestive Heart Failure
- Delirium and Dementia
- Diabetes Mellitus
- Gastrointestinal Bleed
- Healthcare Associated Pneumonia
- Pain Management
- Perioperative Medicine
- Sepsis Syndrome
- Stroke
- Urinary Tract Infection
- Venous Thromboembolism
Healthcare Systems:
- Care of the Elderly Patient
- Care of Vulnerable Populations
- Communication
- Diagnostic Decision Making
- Drug Safety, Pharmacokinetics and Pharmacoepidemiology
- Equitable Allocation of Resources
- Evidenced Based Medicine
- Hospitalist as Consultant
- Hospitalist as Teacher
- Information Management
- Leadership
- Management Practices
- Nutrition and the Hospitalized Patient
- Palliative Care
- Patient Education
- Patient Handoff
- Patient Safety
- Practiced Based Learning and Improvement
- Prevention of Healthcare Associated Infections and Antimicrobial Resistance
- Professionalism and Medical Ethics
- Quality Improvement
- Risk Management
- Team Approach and Multidisciplinary Care
- Transitions of Care
Primary Objectives:
Patient Care:
1. To learn to interview and examine patients more skillfully.
2. To define and prioritize patients' medical problems.
3. To generate and prioritize a differential diagnosis for each patient.
4. To develop and implement rational, evidence-based treatment strategies.
Knowledge:
1. To identify some of the most common safety problems and their causes in different hospitalized patient populations.
2. To explain the role of human factors in device, procedure and technology related errors.
3. To discuss the significance of sentinel event and "near misses" and their relationship to voluntary reporting.
4. To summarize methods of system and process evaluation of patient safety.
5. To define the "just culture."
Practice-Based Learning:
1. To identify gaps in personal knowledge and skills needed to provide care of hospitalized patients.
2. To develop strategies to address the identified gaps in skills and knowledge.
3. To identify errors and learn from same.
Interpersonal and Communication Skills:
1. To communicate effectively with patients, their families and caregive
2. To communicate effectively and efficiently with other physicians.
3. To communicate effectively with all members of the health care team including inpatient team members, outpatient care providers and external agencies.
4. To fulfill all requirements regarding documentation of care delivered to a patient in a timely manner.
5. To communicate important information necessary for the transition of patients from the inpatient to the outpatient setting.
Professionalism:
1. To demonstrate professional appearance and demeanor.
2. To develop an understanding and consideration of various ethical and cultural issues.
3. To complete all necessary documentation in a timely manner.
Systems-Based Practice:
1. To prevent iatrogenic complications and proactively reduce risks of hospitalization.
2. To design evaluation methods and resources to define problems and recommend interventions.
3. To gather, record and transfer patient information utilizing timely, accurate and confidential mechanisms.
4. To develop, implement and evaluate practice guidelines and care pathways as part of an interdisciplinary quality improvement initiative.
5. To formulate age and disease specific safety practices to include reduction of incidence and severity of falls, decubitus ulcers, delirium, healthcare associated infections, venous thromboembolism and medication adverse events.
Attitudes:
1. To appreciate that adverse drug events must be monitored and steps taken to reduce their incidence.
2. To advocate and help foster a non-punitive error reporting environment.
3. To exemplify safe medication prescribing and administration practices.
4. To appreciate that medical errors are likely to be reduced by the use of redundant systems.
5. To understand the risk management issues of patient safety efforts.
6. To lead, coordinate and/or participate in efforts to create a culture in which issues of patient safety and medical errors can be discussed openly, without fear of repercussion.
Supplemental References, Suggested Readings:
Rose, BD (Ed); Up-To-Date, Wellesley, MA, 2009. Available in Preston Medical Library and 24 hour online access. http://www.utdol.com/enterprise.asp
The following topics should be read during the rotation:
1. Overview of the principles of medical consultation and perioperative medicine.
2. Estimation of cardiac risk prior to noncardiac surgery.
3. Evaluation of preoperative pulmonary risk.
4. Prevention of venous thromboembolic disease.
5. Overview of the management of unstable angina and acute NSTEMI.
6. Antiplatelet agents in unstable angina and acute NSTEMI.
7. Overview of the therapy of heart failure due to systolic dysfunction.
8. Treatment and prognosis of diastolic heart failure.
9. Treatment of DKA and hyperosmolar hyperglycemic state in adults.
10. Management of severe asymptomatic hypertension.
11. Brain natriuretic peptide measurement in left ventricular dysfunction and other cardiac diseases.
12. Nonalcoholic steatohepatitis.
13. Aspiration pneumonia in adults.
14. Treatment of community acquired pneumonia in adults who require hospitalization.
15. Treatment of hospital associated pneumonia in adults.
16. Management of moderate and severe alcohol withdrawal syndromes.
17. Approach to the adult patient with upper GI bleeding.
18. Approach to the adult patient with lower GI bleeding.
19. Overview of parenteral and enteral nutrition.
20. Isolation guidelines for hospitals.
21. Overview of the presentation and management of atrial fibrillation.
22. Evaluation of the patient with syncope.
23. Interventional approaches to the management of cancer pain.
24. Overview of cancer pain.
Procedures:
Chest Radiograph Interpretation
Electrocardiogram Interpretation
Emergency Procedures
Other Resources:
The Resident will benefit from interaction with other members of the healthcare team to include nursing staff, case managers, physical, occupational and speech therapists. They will interact with physicians from both medical and surgical specialties and resident physicians from other disciplines. Members of the pharmacy staff and pharmacy residents will also interact frequently with the Resident.
Method of Resident Evaluation:
Each Resident is informally and continually evaluated during the course of the rotation. It will be the responsibility of the Resident to provide the names of both Attending Physicians to the DOM. A summative evaluation form will be completed by each Attending Physician via New Innovations at the rotation end with direct verbal feedback given.
Method of Rotation Evaluation:
Residents are asked to provide direct feedback to the UHS Attending in an informal manner during the course of the rotation. The Resident will complete a formal evaluation using New Innovation at the end of the rotation. Cumulative feedback to Dr. La Charité will be given yearly by the Departmental Chair in a non-identifying manner.
The Core Competencies in Hospital Medicine: A Framework for Curriculum Development. Edited by Michael J. Pistoria et al. Published for the Society of Hospital Medicine by John Wiley and Sons, Hoboken, NJ, 2006.
Printable Version of Hospitalist Medicine (.pdf)