Ten 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. Remember that flunky business-major college roommate of yours? You know what he is doing now? He is upper level management in a Fortune 500 company driving his Lexus, pondering what to do with your student loans! You were smarter than him, and if he can run a business, you can certainly run a residency!
So nine 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 five firms: Red, Blue, Green, Yellow
and Orange. 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
one of the four 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
How Schedules Are Made:
The medical wards at each hospital are divided into four services, fitting with the q 4 call schedule. Each firm is responsible for assigning one person from their firm to staff each ward at each hospital for each four-week block. Check out “The 4+1” System for details on how the four ward services rotate among the five firms. The firm is also responsible for sending 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
assignment. 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 an elective
(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 For The Year:
The Tulane Schedule works on a 5-week blocks system, not by the Gregorian calendar (i.e., month to month). There are 10, five-week blocks in the year, with the remaining two weeks being devoted to the winter holiday weeks…. One of which (Christmas or New Years, your choice) you will have off to spend time with your family… in addition to your four weeks of vacation.
firm will do a four-week block of wards, elective, ICU, ER, etc.
What you do in each 4 week block is up to you and your firm. Importantly,
during these 4 week blocks there is NO CLINIC, allowing you to focus
completely upon that rotation (and reduce the waste that comes with
fragmentation… running from one task to the next, etc). Check
out “The 4+1” System for details
on how this actually improves continuity and efficiency of care in
both the clinics and the hospitals. At the end of your four-week
block, the firm will rotate to the “+1” week… a
week devoted entirely to continuity clinics, both in general medicine
and the subspecialty of your choice. At the conclusion of the +1
week, you rotate back onto another 4 week block, and so on. The diagram
below depicts five intern’s actual schedules- one from each
firm. Notice that one of the five firms is always on the “+1” week,
leaving the other four firms to deal with the wards/ICU/electives.
The switch between the five-week blocks (the 4 weeks +1 week) is
staggered by a week for each firm.
The Typical Schedule By Year
The firm system ensures that you are able to tailor your schedule to whatever your curricular needs/desires might be. The first year provides three elective blocks to either explore the different subspecialties, or if you have already decided upon your ultimate career, to begin crafting a curriculum that will accelerate your trajectory towards that career. All electives at Tulane are truly “elective,” meaning that you will never be forced into doing an elective just because the program needs someone to do “GI” for that month. With twenty standing electives from which to choose, and a program mindset that allows you to design your electives (i.e., international rotations, public policy rotations, school of public health and tropical medicine, research, etc.), your schedule will be limited by nothing other than your own creativity. This is part of the reason that Tulane residents fare so well in the fellowship matches and subsequent employment opportunities.
REALLY COOL FEATURES OF THE FIRM SYSTEM
Maximal Exposure to Your Colleagues:
Why We Start and End Early