The Firm System: Owning Your Own Schedule
 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
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. 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.
 Each
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
Call Schedules:
The call schedule at each hospital is in this same sequence (RuGBY-O:
Red, Green, Blue, Yellow, Orange), with call being staggered at each
hospital by one day (i.e., If Red Firm is on call on-call at Charity
on Tuesday, Red Firm will be on call at Tulane on Wednesday, and
the VA 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 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.
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 “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
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
make the move.
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