ANW Residency policies
Admitting faculty, definition
Attending physician, responsibilities of
Moonlighting 1/house officier responsibilities
Moonlighting 2 responsibilites
Moonlighting 3 responsibilities
Number requirements for procedures
Residents,
responsibilities of
One of the key components of the Internal Medicine residency program at Abbott Northwestern Hospital is the inpatient resident’s service. This service consists of six teams, each with a second year and a first year resident, along with one or two University of Minnesota medical students.
Patients admitted to the resident service will be under the supervision of the admitting faculty. A majority of admits will come from the ANGMA hospitalist, COC, and Medicine Clinic faculty, and some will come from other hospitalists. The role and responsibilities of both full-time faculty and admitting faculty members are the same when they are serving as a patient’s attending physician. The familiarity of attending physicians and residents with each other is important for building trust and communication as well as for the role modeling and other informal education that the faculty bring to the program. Each attending physician must be a committed, enthusiastic, and dedicated physician who is medically competent and an effective team leader and teacher.
Appointment of physicians to the admitting faculty is made by the Medical Education Department in consultation with the Internal Medicine Graduate Medical Education Committee. Continued participation in this program is not a function of an attending's popularity with the residents but is based on a careful evaluation of his or her overall competence as an attending physician and evaluations. Appointment to the admitting faculty is a strictly educational matter and has no impact on any other credentialling issues at the hospital.
RESPONSIBILITIES of the ATTENDING PHYSICIAN
1. The American Board of Internal Medicine requires that "All faculty members must be certified by the ABIM or present equivalent credentials or experience". Each member of the admitting faculty will be an internist or internal medicine subspecialist who admits at least 12 inpatients per year to Abbott Northwestern hospital. In addition, admitting faculty need to be present in the hospital throughout the day, and be readily available to the residents on the case.
2. The attending is usually responsible for informing the patient or family about the involvement of the residents as part of the care team. Patients or families may refuse to be involved with the residents' service. There should not be a different standard of appropriateness for nights and weekends. Admission to the residents’ service is accomplished by telling chief resident or G2 on-call after 4pm weekdays and on weekends that the patient should be on the residents’ service. Either of these two will know if the residents’ service is closed because the maximum admission load has been reached.
3. Appropriate patients are patients who need an evaluation and some active medical care. However, appropriate does not mean only rare disease or critical illness. The residents' service also needs common internal medicine problems. Patients who have already been evaluated and are being admitted for a scheduled procedure or for one day therapies are rarely appropriate for admission. The residents’ service should not be used to perform elective, routine pre-procedural/pre-therapy histories and physicals,. Internal medicine consults should primarily go to the consult service when available, but on weekends occasional consults may be placed on the resident teams. An occasional patient not initially admitted to the residents’ service may develop new problems or diagnoses that make the patient appropriate to be transferred to the residents’ service. The attending should call the chief residents (during weekdays) or G2 resident on call (nights and weekends) to discuss such a transfer.
4. The attending is the leader of the patient care team. This leadership is exercised through a commitment to discussion and the use of medical evidence and critical thinking. Attendings must be willing to take the time to explain and support their conclusions and plans, often with support from the medical literature. An attending should also value the thoughts of the residents and should help the residents cultivate a healthy skepticism regarding medical knowledge and practice.
5. The attending physician will read the residents' notes and respond to them. Attending physicians must make appropriate documentation daily. Attending physicians enter specialized procedure and therapy orders (e.g. perioperative, endoscopy, dialysis and chemotherapy), but will not enter other orders on a resident service patient unless the orders are pressing and the patient's resident team is not in the hospital. In this case, the attending should either call the night float resident or ask the nurse to verify the order with the resident before executing the order so that full communication with the residents is maintained. Our system of morning sign-outs ensures that these pressing orders can then be communicated immediately from the night float resident to the patient's regular resident team. Attending physicians should not implement important patient care measures (e.g. discharges or sending a patient for a procedure) without having discussed the measures with the resident team. We can expect full resident responsibility and reliability when they are treated as full partners and colleagues in the care of the patients. The residents, as students, need critical evaluation of their work and appropriate correction and guidance. This must be done in a respectful and collegial way.
M1 MOONLIGHTING/HOUSE OFFICER RESPONSIBILITIES
6/15/07
Pager 654-5829
The M1/House Officer (5pm — 8 am) moonlighting position is open to G3s and off-ward G2s.
The M1 moonlighter does admissions for ANW hospitalist service and COC clinic pods of ANGMA seven days a week. The moonlighter is generally expected to take 5 admissions (option of 6) on weeknights and 6 admissions on weekends/holidays. All admissions are staffed via phone with the attending for G2s, and ICU admissions are staffed for G2s and G3s. The attending should be called at any time for questions or concerns, regardless of the nature of the admit or training level. The moonlighter will tally the number of admissions for each group (AHS/COC) on the schedule in the lounge. The moonlighter should also call 863-6851 and leave a message denoting the patients admitted overnight.
The M1 moonlighter is also the House Officer, who is available on request by an attending physician, to assist in the evaluation of acute situations which require the immediate attention of an on-site physician. The House Officer is also available to offer acute management of unstable patients while the attending physician or on-call physician is in transit to the hospital. The House Officer also performs death pronouncements and, on rare occasions, may evaluate patients without medical emergencies in order to determine how soon a more complete evaluation should occur.
This coverage is extended to all patients not followed by one of the six inpatient resident teams, and calls regarding these patients must be directed to the teaching team or the "cross coverage" G1 as appropriate.
In an emergency, the House Officer may be called to see a patient before the attending has been notified. If the nursing staff asks for an emergency evaluation, they must document the situation and what conditions made them feel that an emergency evaluation was required. It is the responsibility of the nursing staff to contact the attending physician ASAP and inform them of the situation.
The M1 moonlighter takes all cross cover phone calls for the ANW Hospitalist Service from 11pm to 5 am on Tuesday – Thursdays (except on holidays).
Coverage responsibilities for a house-officer call include the following:
Initial evaluation and assessment of the patient: This includes ordering and evaluating any tests, labs, or x-rays that are felt to be necessary. Typical examples would include stat EKG, CXR, ABG.
Treatment orders essential for the immediate care of the patient. Typical examples may include nebs, nitroglycerin, glucose, etc.
After the initial assessment and stabilization, the House Officer must notify the attending physician. This should generally occur within 20 to 30 minutes. The House Officer must document in the chart the evaluation, impression, and interaction with the attending physician.
Patients may be transfered to the ICU if appropriate and necessary to stabilize the patient. Initial orders in the ICU can also come from the House Officer. Orders for vent settings would be a typical example.
At this point, all further care of the patient is transferred back to the attending physician, allowing for transit time to the hospital if the physician is en route.
Once care has been transferred back to the attending physician it is his/her responsibility to:
Follow-up on tests, labs, or x-rays ordered by the House Officer which were not part of the initial stabilization. Example: House Officer may have the patient intubated, but post-intubation ABGs should go to the attending physician.
Communicate with appropriate consultants as needed.
Resume care of patients needing ongoing management beyond initial stabilization.
The House Officer will not be expected to provide the following:
History/physical or admission evaluations
Non-emergent medicine consultations
Daily rounds or progress notes
Ongoing management or complete evaluation of a patient’s problem beyond what is required for immediate stabilization.
Interpretation of routine EKGs and x-rays which can wait until morning
Consulting consultants to evaluate a patient.
Becoming involved in "family situations" and to deal with social issues, unless a patient unexpectedly decompensates and DNR status needs to be addressed before the attending physician can arrive at the hospital.
Other:
The House Officer may be requested by the attending to interpret emergent/urgent EKGs and after-hour x-rays without examining the patient. This interpretation should also be documented in the chart and communicated to the attending.
The House Officer may occasionally be asked to assess a patient for a condition that would appear to be non-emergent, to help the attending determine whether more complete assessment or consultation can wait until morning.
Falls will be treated as any other medical condition. The attending physician must be notified first and if appropriate may request evaluation by the House Officer.
Emergent situations requiring procedures beyond the skill of the house officer will be addressed by consulting the appropriate specialist after conferring with the attending physician. This may include involving the surgical resident to help manage lacerations. Simple steri-stripping is considered within the role of the House Officer.
The House Officer may be asked to provide brief medical clearance allowing implementation of a psychiatric 72-hour hold. Federal law requires that all patients placed on a 72-hour hold be cleared medically within one hour. The request for the hold will come from the attending psychiatrist, but the house officer may be asked to briefly clear the patient. This will only occur during evening and night time hours.
The House Officer may also be asked to provide evaluation of psychiatric patients who are restrained. Federal law requires a physician visit every 8 hours to document stability and prevent untoward problems as a result of restraining patients. The resident should document patient stability on the checklist provided.
Patients on psychiatric stations requiring immediate transfer to a medicine bed may be followed after transfer by the hospitalists, but both the patient’s attending on the psych floor and the on-call physician for the hospitalist service should consent to transfer. This would also apply to an unassigned patient needing emergent transfer back to the hospital.
Responsibility and liability:
It will be remembered by all that the House Officer is a resident functioning under supervision as the hands, eyes, and ears of the attending who cannot personally assess the patient. From a liability standpoint, therefore, it is expected that the House Officer shall communicate findings to the attending physician who will assume responsibility for care and decision making including the decision to obtain (or not obtain) help from a consultant when appropriate.
This consultant may be an internist if the attending is of another specialty; in some circumstances, it may be appropriate for the House Officer to suggest consulting a staff internist and discuss the case with this person. If the attending physician is unfamiliar with the Abbott Northwestern medical staff, it may be appropriate for the House Officer to suggest consultants in other specialties. If the situation at hand requires consultation by the intensivist service, this may be initiated by the house officer in cases where the attending is unable or unwilling to assume the role of managing the patient’s acute illness.
M2 MOONLIGHTING RESPONSIBILITIES
6/15/07
Pager 654-6157
The M2 moonlighting position is open to G3s and off-ward G2s. This position runs from 5 pm to 8 am every Friday, Saturday, and Sunday.
The M2 moonlighter takes all cross cover phone calls for the ANW Hospitalist Service from 11pm to 5 am Sunday & from 11pm to 8 am Friday , Saturdays, and Holidays. In addition, the M2 moonlighter does admissions for the COC and ANW Hospitalist Service in an alternating fashion with the M1 moonlighter on weekends and holidays. Like M1, the M2 moonlighter is not obligated to take more than 6 admissions on Friday/Saturday/Sunday/Holiday nights, and will not be paid for doing any more than 6 admissions. All admissions will be staffed with the appropriate attending for G2s, G3s need only staff ICU admits. However any moonlighter should call staff for questions or concerns at any time. Call the answering service and ask which attending is on call for that night, as posted schedules can change. The on-call staff can then be paged directly. Ongoing, active issues of patient care from the prior evening are best communicated to the attending the following morning.
There is in-house staff coverage for the ANW hospitalist service Monday through Thursday from 5-12pm. The in-house staff will alternate admissions with the moonlighter during this time. The staff is “on-call” until 8am and is responsible for any admission over the moonlighter’s six.
The M2 moonlighter will record the number of admissions from each group on the schedule in the residents’ lounge, and call 863-6851 to report the admissions to the hospitalist service so they will be seen the next am.
M3 MOONLIGHTING RESPONSIBILITIES
6/15/07
The M3 moonlighting position is open to all eligible G3s and G2s, including those on ward rotations. This position runs from 5 pm to 11 pm seven days a week.
The M3 moonlighter takes telephone calls regarding patients followed by the Minneapolis Cardiology Associates (MCA) and nursing station calls for the ANW hospitalist service patients. This position can be filled from home and the moonlighter will not be required to come to the hospital for patient care.
Calls from nurses regarding patients for whom MCA serves as the attending physician and cardiology-related calls on patients for whom MCA serves as consultant will be routed through the MHI answering service. The M3 moonlighter will be paged directly on his/her personal pager.
Patient care issues that cannot be adequately managed over the telephone can be referred to the House Officer or the on-call cardiologist as appropriate. The M3 moonlighter should not be involved with patients who have not yet been seen by a cardiologist.
M3 moonlighters also take cross-cover calls for the ANW Hospitalist Group from 5-11pm. The calls should be handled similar to the Cardiology calls, with more complicated calls being deferred to the in-house staff. The M3 resident should keep track of the calls separately and record them in the space provided in the resident lounge computer.
This position will be compensated on a per-phone-call basis. The number of phone calls will be determined by counting the number of pages. A conversation that requires the M3 moonlighter to place another call to an in-house physician would still be counted as one call. A page from a station that results in patient care via phone for three patients would be counted as three calls, however. The M3 moonlighter will record the number of calls on the schedule in the residents’ lounge. This is necessarily on the "honor system" with the realization that inconsistencies in number of calls can be investigated by having the MHI operator also tally pages if required.
Parties making changes to the M3 moonlighting schedule will be required to report the change to the MHI operator, to ensure they have an accurate schedule available to them with the proper phone number to call. The operator can be contacted at 863-3663.
RESPONSIBILITIES OF RESIDENTS AND MEDICAL EDUCATION FACULTY
1. Each patient will be carefully evaluated by the residents’ service team in an appropriate and timely manner. The full evaluation of the patient will be completed by the G1 resident or the medical student and the history and physical entered into the electronic medical record. G2 residents will also enter an admission note that contains any corrections or additions to the G1 note or will be a complete admit note on student patients. The attending or covering partner will be called by the G1 or G2 resident as soon as the initial evaluation is complete. In most situations, the G1 and G2 will have discussed the case and will have agreed on their plans for the patient. However, during some particularly busy times, the G1 will call the attending without discussion with the G2 so that patient management is not delayed. The residents and attending will discuss the patient and reach a consensus about the further management of the patient.?
2. The full-time medical education faculty will contribute, without charge, to the patient care and education surrounding each patient during teaching attending rounds. The patients may be examined by the medical education faculty member during these rounds for teaching purposes. Additional discussions about patients between residents and the medical education faculty may occur informally or in formal conferences. All of these contributions by medical education faculty will be made rigorously and honestly, but with awareness that the attending is the leader of each patient's care and that medical decisions are often complex and difficult. In this teaching attending role, a faculty member is not necessarily the attending of record and does not document in the chart.?
3. The residents’ service team will follow each patient closely and completely and will enter timely, and accurate notes detailing their findings, thoughts, and plans. The attending delegates responsibility for patient management to the resident team but must be involved in important decision making. While the definition of important may vary from attending to attending, the residents should not wait for concurrence by the attending before initiating routine diagnostic and therapeutic measures. The team will speak directly to an attending or covering partner whenever an important change in patient condition occurs (e.g., transfer to an ICU or onset of new GI bleeding). For most situations, attendings and residents should be able to communicate through their notes in the chart. However, residents should call an attending to discuss pressing and important patient care decisions rather than wait for routine written communication the next day. Residents will read and respond to other physicians' notes. Suggestions will either be implemented or discussed further with the appropriate physician.
4. Residents will perform the basic procedures required by the ABIM when the procedure is indicated for one of their patients. A resident may opt to refer the procedure to the procedure team, or call the procedure team to obtain staff supervision if necessary. Residents should be supervised by a more senior resident or staff physician who has appropriate expertise in the procedure until the resident has acquired the skill to perform the procedure independently. Residents will track their procedures in the E-Value system. Residents are not competent to perform a procedure independently until they have successfully completed a predetermined number of each kind of procedure. A resident may be asked by nursing staff to provide evidence of performance of the minimum number of procedures required to perform them independently. The required number of procedures are on the residency program website.?
5. The residents are considered full partners in the care of the patients and are to be involved with patients and families in discussions of all issues. The residents will not reach final decisions about important issues such as limitations of care without discussion with the attending. Residents should appropriately initiate discussions about new diagnoses and treatment options but only when they are sure of the completeness of their knowledge and when they are aware of the attending's thoughts about the patient care.?
6. The resident service teams will continue to care for their patients until they are discharged from the hospital since the activities related to discharge are very important. The discharge decision, like all important decisions, should be reached after discussion between the residents and the attending. An infrequent patient may resolve all medical problems and be transferred to a non-medical floor such as psychiatry or obstetrics. For such patients, it may be appropriate for the residents to sign off the case, but only after discussion with the attending. Otherwise, the sign-off option is intended only for situations of major conflict with patients and families where the presence of the residents is detrimental to patient care. The residents should sign off these cases only after discussion with the attending and a chief resident or medical education faculty member. Differences between residents and attendings should be resolvable with discussion, sometimes with the additional input of chief residents or medical education faculty. The residents are responsible for all of the discharge documentation and arrangements for each of their patients. Accurate and timely discharge summaries will be completed by the senior resident on each case, with copies directed to the attending and any referring physicians via the electronic medical record (see separate policy).