Robert Aaronson, M.D., Executive Director and Program Director, Internal Medicine Residency

Tyler Kent, M.D., Transitional Program Director

Harvey Maksvytis, M.D., Associate Program Director, Internal Medicine Residency

Scott Weiss, M.D., Chairman, Department of Medicine, TMC

Alok Sharma, M.D., Chief Medicine Resident (2001-2002)

Shelley Collingham, M.D., Section Chief

Jennifer Kempers, M.D

Douglas Kirkpatrick, D.O.

William Odette, M.D.

Simon Paul, M.D.

Guraprased Raju, MD

KINO GENERAL MEDICINE STAFF

Harvey Maksvytis, M.D.

E. Charles Blanck, M.D.

Iran Ata, M.D.

Gabrielle Ochoa, MD

Khaled Hadeli, MD

Brenden Phibbs, MD

THMEP SECTION CHIEFS

Lionel Faitelson, M.D. (TMC)

Brendan Phibbs, M.D. (Kino)

James McLaughlin, M.D. (Kino)

Harry Calvino, M.D. (TMC)

John Insel, M.D.

Charles Krone, M.D.

Arthur Goldberg, M.D.

Steven Wool, M.D. (TMC)

Leonard Ditmanson, M.D. (Kino)

Robert Brooks, M.D.

Mohammed Sikder, M.D.

Jose Laguna, M.D.

Thomas Rotkis, M.D. PhD

Jon Larson, M.D.

SURGERY/TRAUMA
John Fortune

All rotations are one calendar month in duration.

The R1 year (Internship) includes: 2 months TMC CCU/Cardiology

5 months TMC General Medicine

2 months Kino General Medicine

1 month Community Medicine

1 month Kino Emergency Medicine

1 month of Anesthesia

The R2 year (Junior Residency) includes: 1 month TMC CCU/Cardiology

4 months TMC General Medicine

2 months Kino General Medicine

1 month Community Medicine

1 month TMC Urgent Care Center

1 month Kino Ambulatory Specialty Clinics

2 months of electives

The R3 (Senior Residency) includes: 1 month TMC CCU/Cardiology

2 months TMC General Medicine

2 months Kino General Medicine

1 month Community Medicine

1 month TMC Emergency Medicine

1 month Geriatrics

4 months of electives.

The Preliminary R1 year includes: 6 months TMC General Medicine

1 month TMC CCU/Cardiology

1 month Kino Emergency Medicine

4 months of electives

The Transitional R1 year includes: 3 months TMC General Medicine

1 month Kino General Medicine

1 month TMC CCU/Cardiology

1 month TMC Trauma

1 month TMC General Surgery

1 month Kino Emergency Medicine

4 months of electives

Please also refer to the individual descriptions of each service for any specific requirements.

1) Lines of Responsibility

The lines of responsibility, on both inpatient and outpatient rotations, are based on the following principals:

• An attending physician is ultimately responsible for every patient.
• Optimal resident education requires meaningful clinical responsibilities, including the opportunity to make major management and treatment decisions, with appropriate attending input and supervision.
• The resident’s clinical independence will progressively increase, commensurate with the resident’s evolving abilities. However, an attending physician will remain ultimately responsible.
• To accomplish all of the above, timely, thorough and open communication between residents and attendings is essential.
• On inpatient ward or CCU rotations, the intern’s clinical responsibilities are centered on the care of his or her patients. The intern is the front-line, primary physician for the patient during hospitalization. The intern is under the immediate direction of the team’s second or third year resident. The resident is responsible for the effective functioning of the team in its dual roles of educational forum and patient care entity. The resident supervises the intern in all aspects of patient diagnosis and treatment, contributes to intern education and ensures appropriate attending communication and oversight. The resident is expected to alert the attending or the Program Director/Associate Program Director of any real or perceived difficulties faced in patient management or the proper functioning of the medical team.
• On subspecialty or ambulatory rotations, housestaff responsibilities vary depending upon the service. Lines of responsibility remain, with the attending ultimately responsible for patient care. The houseofficer’s role may vary from primary physician, to consultant, to manager of a single aspect of a patient’s multisystem disease. Many elective rotations include experiences with all of these. Specific expectations of the resident should be discussed with the attending at the beginning of the rotation.

2) Patient Limits

The following limits apply to all inpatient medical services at TMC and Kino Community Hospital:

• No intern shall admit more than 5 new patients in 24 hours, or 8 new patients in 48 hours.
• No intern shall be responsible for the ongoing care of more than 12 patients.
• Each second or third year resident should admit (or oversee the admission of) no more than 10 patients per 24 hours, and no more than 16 patients per 48 hours.
• A second or third year resident shall be responsible for the ongoing care of no more than 24 patients at any one time, including those patients cared for by intern(s) under his/her supervision.

These limits may require that R2’s and R3’s admit some patients by themselves while on call, up to the mandated limits. These patients may later be assigned to a less heavily burdened intern, or

kept" by the resident throughout the patient's hospitalization. A certain amount of "patient shifting" between interns or teams may be required, as determined by the resident, with oversight by the Chief Resident.

Once the limits described above have been met, you are required to refuse new admissions. Please explain to the attending physician why you are unable to accept the patient and refer any misunderstandings to the THMEP office.

However, you should respond immediately to any real or perceived life-threatening emergency, even if a patient limit has been reached. Unless patients can be shifted or discharged immediately to allow for this admission, the attending physician should assume total care for the patient as soon as possible (within minutes to a few hours). Any difficulties with this should be referred immediately to the Program Director, Associate Program Director or the THMEP office.

Any requests by an attending physician to supersede any of these limits must be refused but immediately referred to the Program Director if at TMC, or the Associate Program Director if at Kino.

 

3) Work Hours

• When averaged over any month long rotation, no resident should work more than 80 hours per week.
• In general, night call is every 4^th night on all inpatient services. Call may also be required for Community Medicine and during some electives. In the event of resident illness, scheduling adjustments will be made, and call may increase to no more than every 3^rd night, on average.
• On average, each resident will have at least one full day off per week.
• During Emergency Medicine, shifts must not exceed 12 hours, and must be separated by at least 8 hours off work.
• Schedule changes: Any changes to the published schedule must first be approved by the THMEP office.

4) Writing Orders

All orders for patients on the inpatient teaching services should be written by the medical housestaff. If a medical emergency requires that an attending write an order for a teaching service patient, the intern or resident caring for the patient should be notified immediately and involved in the ongoing patient management. Exempted from this rule are patients not on the teaching service but seen by a medical resident in consultation, usually during an elective subspecialty rotation.

 

5. Daily Notes (inpatient services)

Progress notes must be written for each patient every day, including when on-call. The team’s resident is expected to write the notes on the intern’s day off.

6) Cross Coverage Notes

Cross coverage notes must be written every time a covering houseofficer is called to see a patient. Telephone orders must be given for only the most minor of problems. Sedatives and narcotics should not be ordered over the telephone without first seeing the patient. All telephone orders must be signed within 24 hours.

7) Non-teaching Service Patients

Housestaff are not responsible for the routine care of non-teaching service patients, including admission, orders, phone calls or discharge. However, housestaff are expected to respond immediately to any call for emergency assistance on any patient, including non-teaching service patients. All care for the patient should revert to the attending physician immediately after the emergent situation, unless the patient is then transferred to the teaching service.

8) Sign-out

On every inpatient rotation, housestaff are expected to communicate essential patient information to the covering house officer before leaving for the day. Each house officer departing for home or continuity clinic should also inform the hospital operator to whom he or she has signed-out before leaving the hospital.

9) On/Off Service and Transfer of Patients

• On the day after admission (TMC):

Patients who are transferred to another service on the morning after admission do not count towards the admission cap for the receiving Team. However, they do count towards the cap on the total number of patients that can be assigned to any given intern or resident. General medicine patients who are admitted to the TMC CCU/Cardiology service should be transferred to the general medicine service on morning check-out rounds as directed by the Chief Resident. CCU/Cardiology patients who are admitted to the general medicine service should be transferred to the CCU/Cardiology team the following morning as well. The admitting intern and resident are responsible to communicate verbally to the receiving intern and resident a brief synopsis of the patient’s clinical presentation, and other essential information. Any issues regarding patient transfers are to be directed to the Chief Resident or Program Director.

• When transferring a patient between services:

Whenever a patient is transferred between services (surgery to medicine; medicine to CCU/Cardiology, etc.) later on in the hospital course, the transferring intern should write a concise but complete Transfer Summary. The receiving intern should write an Accepting/Progress note, including a concise summary of the patient's history and any information usually contained in a progress note.

• At the end of the month (both TMC and Kino):

Whenever an intern is leaving the medicine service, the intern should write an Off-Service note, summarizing each patient’s medical care thus far. The receiving intern should likewise write an On-Service note.

10. Consultations

During both subspecialty rotations and the Kino general medicine service rotation, residents may be asked to perform consultations. As always, the attending physician is responsible for the content of these consultations and, as such, must be fully involved in all ultimate recommendations and treatments. For this reason, the resident must discuss the patient with the attending before any suggestions are made and before the consultation note is placed in the medical record. If the attending chooses not to see the patient immediately (at the attending's discretion), the resident and the attending will arrive at a plan over the telephone. The resident will write: "This has been discussed with and agreed to by Dr. (Attending)" and will then sign the consultation note as "Dr. (Resident) for Dr. (Attending)."

Medical consults may also be requested at TMC. The TMC Hospitalist on duty must be contacted and must agree to serve as the supervising attending consultant. Up to 2 consults may be performed by the day call team and 1 consult may be done by the night call team.

11. Completeness of Physical Examinations

The initial complete physical examination of a patient admitted to hospital or when first seen in your clinic should include otoscopy, rhinoscopy, ophthalmoscopy, breast examination, rectal examination, and pelvic examination, unless medically inappropriate. Male residents should always perform a woman's breast examination or pelvic examination with a female chaperone (physician or nurse).

The following protocol is sent periodically to all admitting Teaching Attendings:

* The Program Requirements published in July 2001 by the Accreditation Council for Graduate Medical Education (ACGME) mandates that the housestaff "must write all orders for patients under their care. In those unusual circumstances when an attending physician or subspecialty resident writes an order on a resident’s patient, the attending or subspecialty resident must communicate his or her action to the resident in a timely manner" (V.E.3.).

* If we do not comply with this, we will lose our national accreditation and, ultimately, our residency program!"

 

The THMEP Internal Medicine written curriculum is distributed to each intern at the beginning of residency training, with updates distributed periodically. It delineates THMEP’s educational goals and methods and serves as a guide for planning and implementing our clinical and didactic programs.

Residents are encouraged to discuss the curriculum with their attendings, especially during subspecialty months, when it can help focus didactics on essential clinical topics. The curriculum can also assist each resident in planning self-study, both during clinical rotations and when reviewing for board examinations.

The process of ongoing evaluation between the housestaff and the many components of the THMEP program (attendings, nurses, co-residents, and rotations) is essential to resident education and patient care. Evaluations of each resident are obtained frequently: monthly for every clinical rotation; biannually for continuity clinic; and once at completion of residency. Houseofficers are also asked to evaluate the program monthly, at the end of the year, on completion of the program and periodically after graduation.

It is essential that evaluators be honest. They should write down their criticisms and concerns in a constructive manner, and discuss them in a timely manner with the subject of the appraisal. Likewise, the person being evaluated should realize that an honest critique is part of the learning process, and is essential to maintenance of professionalism.

A formal Clinical Evaluation Exercise (CEX) is performed during internship, and all residents are required to take the In-Training Examination yearly. Medical records are also reviewed, with feedback sent to the residents.

The medical libraries at both TMC and Kino Community Hospital provide housestaff 24-hour/day access to up-to-date periodicals and texts. Materials not available at these sites can be obtained quickly through interlibrary loans, at no cost. Audiovisual educational materials and equipment are also available.

THMEP has provided a PC in both the TMC Medical Library and the call room solely for housestaff use, including literature searches, medical education software use, and general computer needs. The password for the library computer is "THMEP". The Medical Library staff is available to instruct you in computer searches or other general computer issues.

TMC is a local Internet Service Provider (ISP), allowing for ready access to the Internet from most PC terminals around the hospital, including free access to MDConsult, Medline, Arizona Health

Information Network (AZHIN) and other useful databases. Dial-up access from home and general computer assistance can be obtained by calling the Computer Help Desk at 324-1212. TMC also offers free computer classes for a variety of computer applications. Class schedules are available in the Medical Library. For additional information and registration, call 324-2340.

The Kino Community Hospital Medical Library also offers on-line access to Grateful Med and other major medical databases through CompuServe.

The general medicine service at TMC consists of three teams. Each team includes two interns and either a second or third year resident. The Chief Resident (R4) oversees the day-to-day functioning of the entire teaching service, which includes the general medicine and CCU/cardiology services. The general medicine service cares for all medicine patients admitted to the teaching service, with the exception of patients admitted to the CCU or PCCU. However, CCU service patients are transferred to the general medicine service upon leaving the CCU/PCCU. General medicine patients are, as much as possible, clustered on Wards 650 and 750 of the Acute Medical-Surgical Unit (AMSU).

The patients admitted to the general medicine service may be referred by either community-based physicians on our teaching staff or by TMC’s Hospitalists, a group of full-time, TMC-based inpatient physicians. The admitting physician serves as the management attending during the patient’s hospitalization, developing day-to-day management plans with the housestaff, and bearing ultimate responsibility for the patient’s care.

On weekdays between 7 a.m.- 1 p.m. all general medicine/ICU admissions are distributed to the three medicine teams according to a night-call/off-call/day-call rotation (i.e. every 3^rd day). Medicine/ICU admissions until 1 p.m. should be called to the day-call resident, who will direct each patient to one of the interns on the day-call team.

Night call is every fourth night, from about 3 p.m. to 7 a.m., with the CCU team taking night call in rotation with the three general medicine teams. The night call team admits patients to both the general medicine service and to the CCU service. All second and third year residents meet briefly at Morning Checkout Rounds at 7 a.m. where the Chief Resident directs the transfer of patients to the appropriate teams, sign-out occurs, and patients are discussed.

The Chief Resident may change the time of Day call, Long call and daily CCU call. For example, with low admission rates Day call might be ended at 1 p.m., with Night call starting then. The goal is to remove time restrictions on Day call teams as long as THMEP does not lose patients by capping too early.

Morning Work Rounds are carried out by each team. The entire team should be present from 7 a.m. to 9 a.m. to facilitate contact with attendings and consults. However, Rounds should be started as early as necessary so that orders are written before morning conferences begin. Resident/intern teaching should be done at this time. After conferences, patient status and the program of AM orders should be reviewed prior to sign-out.

Morning report (Resident Report or Intern Report) is held four days per week: Resident Report (R2’s and R3’s) is held from 11 a.m. to noon, Tuesday, Thursday and Friday (Friday Resident Report is dedicated to Evidence Based Medicine); Intern Report (R1’s) is from 11 a.m. to noon on Monday. Each team’s second or third year resident is expected to carry the intern’s beepers and to help with urgent Intern work during Intern report.

Teaching Rounds are from 9 a.m. to 10 a.m. on Monday, Tuesday, Thursday and Friday with the teaching attending of the month. These rounds re distinct from management rounds with admitting physicians, and are intended to be didactic.

ICU Rounds occur from 10 a.m. to 11 a.m. on Monday, Wednesday and Friday and are intended to be primarily didactic. They start at the portable CXR board in radiology and then move to the bedside.

A series of Core Lecture in Internal Medicine is telecast from the U of Arizona on Tuesdays 9-10 a.m. The tapes are shown for Friday noon conference.

Hematology/Oncology seminars are held on Wednesdays, from 11 a.m. to noon.

Noon Conference occurs daily. See Daily Conference Schedule.

Attendance at conferences is required when on CCU or wards at TMC or Kino. They fulfill requirements from the RRC which accredits our program. And conferences constitute the bulk of formal teaching at THMEP. Interns and Residents contribute to several conferences by 1.) patient care presentations 2.) formal topic presentations and 3.) participation in dimensions. The day's activities should be planned accordingly, and conferences should start on time.

Ad hoc Management Rounds with admitting physicians should occur every day.

Chief Resident Rounds occur daily from 2 – 3 p.m. with the night-call team

Afternoon Check-Out On every inpatient rotation, housestaff are expected to communicate essential patient information to the covering house officer before leaving for the day. Each house officer departing for home or continuity clinic should also inform the hospital operator to whom he or she has singed-out before leaving the hospital.

Except for afternoons when a house officer is in continuity clinic, no team’s Resident should checkout for the night before the team’s Interns are ready to leave. Each house officer leaving the hospital should check-out to a corresponding member of the night-call team, and should notify the hospital operator of this prior to leaving the hospital.

Weekly continuity clinic at Kino Community Hospital is an ongoing responsibility for each categorical medicine house officer. The THMEP office may cancel continuity clinic only for THMEP holidays, vacation and scheduling conflicts during Emergency Room rotations. Housestaff should checkout to the corresponding house officer on the night-call team and alert the operator of this prior to leaving for continuity clinic. Housestaff are not expected to return to the hospital after clinic, unless they are on night-call.

The intern is the front-line, primary physician for the patient during hospitalization. He or she is under the immediate direction of the team’s second or third year resident, and ultimately answerable to the admitting physician for each patient. The intern is responsible for admitting all patients to his or her service. The intern will do the history and physical under the supervision of the resident, who will then direct the intern in the formulation of an assessment and plan and will discuss this plan with the admitting physician. The intern will then write a brief admission note and dictate a complete admission note immediately. The intern should also write an acceptance note when a CCU/PPCU patient is transferred to the general medicine service.

The intern will, whenever possible, pre-round on his or her patients prior to Morning Work Rounds. The intern will formulate a patient plan for the day with the resident, communicate this to the admitting physician and come to a consensus with the admitting physician, and write all orders. The intern (or the resident, if needed) will write daily progress notes on each patient and additional notes as the clinical situation dictates. These progress notes should include a problem-oriented assessment and plan. The progress notes should serve to document the patient’s clinical status and the intern’s assessment and plan. The chart should not be a forum for sharing one’s attitudes or feelings about the patient or the patient’s care.

The intern should be the first physician called by the medical floor or ICU for questions or problems. However, the intern should, without hesitation, involve the team’s second or third year resident or the admitting physician whenever appropriate. The intern will perform all invasive procedures under the guidance of a credentialed resident or attending physician. (See THMEP’s "Certification & Documentation of Adequate Proficiency and Experience in Performing Invasive Procedures." )

Discharge summaries are to be dictated by the intern as quickly as possible, and certainly within 48 hours. Copies should be sent to the admitting physician, the patient’s primary care physician and to any consulting physicians to facilitate transfer of important clinical information to the outpatient setting.

As above, unless delayed by a real or potential patient emergency, the intern is expected to attend all general medicine service functions (Grand Rounds, morning work rounds, teaching rounds, intern report, noon conference, afternoon seminars, etc.).

The resident is responsible for the effective functioning of the team in its dual roles of educational forum and patient care entity. The resident supervises the intern in all aspects of patient diagnosis and treatment, and ensures appropriate attending communication and oversight. The resident is also responsible for the educational progress, both practical and theoretical, of the team’s interns and medical students, if any.

The resident will see each new admission to the team’s service, with the intern whenever possible, and will write a brief admission note on each patient. The resident will review the intern’s progress notes and will initial each to indicate agreement after writing any necessary comments. The resident should also write a brief acceptance note and speak with the CCU resident whenever a CCU/Cardiology patient is transferred to the general medicine service.

The resident will assist and supervise invasive procedures performed by the intern when appropriate. See THMEP’s "Certification & Documentation of Adequate Proficiency and Experience in Performing Invasive Procedures."

Unless delayed by a real or potential patient emergency, the resident will attend all general medicine service functions (Grand Rounds, morning check-out rounds, morning work rounds, teaching rounds, resident report, noon conference, afternoon seminars, etc.). In addition, the resident should cover for the interns during Intern Report, holding their beepers and helping with their work during this period.

Each General Medicine Resident is expected to prepare an Evidence-Based Medicine seminar during one Friday Resident Report

The General Medicine Residents are expected to suggest appropriate patient names for Pathology/Laboratory Medicine seminar, Radiology conference and other clinical conferences.

The third year resident, with the CCU resident, is expected to organize monthly Morbidity and Mortality conferences. Each death on the medicine or CCU teaching services should be recorded on an M & M sheet (obtainable at THMEP), submitted to the THMEP office and briefly reported at

M & M conference. Two or three patients who suffered either mortality or significant morbidity are fully presented and discussed.

The Coronary Care Unit/Cardiology service is responsible for the care of teaching service patients admitted to and remaining on either the CCU or the Post-Critical Care Unit (PCCU). The CCU service consists of one team, with a second or third year resident and two interns. The Chief Resident (R4) oversees the day-to-day functioning of the entire teaching service, which includes the CCU and the general medicine services.

Community-based cardiologists on our teaching staff usually refer the patients admitted to the CCU service, although other members of the teaching staff may admit to the teaching service with a cardiologist consulting. The admitting physician serves as the management attending during the patient’s hospitalization, developing day-to-day management plans with the residents, and bearing ultimate responsibility for the patient’s care. Ad hoc management rounds with the admitting physicians should occur every day.

All admissions to the CCU service between 7 a.m. and 3 p.m., Monday-Friday, should be called directly to the CCU resident, who will assign the patient to a CCU intern. During weekends, the on-call resident (General Medicine or CCU) takes admission calls. Patients may also be admitted to the CCU service through activation of the A.C.T. (Acute Cardiac Treatment) team, which includes the CCU housestaff.

Night call is every fourth night, from about 3 p.m. to 7 a.m., with the CCU team taking night call in rotation with the three medicine teams. The night call team admits patients to both the general medicine service and to the CCU service. All second and third year residents on the medicine and CCU services meet for brief Morning Checkout Rounds at 7 a.m. to 7:15 a.m., where the Chief Resident directs the transfer of patients to the appropriate teams, and sign-out occurs, and patients are discussed.

The CCU team carries out Morning Work Rounds on the CCU and PCCU, facilitating contact with the admitting physicians and consultants. Work Rounds are attended by the whole team, and are an important time for management decision-making and for resident-to-resident education. If necessary, Work Rounds are completed after morning conferences. Remember that conference attendance is expected, and orders should be written before conferences begin.

Morning report (Resident Report or Intern Report) is held four days per week: Resident Report (R2’s and R3’s) is held from 11 a.m. to noon, Tuesday, Thursday and Friday (Friday Resident Report is dedicated to Evidence Based Medicine); Intern Report (R1’s) is from 11 a.m. to noon on Monday. The CCU resident is expected to carry the interns’ beepers and to help with Intern work during Intern report.

Teaching Rounds are generally held on the CCU at 9 a.m. on Monday, Wednesday and Friday, although the times may vary.

Cardiology Conference occurs every Monday at noon.

Hematology/Oncology Seminars are held on Wednesdays, from 11 a.m. to noon.

Noon Conference occurs daily, and subspecialist teaching faculty hold Afternoon Seminars for the housestaff several times a week. See the posted Daily Conference Schedule.

Ad hoc Management Rounds with admitting physicians should occur every day.

The CCU team may Check-out at 3 p.m., after the General Medicine teams conduct Afternoon Check-out Rounds. On the day following night-call, CCU housestaff may leave for home sooner (assuming their work is done), checking-out after the last scheduled educational activity of the day.

Except for afternoons when a house officer is in continuity clinic, no team’s resident should checkout for the night before the team’s interns are ready to leave. Each houseofficer leaving the hospital for clinic or until the following morning should checkout to a corresponding member of the night-call team, and should notify the hospital operator of this prior to leaving the hospital.

Weekly continuity clinic at Kino Community Hospital is an ongoing responsibility for each categorical medicine house officer. The THMEP office may cancel continuity clinic only for THMEP holidays, vacation and scheduling conflicts during Emergency Room rotations. Housestaff should check-out to the corresponding resident on the night-call team and alert the operator of this prior to leaving for continuity clinic. Housestaff are not expected to return to the hospital after clinic, unless they are on night-call.

The intern is the front-line, primary physician for the patient during hospitalization. He or she is under the immediate direction of the team’s second or third year resident, and ultimately answerable to the admitting physician for each patient. The intern is responsible for admitting all patients to his or her service. The intern will do the history and physical under the supervision of the resident, who will then direct the intern in the formulation of an assessment and plan and will discuss this plan with the admitting physician. The intern will then write a brief admission note and dictate a complete admission note immediately.

The intern will, whenever possible, pre-round on his or her sicker patients prior to morning work rounds. The intern will formulate a patient plan for the day with the resident, communicate this to the admitting physician and come to a consensus with the admitting physician, and write all orders. The intern (or the resident, if necessary) will write daily progress notes on each patient. These progress notes should include a problem-oriented assessment and plan. Additional notes should be written for, and the admitting physician should be notified about, significant changes in the patient’s clinical status. Chart notes should serve to document the patient’s clinical status, your assessment and plan. They should not be a forum for sharing one’s attitudes or feelings about the patient or the patient’s care. The CCU intern should also write a transfer note and initial transfer orders for any patient transferring off the CCU/Cardiology service to the general medicine service.

The intern should usually be the first physician called by the CCU or PCCU for questions or problems. Given the acuity of some of the patients and the problems they develop, the admitting physician may occasionally be called first, but will then involve the housestaff as soon as is reasonably possible. The intern should, without hesitation, involve the team’s resident or the admitting physician whenever appropriate. All invasive procedures performed by the intern must be done so under the guidance of a credentialed resident or attending physician. See THMEP’s "Certification & Documentation of Adequate Proficiency and Experience in Performing Invasive Procedures."

Discharge summaries are to be dictated by the intern as quickly as possible, and certainly within 48 hours. Copies should be sent to the admitting and any consulting physicians to facilitate transfer of important clinical information to the outpatient setting.

Unless delayed by a real or potential patient emergency, the intern will attend all scheduled educational activities. These include CCU service functions (morning work rounds, teaching rounds, cardiology conferences), intern report, noon conferences and afternoon seminars.

The resident is responsible for the effective functioning of the team in its dual roles of educational forum and patient care entity. The resident supervises the intern in all aspects of patient diagnosis and treatment, and ensures appropriate attending communication and oversight. The resident is also responsible for the educational progress, both practical and theoretical, of interns and any medical students on the team.

The resident will see each new admission to the team’s service, with the intern whenever possible, and will write a brief admission note on each patient. The resident will review the intern’s progress notes and will initial each to indicate agreement after writing any necessary comments. If the admitting physician requests that medical housestaff continue to care for a patient after transfer off the CCU or PCCU, the resident should contact the resident on the general medicine service to discuss the patient and assure an appropriate transfer of care.

The resident will assist and supervise invasive procedures performed by the intern when appropriate. See THMEP’s "Certification & Documentation of Adequate Proficiency and Experience in Performing Invasive Procedures."

Unless delayed by a real or potential patient emergency, the resident will attend all scheduled educational activities. These include CCU service functions (morning work rounds, teaching rounds, cardiology conferences), resident report, noon conferences and afternoon seminars. In addition, the resident should cover for the interns during Intern Report, holding their beepers and performing their duties during this period.

The Transitional residents while on the Surgical Service at TMC spend 1 month on the trauma service and 1 month on the general surgery service. Their responsibilities for direct patient care and decision making are as part of the surgical teams on both services. These teams include surgical residents and appropriate attending staff. Direct supervision is provided by the senior residents and/or the attending staff.

The Transitional resident, functioning as a member of the team, is responsible for admitting history and physical examination, daily progress notes, the writing of orders, the general planning of in-house care and the continuing management of patients throughout their course. They attend one or two clinics a week for follow-up of post-hospitalization patients.

The educational goals on these services are to:

• To develop clinical competence in the perioperative management of many of the problems encountered in general surgery and trauma.
• To actively participate in patient care in conjunction with senior surgical residents, including management of critically ill patients on the surgical service.
• To evaluate surgical patients preoperatively in the clinics and Emergency Room and to follow their post operative courses in the hospital and outpatient clinics.
• To participate in the regular educational activities of the surgical service as applicable to categorical first year surgery residents.

Introduction:

The Internal Medicine teaching service is composed of two teams. Each team consists of an attending physician from the department of Internal Medicine, two second or third year resident physicians and two first year interns. Residents and interns are provided by the U of A Internal Medicine residency program and the THMEP Internal Medicine and Transitional residency programs. All members are bound by the rules and regulations of the Department of Internal medicine and the bylaws of the Medical Staff of Kino Community Hospital.

The Internal Medicine teaching service is available for accepting any adult or adolescent patient over the age of 16 admitted to Kino Hospital with a primary medical problem. Patients under the age of 16 may rarely be accepted to the teaching service with the prior approval of the teaching attending. Admission coverage is 24 hours per day and seven days per week. Admissions may be to the intensive care unit, the medical-surgical unit or the Transitional Long-term Care unit, based on patient acuity and admission criteria of those units. Admissions may be from the Emergency Department, Kino clinics and offsite clinics, area nursing homes, transfers from other hospitals and the Pima County Adult Detention Center. Any direct admissions to the teaching service from sources other than the Emergency Department or Kino clinics must have the prior approval of the teaching attending. All admissions to the teaching service must be accompanied by a direct notification of the resident team, including information about the source of the admission and the reasons for the admission.

The call schedule for each resident and intern team is one night in four. Admissions to the teaching service between 7:00AM and 2:00 PM Monday through Friday will be assigned to the "short-call" teams. The first and second "short-call" teams may each admit up to 5 patients each. The "long-call" team will admit patients between 2:00 PM and 7:00 AM. On weekends, the "long-call" team will admit patients for 24 hours. In accordance with residency requirements, an intern will be primarily responsible for no more than five admissions per 24 hours or eight admissions per 48 hours. A resident will be responsible for no more than ten admissions per 24 hours or 16 admissions per 48 hours, including those patients admitted to the intern. It is expected that the resident and intern will function as a team in the care of all patients on their service. In the event the number of admissions exceeds these limits, the Emergency Department physician in conjunction with the medicine attending physician will coordinate care of the patient until the next admitting team assumes their care during duty hours.

All admissions must include a complete history and physical examination which can be either written legibly or dictated and must be signed. The H&P may be completed by the resident or the intern according to the delegation by the resident. Admission orders may be written by the resident or the intern, but must always be reviewed by the resident with the intern. Orders must be written prior to transport of the patient to the unit. Daily progress notes and additional notes recording procedures, events and any change in status must be written by the resident or the intern. Medical student notes cannot serve as official portions of the medical record and also require review and countersignature by the intern or resident. A dictated discharge summary must be completed within 24 hours of discharge of a patient. For patients discharged to a skilled nursing facility or transferred to another hospital, a discharge summary should be completed prior to discharge in order to accompany the patient in the transfer of care. A courtesy notification of a patient discharge to the primary care physician is also encouraged.

THMEP residents should be notified whenever their continuity clinic patients are admitted to the Kino medicine service. Each continuity clinic patient should receive an identification card from the clinic staff or resident (available through either the clinic or THMEP), which should be presented by the patient at the time of presentation to the hospital. This card identifies the resident as the patient’s primary care physician, and directs the hospital staff to alert THMEP to the patient’s admission. This allows the resident to contribute useful medical history and offers him or her the opportunity to remain involved in significant management decisions.

Teaching rounds will be conducted Monday through Friday between 8:00AM and 9:00 AM. Housestaff are expected to have made pre-rounds on their patients prior to Teaching rounds. Following Teaching rounds, radiology rounds and ICU rounds will be conducted followed by Management rounds. All attending rounds should be completed by 12:00PM. All housestaff are expected to attend all rounds, core lectures and noon conferences unless called for an emergency. Work rounds will be conducted by each resident and intern team prior to Teaching rounds in the morning and following noon conference in the afternoon. Interns and residents must sign out all patients to the "long-call" team prior to leaving the hospital. Interns and residents must remain on call for their patients until 5:00 PM.

The "long-call" team shall respond to all "Codes" called in the hospital and the "long-call" resident will run the "Code" unless the resident or the attending for that patient is available in the hospital to respond and run the "Code". The attending physician must be contacted and notified of all "Codes" and all unanticipated deaths on the service. The attending should also be notified immediately of any significant change in status of a patient or any transfer of a patient to another level of care such as the ICU or telemetry.

All housestaff will have, when averaged over a four-week period, one day off per week. However, the resident and the intern of a team should not take the same day off. Days off should be coordinated by the resident teams, but at least one second or third year resident must be available in hospital every day. Housestaff will not work more than 80 hours per week. According to residency requirements, neither interns nor residents may take vacation during the Kino inpatient medicine rotation. Because of the time demands of this service and required limitations on total work hours, medicine residents are not allowed to "moonlight" during Kino medicine rotations.

Internal Medicine consultations to other services are provided by the teaching service for non-urgent conditions between 9:00 AM and 4:00 PM Monday through Friday and 24 hours per day for urgent and emergent conditions. Initial evaluation and consultation is provided by the short-call resident physician, with staffing by the attending physician. The resident must discuss the patient with the attending before any suggestions are made and before the consultation note is placed in the medical record. If the attending chooses not to see the patient immediately (at the attending's discretion), the resident and the attending will arrive at a plan over the telephone. The resident will write: "This has been discussed with and agreed to by Dr. (Attending)" and will then sign the consultation note as "Dr. (Resident) for Dr. (Attending)."

All requests for Internal Medicine consultation must be accompanied by a direct notification of the resident and/or attending physician by the requesting service, identifying the patient and the reason for the consultation request. On occasion, and with the prior approval of the teaching attending, patients with primary surgical problems, including but not limited to hip fractures, who also have complex medical problems may be admitted to, or transferred to, the internal medicine teaching service and managed in conjunction with the appropriate surgical service.

The goal of this rotation is to immerse you in a community-based outpatient medicine experience, with the intention of your becoming a functioning member of the practice, as appropriate to your level of training. As a fully integrated member of the practice, you are expected to keep regular office hours, to follow your outpatients when hospitalized and to take call. All of these experiences should be performed under appropriate supervision by the one or more attendings in your practice. The local Directing Physician is responsible for the overall organization and oversight of your community-based medicine experience. The specifics of the resident's role may vary slightly from practice to practice. You should discuss this with the Directing Physician in your practice at the start of the month. In most instances, you will examine the patient and then discuss any findings and recommendations with the attending. Whenever possible, you will complete all aspects of the encounter, including needed procedures, instructions and charting. It is your responsibility to ensure that the attending physician is aware of all medical decisions, including any to perform an invasive procedure. You are not responsible for seeing each and every patient presenting to the practice on any given day, but you should work with the attending to identify patients appropriate for the outpatient teaching service.

Appropriate resident activities on the community medicine rotation include, but are not limited to: office hours, office-based procedures (treadmills, sigmoidoscopies, arthrocenteses, etc.), front-office and back-office education, hospital rounding, night call, house calls and nursing home visits.

The Geriatrics rotation is a multidisciplinary month, with time spent in several sites. Site specific resident responsibilities and expectations vary, and are best discussed with each site supervisor. However, all usual guidelines for resident supervision and activities pertain (see "General Work Guidelines for all Services").

The R3 Internal Medicine resident in the TMC Emergency Room is expected to evaluate and treat a variety of patients, spanning the spectrum of problems seen at this busy site. Residents are also expected to coordinate patient disposition, which includes contributing to admission decisions. Every patient seen by a resident must also be seen by and discussed with an Emergency Medicine attending, all of whom are board certified in Emergency Medicine.

Scheduling is done by the Emergency Medicine department and is coordinated with the THMEP office. Pediatrics and Emergency Medicine residents from the University of Arizona also participate in the rotation. THMEP policies regarding work hours apply. See "General Work Guidelines for all Services."

A copy of the TMC Emergency Medicine Resident Handbook will be provided at the start of the month and must be returned at the end of the rotation. The Handbook includes specific resident responsibilities, ER policies, critical pathways and useful reference materials.

The R1 experience in the Kino Emergency Department (ED) is busy and diverse. While resuscitating patients in code situations and saving lives in other emergent situations provides the glamour for Emergency Medicine, you will find that the majority of the Kino ED patients need episodic primary care. Their complaints will span the field of medicine and their acuity will range from the mundane (prompting you to think, "Why are you bothering me?") to the truly life-threatening. You will have the opportunity to manage everything from sore throats to septic shock, always with appropriate attending supervision. You are not expected to know how to handle all of the problems you encounter, and you are encouraged to ask questions. One very valuable aspect of this rotation is that you will be working with an attending at all times. If you are not sure whether a child has otitis media or what type of suture to use on a particular laceration, just ask! You are not being graded on what you know. On the other hand, your attitude and intellectual honesty are absolutely important to your learning and to the delivery of quality patient care.

You will receive a schedule prepared by the THMEP office. You may trade shifts with your co-residents but these must be cleared through the THMEP office and Dr. McLaughlin, ED Director. Twelve-hour shifts change over at 0700 and 1900. You are expected to arrive on time to receive sign-out from your colleague so that he or she can leave on time. Your dress should be neat and professional. Jeans and high-mileage athletic shoes are not appropriate. Scrub suits are available and encouraged.

You should expect to be regarded as a key player on the Emergency Department team. You and the attending will both be seeing patients and there is no formal selection process. After you have performed the history and physical, you will discuss each case with the attending and then proceed to order appropriate diagnostics or treatments, with his or her guidance. You will read radiographs and ECGs, and will consult with housestaff and attendings when necessary. You will get plenty of hands-on experience suturing and splinting. Endotracheal intubations and placement of central lines and chest tubes are often necessary and will be available to you, with appropriate guidance. The nursing staff normally performs placement of peripheral intravenous lines, Foley catheters, and nasogastric tubes. However, you may also perform these procedures if you desire, or if needed for credentialing purposes. The attending and nursing staff are available to help you with this. The nursing staff is generally very supportive of medical education. They like working with you, and you are encouraged to use them as an educational resource.

All guidelines for lines of responsibility and work hours pertain, as described in the section "General Work Guidelines for all Services".

The second year resident in the TMC Urgent Care Clinic works closely with one or two Urgent Care Clinic attendings, evaluating and treating individuals with a diversity of illnesses. Each patient under a resident’s care must be seen by, and discussed with, an attending physician prior to disposition. Invasive procedures, parenteral medications and major diagnostic studies (MRI, CT, VQ-scan, etc.) should also first be discussed with the attending. Other specific policies and resident expectations are discussed on site.

The Urgent Care Clinic is open from 8 a.m. to 10:30 p.m. daily, although patient care usually lasts longer. Scheduling is done by the Urgent Care department and is coordinated with the THMEP office. Although shift length and times vary, THMEP policies regarding work hours remain in effect. See "General Work Guidelines for all Services."

The Ambulatory Specialty Clinic rotation is usually conducted in the Ambulatory Clinic Building at Kino Community Hospital, although some clinics may occasionally be held at other sites. The rotation consists of outpatient experiences in gynecology, orthopedics, ENT and ophthalmology, from 8 a.m. to 5 p.m., Monday through Friday. Whenever possible, residents are asked to take an active role in patient care. However, because of the relatively brief time spent in each of these clinics and the specialized nature of many of the procedures performed, much of the rotation is purely didactic. Residents are encouraged to rely heavily on the THMEP curricula for these specialties to ensure that essential topics are addressed and that required competencies are attained. Attendance at each scheduled clinic is mandatory.

Electives are offered in Anesthesiology, Allergy, Cardiology, Dermatology, Endocrinology, Gastroenterology, Hematology/Oncology, Infectious Disease, Nephrology, Neurology, Ophthalmology, Otorhinolaryngology, Pathology, Pediatrics, Physical Medicine/Rehabilitation, Psychiatry, Pulmonary/Critical Care Medicine, Radiology and Rheumatology. Electives are offered in a variety of venues and may include private offices, TMC, Kino Hospital and the University of Arizona Health Sciences Center. Up to three electives may be taken at the University of Arizona Health Sciences Center during the 3-year program.

Residents may engage in a research elective for one month of the 2^nd and/or 3^rd year with prior approval of the Program Director. Additional months of research elective may be granted on an individual basis. Other electives and all research electives require review and approval of the proposed activities.

All elective rotations are conducted under the supervision of a single directing attending, although actual clinical activities may be coordinated with several members of a practice or clinical department. Usual working hours are from 7 a.m. to 5 p.m., Monday-Friday. However, housestaff should discuss this and other expectations with the directing attending at the beginning of the month. Some elective services do require weekend and night-call work. An 80-hour work week limit applies.

Each categorical resident spends one afternoon each week throughout the three-year residency in continuity clinic. All clinics are conducted through Kino hospital, in the adjacent Ambulatory Clinic building. As this experience spans all years of residency, it enables the housestaff member to follow some patients throughout training and to serve them as their primary care physician.

A THMEP faculty member, who is ultimately responsible for every patient seen, supervises each clinic. As such, timely, thorough and open communication between the resident and the attending is essential.

Patients in the continuity clinics should be provided with a THMEP Physician Identification Card by the resident, a copy of which should be stapled to the Kino Hospital chart. This card identifies the resident as the patient’s primary physician and requests that the THMEP office be notified of any hospital admissions or other important medical events. The TMC Chief Resident will alert the resident of any such event. Residents are encouraged to remain involved in the care of their patients whenever they are hospitalized, communicating vital patient history to the admitting physician and contributing to medical decision-making.

Unless on night-call, house officers are not expected to return to work after continuity clinic. Before leaving for clinic, an intern should hand over unfinished work and all ongoing patient issues to his or her resident, who will then be responsible to sign-out to the appropriate night-call intern at the end of the day.

In addition to regular Teaching Rounds and Management Rounds

• Mandatory for housestaff on TMC inpatient rotations; otherwise, strongly encouraged:

Grand Rounds Wednesday, 8 a.m.

Resident Report (R2/R3) Tuesday, Thursday and Friday, 11 a.m.

Intern Report (R1) Monday, 11 a.m.

General Medicine Core Lectures* Friday, 1 p.m. (*videotaped)

Afternoon seminars** vary (**unless in Continuity Clinic)

Noon Conference Monday through Friday, noon

• Includes: Morbidity and Mortality Conference

ICU Core Lectures

• Mandatory for housestaff on Kino inpatient general medicine rotations:

General Medicine Core Lectures weekly

ICU Core Lectures twice monthly

Grand Rounds twice monthly

Morbidity and Mortality monthly

Journal Club monthly

Noon conference varies

• Each THMEP resident must, at some time during the R2 or R3 years, attend each of the following meetings at least twice :

TMC Medical Affairs Committee 1^st Tuesday, monthly at noon

TMC Ethics Committee 3^rd Tuesday, monthly at 7:30 AM

Medical Morbidity & Mortality Conference is a vital forum for discussing untoward outcomes and opportunities to improve medical care.

1. Patients should be referred to by their initials, not their name.
2. A certain amount of structure and formality will hopefully facilitate discussion. To this end, the presenter will be provided with a podium and a pointer.
3. The program should begin with the Senior resident (or his or her substitute) presenting the total number of deaths on the service, dividing these into "expected" and "unexpected" deaths. All deaths on the medical ward and CCU service should be recorded by the houseofficer involved on a Morbidity and Mortality sheet which will be saved at the THMEP office. However, only a few cases, picked by the chief resident or program director should be presented fully.
4. Whenever possible, the intern involved in the patient’s care should present the case. When this is not possible, the responsible resident should do so.
5. Whichever house officer presents the case should consider it his or her responsibility to contact the key physicians involved, and arrange for their attendance. If this is not possible, a substitute physician in the appropriate discipline should be asked to attend.
6. Whenever possible, pathology and/or autopsy slides should be presented. The pathologist should be invited well ahead of time, to avoid scheduling conflicts.
7. The case should be presented in such a way as to highlight the clinical dilemmas or medical mishaps.
8. Next, questions should be entertained from the audience.
9. At this point, the house officer presenting the case should be prepared to give a short synopsis of his/her opinion about what is to be learned from this case. The invited physicians should be given an opportunity to describe their opinions and offer more information about the clinical entities described. The house officers involved in the case are expected to have read sufficiently about the subject in question to discuss it from a knowledgeable perspective.

1. Clinical Vignettes:

All PGY-2 Categorical Medical Residents are expected to prepare a Clinical Vignette, including a concise medical history, physical examination, hospital course, review of literature and scholarly discussion. These vignettes are presented to a sampling of the THMEP faculty in the Spring, and the best is chosen to represent THMEP at the annual Arizona-chapter American College of Physicians meeting in the Fall of the PGY-3 year. All vignettes but the one chosen for presentation at the ACP meeting are prepared as posters, also for the ACP meeting. The Medical Photography Department at TMC and the THMEP office can assist with poster preparation.

2. Clinical Pathologic Conference/Grand Rounds:

Each PGY-3 also presents one Clinical Pathologic Conference at Grand Rounds. The resident presents a medical history, physical examination and, when appropriate, hospital course. An invited faculty member is asked to solve the diagnostic or clinical dilemma raised by the case. Pathologists, radiologists and other ancillary staff are asked to review the pertinent studies at the appropriate times, and the "answer" is then revealed. The resident then delivers a discussion of the topic at issue, including a thorough review of the medical literature. A separate faculty member with particular expertise in the area of discussion should serve as faculty preceptor and can assist with this discussion. THMEP will help enlist an appropriate preceptor.

3. Research and Publications

Residents are encouraged to broaden their understanding and contribute to medical knowledge through publication of case studies, clinical reviews and/or original research. The Program Director, Associate Program Director and many of the THMEP clinical faculty are available to assist in the preparation of case studies or clinical review articles. Clinical research opportunities are available through the THMEP sites, the University of Arizona and local, private research concerns. Residents may also participate in basic research on an elective basis at the University of Arizona.

 

Every resident must maintain current ACLS certification, on file with the THMEP office. To facilitate this, an ACLS course is included in THMEP Orientation Week, given just prior to the start of Internship clinical duties. An animal lab is also provided, allowing opportunities to review thoracentesis, chest tube insertion, cricothyroidotomy and endotracheal intubation.

THMEP provides a number of other learning tools that residents are encouraged to use. These include the Medical Knowledge Self-Assessment Program (MKSAP), Mayo Internal Medicine Board Review audiotapes, JournalWatch, MD Consult, the ABIM In-Training Examination, the American College of Physicians’ Journal Club, Annals of Internal Medicine, and heart and lung auscultation audiotapes. The medical libraries at TMC and Kino Community Hospital also provide a number of multimedia resources available to you.

Both TMC and Kino Community Hospital offer comprehensive Clinical Laboratory services, although some tests may be sent to outside laboratories. Clinical laboratory facilities and their staff are accessible to medical residents 24-hours/day and are available to help you perform and interpret Gram stains, wet-mounts and other essential tests.

Timely completion of medical records is a requirement for ongoing hospital staff privileges and for continued employment with THMEP. Failure to complete medical records may result in suspension from the residency program without pay or dismissal. During a resident’s suspension from clinical activities while on inpatient services or emergency medicine, other residents may be required to cover. Any time missed while on suspension must be made up at the end of the residency program.

The American Board of Internal Medicine requires observation during residency training of satisfactory skill in the performance and interpretation of invasive diagnostic and therapeutic procedures. Furthermore, many hospitals and clinics now require documentation of formal training, experience and competency in performing invasive procedures for credentialing. For these reasons, the following guidelines have been adopted.

1. All housestaff must become familiar with the accepted indications for and potential complications of each invasive procedure they perform, and must be able to knowledgeably counsel the patient on these.

2. The houseofficer performing the procedure is responsible for obtaining prior consent for the procedure and is responsible for adequate documentation in a procedure note. The houseofficer is also responsible for follow-up of both the results of the procedure and any complications or potential complications.

3. Any houseofficer either performing or supervising an invasive procedure must fill out the "Documentation Log for Internal Medicine Procedures", including patient identification, medical record number, hospital, procedure type, evaluation of procedure, indications, complications, and follow-up intended. These log books can be obtained in the THMEP office, and the forms are kept in the resident's permanent file. The procedure form must be completed and signed by the attending or supervising resident (Level 3 privileged.). One copy should be returned to the THMEP office as soon as possible for documentation purposes. The other copy should be retained by the house officer. 

4. Credentialing for the performance of invasive procedures is based on three levels of clinical privileges:

Level 1 - The individual can perform the procedure only under the direct supervision of either the attending physician or a resident with Level 3 privileges.

Level 2 - The individual can perform the procedure under indirect supervision of the attending physician. That is, the attending physician must explicitly agree that the procedure is appropriate, and must be aware that the resident is performing this procedure.

Level 3 - The individual can both perform the procedure under indirect supervision of the attending physician and can supervise and certify others performing this procedure.

Entering PGY-1's are Level 1 in all procedures.

Level 2 privileges should be obtained during the PGY-1 year for most procedures.

Whenever possible, Level 3 privileges should be obtained upon promotion to the PGY-2 year. However, Level 3 privileges are only granted by the Program Director when the observation criteria for the procedure are met AND the trainee’s performance and understanding of the risks and benefits of the procedure make the granting of the privilege appropriate.

Privileging status for any procedure can be viewed by the resident and appropriate Hospital Staff on the TMC Intranet home page, select Physician & Allied Health, then select Practitioner Privilege Site. Instructions on that screen tell you how to access your name and your privilege status of required invasive procedures. Procedures in black print indicate you are qualified to do the procedure, red indicates the procedure needs to be done under direct supervision of either the attending physician or a resident with Level 3 privileges, and green indicates that the resident is qualified to proctor (supervise) the procedure. Required procedures are also listed on the next three pages of this handbook.

The THMEP Internal Medicine Program recognizes three categories of clinical procedures: (a) Entry level procedures (b) Basic level procedures and (c) Advanced level procedures. All invasive procedures require prior explicit approval by the attending physician, unless marked "*".

A. Entry level procedures: Entry level procedures are simple, require limited expertise and are easily learned. The required procedures should be performed early in the PGY-1 year. Upon satisfactorily completing these procedures, Level 3 privileges are granted.

B. Basic Procedures: Basic procedures are more complex, require more expertise, and are more difficult to master. Since they are necessary to the effective functioning of the 2^nd year resident, Level 2 privileges should be obtained during the first year of training. The Program Director will approve Level 3 privileges for appropriate candidates, usually at the start of the 2^nd year. When performed non-emergently, these procedures always require the express permission of the attending physician.

# If emergency endotracheal intubation is required, nursing staff should be instructed to call for anesthesia backup immediately and emergency endotracheal intubation should proceed after preoxygenation with 100% oxygen by bag-valve-mask. If unsuccessful, bag-valve-mask ventilation should continue until the arrival of an anesthesiologist (or another individual with expertise in endotracheal intubation). Elective endotracheal intubation should never be performed by a resident without the express permission of the attending. In addition, an anesthesiologist (or another physician with adequate expertise in endotracheal intubation) must be present for backup before the beginning of the procedure.

C. ADVANCED PROCEDURES: Each resident is credentialed Level 1 throughout training, and is required to perform these procedures under the direct supervision of an attending physician.

THMEP holidays are: Christmas

New Year’s Day

Memorial Day

July 4^th

Labor Day

Thanksgiving

THMEP housestaff are given a total of four weeks of paid vacation per year, to be taken in one-week blocks. No more than one week of vacation may be taken from any month long rotation. Two weeks of vacation may be taken consecutively, provided they are the last week of one rotation and the first week of the following rotation.

A. Interns (R1) may not take vacation from:

1. General Medicine at Kino Community Hospital

1. Emergency Medicine at Kino Community Hospital
2. At the same time as another intern on the same team
3. ONLY one intern per team may take vacation while on wards or CCU at TMC. Vacation for a given month will be granted on a 1^st come basis.
4. Pediatrics (elective)

B. Residents (R2 and R3) may not take vacation from:

1. General Medicine at either Kino Community Hospital or TMC

2. CCU/Cardiology at TMC

3. Pediatrics (elective)

C. All housestaff may not take vacation during:

1. The first week in July

2. The last week of June, with the following exception: Interns who begin residency elsewhere on July 1 may take vacation during the last week of June providing vacation time is due and adequate coverage of the service is maintained.

Unfortunately, houseofficers and their families get sick during the year and it is necessary to provide coverage for housestaff who are not able to work a back-up schedule will be issued each 6 months. The following guidelines are an attempt to cause the least disruption to patient care and the educational process.

The training program is obligated to provide interns to the following services: Kino inpatient general medicine, CCU, and Kino ER. If an intern on one of these services is unable to work because of illness (or family illness), the intern on elective will be asked to drop the elective to cover the service vacated by the sick intern. As there are two interns on each TMC inpatient ward team, intern coverage will not usually be required on this service, although special circumstances may require additional intern coverage.

The training program is obligated to provide residents on inpatient general medicine (TMC and KCH) and the CCU. If a resident on one of these services is unable to work because of illness (or family illness), coverage will be required. If the anticipated absence is for a single non-night-call day, the day-call resident on the general medicine service will be asked to supervise the absent resident’s team. If the addition of this team’s patient census would violate the limits on patient number, one intern and his/her patients will be supervised by the remaining (post-call) resident. If the absence is greater than 24 hours (or if the absence is for a night-call day), a resident on an elective service will cover the absence.

Housestaff will not be asked to give up scheduled vacation time to cover for sick residents.

If the resident is unable to come to work, he/she must obtain permission from the Program Director or Associate Program Director and the attending physician to whom the resident is assigned. Approval may not be granted by the Chief Resident or another resident. In cases where this policy is not honored, disciplinary action will follow. Appropriate actions might include probation, suspension or permanent dismissal from the program.

During your internship and residency, you will occasionally be required to care for patients with known HIV infection, chronic hepatitis or other blood-borne and communicable diseases. If you have to draw blood or obtain other body fluids from these patients, it should be obvious to you that gloves must be worn during the procedure and great care should be exercised in handling the fluid.

Because patients may be infected with such diseases and not know it, the Tucson Hospitals Medical Education Program (Tucson Medical Center and Kino Community Hospital) has instituted Universal Precautions for the handling of body fluids and secretions. What this means is that all patients are to be regarded as potentially infected with HIV and other communicable diseases and gloves must be worn when handling body fluids from any patient.

After using needles for drawing blood or other purposes, the needles should not be recapped -- they should be placed directly in the nearest disposal unit designated for such purposes. Most needle sticks occur when people try to recap the needle.

If a needle stick should occur, you should follow the procedures outlined on the following pages/paragraphs.

If you have any questions about proper handling of body fluids, please ask your senior resident or attending before attempting the procedure.

For your safety, following is the policy concerning medical care and follow-up for sharps injuries, (needle sticks, scalpel injuries, etc.) and bodily fluid exposures that occur on the job. If you suffer a sharps injury or if you are splashed with bodily fluids to your mucous membranes:

• Call TMC Employee Health within 8 hours of injury at extension 47106.
• Your Hepatitis B antigen status will be determined and you will vaccinated if necessary.
• You will receive Hepatitis B immunoglobulin prophylaxis and treatment if indicated.
• You will be counseled and offered serial HIV AB testing.
• You will be referred to an infectious disease physician for AZT prophylaxis if indicated.
• The source patient, if known, will be counseled and asked to consent to HIV AB and Hep B₅A_g testing if indicated. Blood will be drawn on the source patient with consent.

NOTICE TO EMPLOYEES (TMC/THMEP)

Re: Human Immunodeficiency Virus (HIV)

and Acquired Immune Deficiency Syndrome (AIDS)

Employees are notified that a claim may be made for a condition, infection, disease of disability involving or related to the Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS) of the Industrial Commission of Arizona. Such a claim shall include the occurrence of a significant exposure at work, which generally means contact of an employees' ruptured or broken skin or mucous membrane with a person's blood, semen, vaginal fluid, surgical fluid(s) or any other fluid(s) containing blood. AN EMPLOYEE MUST CONSULT A PHYSICIAN TO SUPPORT A CLAIM. Claims can not arise from sexual activity or illegal drug use.

Certain classes of employees may more easily establish a claim related to HIV or AIDS, if they meet the following requirement:

1. The employee's regular course of employment involves handling or exposure to blood, semen, vaginal fluids, surgical fluid(s) or any other fluid(s) containing blood. Included in this category are health care providers, forensic laboratory workers, fire fighters, law enforcement officers, emergency medical technicians, paramedics and correctional officers.

2. NO LATER THAN TEN (10) CALENDAR DAYS after the possible significant exposure which arises out and in the course of employment, the employee reports in writing to the employer the details of the exposure as provided by Commission rules. Reporting forms are available at the hospitals or from the Industrial Commission of Arizona 800 W. Washington, Phoenix, AZ 85077 (602) 542-4661 or 2675 E. Broadway, Tucson, AZ 85716 628-5188. If an employee chooses not to complete the reporting form, that employee may be at risk of losing a prima facie claim.

3. NO LATER THAN TEN (10) CALENDAR DAYS after the possible significant exposure the employee has blood drawn, and NO LATER THAN THIRTY (30) CALENDAR DAYS the blood is tested for HIV by antibody testing and the test results are negative.

4. NO LATER THAN EIGHTEEN (18) MONTHS after the date of possible significant exposure at work, the employee is retested and the results of the test are HIV positive or the employee has been diagnosed as positive for the presence of HIV.

 

Participation in graduate medical education is considered a full-time commitment. As such, "moonlighting" is generally discouraged. Should you decide to moonlight outside the THMEP educational program, the following policies apply:

• Permission must be obtained for the specific activity from the residency Program Director. He has the prerogative to deny the request.
• The number of hours spent on moonlighting activities must be reported monthly to the Program Director and will be documented in the resident's records.
• Moonlighting must not interfere with the performance of your assigned patient care responsibilities and educational exercises.
• The total number of hours permitted for both the residency and moonlighting combined may not exceed 80 hours per week averaged over a four week period.
• THMEP will not provide medical liability insurance for any moonlighting activities.
• You must have a regular Arizona medical license to participate in such moonlighting.

Vacation time may be used for maternity or paternity leave. Thereafter, further time off is permissible but without pay as permitted by American Board of Internal Medicine regulations. A complication of pregnancy or the post-partum period resulting in a longer absence from the program will be regarded as a "sickness" under our disability program.

As residents, you will now have the ability to prescribe narcotics and other prescriptions for patients. This privilege also carries a tremendous responsibility. The misuse of narcotic medications, or even the appearance of misuse, can be one of the most serious and damaging threats to a young physician's career.

Therefore, it is essential that you never prescribe narcotics for yourself, or ask for them from a nurse or from a pharmacist. As a general rule, you should never prescribe any medication for yourself, and if you are in need of a prescription medication, you should establish care with one of the physicians here or under your health plan no matter how trivial the problem may seem.

Likewise, it is against Arizona State law to prescribe narcotics for a member of your family.

As a general rule, you should never prescribe narcotics for someone who is not under your direct medical care. The problem for which the drug is being prescribed must be in the chart and the number and dose of the medications must also be entered in the chart. Never write a prescription for a fellow physician, nurse, secretary or anyone else who asks you for narcotics. Just inform them that it is against the policy of THMEP and that you could lose your license.

Residents must personally see any patient before ordering Benzodiazepines or Narcotics. These medications should never be ordered on a patient without first assessing the patient. A short note should be written as to why a Benzodiazepine or Narcotic medication is being given.

It is also the policy of THMEP that residents and interns should not give medical advice or write prescriptions for ancillary staff such as secretaries, nurses, clerks, etc. A number of legal and professional conflicts arise when this happens and it is not in your best interest to try to help someone out in this manner. Again, if someone does ask you for medical advice or any kind of prescription, you must refer them back to their primary care physician or suggest that they see one of the members of the medical staff.

There will NO exceptions to the above rules.

The objective of the Resident Support and Impaired Resident (RS/IR) program is to retain valued residents who have problems that affect their job performance. These programs have been developed to assist residents in coping with stressful clinical or personal situations.

THMEP recognizes that most problems can be successfully corrected when they are

identified in the early stages and referral is made to an appropriate level of care. This applies if the problem is one of physical or mental illness, emotional stress, financial, marital or family distress,

alcohol or drug, events triggered by adverse clinical outcomes, mal-practice events, or professional relationships. Unless the situation endangers a patient, visitor, or family member, residents may voluntarily access these programs. Otherwise, participation will result from a non-voluntary referral. All communications are confidential.

All records are the property of the THMEP RS/IR Program. All records will be kept strictly confidential to the extent provided for by statute or regulation, and will not be noted in any official THMEP record. Information may only be released with the written permission of the resident in accordance with state or federal regulation, or in response to a court order. Records will be kept for a period of five years.

The RS/IR program is available to all THMEP Residents. Residents may contact THMEP or Tucson Medical Center's Employee Assistance Program (EAP) for an appointment or referral (324-1166).

The Residency Program leadership is responsible for documenting resident performance and conduct, and when needed, to take appropriate action for correction, as provided by this program. The leadership will not attempt to diagnose the medical or behavioral problem that is causing the inappropriate behavior, but will facilitate the formal or informal referral to assist the resident at the residency program's expense.

The Residency Program Director will facilitate the referral of a resident to the RS/IR program before, during, or after a disciplinary step.

The Residency Program leadership may contact the TMC EAP and request a confidential consultation concerning a resident. EAP may also provide support/counseling to the leadership regarding critical incident stress management, communication skills, conflict resolution, grief and change transition, and other issues.

2. Resident Support System

Residents may contact the TMC EAP office to obtain a referral or schedule an appointment to meet with a counselor for an initial assessment or evaluation of need. Counseling services are available at no charge to residents.

TMC EAP referral services include individual, couple or family counseling, alcohol and drug abuse evaluation and rehabilitation referral, and referral for other addictions, such as gambling, sex, work, etc. Other services include: financial counseling, legal service, divorce counseling and support groups, parenting information, healthcare-burnout information, caregiver concerns and resources for the elderly, grief and loss counseling, and care for the caregiver.

In the event of a critical incident involving a THMEP resident and a participating institution any staff member or physician may request a debriefing by the EAP office. All personnel directly involved are invited to participate. Debriefings are conducted by the critical incident stress management team. Individual debriefings are also available.

In a situation where the behavior or action of a resident jeopardizes the care of a patient or creates conflict with staff, the resident may be referred to the EAP office to arrange for services such as conflict resolution, mediation, assessment, and short term counseling. Residents may elect to utilize EAP counseling, or arrange for their own private follow-up.

Disciplinary processes will be in accordance with THMEP "Disciplinary Action and Appeals" policy and/or the Bylaws of a hospital's Professional Staff.

This has been developed for the purpose of protecting patients from a resident who may be guilty of unprofessional conduct, or otherwise unable to safely engage in the practice of medicine. The program is conducted in collaboration with the Arizona State Board of Medical Examiners (BOMEX), and is in accordance with Arizona State Statute ARS Article 3, 32-1451.

Self-referral is encouraged and is consistent with the policies of BOMEX. All referrals are confidential except reporting as required by ARS 32-1451. A self-referral occurs when a resident contacts the residency program director or TMC's EAP staff directly. A self-referral is recorded in the resident's file but information may not be released except as provided by the Bylaws of the Professional Staff of the involved institution.

B. Non-voluntary Referral:

Non-voluntary referrals are made when the resident is found to be in violation of THMEP or institutional conduct guidelines such as: prohibiting practice while under the influence of alcohol or illegal drugs, or the use, possession, sale, purchase, transfer, or negotiation for sale of drugs on institution property or the institution's Bylaws of the Professional Staff. Referrals may result from alcohol or drug testing programs or law enforcement programs. Bomex reporting will occur in such cases, and in accordance wit ARS statute 32-1451. Referrals may also result from the resident acting in violation of any hospital policy, rule, regulation, or standard of performance that, in the opinion of the hospital medical staff leadership, or Professional Staff Office Leadership, might endanger the safety or well-being of a patient or those involved in the care of the patient. Referred residents will be entered into the Impaired Resident System for tracking purposes, in accordance with BOMEX regulations. The resident will be required to agree to the terms requested including reporting of treatment progress and random alcohol and drug testing. Should a resident refuse to agree to the terms, fail to successfully complete the program, or violate the terms of the agreement, then termination of employment and privileges or other disciplinary action may be implemented and BOMEX and/or other appropriate licensing agencies will be notified. All referrals are recorded in the resident's file.

 

4. Internship Mentoring Program

Each PGY 1 Resident (Intern) is assigned to a PGY-3 Resident, who serves as a mentor to the intern during his transition through the PGY-1 year.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

06/01/2001

Bedside teaching should occur at least twice a week.

The following is a list of the basics to help assure a successful and enjoyable trip to the patient's bedside when you are accompanied by residents and/or students. When done well, patients enjoy bedside teaching… students and residents do as well.

I. Setting the ground rules

1. Make sure that your team knows what you expect of them - teach professionalism
2. Cover bedside etiquette
3. Limit beeper interruptions
4. Begin on time (everyone present at the start)
5. Schedule with the patient whenever possible (Have the resident arrange.)
6. Invite the patient's nurse when feasible (unfortunately, this is not often an option)
7. When at the bedside, limit your use of medical jargon

II. Introduction

1. Have the patient's doctor (student, intern, resident, you) introduce all members of

the team

2. Explain the purpose of the visit
3. Allow the patient a polite refusal (rarely necessary)
4. Introduce yourself to family members if present; invite to stay, but only if okay

with the patient

5. Explain that much of what you and the team discuss may not apply directly to this particular patient
6. Invite participation and questions by the patient
7. POSITION THE PATIENT APPROPRIATELY; position your team around the

bedside

III. The Presentation (History)

1. Avoid beginning the presentation with a statement about the patient's gender and

race; these should be obvious.

2. Do not refer to the patient by his-her first name unless you know for sure that it is

appropriate

3. Avoid sitting on the patient's bed unless there is a reason to do so
4. Do NOT avoid sensitive material… just treat it in a sensitive manner
5. Allow interruptions by the patient, the students and residents, and by yourself to

highlight important points or to probe in more detail

6. Never, EVER embarrass the patient's doctor - the student/resident won't like it

and neither will the patient

IV. The Presentation (Examination)

1. Examine the pertinent or illustrative parts yourself
2. Invite the resident/students to examine the patient
3. Allow the patient to participate (many will greatly appreciate hearing the murmur or feeling the spleen that the rest of you seem so excited about)
4. Ask the team members to demonstrate proper techniques
5. Allow time for the team members to appreciate the findings; remember that it may take a while (and some ingenuity on your part) for a student or intern to truly hear an S4 for the first time

V. The presentation (Labs, etc.)

1. Stay at the bedside if possible
2. Have pertinent radiographs, EKG's, etc., available
3. Allow the patient to review

VI. Discussion

1. Remind the patient that not everything said will apply to them; be explicit when

what you are discussing is directly applicable

2. Question junior team members first
3. Avoid asking theoretical questions to the patient's primary doctor; missing them in front of the patient is quite hard on the resident/student and may belittle them in the eyes of the patient
4. Don't allow "one-upmanship" to occur
5. Avoid asking the "What am I thinking?" question - you know, the ones that make a point but are primarily designed to make you look good
6. "I don't know" is an appropriate answer - both for you and for your team; it should be followed up, though, with a search for the correct answer if important

As you are about to leave the patient's bedside, allow his/her time for questions (although most will have been answered). Ask for feedback from the patient about the process. Oh and be sure to say thanks.