Eight years ago when I took over the Tulane Internal Medicine program, this was my wager: If you find great residents, and teach them how to run a program, they will do it better than any administrator. Why? Because the residents are on the front line; they know best what works and what does not. And if you think about it, people of your age, with almost a decade of higher education behind them, can certainly run a business (i.e., that flunky business-major college roommate of yours is now upper level management in a Fortune 500 company driving his Lexus instead of pondering your student loans), why should they not also be able to run a residency?

So eight years ago, the Tulane Internal Medicine Program was turned over to the residents, making Tulane the only truly resident-owned, resident-run program in the United States. The residency was divided into four firms: Red, Blue, Green and Yellow. Each resident is assigned to a firm with which they will remain during their tenure at Tulane. Each firm operates like its own business, running one of the four services on the medical wards at each of the three hospitals in the Tulane system, and two of the eight clinics in our system. The bottom line is this… you have control! After three years of being in the Tulane system, you will learn not only medicine, but also the leadership and management principles that will make you a great leader in medicine upon your graduation.

How Schedules Are Made:

The medical wards at each hospital are divided into four services: one for each firm. Each firm is responsible for assigning one person from their firm to staff each ward month at each hospital each month. The firm is also responsible for sending one person per month to staff the med-consult duties and one person per month to staff the ICU assignments.

In the spring of each year, the firm sits down with the responsibility of staffing each of these assignments. The residents (not the program director) decide who will do each month. This gives the residents full flexibility in building their schedules. This is important, because residency is three years of your life, but it shouldn’t be all of your life. If you have a family vacation planned in February or a friend’s wedding in September, you should have the luxury of scheduling electives or ambulatory months (weekends off, no call) for these months. If you want to begin a research career, you should be able to block two electives together to have some time to start your project. By working within your firm, you can make this happen.

The Typical Schedule by Year:

The Tulane Schedule works in 4 calendar week blocks, not by the Gregorian calendar (i.e., month to month). Interns will begin the intern year on June 23, and rotate to different rotations every 4 weeks; we always switch rotations on a Monday. Upper-level residents (R2 and R3) rotate every four weeks as well, but one week after the interns switch. This ensures that whenever you enter a new rotation, you will have a resident who has been on that service for 3 weeks to help you get acclimated.

With 52 weeks in the year, there are 13 four-week blocks. Every resident gets four of these weeks off for vacation (taken during ambulatory or elective blocks) as well as one of the two holiday weeks (New Years or Christmas).

Call Schedules:
The call schedule at each hospital is in this same sequence (RuGBY: Red, Green, Blue, Yellow), with call being staggered at each hospital by one day (i.e., If Red Firm is on call on-call at Tulane on Tuesday, Red Firm will be on call at the VA on Wednesday, and on-call at Charity on Thursday). Because this cycle repeats every four days from now until eternity, the Red Firm Resident knows when the Red Firm will be on call 40, 100, and 300 days from now. And because the Red Firm resident knows what month he has chosen to be the ward resident for say, Charity Hospital in April, he knows from the first day of the year what days he will be on call in April. This is great, because it allows you to make weekend plans, even during call months several months away.

Maximal Exposure to Your Colleagues:
While it may seem that being in a firm locks you into working with only ¼ of the residency, the opposite is true. Because each firm sends one member to staff each of the four teams, you will work with members of the other three firms each month. When in clinic, you will work directly with members of your firm.

Interns:
Interns are assigned a firm as well, but while on the wards they work with a resident not in their firm. Red or Green firm interns (Red/Green Firm clinic days are Monday and Thursdays) are always assigned to either a Blue or Yellow ward team (Blue/Yellow Firm clinic days are Tuesday and Wednesday), and vice versa. This means that at least one member of the team will be available on the wards (i.e., not in clinic) each day so that no one has to return to the wards to complete patient care after their clinic.

Clinics:
Each firm operates its own continuity clinics: one at the VA and one at Charity. The operation of the clinic in determined by the firm. If a resident has to miss a clinic (i.e., vacation, post-call clinics, ER and ICU clinics are cancelled.), a firm member is there to pick it up.

Jeopardy:
People get sick, and things come up. When it does happen that you need someone to cover you, another one of your firm colleagues will gladly provide the jeopardy coverage. Why? Because within your firm team, he knows that there will come a time when he needs you to cover him. Look at the grida on the sample “Pegasus” program again; exactly half of your firm will on ambulatory or elective when you are on the wards. This means half of your firm is available to provide coverage for you if you have to be out.

Taking Control:
Each firm designs its own Quality Improvement Project each year. The Tulane QI kit will walk you through how to identify an area of improvement (on the wards, in your clinic, in the program, etc.) and design a proposal to make the improvement. Because the firms run their own show on their service and in their clinic, they have first-hand knowledge of what needs to be improved. While most residents around the country are helplessly at the whim of the system in which they work, the Tulane resident owns his or her own solutions. And in doing so, the Tulane Resident masters the Systems of Care Competency, and the skills of owning and operating his or her own clinical practice. Tulane is about training leaders in the health care field, and this is a key component to their success when they leave residency training.