INTRODUCTION
The Sinai-Grace hospital Internal Medicine Training Program offers you training of exceptional quality and balance. Our goal is to provide an optimal, individualized educational experience, humane work scheduled without compromising training standards and to develop competent internists who combine excellent interpersonal skills with superb clinical acumen.
The Sinai-Grace based program in internal medicine is fully
integrated with
The Sinai-Grace based program includes a strong general
medicine inpatient service, a complete range of medical specialties serivices, and a busy ambulatory center for outpatient
training experience. The program is supervised by over 25 full-time and
part-time Sinai-Grace based faculty. All educational, research and service
activities of Sinai-Grace Internal Medicine Training Program are under the
direction of the office of the Chief of Medicine at
Physician Title/Specialty
Hematology/Oncology
Mohamed Siddique, MD Program
Director, Internal Medicine Training Program;
Chief of
General Internal Medicine
Marc Feldman, MD Associate Director; Internal Medicine Training Program;
SGH Year III Medical Student Clerkship Coordinator;
General Internal Medicine/Geriatrics
Director, Sleep Laboratory;
Geetha Krishnamoorthy, MD Director, Internal Medicine Board Review Course;
General Internal Medicine
John Haapaniemi, DO Section Chief, Pulmonary/Critical Care Medicine;
Chief of the Medical Staff, SGH
Thomas Piskorowski, DO Medical Director, MICU;
Pulmonary/Critical Care Medicine
Elie Aboulafia, M.D Director, Vascular Laboratory
Antonio Carrillo, MD Section Chief, Cardiology
Marc Meissner, MD Cardiology/Electrophysiology
Hassan Makki, MD Pulmonary/Critical Care Medicine
Director, MICU
Manuel Sklar, MD Section Chief, Gastroenterology
Anupam Suneja, MD Geriatric Medicine
DEPARTMENT OF INTERNAL MEDICINE
The Department of Internal Medicine is the largest medical department
at
Ambulatory Medicine
One half day each week, residents have office hours at the
medical clinic in the Sinai-Grace Primary Care Center which is located at
Additional elective outpatient rotations are available with numerous private attending physicians, and many subspecialty clinics are also available.
Critical
Our 51 bed state-of-the-art critical care units are staffed by intensivists, pulmonologists and cardiologists. The center offers clinical experience with an array of critically ill patients with medical, cardiac, trauma or post-operative problems. Our critical care units include the Surgical Intensive Care Unit, Medical Intensive Care Units, Cardiac Intensive Care Unit and the Intermediate Medical Care Unit.
Intermediate Medical Care Unit
This 28-bed step-down unit complements the critical care unit and is staffed by full-time faculty.
This 41-bed unit complements the Cardiac Care Unit and is staffed by physician assistants and/or full-time staff physicians.
The hospital maintains an active inpatient, acute/chronic dialysis unit. Our residents are exposed to all the complexities of management of these patients.
PROGRAM DESCRIPTION
The goal of the
The quality of our resource base is unparalleled in the region, including patients, facilities and faculty. The program offers the necessary depth of knowledge and experience to pass the American Board of Internal Medicine (ABIM) certifying examination with the flexibility of achieving individual goals.
WHAT IS INTERNAL MEDICINE?
· The largest primary
care specialty in the
· Is an ever-changing and rapidly advancing discipline.
· Involves the diagnosis and non-surgical treatment of all illnesses in adults and adolescents.
· Its practitioners must continually update their knowledge in many areas including:
· Allergy
· Arthritis
· Blood diseases
· Cancer
· Diabetes
· Digestive diseases
· Illness in elderly
· Diseases of the heart and blood vessels
· Hormonal disorders
· Hypertension
· Infections
· Intensive Care
· Kidney diseases
· Respiratory disorders
· Internal medicine also incorporates an understanding of:
· Wellness (disease prevention and health promotion)
· Substance abuse
· Mental health
· Medical ethics
· Women’s health
· Effective treatment of common problems of the eye, ears, skin, nervous system and reproductive organs
Residents have several options to get help if they feel their resources are inadequate to cope with their workload during an in-house call or they are uncomfortable with a particular clinical or administrative situation:
1) The resident can contact one of the three CMRs who can provide advice and/or direct additional resources to assist the resident.
2) The resident can contact the IMCU attending physician, who is an attending physician caring for patients in Intermediate Medical Care Unit, and who is physically present in the hospital. The IMCU attending physician’s job description includes providing support to any of the medical residents on in-house call when necessary.
3) The resident can contact the physician administrator on-call for the department of medicine. This is a senior faculty member who is available by pager or phone to help with administrative issues primarily but can also assist with clinical problems. The physician administrator call schedule is posted on-line and in the department of medicine.
4) The resident can contact the program director, either of the two associate program directors or any of the senior faculty members by pager or phone. All of these individuals have made commitments to help any medical resident requesting assistance.
Contact information for all of the individuals mentioned above can be obtained on-line from the DMC corporate directory, from the Hospital communications operator and from the department of medicine pocket phonebook that is published and widely distributed annually.
WHAT IS AN INTERNIST?
An internist is someone who is:
· A trained specialist who possesses a personal and long-term commitment to patients, broad knowledge and skill in diagnosis and treatment, and has a caring bedside manner which encompasses the humanistic qualities of integrity, respect, compassion, sensitivity and listening.
· Trained to treat both the common and the complex illnesses and offers high quality primary care to adults and adolescents in the office or clinic, during hospitalization, in long-term and in hospice care facilities.
· Trained to be non-judgmental in understanding human behavior which enables them to help people alter harmful behaviors and to motivate patients to get and stay well.
· A coordinator of patient care when other medical specialists, such as when surgeons, are involved in the care of a patient.
· Often serving dual roles as primary physicians to patients and as medical consultants to physicians in other specialties.
PHYSICIAN IMPAIRMENT: BEING AWARE
· Over 100 articles in the past decade have been published regarding substance abuse among medical students, residents and practicing physicians.
· Identification of substance abuse is always difficult.
· Recognition of commonly described signs of substance abuse is important. These signs include:
· Poor rapport with patients and families
· Unreliability
· Frequent absences
· Inappropriate appearance
· Inability to work collaboratively with other health professionals
· Inadequate preparation
· Inability to adequately plan a patient assessment
· Inability to implement management plans
· Awareness of these signs, and sudden changes in performance, is essential in reporting concerns about a colleague’s behavior and competency to the program director. This information can lead to:
· Timely, appropriate and helpful intervention.
· Recognition and intervention can achieve the ultimate goal of rehabilitation and recovery for the physician in training.
PROGRAM
OVERVIEW
PGY I - Intern
The emphasis at this level of training is the application of the knowledge acquired during medical school. This is accomplished through rotations on the general medicine wards. Emergency medicine and critical care rotations provide in-depth exposure to acutely ill patients. During each ward rotation, our residents function as a team consisting of two PGY-Is and one PGY-II or III. The team approach is the foundation for all our medical services. Attending staff is available 24-hours a day. Teaching and patient care rounds are conducted daily.
The rotations for the PGY-I year are listed below:
General Medicine - 6 months ED - 3 or 4 weeks
Cardiology Floor - 1 month MDM - 1 month
MICU - 1 month Psychiatry - 3 or 4 weeks
Vacation 3 weeks Elective 1 to 2 weeks
PGY II - Resident
The major emphasis at this level of training is the expansion of each resident’s knowledge base and development of teaching and leadership skills. Subspecialty rotations are the basis for the PGY II curriculum. Each rotation combines experience in outpatient ambulatory clinic, consultation and inpatient care.
The rotations for the PGY-II year are listed below:
General Medicine - 3 months Pulmonary - 1 month
MICU - 1 month Endo - 1 month
Cardiology Floor - 1 month ID - 1 month
Heme/Onc - 1 month Neurology - 1 month
Nephrology - 1 month Vacation - 3 weeks
PGY III - Resident
The major emphasis at this level of training is the consolidation of each resident’s knowledge base. Each resident assumes the role of a unit supervisor, teacher for first year residents and medical students, and provides consultations to other services.
The rotations for the PGY-III year are listed below:
General Medicine - 2 months Rheumatology - 1 month
MICU - 1 month Geriatrics - 1 month
Cardiology Floor - 1 month Elective - 4 month
Gen. Medicine Consults 1 month Vacation - 3 weeks
GENERAL MEDICINE WARD ROTATION
PURPOSE
The purpose of the General Internal Medicine Ward Rotation is to provide an intense and broad inpatient experience resulting in the acquisition of knowledge and skills necessary to manage patients with complicated multisystem diseases.
TEAM STRUCTURE
• Team Leader – PGY-II or PGY-III medicine resident
• Two (2) interns
• One sub-intern (WSU year 4 medical student; depending on student scheduling).
• One or two WSU III year 3 students (depending on student scheduling).
• One or two PA students, podiatry residents or pharmacy interns
Each team will have one teaching-attending physician assigned for the month. There will be six or seven “A”-Medicine teams on the wards at all times.
CALL SCHEDULE
Long Call
• Every 7th day. Starts at
• Admission Cap: 10 patients per team.
Long call team starts code blue coverage at
Short Call
• Twice per week beginning at
DAILY SCHEDULE
Work Rounds
• Should start promptly at
• Rounds last until
• On post-call days, work rounds will be conducted by the teaching attending. All new patients admitted on the call day will be discussed. The post-call team should have seen their old patients preferably prior to work rounds with their teaching attending.
Morning Report
• This is a mandatory conference held
on Monday, Tuesday, Wednesday, Friday and Saturday which begins at
• On Thursdays, Medical Grand Rounds
are held in the Ground Floor Auditorium from
Peripheral Smear Slide Rounds
• The schedule for peripheral smear rounds is distributed by e-mail and posted in the Department each month. The teaching microscope is located in the small conference room. You will have these rounds weekly when assigned to the medical wards. Your team’s assigned day is linked to your call day for the month. These rounds are mandatory.
• The team should be ready with CBC data and all important peripheral smears of the patients admitted on their last call day.
• Peripheral smear rounds are conducted by a faculty member with expertise in evaluating blood smears.
Teaching Rounds
• Teaching rounds are conducted by the team’s teaching attending three times per week for 1.5 hours per session.
• Occasionally, teaching rounds may be conducted by a “visiting professor” from central campus.
• This is a mandatory conference from
• From
Chart Rounds
• Chart rounds should start between
• Patient charts should be reviewed for completion of planned activities. Problem lists should be updated.
• This time should also be used for relevant teaching by the resident.
Sign Out
• Interns should give a detailed written and verbal sign out to the corresponding intern on call after 5:00 pm. Residents should give sign out to the resident on call if any serious problems are anticipated.
RESPONSIBILITIES
Non-Call Day
1. See the assigned patients, check
lab/radiological studies and be ready for work rounds by
2. Present patients on rounds and take notes on things to be done that day. Round with charts and write orders during rounds.
3. Attend all conferences/teaching rounds as described.
4. Write notes on all patients daily using “SOAP” format.
5. Carry data cards for all patients (available in Medicine office) or use an PDA (e.g. Palm, Clie or pocket PC) to tract patient data. Data should be updated daily.
6. Procedures should be done by interns with resident supervision.
7. Attend chart rounds with resident, update problem list.
8. Fill out discharge instruction forms, medication prescriptions and dictate a discharge summaries on all patients upon their discharge from the hospital.
9. Give detailed written and verbal sign
out on their patients to the corresponding intern on call after
10. Communicate with attending physicians regarding patient care.
11. Write detailed transfer summaries, on-service and off-service notes and acceptance notes with a detailed impression and management plan.
Call Day
1. See the assigned patients, check labs prior to a.m. rounds.
2. Carry code blue beeper from
3. Finish follow up and notes on patients already on the service.
4. Interns will be assigned new patients by the residents. Interns should do a detailed H&P and write the H&P on all their new patients.
5. Required procedures (LP, central line, etc.) should be done with resident supervision. Gram stains; peripheral smears and x-rays should be reviewed with the resident.
6. Old charts of the patients who have been admitted to the hospital in the past should be reviewed and a brief summary of the old admission data should be included in the admitting H&P.
7. Service sheets and problem lists should be completed and placed in the chart for all admissions.
8. Cover 5797 for intern-A or 5799 for
intern-B (cross coverage beepers) after
9. Cross coverage is primarily done by interns with resident’s help.
10. Respond to all code blues.
11. Data cards (electronic or paper) should be filled out for all patients.
12. Code status (i.e. limitations placed on treatment) should be addressed in appropriate situations.
13. Attending physicians of all new patients should be contacted and the management plan discussed. You must always care for patients under the supervision of an attending physician.
Resident
Non-Call Day
1. Start work rounds promptly at
2. See all the patients on the service and formulate a management plan for the day for each patient during work rounds.
3. Attend all conferences/teaching rounds as described.
4. Help interns in carrying out the day’s activities, supervise and teach procedures.
5. Ensure the presence of the team at all conferences.
6. Make sure attending physicians are contacted about management plans, discharges and consults.
7. Teach interns and students during work rounds and chart rounds.
8. Conduct regular x-ray rounds.
9. Conduct chart rounds preferably on all days except weekends and post call days.
10. Work closely with sub-interns and co-sign all their orders.
11. Dictate discharge summaries for all charts not dictated by the sub-interns on their ward team.
Call Day
1. Carry code blue beeper from
2. See and examine all new patients including transfers assigned to the ward team, discuss management plan with interns and students and dictate detailed H&P.
3. Supervise cross coverage by sub-intern and co-sign their orders.
4. Review gram stains, peripheral smears and x-rays with the team.
5. Make sure attending physicians are contacted for all new patients and for problem cross-coverage patients.
6. Function as the code blue team leader, fill out code blue form, contact attending, family or MICU as needed and talk to family regarding an autopsy and organ donation, when appropriate.
The three-year experience at
EVALUATION AND EXAMINATIONS
1. Each resident is evaluated by all team members and the faculty rounder. Oral feedback is given mid-month and at the end of month. A webbased evaluation is completed at the end of each month using MyEvaluations.com.
2. Each PGY-1 is observed doing a complete history and physical examination at least once during their first year by a CMR or other faculty. Adequacy of clinical skills is evaluated by the observer.
3. All PGY-Is,
PGY-IIs and PGY-IIIs take
the National In-Training Examination during October of each academic year. This is a standardized multiple-choice test
administered to medical residents across the
4. Each month an Internal Medicine exam is given to all interns and residents via the internet. One subspecialty area is covered per month. The answers are graded and feedback is given to the housestaff.
REQUIRED RESOURCES
1. A current standard textbook of internal medicine, such as Cecil’s or Harrison’s.
2. A manual of medical therapeutics, such as “The Washington Manual.”
3. Current journal articles provided by the Chief Medical Resident during morning report or by the residents themselves as apropos for interesting or complex patients seen on the medical team.
4. Current MKSAP published by the ACP-ASIM.
5. OHEP Internal Medicine Board Review Course which uses as its curriculum the “Mayo Internal Medicine Board Review” text.
NOTE: The last two sources are especially relevant for PGY-IIIs.
THE DAILY BULLET CASE PRESENTATION AND DISCUSSION
1. A bullet case presentation is a one minute oral synopsis of the patient’s initial presentation (signs & symptoms) to hospital.
2. For the discussion, each active problem is prioritized from most to least important and addressed in order of priority with the following components:
a. How the working diagnosis was made (physical exam, lab, or other studies) and what workup is underway to confirm the diagnosis.
b. Initial therapy.
c. Response or expected response to therapy.
d. Estimate of when the therapeutic goal for the problem will be reached so that the patient can be discharged from the hospital.
e. How the problem should be followed as an outpatient.
NOTE: The discussion should be concise and last about 2-3 minutes. Discharge planning starts when the patient is first seen on the floor (i.e., social service vs. home health care, PM&R, etc.)
4. Basic questions to consider to facilitate organizing your thought process:
a. Why is the patient here?
b. What are the patient’s problems?
c. What is being done for the patient’s problem?
d. What
has to be accomplished so the patient can go home?
e. When can the patient go home?
f. How will the patient be followed after hospital discharge?
g. Are there any financial or social barriers with regard to the post discharge plan?
If you can’t answer all of these questions, your evaluation of the patient’s clinical situation is incomplete.
WORK CONDITIONS
Duty Hours
All house officers have one full day (24 hours) away from hospital and outpatient responsibilities weekly. Duty hours will not exceed 80 hours per week including “on call” hours. An “On call” day will last no more than 24 hours and residents must leave the hospital within 30 hours of the start of “call” to go home and rest.
Post Call Day
Attending Work Rounds:
To be done on post-call day with attending rounder/faculty
between
Evaluation and Feedback
Mid and end month meetings with your rotation supervisor
provide immediate critique to residents about your current rotation
performance. The evaluation of your performance on the rotation will be done
using the MyEvaluations.com website each month. This evaluation will become
part of your permanent file. You should also meet with your advisor at least
quarterly. At each meeting an evaluation form will be completed (using
MyEvaluations.com) and signed by both you and your advisor. These evaluations will
be a permanent part of your personnel file at
Order Writing
All orders on teaching cases are to be written by assigned residents and students. See policy section.
Advisor-House Officer Program
House officers are assigned a personal advisor from among the full-time faculty. In concept, the advisor acts as a big brother/big sister, advising the resident in professional as well as personal decisions. Residents may select alternative or additional advisors. All residents and interns will meet regularly either with their advisor or a designated faculty member as described in Evaluation and Feedback above.
At that time, the house officer’s file will be reviewed for procedure logs, in-service results, evaluations, etc. The house officer’s goals, objectives, progress and/or concerns, etc., will also be discussed. A brief summary of this meting will be documented and signed by both parties. These evaluations become a permanent part of the personnel file.
NON-TEACHING SERVICE
PHYSICIAN ASSISTANT (PA) SERVICE
INTRODUCTION
Patients from nursing homes, stable patients requiring prolonged hospital stay may be admitted to B-Service which is covered by physician assistants (PAs). The PAs on this service function similar fashion to housestaff on the teaching service (i.e. they are responsible for writing progress notes, orders, on-going management, etc.). Housestaff have no direct responsibility for this service. However, house officers are responsible for pronouncing death (when requested by the PA) and for any and all code blues in the hospital. Procedures on B-Service medicine patients are to be done by A-medicine upon request.
Attending Physician of Record
• The physician who has accepted responsibility for providing care to the patient during the patient’s hospital stay.
• This physician provides feedback on the day-to-day management of the patient.
ADMISSIONS/TRANSFERS
Transferring patients from A-Service to B-Service does not occur except in rare cases that will be considered on a case-by-case basis by the chief medical resident. In the event the transfer is deemed necessary, the attending physician of record or his designee (i.e. covering physician) must be notified of the transfer.
RESIDENT
RESPONSIBILITY TO
“NON-TEACHING PATIENTS”
It is the policy of this residency program that residents manage patients that are assigned to a specific teaching service. In general “non-teaching” patients are the responsibility of physician assistants, moonlighting physicians and attending physicians.
Situations may arise when a “non-teaching” patient requires the immediate assistance of a resident. These situations are generally emergencies such as a cardiac arrest or a serious allergic reaction. In these emergent situations the medical residents have a responsibility to care for the patient. Whenever, a “non-teaching” patient is evaluated for transfer to the teaching service, the resident doing the evaluation will communicate directly with the “A-medicine” resident.
PROBLEM LIST
On admission, the problem list (Blue heavy stock paper) should be placed in front of all patient charts. All active problems should be listed in order of severity. Inactive problems should be listed on the provided column.
This problem list should be reviewed during chart rounds and should be updated (i.e., indicate if problem is resolved, add new problems, etc.). The problem list is part of the medical record and this should be filled out on a consistent basis. This is primarily the intern’s responsibility.
“AT RISK” LIST
PURPOSE: To provide coverage for the inevitability of a house officer’s illness.
1. Each month an “at risk” list is made of those Sinai-Grace residents who are on a non-call or research month. The purpose is to provide coverage for any resident or intern who cannot fulfill their duties because of illness. Sinai-Grace residents cover Sinai-Grace Hospital services (ICU, medicine wards, etc.) irrespective of whether the intern/resident who is ill is a Sinai-Grace based resident or a rotator, (e.g., Transitional, Anesthesia, etc.)
2. Interns will only cover interns. Interns cannot cover a resident.
3. Because of the limited number of interns available during a given month (they have few non-call months), PGY-2s and PGY-3s may be “at risk” to cover either an intern or a resident.
4. During the month you are “at risk,” you are expected to be available (i.e. available by pager at all times during the 24 hour period) on the assigned days. NO EXCUSES for unavailability will be accepted. The schedule is available early enough the previous month so that your plans can be made accordingly.
5. If you are sick on your “at risk” day, it is your responsibility to inform one of the CMR’s immediately about your illness preferably by 7 AM of your day “at risk” (Inform a CMR immediately if you become ill later during the day). Reporting an illness at the time you are contacted to fulfill your at risk responsibility will be regarded as unprofessional behavior.
6. The “at risk” intern or resident cannot switch or cancel their call without approval from the CMRs or the Program Director.
7. If the “at risk” intern or resident is not available for the call, the Program Administrators Committee (Program director, Associate Program directors, CMRs and Program administrator) to evaluate the circumstances and decide what action to take. Actions may range from a reprimand to formal probation for unprofessional behavior. Extra “at risk” day may also be assigned in future months.
8. Situations for which the “at risk” list may be used for coverage include but are not limited to: Covering call on an inpatient rotation and covering daily work for an inpatient rotation. The Program Administrators Committee (or its designee) will decide if the “at risk” list will be utilized in any given instance.
9. Rotations during which you will be placed on the “at risk” schedule:
a. Elective rotations (i.e., any non-call month)
b. Subspecialty rotations (i.e., any non-call month)
c. Research Rotations
DEPARTMENT OF
INTERNAL MEDICINE
ATTENDANCE POLICY
All time away from training must be approved by the Program Administrators Committee. In general, all requests for time away from training, for any reason, are to be made in writing and given to Carol Maurizio (or her designee) in the Medicine Education Office. Situations that occur suddenly, such as unexpected illness, should be communicated to the Medicine