Residents in the Department of Internal Medicine rotate through the University of Michigan Medical Center, the Ann Arbor Veterans Affairs Healthcare System, and numerous community-based General Medicine and subspecialty practices. Together, these settings provide the trainee with exposure to a diversity of patients and their diseases.
The University of Michigan Medical Center
Consistently rated by the U.S. News and World Report as one of the top hospitals in the United States, this world-class facility, housed in a modern facility that opened in 1986, serves as a referral center for the entire state of Michigan and the upper Midwest of the United States. The institution attracts a broad and diverse patient population, which together with state-of-the-art technology, computerized medical information systems and strong ancillary support services creates an outstanding learning environment. The Department of Internal Medicine has more than 1,500 admissions to its service each month. The inpatient operations are designed to maximize exposure to the expertise of our faculty, on the part of the patients as well as the learners.
Veterans Affairs Ann Arbor Healthcare System (VAAHC)
Located just 0.5 miles from the University of Michigan Medical Center, the VAAHC is a major referral institution within the Veterans Health Agency. It is responsible for providing primary, secondary and tertiary care to veterans residing in the lower peninsula of Michigan and also Northwestern Ohio. A new clinical addition, which houses the intensive care units, a new medical procedures unit, and all general medicine and ambulatory specialty clinics, opened in May of 1999. More than 3,000 patients are admitted annually to the Medicine service. All of the attending staff physicians are full-time faculty members of the University of Michigan Medical School, with full representation of all subspecialties.
General Comments and Sample 3-year Schedule
Residents rotate through a variety of inpatient services at the University Hospital and the VA Medical Center.
At the University Hospital, the rotations are designed to match the expertise of our faculty to the presenting complaint of the individual patient. The VA hospital inpatient services help to provide a broad general medicine experience including ICU patients. Together the experiences provide excellent clinical and teaching exposure.
At the University, Subspecialty, Generalist, Hospitalist and Critical Care services have been created to provide a balanced experience for the residents and early exposure to subspecialty attending staff in the major medical specialties. Each service has a faculty director who is responsible for the coordinated clinical and educational activities for that service. An updated curriculum of goals and objectives, along with material from conferences such as slide shows and important journal articles is available on a web-based platform available from any computer in the hospital. Throughout their course of training, residents are exposed to both generalists and specialists as supervising attending physicians, who are selected based upon teaching evaluations. All of our inpatient attendings serve as both the inpatient care supervising physician and the teaching attending. There are no private attendings. Our inpatient services both care for the general medicine needs of the surrounding community and serve as a tertiary referral center.
Inpatient Service Configurations
Following is the current configuration of inpatient services in our residency program:
There are four General Internal Medicine services, each with one senior resident, and two interns. These services admit general medicine cases as well as a wide variety of endocrine, renal, rheumatology, and infectious disease patients.
There are two different subspecialty services - Gastroenterology and Hematology/Oncology. Two senior residents, and four interns staff each subspecialty service which is staffed by leading experts in these specialties.
The Hospitalist service is staffed by four senior residents and staffed with hospitalist attendings. They care for both general medicine and subspecialty patients, accepting admissions after 5 p.m. The senior residents cap at five new admits. This service provides a broad patient care experience and exposure to attendings in the rapidly growing field of hospital medicine.
Three Cardiology services each have one senior resident, and two interns. The cardiology services follow patients admitted to the telemetry floor.
Our CCU is staffed by two senior residents and two interns, under supervision of the cardiology fellow and attending, and is a closed intensive care unit. Teams alternate admissions.
The Critical Care Medicine service consists of five house officer teams, each with one senior resident and one intern who work under supervision from the pulmonary/critical care fellow and attending. The CCMU is a closed intensive care unit. At night, these teams (with the exception of the hospitalist service) are staffed by our night team interns and seniors.
The general medicine service consists of four teams each with one attending, one senior resident and two interns. The intensive care unit team consists of three senior residents, a pulmonary fellow and a faculty from the division of Pulmonary and Critical Care. A faculty only hospitalist team serves to help keep case volume on the resident teams stable.
Call structure varies based on service. The cardiology teams, and the three seniors in the VA ICU alternate admissions every third day and have one day free of admissions/holdovers. Our VA and University general medicine services take call every fourth day and also have two days free of admissions/holdovers. Call days are from 7 a.m. until 9 p.m. for interns. Post-call days are from 7 a.m. until 7 a.m., and the remaining days begin no later than 7 a.m. and end when work is done.
Interns have night team rotations, but they do not have overnight call.
Non-resident Covered Services
In addition to the resident services, there are several non-resident services that help to reduce resident workload. At the University Hospital there is a large hospitalist service service run by faculty that manages a census of 110 patients (about 30 percent of the total inpatient medicine census) without resident involvement. In addition bone marrow transplant, chemotherapy, post-cardiac procedure, and heart transplant patients are cared for by non-resident services. The VA has its own non-resident hospitalist service that manages up to 20% of the inpatient medical census.
Computers and Technological Innovation
At both the Ann Arbor Veterans Affairs Healthcare System and the University Hospital, an extensive electronic medical record, which includes more than 10 years of patient information, allows quick-and-easy access to patient care data (including all documentation) both on- and offsite. The system at the University incorporates sign-out functions and allows for easy generation of a discharge summary thereby eliminating the need for dictating charts in the inpatient setting. Computer order entry has been in place at the VAMC for several years and a state-of-the-art order entry system was implemented at the University Hospital in 2008. To help facilitate patient care, all interns are issued wireless-internet ready laptops to be used during their intern year. In addition there is ready access to computer terminals on all units at the University and VAMC. UMHS is implementing a new EPIC based EMR in 2014.
Clinical and Ancillary Support
Ancillary support is excellent at both hospitals. The University Hospital has 24-hour phlebotomy and IV services along with the full array of radiology and other support services. The VA Hospital also has regular IV and phlebotomy support. All radiology studies, including CT scans and MRIs are completely digital (filmless) at both hospitals.
Residents rotate monthly through the consult services for each of the individual medical subspecialties as part of elective rotations. The elective rotation for each of the subspecialties is coordinated to include scheduled time in the outpatient clinic, combined with daily rounds on the consult service. The aim of these rotations is provide focused exposure to subspecialty medicine (including outpatient clinics as described in the outpatient clinical experience section) which is vitally important in helping residents make informed career choices. Every effort is made to provide early exposure to those residents interested in particular specialties. These rotations also allow all residents to learn the important role of medical consultant to both medical and surgical teams – something that is equally relevant to residents pursuing generalist or specialist careers.