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Clinical Service and Rotation Structure

CLINICAL SERVICE

Our fellows act as consultants at the UM Hospital (UMHS) but have no primary patient care for any inpatients at either facility. Fellows perform an average of 70-120 consultations per month and may follow a service of 12 to 24 patients at a time for inpatient concurrent care. At the Ann Arbor Veterans Affairs Hospital (VAMC), fellows perform about 30-35 consultations per month and may follow from 10 to 20 patients at a time.

Clinical consultation blocks are scheduled during July-December during the first year and from January-June during the second year of training. Within these 6 month blocks, fellows alternate months of service at the UMHS and the VAMC (i.e., a total of 3 UMHS and 3 VAMC blocks during each block).  During these blocks, coverage for at least two full weekends will be supplied by fellows not on service to reduce fatigue and burnout.  This schedule provides a largely uninterrupted year to (month 7 to month 18) to pursue a significant research project and elective opportunities.

Rounds at both hospitals follow a similar format (see chart below).

Rotation Schedule:

UNIVERSITY HOSPITAL

 

Monday

Tuesday

Wednesday

Thursday

Friday

AM

7:30 Rounds

 

8:00 University Clinic (a)

8:00-9:00 Chief’s Rounds  (Case Conference)

8:00 Overflow Clinic (b)

8:00 VA Clinic (c)

PM

1:00 Micro Lab Rounds (d)

1:30 Faculty Teaching Rounds

1:00 Micro Lab Rounds

1:30 Faculty Teaching Rounds

12:00-1:00 ID Grand Rounds/Journal Club

1:00 Micro Lab Rounds

1:30 Faculty Teaching Rounds

1:00 Micro Lab Rounds

1:30 Faculty Teaching Rounds

12:00 IM Grand Rounds

1:00 Micro Lab Rounds

1:30 Faculty Teaching Rounds

(a) All fellows (frequency may be reduced while at VA clinic for laboratory based research fellows)
(b) Scheduling with fellow permission for urgent follow-up
(c) Month 7-18 of fellowship
(d) Micro rounds at 3:00 pm at VA
(e) Journal Club once a month, pediatric ID once a quarter, includes research conferences, visiting speakers, M&M

Consult patients are seen and evaluated by the fellow and/or medical residents, medical students and attendings in the morning.  The morning hours are also used to conduct follow-up visits to previously evaluated patients.  After the lunch hour, the fellow and the consult team meet with the attending physician to present the new consults and to discuss the progress of patients being followed by the team.  Each new patient and selected follow-up patients are seen with the attending physician and a clinical note composed by the attending, fellow or resident describing the evaluation, diagnostic formulation and management plan is added to the patient’s chart. In most cases, attending physicians write notes for patients seen by medical students. Patient-based teaching occurs during the case presentation and/or at the bedside.  The fellow, attending (or an Internal Medicine Resident) writes a formal consultation report.  The attending physicians review and sign all clinical notes placed in the electronic record, both on new and follow-up patients.

Clinical Microbiology rounds are incorporated into consult rounds on a daily basis (Mon.-Fri).  At the UMHS, these rounds begin at 1:00PM and last until 1:30PM.  At the VAMC, lab rounds occur at 3:00PM.  Laboratory rounds permit the team to learn about and to discuss new significant cultures from hospitalized patients.  In addition, for teaching purposes, the Laboratory staff (under the direction of the staff doctorally trained microbiologist) at the UMHS prepares daily demonstrations of culture and staining techniques or microscopy.

Consult patients seen at the UMHS who require outpatient follow-up are scheduled in the fellow’s outpatient clinic.  If the fellow’s clinic spots are filled, the attending on service will see the follow up patients.  If the attending on service does not have a University clinic, alternative arrangements will be made.

AMBULATORY CLINIC

At the University Clinics, our fellows complete an average of 150 visits per year in the outpatient setting. The majority of these patients were initially seen by the fellow as inpatients including many being treated with outpatient IV antibiotics.   We think it is critical that fellows are involved in the entire episode of care.  Some of these visits are with individual patients that a fellow may follow continuously for the two years of their fellowship.

The fellows have significant responsibility in these clinics. They are the first to see the patients, to assemble all of the necessary data, review it and develop a management plan. The plan is then discussed with a faculty member, and the faculty member either approves or amends the plan. At both outpatient facilities, patients requiring continuing care are assigned to the fellow who performed the inpatient consultation. More than one faculty member may supervise a case on subsequent visits, however a fixed group of attending physicians staff the fellow’s clinics to improve continuity of care. Patients are not transferred from fellow to fellow or from fellow to attending until one of the trainees graduates from the program. At that point, all of the patients assigned to a graduating fellow are transferred to an incoming fellow or faculty member.

Clinics are never held without the physical presence of an attending physician.  After evaluating patients, fellows present all of the relevant clinical data to the attending faculty member, in the clinic staff room, while the patient is still present. The faculty member may use this opportunity to teach, to recommend reading or specific research relevant to the patient’s problems, and to supervise specific details of the management. The faculty member will review and confirm critical physical findings. Fellows will then dictate notes concerning the patients’ visits, which are reviewed by the faculty member before they are added to the medical record.  The fellow’s note is always co-signed by the faculty member.  Fellows will, with rare exception of emergency follow-up, be limited to two weekly clinics.

The HIV/AIDS clinic requirement will be met for all fellows at the VA medical center.  Fellows will see HIV/AIDS patients at the VAMC ID outpatient clinic, and follow them during the course of their fellowship.  All fellows will participate in this rotation for at least 12 continuous months.  Fellows may see additional HIV/AIDS patients in their University Clinic as well, and interested fellows may attend the HIV/AIDS clinics at the University generally during non- inpatient service months.
 
 
   
 
   

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