THMEP

HOUSESTAFF MANUAL

2007 - 2008

TABLE OF CONTENTS

Welcome

THMEP Key Faculty Listing

Description of the Programs

General Work Guidelines

         Lines of Responsibility

         Patient Limits

         Work Hours

         Writing Orders

         Daily notes

         Cross Coverage Notes

         Non-teaching Service Patients

         Sign-Out

         On/Off Service and Transfer of Patients

         Consultations

         Completeness of Physical Examinations

Inpatient Admitting Protocol (At TMC)

Bedside Teaching

Curriculum

Evaluations

Medical Libraries at TMC, UMC and SAVAMC

Protocol for the TMC General Medicine Service

TMC General Medicine Responsibilities

General Surgery

Protocol for SAVAMC General Medicine Service

Community Medicine (Private Offices)

TMC Emergency Medicine

Minor Emergency Clinic (MEC)

Electives

Conferences

Medical Morbidity and Mortality Conference

Privacy/Confidentiality

ACLS Certification

Learning Tools

Clinical Laboratory

Medical Records

Certification & Documentation of Invasive Procedures

Time off:

         THMEP Holidays

         Vacation

         Coverage During Illness

         Policy for Resident Absence from Work

Universal Precautions

Sharps Injury/Bodily Fluid Exposure

Work Exposure to Bodily Fluids

Moonlighting Policy

Parental Leave Policy

Policy on Narcotics and other Prescription Medications

Resident Support/Impaired Resident Program

June 1, 2007

Dear Physicians:

Welcome to the Tucson Hospitals Medical Education Program and to Tucson! Each of us at THMEP and the full-time, part-time and voluntary teaching staffs at Tucson Medical Center, University Medical Center and the Southern Arizona VA Medical Center are delighted you have joined us. We look forward to an exciting and productive year together.

This manual is intended to help orient you to the policies, schedules and expectations at TMC and elsewhere for housestaff members of the Transitional Year Program and for the University of Arizona-Tucson Hospitals Internal Medicine Residency Program (THIMRP) residents while at TMC and on community rotations. While it is unlikely that you will "digest" all of this in one sitting, we hope you will read through this important manual and refer to it from time to time to clarify areas of confusion.

Because the landscape of medical education changes rapidly, and because THMEP is committed to meeting the evolving needs of our housestaff, changes in the information contained here are likely. Our core belief in the value of community-based medical education, our philosophy of education through patient care and didactics and our understanding of you as both our student and our colleague will not change.

All of us at THMEP are dedicated to helping you succeed, now and in the future. Essential to this is our ability to recognize both our successes and our troubles, and to respond to each appropriately. We look to you to share your observations with us, and we welcome your input.

We look forward to working with you during the coming year. Please do not hesitate to speak with any of us at THMEP if we can help make this year’s transition easier, or if we can help in any other way.

TUCSON HOSPITALS MEDICAL EDUCATION PROGRAM

 Robert Aaronson, M.D., Executive Director, THMEP and Associate Program Director, THIMRP

 Tyler Kent, M.D., Transitional Program Director

 Steven Wool, M.D., Chairman, Department of Medicine, TMC

Sanjay Bhartia, M.D., Chief Medicine Resident (2007-2008)

John Kuczynski, M.D., Chief Medicine Resident (2007-2008)

Daniel Van Handel, M.D., Chief Medicine Resident (2007-2008)

TMC HOSPITALIST SECTION STAFF

Shelli Collingham, M.D., Director for Resident Education

William Odette, M.D., Section Chief

Soheila Nouri, M.D.

Cynthia Ogden, M.D.

UNIVERSITY MEDICAL CENTER (UNIVERSITY OF ARIZONA)

William Johnson, M.D., Interim Program Director, THIMRP

THMEP SECTION CHIEFS (AT TMC)

   CARDIOLOGY

   INFECTIOUS DISEASE

         Timothy Marshall, M.D. 

      Marcelo Nasif, M.D.

   EMERGENCY MEDICINE

   NEPHROLOGY   

        Eric Ruhe, M.D.

     Mohammed Sikder, M.D.

    ENDOCRINOLOGY

   MEDICAL NEUROLOGY

         Jonathon Insel, M.D.

       William Lujan, M.D. (Site Coordinator)

   GASTROENTEROLOGY

   PEDIATRICS

         Charles Krone, M.D.

         Mary Jo Ghory, M.D. (Site Coordinator)

   GENERAL MEDICINE

   PULMONARY/CRITICAL CARE

         Steven Wool, M.D.

         Robert Aaronson, M.D.

         Thomas Rotkis, M.D., PhD

   GERIATRICS

   REHABILITATION MEDICINE

         Steven Wool, M.D.

         Jon Larson, M.D.

   HEMATOLOGY-ONCOLOGY

   SURGERY

         Haroon Ahmad, M.D.

    Terrance Adkins, M.D. (Site Coordinator)

     Daniel McCabe, M.D.     

DESCRIPTION OF PROGRAMS

The Transitional R1 year includes:

3 months TMC General Medicine/ICU

1 month SAVAMC General Medicine/ICU

1 month TMC Critical Care

1 month TMC Surgery

1 month TMC Emergency Medicine

For details on the Internal Medicine and General Surgery Residency Programs, please visit the following websites:

 University of Arizona - Tucson Hospitals Internal Medicine Residency Program: www.meded.arizona.edu 

University of Arizona - Tucson Hospitals General Surgery Residency Program: www.surgery.arizona.edu

GENERAL WORK GUIDELINES FOR ALL SERVICES

             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 rotations, the R1's clinical responsibilities are centered on the care of his or her patients. The R1 is the front-line, primary physician for the patient during hospitalization. The R1 is under the immediate direction of the team’s R2 or R3. The R2 or R3 is responsible for the effective functioning of the team in its dual roles of educational forum and patient care entity. The R2 or R3 supervises the intern in all aspects of patient diagnosis and treatment, contributes to R1 education and ensures appropriate attending communication and oversight. The resident is expected to alert the attending or members of the THMEP Administration 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 medicine services at all sites:

·        No R1 shall admit more than 5 new patients in 24 hours, or 8 new patients in 48 hours.

·        No R1 shall be responsible for the ongoing care of more than 12 patients.

·        Each R2 or R3 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 R2 or R3 shall be responsible for the ongoing care of no more than 24 patients at any one time, including those patients cared for by R1(s) under his/her supervision.  On teams with only one R1, the total team cap with be 16 patients.

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 R1, or kept" by the R2 or R3 throughout the patient's hospitalization. A certain amount of "patient shifting" between R1's or teams may be required, as determined by the R2 or R3, 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 or other members of program administration.

Any requests by an attending physician to supersede any of these limits must be politely refused but immediately referred to the Program Director or other appropriate members of the program administration.

3)

   Work Hours

·        When averaged over any month long rotation, no resident should work more than 80 hours per week.

·         No resident may work more than 30 hours continuously, with 24 hours spent admitting new patients and/or caring for ongoing patients, with an additional 6 hours for ongoing patient care.

·        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 Residency 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 R2 or R3 is expected to write the notes on the R1'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 houseofficer departing for home or continuity clinic should also inform the hospital operator whom he or she has signed-out to before leaving the hospital.

9)

   On/Off Service Notes

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

10)

   Consultations

During both general internal medicine and subspecialty rotations, 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 attendings 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)."

At TMC, internal medicine consultations are usually performed under the direction of one of the TMC Hospitalist's.  The TMC Hospitalist on duty must be contacted and must agree to serve as the supervising attending consultant. Up to 2 consults each may be performed by the day call and the night call team, with these encounters counting towards the admission cap.

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).

TRANSITIONAL YEAR RESIDENCY PROGRAM GOALS AND OBJECTIVES

             C.  For students who are planning to serve in organizations such as the public  

                   health service or the military as a general medical officer prior to completing

                   a program in graduate medical education or              

             D.  For students who must have at least one year of fundamental clinical education 

                   prior to entering a career path which does not require broad clinical skills such

                   as administrative medicine or non-clinical research.   

I.     The program will require and measure resident's competence in patient care, medical

        knowledge, interpersonal & communication skills, professionalism, system based 

        practice and practice based learning improvement.  Curriculum and assessment will 

        occur throughout the Transitional Year during orientation, monthly rotations,  

        housestaff meetings, tutorials and relevant assignments.     

Patient Care:        The resident will be able to orient easily to clinical duties as

                               manifested by timely clinical workup of patients                

                               Complete accurate & timely history & physicals as determined

                               by satisfactory global evaluations and chart reviews

                               Perform basic procedures as manifested by satisfactory Mini-CEX

                               evaluations

                               Have good diagnostic and treatment decisions as determined by 

                               global evaluations, and Mini-CEX evaluations

Medical Knowledge:     The resident should be able to acquire & continually review

                                        basic clinical knowledge as determined by his scholarly activity,

                                        written examinations and daily clinical interaction

                                         This objective will be measured by nurse evaluations and global monthly evaluations

                                          Measuring tools will include global evaluations and formal scholarly presentations

Practice Based Learning:   The resident should be able to correct shortcomings

                                              Measurements will include scholarly activity, global

                                              evaluations and select reading presentations on rotation

                                              Satisfactory completion of this objective will be determined

                                              by completion of project assignments and global evaluations

A.  The objective of mature, clinical judgment under proper supervision will be accomplished 

      by: 

    iv.  Implement appropriate therapy and management for most patients with common clinical 

          entities

           1.  To expand on the ability to obtain accurate medical histories and perform

                comprehensive physical examinations on all patients.

           2.  To utilize this database to formulate plans for accurate diagnosis and 

                 appropriate therapy to be applied in various clinical situations.

           3.  To participate in the regular educational activities in conjunction with the categorical 

                medicine residents on the general medical wards and in the CCU.

           4.  To acquire some clinical skills in the management of critically ill patients both in the 

                CCU and ICU.

           1.  To develop clinical competence in the perioperative management of many of the 

                problems encountered in general surgery, inpatient and outpatient services.

           2.  To actively participate in patient care in conjunction with senior surgical residents,

                including management of critically ill patients on the surgical service.               

           3.  To evaluate surgical patients preoperatively in the clinics and Emergency Room

                and to follow their postoperative courses in the hospital and outpatient clinics.

           4.  Understand the decision-making process required of the surgeon and the principles

                on which the decisions are based. 

           5.  Understand the basics of the surgical procedure performed, including tubes placed,

                drains placed, lines placed, etc.

           6.  Develop, with the aid of senior resident and attending surgeon, a postoperative

                plan of care and surveillance.  Anticipate problems particular to this patient or

                disease entity.

           7.  To participate in the regular educational activities of the surgical service, as 

                applicable to categorical first year residents.

         1.  To provide an intensive experience in the acute management of all patients who 

                 present to the Emergency Department; this includes both medical and surgical 

                 specialties.  Residents will be exposed to a variety of medical, surgical, 

                 gynecologic and psychiatric problems.

           2.  To obtain those manual skills necessary to evaluate and repair lacerations, splint 

                orthopedic injuries, place venous access lines and other skills necessary in the

                Emergency Department.

         3.  To work as a team  member in the resuscitation of patients  suffering both medical 

                 or surgical catastrophes.

           4.  To learn to triage patients based on the acuity of their condition when first seen in 

                the department. 

         5.  To obtain experience in the management of urgent care patients, in addition to the 

                emergency room patients.

                both high quality patient care and educational input.

           1.  To provide ambulatory care as part of the rotations on the general surgery through 

                   outpatient clinics.

           2.  To incorporate equivalent ambulatory care experience through the Urgent Care 

                   section of the Emergency Medicine Department throughout the month's 

                   rotation.                

           3.  To provide the majority of ambulatory care experience during rotations in medical, 

                   surgical, or other fundamental clinical skill rotations.

                  b.  Remedy a lack of exposure to a particular specialty of importance during their&nbs