Family Practice Service Rotation Overview

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 junior attending for all family practice in-patients.  The details of the case will be discussed with the attending at rounds in the morning.

1. ICU/CCU/NICU: Family Medicine Clinic patients admitted to the ICU/CCU will be admitted by the resident to the Family Practice Service . The Family Medicine faculty attending and the residents round on the patients daily and manage the patient with the ICU Attending consulting.  Upon discharge from the unit, the patient continues to be followed by the FPS.   The FM Hospitalist R2 is responsible for the initial evaluation and transfer of patients to the ICU/CCU/NICU depending on the age of the patient.

2. Term Obstetrical Patients: (36+ weeks gestation) are admitted by the senior resident unless other coverage has been arranged. Patients in active labor will be further managed by their primary resident.  OB patients necessitating admission to antepartum will be admitted by the family medicine team.   The FM Hospitalist R2 is primarily responsible for management of the patients until their PMD arrives in house. (see OB curriculum for details).

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).

The FM Service (FMS) rotation comprises the major portion of the General Medicine curriculum. It functions independently of the hospitalist-run Internal Medicine/CCU Service, although they parallel each other in accepting general medical admissions. The FP Service will also admit and manage pediatric cases and medical complications of pregnancy.  

Admissions to the FP service come from:

1. FP Clinic Attendings and residents:

Clinic residents and attendings may admit patients to the FP Service. The admitting resident takes complete H&P, writes orders, and manages cross-cover, etc.  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. 

2. Internal Medicine Panel of attendings/hospitalists:

Admissions also come from a designated panel of doctors in the community.  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.   

Residents may also accept admissions from non-panel attendings, unless they are completely swamped with clinic patient admissions, OB triage, etc.

3. ER patients with no doctor:

Patients who present to the ER but who do not have a primary provider may be admitted to the family medicine service.  Typically, 1-2 such patients are admitted per day.  

The FPS team consists of R-1, R-2 and R-3 members to total 5 residents who on on the day team.  There is an R1 and a senior resident (R3 or an R2 on night float on the FM rotation or the R2 Hospitalist rotation) who provide night coverage for the FMS patients, new admissions and OB triage.

1.  The R-3 - is the team leader and supervisor. The R-3 conducts daily 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. 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 facilitates a weekly case conference during which an intriguing inpatient case is presented and discussed.

FP service patients - The R-3 should assume the role of junior attending for management decisions regarding FP service patients.  When decision points arise in their management, the R-3 is actively encouraged to make clinical decisions about the patients care that may be posed by the intern involved in the case.  These decisions should be reviewed with the attending in a timely manner depending on the complexity of the patient's illness.

 2.   The R-2 Hospitalist   –  The R-2 FM Hospitalist works closely with the FMS team, coordinating admissions to the team and managing triage of patients arriving in the ED.  The R2 is responsible for phone triage during the day for incoming calls to the FMS service or when on night float, covering PM calls as well as supervising the FMS R1 on duty at night.  The R2 hospitalist manages patients in early labor and in OB triage, reporting to the on-call attending for OB.  The R2 FM hospitalist attends teaching rounds for the FMS service and works under the direction of the R3 FMS chief to coordinate admissions, transfers and supervision for the team.  The nighttime back up resident is either the R-2 hospitalist or an R-2 or R-3 night float resident. S/he provides in-house back up from 7 PM until 7:00 AM 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 R-2 resident and review the orders and treatment plan. R-2 residents are required to read and co-sign all admission H&P's; amendments will be discussed with the R-1.  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.  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 an R-2 or R-3. 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 FM Attending - is an FM faculty member 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.  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.

Call begins for FMS team members at 9 am daily. Night call begins for floating seniors at 5:00pm. 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.

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. 

All FP service patients should have an "FP Service" label on the front of the chart stating who the primary resident is and the pager number for the intern on call.

If a ward patient or new admission requires transfer to the ICU/CCU, the FMS team will continue to care for the patient in the ICU.  Transfer orders and transfer note will be written by the designated R2 FP on call 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.

All residents will have PALS certification early in their R-2 year. The on-call residents will be alerted to hospital wide adult codes, which are supervised by the medicine house staff. The family medicine inpatient resident should attend all adult codes, especially at night, to offer assistance to the code team.

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.

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.

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. No vacation is taken during the FMS block.  

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 1-2 night float, teamed with an R-1 and R-2 duo.

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.