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The Firm System:
Owning Your Own Schedule, Owning Your Own Life…
On-The-Job Training To Become a Great Leader


Friday SchoolTen 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 ten 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, each named after the first five chairs of medicine starting in 1837: Ray, Musser, Burch, Elliott, and Mackey.  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! And this is important not only because life is more fun when you are making your life decisions for yourself, but also because of the valuable leadership skills you’ll develop in the context of training. Add this to the formal “leadership training course” you’ll receive as a part of the CAS curriculum, and you are well positioned to change the world as a leader upon leaving the program.  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, 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. Who that person will be is up to you and your firm. 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 and CCU 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-block 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.

Description: ample Schedule - Tulane IM ResidencyEach 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

Sample Yearly Schedule - Tulane IM ResidencyThe firm system ensures that you are able to tailor your schedule to whatever your curricular needs/desires might be. Each year provides at least 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:
While it may seem that being in a firm locks you into working with only 1/5 of the residency, the opposite is true. Because each firm sends one member to staff each of the teams, you will work with members of the other four firms each month. When in clinic, you will work directly with members of your firm, providing a balanced exposure to all team-members on the Tulane team.

Intern Mentorship:

Interns in a firm are paired with residents from their firm. Because of the size of the program, we have the luxury of not pairing interns with the same resident more than once, but the resident cohort is afforded the opportunity (via “collective intelligence”) to provide meaningful feedback and guidance to each individual intern twice a year. This is one more avenue of strategic planning for you… in addition to the advice you’ll receive from your twice-yearly meetings with your firm’s chief resident, your firm’s assistant coach (associate program director) and Coach Wiese.  It takes a village to build the great physician, and as an intern, you will have your firm’s upper level residents looking out for you.

Clinics:
Each firm operates its own continuity clinics: one at the VA, one at Charity and one at one of the residency-owned community-based clinics. The operation of the clinic in determined by the firm. If a resident has to miss a clinic, 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 grids on the sample schedule 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.

Why We Start and End Early
The Tulane year starts at the beginning of the last week of June (i.e., one week earlier than many programs). The reason for this is three-fold. First, interns arriving to the program usually have to pay for the month of June’s rent anyway. Our experience was that they were more or less waiting around, ready to start…. And after the interview season’s expenses… their credit cards were maxed, and they were ready to receive a paycheck! So why not start early. But the second reason was for the prelims. Tulane is a nationally focused program, and most of our interns come from all over the country. Many of the prelims have their core program (radiology, anesthesiology, dermatology, etc) waiting for them in a different city. Starting the year one week early enables finishing the year one week early… enabling the prelims one week at the end of the year to travel to their new destination. For the categoricals, the year ends one week early as well… they just promote to the next level one week early. The same will happen between the R2 and R3 year…. Which enables our categoricals who match to a fellowship at a distant location one week of travel time at the end of the third year to have an extra week to make the move.