Department of Medicine

Residency Program

Residency Handbook

II. ROTATIONS

A. General

1. Goals and Objectives for Clinical Rotations
At the beginning of each month, a written curriculum consisting of rotation goals and objectives will be distributed in the resident's mailbox located in the Department of Medicine office. It is the responsibility of each resident to review these with his or her attending prior to each rotation. All goals and objectives are located on New Inovations as well as the Department of Medicine web site.

2. Evaluations

 Attendings, nurses, some ancillary personnel, and patients will complete evaluations on residents. Residents will be asked to complete evaluations of each attending, each rotation, and other residents with whom they have worked. The evaluations we receive provide invaluable feedback on your performance and will be relayed to you quarterly. You have the right to review your faculty evaluations at any time, though peer and nursing evaluations remain anonymous.

Evaluations will be completed by the resident online through a web-based system called New Innovations. These will remain confidential and will not be viewed by the faculty or your peers. Resident evaluations of faculty are seen only by the chairman, though he reviews them prior to annual Faculty Reviews. Please complete these evaluations within 2 days of the end of your rotation.

3. Duty Hours

 Per ACGME regulations, all house staff are limited to 80 hours of work per week (averaged over 4 weeks), must have at least 10 hours off after any in-house duty, and can only take 24 hours of continuous call plus up to a maximum of 6 additional hours for patient care and teaching activities. In addition, all house staff must get one 24-hour period off each week (averaged over 4 weeks). Post-call interns and residents are excused from clinic, but it is their responsibility to cancel their clinic at least 3 weeks in advance of the month in question. Your fellow residents and/or the chief resident will be asked to see those patients who show for a resident's clinic that has not been cancelled.

4. Procedures

 During your residency you will have the opportunity to perform various procedures. Some of these are required in order to sit for the Boards at the end of your residency and some are elective. Procedures must be supervised by someone deemed certified to supervise and may include your ward attending and upper level residents. For certain procedures that your ward attending may not

feel comfortable helping you with, or at times that the attending is

not available, the on-call KIP hospitalist will supervise you if you call them at pager #2737 and make arrangements.

Note that this does not include procedures in the ICU. Please also note that your attending or KIP should be notified prior to any

procedure even if the resident has accumulated the minumum

number of procedures to be considered competent to perform them independently.

The procedure should immediately be documented in New Innovations and the attending encouraged to immediately log on to NI to sign off on it.

5. Scheduling

 All schedule requests need to be turned into the Chief Resident 45 days prior to the month in question, or it will not be considered. For example, a vacation request for May 25-May 30 needs to be turned in by April 1. Endocrinology requires 4 months notice for vacation requests.

The yearly and monthly schedules are now on New Innovations. Any schedule changes must go through Sissy to be approved and entered in NI.

B. General Medicine (Wards)

1. Typical Day:

On Call/Pre-Call

600-800     Resident/intern rounds

800- 900    Morning Report (residents-mandatory; interns-optional)

900-1100   Attending rounds

1030-1200 Teaching Rounds (Tues,Thurs)

1200-1300 Noon Conference

1300-1700 Patient care/clinic

Post-Call

630-800      Resident/intern rounds

800-900      Morning Report

900-1200    Attending Rounds

1200-1300   Noon Conference

1300 - 1700  Attending Rounds or Home( if post- night call)

During the ward months, interns are expected to be in the hospital by 7:30 AM or earlier, depending upon the patient load. Notes should be on the chart by 9:00 AM . Interns are expected to stay until 5:00 PM or until their work is finished. However, post-call interns should complete their work by 1:00 pm and check out unfinished work to the other intern or the resident on the service. Charts should be reviewed prior to leaving in order to act on attendings and consultants recommendations left during the day.

If the intern finishes earlier, they may leave with permission of the supervising resident and if the intern on call is willing to cover their patients, but must leave their beeper on to answer calls on their patients until 5:00 PM .

2. Admissions

a) Process   
 1) Through ER:
When there is a patient needing admission to house staff medicine, the ER physician will contact the on call resident. If the intern is called first, they should immediately notify the resident. Every attempt should be made to see the patient as soon as possible. If it is obvious that the patient needs to be admitted, avoid the temptation to go through a lengthy history and physical and chart review in the E.R. and try to get admission orders written quickly. If a delay is anticipated, then the ER physician should be notified. It is generally advised that the H&P be written on the floor (a written H&P must be on the chart within 12 hours or the beginning of management rounds the next day, whichever comes first). In addition, a dictated H&P must be done within 24 hours of admission.

If the HSM team disagrees with the ER physician that a patient needs admission, then the managing attending must be contacted prior to patient's discharge.

 2) Through Clinic:
All admissions made through the clinic must have an H&P by the intern on call. If a resident admits a patient through the clinic, he may write a Resident Admit Note. However, it is the responsibility of the on call resident to ensure that there is a Resident Admit Note on the chart. Admission orders must be written by the intern on call. The clinic MD should only write non-substantive orders. If the patient is being admitted by a non-MD (e.g. Nurse Practitioner), the intern or resident must go to the clinic and write the admission orders. You should try to see all patients in the clinic if possible.

 3) Direct admits:
Some patients may be admitted directly to the floor by a faculty physician. That attending should contact the on-call resident and/or intern to discuss the case. The patient can then be seen by house staff  upon arrival to the floor and the H&P and orders completed.

b) Second-On-Call Resident
A senior level resident is also assigned second on-call responsibility starting at 5:00 PM . This resident should be readily available by beeper or phone call to the first on-call resident if help is needed. If a resident plans to be out of town or is unavailable for some other reason, then she/he should switch with someone else. The second-on-call resident should also be available to cover the ICU if the ICU resident is unable to do so. If second-call resident does not respond, the chief resident should be called.

c) Admission Caps
The maximum number of patients admitted by an intern is five (5) per 24 hours or eight (8) per 48 hours, plus up to 2 ICU transfers. Any transfers over 2 count as an admission. If an intern has 5 admissions prior to 24 hours, the resident alone should admit all other patients. The resident can admit a maximum of 10 patients in 24 hours or 16 patients in 48 hours, plus up to 4 transfers. If the maximum number is reached (10), the 2nd call resident must come to the hospital and take any additional admissions. The resident will distribute the admissions amongst the interns the next day. The on-call intern is to be physically in-house until their call is over, despite achieving the admission cap for that 24-hour period.

After the limit is reached, the attending has discretion on whether any patients "roll over" to the next team. The intern who picks up a patient who has rolled over to the next day is responsible for writing an admission H&P. The resident on call should notify the attending when the admission cap is nearly reached so that the attending can call the ER to close the team to unassigned admissions.

House Staff Medicine admits both assigned patients and unassigned patients (those with no UT physician). Assigned patients are those from the Residents' Clinic and Faculty Internal Medicine. Unassigned patients with no prior admission to UT are alternated between the teaching service and KIP, until the admission caps are reached. However, prior to reaching the cap, if an unassigned patient with prior admission is readmitted within the next 30 days, the patient goes to the service that last admitted them.

d) Readmissions
Any patient readmitted to the house staff service within FOUR days of discharge by another team goes back to the original team. However, the patient should still be admitted by the on- call team. Any patient transferred from the floor to the ICU, goes back to the original team upon transfer out.

e) No-Fire Policy

No inpatient service (House Staff medicine or KIP) that accepts unassigned admissions can "fire" or refuse to admit an unassigned patient, per a meeting with Drs. Lacey (Chief Medical Officer), Panella, Beuerlein, and Bard.

3. Discharge

a) Planning
If your patient came from a nursing home or other facility or you expect that they will be discharged to another facility from the hospital, fill out the skilled nursing form papers early and consult case management to help facilitate the patient's discharge. Case managers are assigned to each floor. It is recommended that you get to know them and their beeper numbers. Remember, the sooner that you consult them, the quicker your patient can leave the hospital. They also help with patients who have no insurance.

Things to think about before discharge:

• Is my patient on oxygen? Does he need home O2?
• Does he still have a Foley catheter or central line in?
• Has he been ambulating or at least able to transfer from bed to chair?
• Is he eating?
• Is he voiding urine and stool?
• Switch from IV medicines to PO medicines as soon as appropriate. Remember this especially when transferring a patient to a nursing facility. The more your patient costs the facility, the less likely they will be to accept them.

 b) Discharge summaries
Every attempt should be made to dictate a summary at the time of writing the discharge orders when the details of the case are fresh in your mind. At the latest, they should be dictated within 48 hours of patient's discharge. The summary and the discharge orders written in the chart should make absolutely clear which MD will be following the patient and how the patient can reach that MD. Please include an order to fax the discharge orders to the primary care physician (faculty, resident, or outside MD). The intern is responsible for the discharge summary. If the patient is followed by a 4th year student, the student or the resident should do the discharge summary. In the case of a third year student, the intern should do the discharge summary.

Discharge summaries on patients with a lengthy hospital stay who are discharged before the third of the month should be done by the intern who took care of the patient the previous month. Following that, the new intern should have enough knowledge of the patient to dictate the summary. Diagnosis "present on admission" should be listed as such. Be sure to include level of malnutrition and chronic kidney disease if present.

Discharge summaries should include:

1. discharge diagnoses
2. procedures performed
3. hospital course
4. disposition and follow-up
5. pending results
6. discharge medications

c) Clinic Follow-up
Follow-up in the clinic for established clinic patients should be made with the clinic resident who sees the patient in the clinic. If that resident is already booked, it is the responsibility of the ward team to follow up on that patient one time in the clinic and then send the patient back to the original resident.

For patients who are new to the Medicine Residents Practice, the intern who has followed the patient in the hospital should also see them in the clinic. If the intern is a non-medicine

intern (e.g. Family Practice or OB-GYN), then the resident should follow those patients in the clinic.

4. Call

Interns take call every 3rd day, but alternate between day call (8:00 am-5:00 pm ) and night call ( 5:00 pm-8:00 am ) on Monday through Friday and 8:00 am-8:00 pm days and 8:00 pm-8:00am nights, Saturday thru Sunday. Residents are on call with their team for the day time only until 7:00 pm every 3rd day. Night call is taken by 2 night float residents who alternate every 5 days, 5 on-5 off, from 7:00 pm to 8:00 am .

5. Miscellaneous

a) Sign-out
Sign out rounds are MANDATORY . All interns on wards must sign out with the on-call intern before leaving for the day. A formal sign-out sheet should be used. The ward resident is advised to check out the sickest patients with the resident on call. Sign out rounds for MICU should be in depth, and the covering resident should be made aware of any anticipated problems and the course of action to be taken. The moonlighting resident that is on call alone should sign off the next morning to the ICU team. For this purpose the entire ICU team is expected to be present at 7:30 AM and make formal sign-out rounds with the moonlighter; and these rounds should be documented in the progress notes. A sign-out sheet should include patient name, MR #, room #, brief problem list, code status, anticipated problems, and/or special studies that might require action that night.

b) Codes
The code beeper will go off for any code in the hospital.. The medicine resident on call is to run the code with the help of the medicine intern. If the patient's physician is present and wishes to assume responsibility for code, he/she may relieve the medicine code team. Other residents or private attendings may run codes on their own patients if they so wish. The resident who runs the code should sign the code sheet at the end of the code and make a note in the progress sheet. The patient's attending should be notified about the situation immediately. The code beeper must be physically handed over to the next resident by 8:00 AM.

c) Cross-Cover
Interns on call are responsible for house staff medicine cross-cover. ICU cross-over is the responsibility of the ICU intern (or if there is no ICU intern, the ICU resident). Residents are available to help with difficult cross-cover issues. Interns are encouraged to use verbal orders sparingly. If in doubt, go see the patient (and leave a note)! All verbal orders must be signed within 24 hours. Other team members may sign these.

d) Pronouncing a Patient Dead

For patients not on a ventilator, a patient should be examined and the following findings noted on the chart:

1. time of death and date
2. patients medical illness (major)
3. whether patient was coded or was DNR
4. examination:

• presence of pulse
• pupillary response
• presence/absence of spontaneous respirator
• response to painful stimulant

       5.  notification of next of kin, chaplain (if necessary), and                   attending physician

       6.  whether an autopsy was requested and if permission            granted.

Patients on a ventilator are more complicated and may require an apnea test or cerebral perfusion study.

e) Ordering Consults
Please try to be courteous when consulting another service. Consult early in the day when possible, especially on Fridays and weekends. You will appreciate this when you are rotating on electives and have to see the consults. Consults must specify to (1) see at convenience (2) see within 24 hours (3) see ASAP or (4) see STAT. The latter two need to be approved by the attending and a call made by the referring physician.

Consultants are encouraged by the Department of Medicine not to write orders. In order for this to work, interns need to check their patient's charts later in the day to follow-up on consultants recommendations.

f) Checking Radiology Results
Radiology reports are first available on the dictation system. Using any phone, dial 6976 to access the system.

User ID= 999#
Work type= *23
Cardiology reports enter 1   

Radiology reports enter 2

Then enter medical record number followed by #.

These reports have not been verified by an attending radiologist so it is best to follow up on the verified report in PowerChart when it is available.

If you have a stat order or the dictation is not found you can ask a radiologist in the ER to help you or page the radiology resident for help #3333.

g) Restraint policy
It is in the goal of UTMCK to limit the use of physical or chemical restraints as much as possible. This might include the use of appropriate pain medications or anxiolytics, ambulation, use of a family sitter, reorientation, toileting, or use of glasses/hearing aids.

The use of restraints is authorized based on appropriate circumstances, but must be confirmed by a documented examination and assessment within 24 hours of a verbal order. If restraints are continued, a patient must be re-examined and a new note and order set completed each calendar day.

If restraints are ordered by a consultant, the ordering physician must contact the primary physician responsible.

If restraints are removed by a physician order and replaced, a new written assessment and order must be completed.

"Code Green" refers to behavioral leather restraints placed on a patient who is an imminent danger to himself or others and requires an assessment within one hour (e.g. actively suicidal).

h) Unacceptable Abbreviations
The following abbreviations are unacceptable in any part of the medical record including notes, orders, or prescriptions:

Not Acceptable                     Acceptable

.1 mg                                         0.1 mg

1.0 mg                                        1 mg

QD                                             Daily

d                                                 Day or dose

QOD                                          Every other day

IU                                               International Unit

MgSO4 or MSO4 or MS           Magnesium Sulfate

ug                                               micrograms

U                                                Unit

TIW                                            three times weekly

C. Elective Rotations

1.Duty Hours
Hours on elective rotations are dependent on the supervising attending. Some attendings start their day at 7:00 AM while the others start at 9:00 AM . The resident and intern leave when the attending is finished or when the attending allows them leave. (Post-call residents should remind their attendings of the need for them to be finished by 1:00pm .) Please note the 80 hour limit applies on elective rotations, but is rarely an issue.

2. Scheduling

 A resident scheduled to do an elective should make a choice at least one month in advance. Please contact Jane Obenour and tell her which rotation you are interested in and she will check to see if it is possible.

3. Cardiology
Cardiology call is either 6 AM to 6 PM or 6 PM to 7 AM  for a total of 4-5 days plus one 24 hour call on a weekend day each month and is assigned monthly to be consistent with their primary  cardiology preceptor's call. Interns and residents taking the call are expected to handle all problems on University Cardiology (UC) patients and also respond to any cardiac problems or emergencies on private patients. They are expected to do cardiology consults and also admit patients from the ER. They should directly communicate with the cardiology attending on call for any questions or problems. The cardiology intern or resident on call also pronounces UC patients who expire during the night if the attending is not in the hospital. (Please notify the Chief Resident or the Program Director if patients are being admitted by UC without notifying you.)

4. Specialty Rotations

 Endocrinology--Endocrinology Consultants office is located at 1450 Dowell Springs Blvd., Suite 300 . Take the Papermill exit off I-40 and turn right onto Weisgarber. Proceed to Middlebrook Pike, turn left & go approximate.½ mile to right on Dowell Springs Blvd. The office is on the right in the Cornerstone Building . Phone #  637-8812. Please note: Any vacations taken during the Endo rotation must be requested 4 months prior to the beginning of the rotation.

5. Ambulatory Rotation

 Several ambulatory medicine experiences have been selected. The resident will be expected to view the online curriculum for each prior rotation. This will provide details of office location, phone number, and key faculty. Attendance is very important. If a resident has more than two unexcused absences they will receive an "unsatisfactory" evaluation for the rotation and be required to repeat the experience prior to completion of the residency. Vacation is allowed during most of these rotations, but must be approved in advance. Vacation requests must be received completed in DOM no less that 45 days prior to the beginning of the rotation.

The Adolescent Health rotation will be assigned either the UT Student Health Center or with Dr. Lori Baxter. If the resident is assigned to the Student Health Center, a letter should be obtained from the department and taken to UT Parking Services on Neyland Drive to obtain a parking permit. The Student Health Center is located on Summit Drive. From Alcoa Highway take a right onto Cumberland Avenue, right at the second traffic light onto Volunteer Boulevard. Turn left onto Pat Summit Drive immediately after the track field. The Center is on the right.

If assigned to Dr. Lori Baxter, the resident should take Hwy 321 through Alcoa/Maryville. After passing Blount Memorial Hospital on the left, turn right at the bottom of the hill at the next traffic light onto Tuckaleechee Pike (Smith's Mortuary will be on your right). Turn right into Cedar Creek Professional Bldgs. onto Smithview Drive . Dr. Baxter's office is the 3rd building on the left (Cedar Creek Pediatrics). (379-2277).

The resident will be allowed to indicate their preference for assignment during the Rural Health rotation

Nephrology--This rotation now includes an afternoon each week on Thursdays at the Hypertension Clinic with Dr. Thomas Miller at Baptist Hospital. Contact Patsy, his nurse, at 632-5959 to coordinate.

ENT rotation with Dr. Upchurch - This is in his office in the professional building next to Methodist Hospital . Take I-40 west. Pellisippi Parkway North to Oak Ridge . After crossing the bridge take a right on Lafayette Ave. Right on Oak Ridge Turnpike. At 5th traffic light turn left on Tennison Ave. Parking is free.

ENT rotation with Dr. Seals--Ft. Sanders Professional Bldg. (546-5477)

ENT rotation with Dr. Hutson-- Baptist Professional Bldg. (573-7961)

Brakebill Nursing Home --From the hospital, go north on Alcoa Hwy. Take the Neyland Drive exit and turn right onto Neyland Drive . At the top of the hill, turn left onto Kingston Pike. Just past the 3rd traffic light ( Western Plaza is on your right) bear left onto Lyon 's View Pike. Go approximate. 2 miles to Brakebill Nursing Home on your right (there is an art gallery across the street).

Ambulatory Rotation--Satifactory completion of this rotation is based on attendance. If a resident has more that two un-

excused absences, they will receive an "unsatisfactory" evaluation for the month and will repeat it during the final month of their residency.

Dr. James Farris' office--take I-75 North to the LaFollette exit

(#134). Turn right and go approx 7 miles on Highway 25W. Proceed into LaFollette and look for the CVS Pharmacy (close to Pizza Hut). Their office is beside the pharmacy at 109 Independence Lane, Suite 200. The telephone # is (423) 562-4968.

Dr. John Zirkle/Dr. Stephen Gantte's office --Take I-40 East to the Strawberry Plains exit. Turn left onto Hwy. 11E to Jefferson City . Follow the signs to the hospital. Telephone # is 475-2061.

D. Emergency Room

The ER department schedules interns and residents in shifts. These are scheduled before the start of the month by the supervising ER physician. A shift is 7 AM to 7 PM or 7 PM to 7 AM with a total of 14 to 15 shifts per month (usually 7 days and 7 nights).

E. Intensive Care Unit

1. Duty Hours
When not post-call, interns and residents are expected to stay until 6:00 PM , unless the attending allows them to leave earlier than that. Post-call interns and residents should leave the ICU by noon. One resident should be present in the ICU by 6:00 am every day.

2. Transferring Patients to the Floor
It is the responsibility of the ICU intern or resident following an ICU patient to call the HSM intern promptly prior to the patient's transfer to the floor.

3. Patient Transfers to Critical Care
If critical care is consulted or asked to assume care of a patient by another service and the critical care resident does not agree that the patient needs to be transferred to CCM, the critical care resident must discuss the case with the critical care attending and document it.