Ask yourself this as you look at different residency programs. Just how committed is each program to education? This is the question I asked when I took over the residency program at Tulane, and here were some of my thoughts.

Tulane was already in compliance when the RRC passed new work-hours regulations five years ago. But even so, I recognized that there were forces intrinsic to the standard residency system that limited education. The work-hours regulations heightened the tension. Consider the following in the standard residency program system:

1. Noon conference occurs at noon. Ok, seems reasonable; everyone should be able to attend. However, the residents’ morning is devoted to morning report, work rounds, and attending rounds. During these rounds, patient-care plans are made and refined. But here’s the problem: When does all of the work that was planned during morning rounds get done? The answer is that something has to give: either residents plow into the noon hour to get work done (so that they can get to clinic or get home at a reasonable hour to be under the work hours regulations), or residents attend noon conference and defer patient-related tasks until the afternoon. In the first scenario, ward service supercedes education. In the second scenario, the resident has to sacrifice patient care for education. The bottom line is that no resident should have to choose between the two, and the current system makes the resident make that unfair choice.
   
   
2. Let’s say residents make it to noon conference. My experience was that residents were frequently late to noon conference, and this was no fault of their own. By the time the resident left the wards to get to noon conference, get lunch, and then get situated in the conference room, he or she had already lost 20 minutes of the conference. Of course the resident could leave attending rounds early to make it to noon conference on time, but then he or she had sacrificed 20 minutes of attending rounds. This too, seemed to be an unfair choice to force upon the resident.
   
   
3. And let’s say that the resident made it to noon conference on time. Still, the operations of the wards continued, and the nurses continued to page the resident during the conference. The flow of the conference was constantly disrupted by residents answering pages. Again, no fault of the resident; he or she was again placed in the unfair position of balancing patient care with education.
   
   
4. And then, of course, there is clinic. Residents would have to leave noon conference early to get to clinic, and this further compromised resident education.
   
   
5. And finally, there was the educational format of a typical noon-conference schedule: didactic lectures with powerpoint. Pain. The educational experts will tell you- at best, there is 20% retention of knowledge from a didactic lecture. And lectures rarely replicate the type of knowledge a resident needs. For example, when was the last time a patient presented with a chief complaint of “I have lupus nephritis. Please help me.” To the contrary, patients present with a problem (“There is swelling in my legs and I have a rash”) and the physician must work forward from the complaint to make the diagnosis and design the management; not backwards from the diagnosis to identify the symptoms.
   

I thought this position of compromise was unfair, and to solve the problem, we went outside of the box to develop a new system of resident education. This system is FRIDAY SCHOOL, and here is how it works.

Fridays are protected time. The day’s schedule works something like this...

The day begins at 7:30 AM with work rounds with the residents and interns. There are no pre-rounds on Friday, and from 7:30 AM to 8:30 AM, the residents and interns (without attendings) make a plan for each of their patients. At 8:30 AM, the resident hands his or her pager to the attending. The resident then departs for FRIDAY SCHOOL (see below). The interns begin attending rounds with the attending from 8:30 AM until 10 AM. From 10 AM to noon, the interns have time to carry out patient care plans.

RESIDENT Friday School

From 9:00 AM to noon, the residents convene for FRIDAY SCHOOL. Residents are grouped into their firms (Red, Green, Blue, Yellow) and work together problem-solving mystery vignettes. Each module begins with a patient with a mystery diagnosis… a patient presenting with a chief complaint, and the important initial history and physical examination. If you’ve read the New England Journal CPC series, the model is similar. The firm teams work as a team to establish a differential diagnosis and then make a guess as to the final diagnosis. 50 points are awarded to teams that arrive at the correct diagnosis based upon the history and exam alone. The teams then order labs appropriate for the diagnosis (minus 5 points for each $1000 spent). For each diagnosis they choose, the teams get a module packet that contains the essential questions (from the boards plus some) as derived by recent literature on the topic (i.e., the questions are derived from original or review articles published within the last two years). After going through the questions, and doing internet/pubmed research to find the answers, the firm team discusses their findings and then reaches their final diagnosis (worth another 50 points). When all firms have completed their search, an expert faculty member comes in to discuss how he or she would approach the case, and pertinent diagnosis and management pearls that go with the case. The final answer is revealed, and the firm champion for the day (i.e., the firm with the most points) is declared. Resident then have time with the faculty to discuss any questions they had in their deliberations.

The great part of Friday School is that teaches so much more than just the topic being addressed. It is the real world approach to medical care… Friday school mimics what the residents will do every day in their practice. Unlike power-point lectures that start with a diagnosis (i.e, the lecture on lupus), Friday School cases begin with a patient problem (e.g., joint pain and fever) and work forward to the disease and its management (e.g., Lupus). The model emphasizes that clinical reasoning is important for effectively moving from the long list (i.e., all possible causes) to the short list (i.e., the five or so things that fit the case); great clinical reasoning is rewarded in the competition (50 points up front). Further, the model teaches that cost containment is all of our responsibility (i.e., negative points for spending too much on the labs). It models the behavior of the great physician: start with the differential diagnosis, then use all available resources (i.e., the internet, textbooks, colleagues) to learn more about the presentation and management of each disease on the differential…. Then make your decision. It teaches teamwork: firms work together as teams as active learners instead of the individual, passive learner-model of powerpoint lectures. And it’s fun… the fun part of internal medicine was and is the detective-like deductive reasoning that went into solving mystery cases. Of course, the residents learn the board objectives for a topic, but they also learn the most up-to-date information on each disease being considered. Because this is an exercise in comparing why one diagnosis fits better than others, residents also learn to compare and contrast diagnoses…. And in medicine, it is as important to know why it is not lupus as it is to know why it is sarcoid. Finally, each team has a scribe that records the content of the groups investigative efforts. After Friday school, the review articles used to construct the modules are emailed to the residents, and the resident firms email each other the notes from their own discussion. Over the course of a three year curriculum, every ABIM learning objective is addressed, and each resident has his or her own study guide. Most importantly, each objective is addressed in a format that makes sense for not only the boards, but also for the wards. Of course, the added benefit is that each resident learns practice-based learning skills (i.e., how to use the internet, books, etc. to find the answers to questions derived as part of solving a mystery patient case) that will last a lifetime.

At noon on Fridays, the interns return from the wards to hand off their pagers to the residents, who have just finished their Friday school. The residents take back their pagers from the attendings, and return to the wards to complete any remaining patient-care tasks. At noon, all residents and interns come together to participate in one of four regularly scheduled repeating conferences:

1. First Friday of the Month: Morbidity and Mortality. The chief resident chooses the speaker based upon the case. When available, a case that has gone to autopsy is discussed by faculty members from both the departments of pathology and internal medicine. Relevant photos are shown and the pathologic findings are reviewed.
   
   
2. Second Friday of the Month: Stump the Chump (Usually, Wiese). This conference is organized in concert with the department of pathology to present a case seen on the ward during the previous month using pathologic images as its primary teaching modality. The format is case presentations followed by discussion and review of relevant pathologic material.
   
   
3. Third Friday of the Month: Subspecialty Grand Rounds
   
   
4. Fourth Friday of the Month: All-Housestaff Firm Jeopardy Competition
   

INTERN FRIDAY SCHOOL

From 1:30 PM to 4:30 PM, the interns have protected time.. No pagers, no responsibilities. just protected time to participate in their Friday School Seminar. Intern Friday School works just like the Resident Friday School, except that the topics are focused at the level of the intern, both in complexity and in emphasis (i.e., ward tasks, night float tasks, medical emergencies, etc.).

On-call interns return to the wards after Friday School. All other interns are off for the day, and pick up their pagers the following morning from their residents. Check out the Intern-School Schedule for 2007-2008.

The important elements in any residency program, as with life, is not in the materialistic bling…. It’s in the virtues, principles and mission statement of the team. Beautiful hospital lobbies, for example, cannot substitute for what happens in the patient rooms. But there is something to be said for showing your commitment to residents needs, comfort and education.

When you see the Friday School room, you’ll now palpably feel the commitment of Tulane to its resident team. The wall-to-wall whiteboards permit teaching at any possible moment… the leather chairs enable the comfort necessary for our three-hour Friday School sessions…. The coffee/sodas/food remove fatigue/thirst/hunger as distractions to the learning environment… the computers and textbooks enable the discovery of new knowledge that is the Tulane philosophy… and of course the one-of-a-kind, hand-carved Friday School tables (designed and created by Wiese) are representative of the unique character of Tulane’s Team, and Wiese’s commitment to this team. If you are interested, you can check out the Creation of the Friday School Tables, with a philosophical commentary by Wiese on how they represent for what Tulane stands.