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Rotation Information (back to top) Faculty: Maureen Brown, MD Resident Chairperson (2001-2002): John Lippmann, M.D. All Family Medicine Clinic patients are initially admitted to the FP service. If admitted from the clinic, the admission is cleared with the clinic faculty. R-3s will function as the team leader and will act as the "attending" for all family practice in-patients, and patient care questions will be triaged by the R-3 first. In a similar fashion, patient management questions for those patients that are admitted in the middle of the night will go through the R-3 first. Attendings will be informed in a timely fashion by the R-3 and the details of the case will be discussed in the morning. Unstable Admissions to Swedish Hospital: 1. ICU/CCU/NICU: Family Medicine Clinic patients admitted to the ICU/CCU will be admitted by the resident to the Family Practice Service or to the ICU attending. The Family Medicine faculty attending and the primary resident may round on the patients daily and provide input regarding management. Frequently, a critical care physician from the medicine teaching panel will also be involved. Upon discharge from the unit, the patient is picked up by the FPS. Clinic patients admitted to the unit may be followed by the inpatient team if agreed upon by all team members and the faculty attending. (For a more thorough discussion of ICU/CCU topics, please see chapter 11) 2. Term Obstetrical Patients: (36+ weeks gestation) are admitted by the primary resident unless other coverage has been arranged. The primary resident must provide or make arrangements for in-house coverage for such patients who are in active labor (see OB curriculum for details). Obstetric patients at less than 36 weeks gestation are admitted to the inpatient Family Medicine service. Weekend or evening admissions are the responsibility of the inpatient resident, although the primary resident may be notified and may elect to admit the patient. 3. Patients Requiring Immediate Surgery: The resident who makes the decision to admit a FPC patient for immediate surgery may arrange for a family practice resident to assist on the case. The primary resident gets first choice. The admitting resident has second choice, but may elect to offer the case to any other available resident. However, if an available resident cannot be found, the admitting resident is responsible for the case. If needed by the surgeon, these patients are followed by the primary resident and the resident on the surgery attending's panel (i.e., the surgery service). Family Medicine Service Guidelines Function of the Service The FP Service (FPS) rotation comprises a significant portion of the General Medicine curriculum. It functions independently of the Internal Medicine/CCU Service, although they parallel each other in accepting general medical admissions. The FP Service will also admit and follow pediatric cases, medical complications of pregnancy, and selective gynecologic problems. Admissions to the FP service come from: 1. FP Clinic Attendings and residents: Clinic residents and attendings may admit patients to the FP Service. All clinic patients will be admitted to the FP attending of the month, with the exception of individual faculty patients. The MD who makes the decision to admit the patient will perform initial evaluation and stabilization, with holding orders as needed. The role of the primary clinic resident in the care of the patient while hospitalized is variable and is dependent upon availability, time, and interest. The admitting resident functions as usual, writing complete H&P, orders, and managing cross-cover, etc., unless the clinic resident and FP Service resident agree to function differently. 2. A loosely designated panel of attendings: Most admissions come from a designated panel of attendings. The purpose of the panel is to cultivate a harmonious relationship between residents and attendings and, thereby, facilitate a better learning experience by establishing a more definite and visible role for the residents, by involving residents more in the decision-making process and the writing of orders, and by decreasing the frustrations that can result from ambiguity of roles in the management of patients. The list of attendings is selected by the residents and the FP faculty at the annual Curriculum Day Retreat and is subject to periodic review by the Medicine committee and faculty who will address any problems regarding a particular attending's performance. Residents also accept admissions from non-panel attendings, unless they are completely swamped with clinic patient admissions, OB triage, etc. 3. Some ER patients with no doctor: Patients without primary physicians admitted to the ER may be admitted to the FP Service and have the FP Service attending function as the main attending. This must be cleared with the faculty member prior to admission since that person will be the attending physician of record. If the census of the service is low, the faculty member should not deliver no-doc admissions. Roles The FPS team consists of R-1, R-2 and R-3 members to total 7 residents who alternate every fourth night call. 1. The R-3 - is the team leader and supervisor. The R-3 conducts ward rounds in a format which they choose, which typically includes X-ray review, bedside rounds on new patients, and work rounds. When on call, s/he is responsible for primary daytime supervision of the R-1 on call. The R-3 will write an abbreviated Senior Resident Admit Note on each admission when on call. S/he maintains a log of admissions. S/he does not follow individual patients or write progress notes on a regular basis, except during weekend coverage. The R-3 attends and coordinates all ward team functions. R-3's generally have 2 half-days of afternoon clinics per week and should not be assigned drop-in doctor duties. The R-3 insures that there are adequate numbers of admissions on the service (R-1's should be managing a minimum of 3 patients each, and a maximum of 10). Teaching: The R-3 should assign a mini-didactic topic to each R-2 weekly (15 min discussion on patient related topic). The R-3 presents one didactic per week during attending rounds.
2. The R-2 – Each of the (2) R-2's will supervise the daily work of two R-1's on the team. The R-2 is the supervising resident when the R-1 is on call. R-2's will have two interns that they are specifically responsible to supervise. Supervision consists of reviewing orders, radiology studies, medication dosing, patient safety related factors, and examining patients whose acuity or complexity requires it. R-2s on the service supervise the R-1 during non-call days until the back-up night resident comes on duty. The nighttime back up resident is either the R-2 on service or an R-2 on a non-call service. S/he provides in-house back up from 5:00 - 5:30 p.m. until 8:00 a.m. for admissions and cross-cover. At the beginning of the year when the interns are less experienced, the back-up resident should see every patient and go over the orders and any pertinent labs with the R-1. As the year progresses, the R-1 may not require such close supervision, but s/he should still present every admission to the back-up resident and review the orders and treatment plan. R-2 residents are required to read and co-sign all admission H&P's, which they may amend at their discretion. R-2's are not required to be present for the initial H & P, but should perform their own evaluation of patient within an hour of admission. The R-2 will write an abbreviated Senior Resident Admit Note on each admission when on call. R-2's generally have 1 half-day of afternoon clinics per week and should not be assigned drop-in doctor duties. Teaching: The R-3 will assign a mini-didactic topic to each R-2 weekly (15 min discussion on patient related topic). 3. The R-1 - shares call every fourth night with team members, functioning under the supervision of the R-3 or on-call backup resident. Because the R-1 carries the FP Service pager and answers admission and cross-cover pages, it is his/her responsibility to call the supervising resident when there is a new admission or question. Unless the patient is seriously ill, the R-1 should see the patient first. It is highly recommended that the R-1 discuss with the back-up resident what his/her need and expectations are. As on the Medicine service, the R-1 is expected to contact the patient's attending to discuss the treatment plan. Daily notes should be on the chart by 9 a.m. They have one afternoon clinic per week, which will not be scheduled on their call days or post call days. 4. The FP Attending - is an FP faculty person assigned to the FP Service on a two-week rotation. His/her role is that of consultant/teacher, as well as attending with direct patient care responsibility for the Family Medicine Clinic patients while in the hospital. He/she will go over all clinic admissions with the R3 as well as the resident taking care of each admission and is expected to round daily on the clinic patients and discuss management issues with the primary R-1 or R-2 involved. FP attending rounds are held Mondays, Wednesdays, and Fridays from 11:30-12:30. The FP attend will present one topic per week in attending rounds. Cases may be presented and/or any pertinent inpatient or outpatient topic may be discussed in a didactic fashion. Two Fridays per month at 12:15, Dr. John Olsen from cardiology presents cardiology rounds. The FP attending is expected to be present at daily work rounds. S/he should also be available to act as a liaison for conflict resolution between the ward team and private attendings. On weekends and holidays, other faculty members may rotate call responsibilities. Didactics & Work Rounds Monday 7:30 am: Morning openers. Admitting resident presents new admissions to the team in a concise format. Progress is reviewed on other patients. The attending will be present to hear presentations on service patients and provide input as necessary. The bulk of teaching should be reserved for attending rounds. Saturday 8:00 am Sunday 9:00 am: FP service residents round with the weekend faculty attending on clinic patients on the service. Monday, Wednesday & Friday 11:30 am - 12:30 pm: Family Medicine Attending Rounds - most didactic or case teaching should be reserved for this time. Tuesday afternoons: Residency didactic teaching conferences Wednesday 7:30 am: Family Medicine Case Conference Thursday 10:30 am: Radiology rounds Medical Student Participation Medical students from the University of Washington or other medical schools will occasionally participate in clerkship electives on the Family Medicine Inpatient Service. The medical students, depending on their year of medical school and degree of experience, will assume appropriate responsibilities in patient management, but it will always be under the direct supervision of faculty and residents. Requirements include: 1. Students will make it clear to patients that they are students and that they work directly with a supervising physician. 2. Students will be preferentially assigned Family Medicine Clinic patients, but non-FPC patients can be assigned with the approval of the private attending physician. 3. Students will co-manage patients with R-1's with direct supervision of a senior resident. 4. Students will hand-write an admission history and physical exam on patients, and it will remain in the medical record. It will be reviewed, critiqued, and co-signed by the supervising physician. The supervising resident physician will be responsible for the official dictated H& P and discharge summary. 5. Students will take in-hospital call on an every-seventh night basis, teamed with either an R-2 or R-3 resident. 6. Students will be responsible to arrange their own housing while in the Seattle area, as well as provide their own malpractice insurance and health insurance. 7. The number of patients followed by any student will be determined by the supervising R-3 resident, based on the student's year of medical school and demonstrated ability. 8. The evaluation form for the student's performance will be completed by the FP attending of the month, with input by all team members. Call Call begins at 9 am daily. Night call begins between 5:00 - 5:30 pm. The on-call resident(s) will not be scheduled in clinic that day. Generally, the admitting resident will take all admissions during the 24-hour call period. At the discretion of the supervising R-3 on service in a particular month, this plan may be changed. On a particular call day, admissions may be limited to 5 per 24 hours at the resident's discretion. Two exceptions to the limit will be that 1) all clinic patients admitted via the ER will be admitted to the FP service and 2) Vashon Island patients will be admitted to the FP service at all times. Admissions are presented at 9:30 am ward rounds each morning. Charts As a service to the attending, residents will dictate all admission notes, as well as have a brief handwritten H&P on the chart by the morning after admission. Discharge summaries will be the obligation of the attending physician , except for clinic patients admitted. In those cases, the FP service admitting resident will dictate the discharge summary, with the attending or primary resident being responsible for addressing outpatient follow-up matters. Clinic resident patients should be admitted with the FP service attending listed as admitting attending. Faculty patients admitted to the service will be admitted under that faculty's name. All FP service patients should have an "FP Service" label on the front of the chart stating who the primary resident is and the bellboy number of the service. A communications sheet should be placed in the front of the chart.
Transfer of Patients to the ICU/CCU If a ward patient or new admission requires transfer to the ICU/CCU, the resident on duty may contact the admitting senior Medicine resident to notify them of the transfer. Transfer orders and transfer note will be written by the FP service resident. Once the patient is in the ICU/CCU, a member of the inpatient team will informally follow the patient and report on the patient's progress during rounds. The FP service resident will resume care when the patient is transferred out of the unit. Codes The inpatient on-call R-2 or R-3 will hold a pediatric code pager and will be responsible for supervising the rare instance of pediatric codes. All residents will have PALS certification early in their R-2 year. The on-call resident, regardless of year in training, will also be alerted to hospital wide adult codes, which are supervised by the medicine housestaff. The family medicine inpatient resident should attend all adult codes, especially at night, to offer assistance to the code team. ER Responsibilities On times when there is no FP resident in the ER, the ER may call the FP service resident, in his/her capacity as clinic call resident, to evaluate FP clinic patients in the ER. The FP clinic call resident is obligated to see any FP clinic patient in the ER who s/he instructed to come to the ER in a previous telephone contact, except between 12 midnight and 7:00 a.m., when he/she may elect not to see these patients. Clinic patients who arrive in the ER without prior telephone contact may be seen by the resident at his/her discretion, depending upon other responsibilities. Sign-off The FP service may sign off patients (when O.K.'d by the supervising R-3) when a patient's medical problem has stabilized and the patient is only awaiting placement or when there has been unresolved conflict between the ward team and the attending over management. Weekends and Vacations Each resident is allowed one full weekend off per month. On weekends, the post-call and on-call residents round on the entire team's patients. One week of vacation time may be taken per block by one of the R-2's if they so elect, during those months when there are five residents on the team. Other vacation requests will be considered by the chief resident. Emergency Department Rotations for R-1s Time Commitments
2. The first day of the rotation the resident is expected to present a schedule of obligation for the month. Any other special request must be accompanied by a letter of approval from Dr. Tuggy. Permission for such special request will still be given at the discretion of the Emergency Attending. 3. Prior to beginning the rotation, an orientation to the department will be given by the Department Manager, Julie Campbell, RN. This orientation should be scheduled in advance with Julie (386-2592). 4. The R-1 will be released at the discretion of the Emergency Attending Physician two to three times a week at 7:30 A.M. to go to South Surgery to practice intubations. Residents should go to the anesthesia workroom in main surgery on those mornings for assignments. 5. Two mornings every week R-1's will be excused for clinics in the FPC.
Dress Code 1. All residents are expected to wear a white coat with the appropriate Swedish Hospital blue identification tag/photo I.D. 2. Male residents will be expected to wear a tie. 3. Residents will be expected to wear stockings or socks; bare feet and thong sandals are not acceptable. Didactic Experiences 1. Emergency Medicine differs from Family Medicine in that in the Emergency Department multiple patients must be handled simultaneously. The R-1 must realize this is a goal, but will not be expected to manage more than one patient. R-3's will be expected to manage several patients simultaneously. 2. It is impossible to teach anyone the full scope of the pathology that presents in the Emergency Department. What we hope to do primarily is to develop judgment and to teach an approach to the emergent problems you will face in primary care. 3. The R-1s will be expected to learn to recognize, treat and appropriately handle disposition of acute problems such as MI, pulmonary edema, bronchospasm and traumatic injuries. 4. Techniques such as suturing, splinting, intravenous line placement and ABG collection will also be emphasized. 5. In addition to the above, R-1s will be required to show a proficiency in basic CPR and familiarize themselves with emergency equipment. Julie Campbell, RN, Department Manager, will be responsible for working with the resident on these skills. Prescribing of appropriate medications will be emphasized during the R-1 rotation. The attending physicians will help with this instruction. Chart completion should also be learned at the R-1 level. 6. Residents should present a list of any specific areas of interest the first day of the rotation. The Emergency Attendings will make every effort to work with the residents in reviewing such interests. 7. Dr. Mailman has developed a reading file for all residents in the ED. Residents should familiarize themselves with the contents and use this for reading material during slow time in the ED. 8. Evaluation of the R-1's performance during the rotation will be made by all the attendings. The review will then be given to Dr. Tuggy for inclusion in the resident's file. Relationship with the Emergency Department Attending 1. The Emergency Attending has the ultimate responsibility and liability for every patient seen in the Emergency Department. Furthermore, Medicare/ Medicaid regulations require the attending to have reviewed every case with the housestaff. 2. The R-1, therefore, should present every case to the Emergency Attending prior to ordering any labs or contacting any other attending. The Emergency Physician and the resident will decide on an appropriate course of diagnosis and treatment together. Family Medicine patients must also be reviewed by the Emergency Attending as they are technically E.D. patients while in the E.D., although FPC residents will be responsible for evaluation and treatment of all FPC patients. The latitude to relax these guidelines will be at the discretion of the attending, not the resident. 3. Before a resident can admit a clinic patient, the ED physician must first discuss the case with the FP attending physician, who will then determine whether to admit the patient; then the on-call resident is to be contacted by the FP attending physician. This policy also includes No-Doc admissions; our FP faculty has to OK any No-Doc admits before a resident physician can evaluate the patient in the ED. Emergency Department Rotations for R-2's Emergency Department experience for R-2's is provided at the Mary Bridge Children's Hospital. See Pediatrics section.
Emergency Department Rotations For R-3's Time Commitments The resident will be expected to report to the Emergency Department at 6:00 P.M. on weekdays and 12:00 noon on Saturday and Sunday. The resident may leave the E.R. at 10:00 pm after checking with ED staff to be sure that no Family Medicine patients are present or en route. S/he remains responsible for any Family Medicine patients that need to be seen emergently until 12 midnight. The resident sees all Family Medicine patients and is supervised by the ED attending physician, and the Family Medicine faculty on call is the ultimate backup. When patients are admitted through the ED on these days, the resident on call for the FP Service is expected to be available to see and admit the patient. R-3's will be assigned a total of 45 shifts in the ED during the third year. In House Emergencies (See "Duties of Back-Up Resident.") Dress Code (Remains the same as for R-1's.) Experience R-3's are expected to build on their experience gained as an R-1 in the ED as well as their hospital rotations. R-3's learn the systematic approach to patients seen in the ED setting, and treat the spectrum of problems ranging from simple surgical problems to managing the critically ill. The residents work closely with the ED attendings to outline diagnostic, therapeutic and disposition planning. Every patient is presented to the ED attending physician before the patient leaves the department. The resident should contact the patient's private physician for any admission, questions about disposition and most problems that will require follow-up. Evaluations Each resident's performance is evaluated periodically by the ED staff, and results are presented both in writing and directly to each resident. Early on, this gives feedback so adjustments can be made and progress assessed. Emergency Department Coverage When a Resident is Not on Duty in ED It is the expectation that all FPC patients presenting to the ED will be seen by a resident when a resident is assigned to duty in the ED. On other shifts, the senior resident on the Family Medicine service, who is also on-call for the clinic population, will see FPC patients instructed by him/her to come to the ED for evaluation except after midnight. In these instances, the resident will call the ED and notify the staff that a FPC patient will be arriving. Upon arrival of the patient, the FP resident will be notified by the ED staff and will see the patient in the ED. FPC patients who arrive unannounced to the ED without prior telephone triage by the FP resident on call for the clinic will be treated like all other ED visitors and may be seen by the ED staff without contacting the FP resident on call. Parent-Child Development Elective This is an elective for residents (male or female) that become new parents during residency. The educational objectives are as follows:
To
be able to experience the role of physician as patient.
To develop expertise in the management of pregnancy and delivery by immersing residents in the medical literature on these issues while concomitantly experiencing the state To
be able to express an understanding of the effect of childbirth on career
To
form a working partnership in the small group setting with fellow residents
and faculty members as the foundation for subsequent patient-doctor and
professional relationships
To
become familiar with general literature and psychosocial literature relating
to childbirth and parenting
To
study sociological and cultural aspects of parenting, including the changing
role of fathers, the reemerging role of the midwife, the differences between
ethnic groups with respect to parenting roles
To complete an independent project. This project must be approved thirty days prior to the start of this elective. The resident will still have three half days of clinic per week. The following readings should be completed over the R-1 year while on FP Inpatient Service:
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