Know this: the cardinal feature of any great physician is that he or she has the ability to make decisions with confidence, and every decision that he or she makes is done with prior thought as to the consequences (both good and bad) before the decision is made. And in no specialty is this skill as important as it is in internal medicine. Internal Medicine is not a game of checkers, where you merely respond to your opponent’s move. It is a game of chess… where every move must be made by thinking four, five, six moves down the game. Unlike the surgeon who can bovie his mistakes, the internist cannot take back the beta blocker she injects into the IV. The ability to quickly make decisions with confidence is what will define your excellence- that is for sure. And mastering that ability comes from only one road: continual practice in making decisions.

Put another way: Do you remember how useless the “shadowing” of first year of medical school was? Merely following along, having orders barked at you without explanation left you feeling superfluous. Why continue that into residency? Tulane is a program built on autonomy, with residents routinely and consistently put into the position of making decisions. After two years of doing this, our third-year residents operate like faculty. And in any great residency program, this should be goal. Why follow along when you can be in the game?

The structure of the Tulane day has been built on this principle.

7- 7:30 AM: Pre-rounds
Pre-rounds include everything you do before you joining your team for work rounds. The purpose of pre-rounds is to gather the necessary information to make management decisions about your patients. It begins by taking sign-out from the nightfloat, and talking with the nurses who provided care for your patients overnight. Then there are quick visits to each patient where a focused history of the events overnight is obtained, and focused physical examination is performed. Patients are re-assured that you’ll be back in less than an hour to spend more time with them. The goal of pre-rounds is to collect all of the information you need to make decisions for your patient- that will be the expectation on work rounds.

8:00 AM: Work Rounds
Work rounds begin at 8 AM each day and include the entire team, except the attending physician, and are directed by the senior resident. All management decisions are made during work rounds by the senior resident, and the resident will begin the discussion of each patient by asking you what you want to do for the patient. While it may seem intimidating at first, this is the first step towards becoming the master clinician. Soon your whole way of thinking will change to that of being in control… and responsible. This is the beginning of greatness. The expectation is that the team will have an assessment and plan on each patient prior to attending rounds. This will allow the attending to check your work, provide advice or modifications, and to spend most of his or her time teaching you about your patients.

9:00 AM: Morning Report
Tulane’s morning report is a graduate–level discussion conference, focused upon honing the clinical reasoning abilities of the residents. It is not a lecture or a perfunctory report of a case admitted to the hospital the previous night. It is definitely not a census-like run-down of each patient admitted to the hospital the previous night (useless). Morning report is an opportunity for one of the residents to present a fresh case (the variety and volume of patients admitted to the Tulane Hospitals permits this), and then to have the other residents actively exercise their clinical reasoning methods in diagnosing and designing appropriate management for the patient. Once again, medicine is learned by active participation, not passive listening. The diversity of residents in the Tulane Residency makes this a unique conference. By now you know that there is more than one way to approach the same symptom or disease. Having residents who have trained at over thirty-five different medical schools permits a discussion where multiple methods of approaching the case are shared. There is no dogma in Tulane’s Residency, because dogma is the death of free thought. And free thought is what enables the art of medicine (and what makes it fun).

So the focus is on clinical reasoning, but picking up additional medical knowledge is not excluded. The following day, the chief resident finds and summarizes an article highlighting the salient features of the case discussion. Morning report then, is a nice marriage between honest problem-solving (and the fun of solving a non-canned, prefab case) and reviewing the evidence-based guidelines for treating the disease.

10:00 AM: Attending Rounds
Attending rounds begin at 10:00 AM at each hospital. The whole team walk-rounds to see each patient in person. Attendings do not write full notes while on rounds, but rather spend the time seeing patients with the team, and reviewing the decisions the team made during work-rounds. Teaching occurs at the bedside, just the way medicine was meant to be practiced.

12:00 Noon: No Noon Conference!

Wow, are you going to be disappointed by this. There are no noon conferences at Tulane. I know, I know… how can you live without a power-point lecture in the middle of the day, with pagers going off all around you… the crummy Chinese food that the Big-Pharma rep bought your soul with…. And the incessant snoring of your colleages…. All the while wishing you were back on the wards because there is so much to do? For all of these reasons, we dispensed with noon conference. During the noon hour, you can finish attending rounds if your attending is in the teaching zone…. Or you can have lunch with your team… or you can finish some patient management issues (which will happen fast, since every other resident in the hospital is asleep at their noon conferences). Don’t worry about the curriculum, we’ll take care of that at FRIDAY SCHOOL…. Check it out! You are going to love this.

If you are worried about leaving the wards to go to clinic, don’t be. The rule is that no one returns to the wards after clinic. Through the genius of the firm system and the year-long PEGASUS planning software, we will make sure that when you are in clinic, your resident will not be…. And when your resident is in clinic, you will not be. There will always be someone on the wards in the afternoon to advance patient care.

So you know, all post-call clinics are cancelled, as are clinics during ER months, vacation, and ICU rotations. It just doesn’t make any sense to have you falling asleep while interviewing a clinic patient.

Residents that demonstrate proficiency in their continuity clinics have the option of converting one of their continuity clinics to a subspecialty continuity clinic in the middle of their second year. This preserves the RRC 108-week requirement for General Medicine continuity clinic, while still enabling the resident to begin a career in the future subspecialty of their choice.

Teaching
If you are not in clinic, the expectation is that you’ll be on the wards advancing patient care, doing procedures, or teaching your medical students. This will be a great opportunity to practice the “coaching skills” that Dr. Wiese will teach you. Remember, since the ward services are supervised by teaching hospitalists (who have not competing time commitments) you’ll have someone there throughout the day to help you with procedures, answer questions, or teach you.

4 to 5 PM: Sign-out
Hey, when you are done, you are done. When patient management is completed, and you have done (or received) some teaching…. It’s time to leave. No one will think less of you for leaving earlier in the afternoon- time to enjoy New Orleans! Before you leave though, you’ll want to sign-out with the nightfloat intern. The Tulane Residency uses the internally-designed, Iatrodesign on-line sign-out system.

This Hippa-compliant, on-line system allows each firm to enter patients admitted to their service on the day of their call. As patients are discharged from the service, patients are removed from the system. Here’s the cool part: The information from all patients admitted by a firm member are downloaded to a database. This allows the resident, and the program director, to have a patient log of each patient seen by each resident (thereby guiding reading strategies to fill in the gaps of diseases not seen by the resident). The system is accessible by all night-float interns, allowing for strong continuity of care. It is also accessible by social workers and attending physicians, allowing at-home access to the firms activity and volume. And when you have a day off per week (as you will), it will be nice to log on to the internet from home and see how many of your patients have gone home prior to coming back into work the following day. The final benefit is that there is no more re-creating sign-out systems.

FRIDAYS
The daily schedule is modified a bit on Fridays to make room for Friday School. Check out this educational innovation under curriculum.

YOUR DAY: CALL DAYS & POST-CALL DAYS

On-call days are like non-call days with the following exceptions. You will start the day at 8 am with “discovery work rounds” (i.e., no pre-rounds) where you and your resident will see each patient together and formulate a plan. New admissions begin at 8 am, and continue through the following morning until 8 am.

The teaching hospitalist will do abbreviated attending rounds in the morning such that you can get to any new admissions. He or she will return later in the evening to do on-call rounds. This is the opportunity for the hospitalist to spend a little more time with the team, teach leisurely (since neither he nor you have anywhere to go…. Being on call and all), and take care of a few admissions from that day (some of whom may even be ready for discharge at that time). This also reduces the time pressures for the following morning.

On the post-call day, there are no pre-rounds or work-rounds. You will round with your attending physician from 7 AM to 10 AM. Any admissions that come in from 7 AM to 8 AM are held over to the next on-call team. From 10 AM to noon, the clean-up work begins… taking care of any last procedures, and enacting the plans your team has made for each patient. By noon, you’ll be on your way home. The PEGASUS program allows us to predict your daily schedule for the whole year, so we’ll know when you are post-call. This means that all post-call clinics are cancelled in advance without inconvenience to you or your patients.

Tulane Nightfloat System

Does Tulane have a Nightfloat System? Yes and No.

Let me give you my take on nightfloat… Nightfloat seems like a really good idea when you think about having the time to focus on your admissions on a call day without the hassle of nightfloat duties. Then you realize that someone has to be that nightfloat, and when it is your elective month, guess what? In most programs, that person is going to be you. Nightfloat in most programs is also ultimately non-educational… you are on your own with no resident assigned to teach you, no attending physician to teach you the following day, and no organized team for camaraderie; the result is that you end up making the same mistakes again and again, walking a very lonely road.

For nightfloat systems that take admissions overnight and then sign them out the following morning, you also introduce the pain of multiple handoffs, the pain of trying to re-do an admission in the morning (the nightfloat work doesn’t really save you much time), and the loss of quality of care that goes with each handoff.

Yet you do not want a program that has no support for you while on call. The Tulane nightfloat solution is this:

Each team has two interns instead of one. On alternating call days, one of the interns does 70% of the admissions and 30% of the nightfloat; the other intern does 70% of the nightfloat and 30% of the admissions. Since both interns are part of the same team, they both enjoy the support of having a resident and an attending responsible for their teaching: they don’t make the same nightfloat mistakes again and again. All of the admissions go through the on-call team, so there are no patient handoffs the following day. Since there are two interns, there is always the opportunity for one of the two to hold both pagers for a few hours to allow the other to get some sleep (and vice versa). And best of all, when you are on call, you are on call; when you are not on call, you are not on call. Namely, when you are on one of your six non-call months, you will not be called in for nightfloat duties. You can enjoy these months and make the most of developing yourself and your life both in and out of medicine without the hassle of having to do nightfloat duties.