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The “4+1 System:” The Model of Efficiency!

Choosing the right residency program can be difficult. There are, of course, some elements that are immediately apparent: the patients for whom you will provide care, the residents with whom you will work, the faculty, the curriculum, the city, and the program’s outcomes. But there are other important elements that are very important… but not initially apparent unless you think ahead about what residency will be for you. As you read below, remember these central tenets about systems re-design… “Systems drive function,” and “The definition of a good system is that it puts good people in good positions; the definition of a bad system is that it puts good people in difficult positions.” The results you get in resident performance are dictated by the system in which they work. Every system is perfectly designed to produce the results that it does.

The ACGME requires all internal medicine programs to have continuity clinic experience, and in recent years, the required number of clinic sessions has increased from 108 to 150 half-day sessions over the three years. In this respect, virtually every residency program is the same… employing a system in which continuity clinics overlap with wards, electives and ICU rotations. While on the wards, for example, you can expect to be pulled away from the hospital one to two half-days per week to be in clinic.  There are 156 weeks in residency training (3 years x 52 weeks/ year). If you subtract out 4 weeks/ year for vacation, the twelve weeks of ICU over three years, the four weeks of ER…  you are down to 128 weeks in which clinic can occur. (156-12-12-4= 128). The result is that every week on the wards or elective needs to have at least one half-day of continuity clinic… and some weeks will require two. 

The Problems with the Standard Residency Training Program Systems

But while it looks good on paper, the “standard system” of overlapping clinics with ward/elective rotations has the best of intentions, it fails you miserably. And only an ingenious training program will have figured out a solution to it.

But to appreciate the beauty of the solution, here are the problems with the standard system employed by other training programs. Just by virtue of having done your sub-internship, you’ll recognize the problems. If you want a more detailed explanation, click here (PROBLEMS WITH THE “STANDARD SYSTEM”).

1. The old system is littered with fragmentation and waste… you start one task (managing your patients on the wards), and then have to leave it half-done as you move to the next task (clinic or conference)… forcing you to come back again to either complete the task, (or often) to start the task all over again. Every time you leave one task and move to another, you lose energy, time, focus and efficiency.  (Tell Me More About This)

2. The old system limits your ability to focus on your patients (i.e., you’ll be thinking about the wards while you are in clinic and vice versa)… (Tell Me More About This)

3. The inefficiency of starting one task and then moving to another… then another… etc.,  expands your work hours (i.e, because of the inefficiency and the fact that you have to return to the wards after clinic). (Tell Me More About This)

4. The old system limits your days off. It is likely that the resident and intern’s clinic schedules will be staggered in order to keep some activity moving on the wards.  Because of this stagger, you can’t take days off on your clinic days, nor on the resident’s clinic days. Subtract out call days and post-call days, and you are down to a maximum of three days off per month (and no golden weekends). (Tell Me More About This)

5. Also because of staggering the resident and intern clinics, the old system limits your resident-to-intern teaching (because either the resident or intern is in clinic each day)… (Tell Me More About This)

6. The old system intensifies the ward rotations (there is only one person around in the afternoon; work carries forward from the previous day because it doesn’t get done in time, etc). (Tell Me More About This)

7. The old system does little to advance your career decision-making or competitiveness (i.e., there is limited exposure to subspecialties, and limited engagement while on subspecialty electives).

But it has to be this way, right? In programs that are wed to the “that’s the way we have always done it” philosophy, the answer is unfortunately, yes. But for that rare program (Tulane) that has let the residents own the team and make the decisions… you might just find that a better world could exist… if only you let the people who know about the problems… the people with the creativity to solve the problems, … make the decisions. Enter the “4+1,” Tulane residents’ newest innovation.

 

THE 4+1 SYSTEM

Here’s how the “4+1” works. The year is divided into 10, five-week blocks (the remaining two weeks of the 52-week year are the winter holiday weeks, of which you will have one of the two off to spend time with your family… in addition to your four weeks of vacation).

The first four weeks of your block are devoted to wards, electives or ICU/ER rotations. The last week of the block is devoted solely to ambulatory clinics (i.e., your continuity clinics).


There are five firms in the Tulane system, and each firm shifts blocks on a staggered basis. This means that one firm will always be on their “+1 week”… the other four firms will be in their “4 week block rotations.” As the red firm rotates off of their “+1 week” another firm (the blue firm, for example) rotates onto their “+1 week.” This always keeps four of the five firms on the wards to take care the ward rotations (i.e., every 4th night call= four firms). The diagram below will help to illustrate how the firms switch…. In this diagram, only one intern from each firm is depicted.

“The Four Week Blocks”

During the first four weeks of a block, you will do wards, electives, ER, ICU, etc. just like you would in most programs. The order in which you do them will be your choice (see The Firm System of Control). The difference is that there is NO CLINIC DURING THESE BLOCKS. Each day, you will arrive on the rotation (wards, electives, etc.) and be able to truly focus on that rotation. Since neither you nor your resident will have clinic, you will have the focus you need to truly engage in the management of your patients… the pressure to get things done in the early morning will be lifted. And since you won’t be running to clinic in the afternoon, any task that you start, you will be able to finish (the solution to problem #1 and problem #5 of the old system).

And with no clinic requirements in the afternoon… the schedule of the day dramatically changes to reduce the fragmentation and improve efficiency. You’ll start the day doing pre-rounds, and then resident rounds… where you get to make all of the decisions on your patients. Since there are no clinic limitations in the afternoon, morning report no longer “has” to occur in the morning. Indeed, at Tulane, there is no morning report….because morning report has moved to the afternoon. Instead of morning report, you’ll have “Afternoon Delight” which starts at 3 PM. (Why settle for “morning report” when you could have “afternoon delight?” Seriously, who doesn’t love “afternoon delight?”). By moving morning report to the afternoon, there will be no broken fragmentation in the morning. You can focus on your resident rounds, and (gasp!) even get some orders started in the premium part of the day (the solution to problem #6 of the old system). Your patients will get tests, consultations and discharges done earlier, and they’ll thank you for that. They’ll spend less time in the hospital (improving patient safety) and the “carry over” from one day to the next will be less… further reducing your work intensity (remember, each additional day that a patients stays is another note to write, more time that cuts into pure teaching time on attending rounds, and an another opportunity for iatrogenic complications).

And when the attending has finished her conferences with the social workers/ nurses (to help accelerate your patients’ discharge), she’ll join you at 10 AM to conduct attending rounds, where you can review your management decisions (see what you did right, change what you did wrong), and receive unfettered teaching…. Because there is no time pressure to finish before someone has to rush off to clinic. And because there is no noon conference to rush off to (noon conference has been replaced by “Friday School”), there will be no fragmentation there either.

As attending rounds end, there will be no pressure to be anywhere other than where you are… the Tulane system keeps you with your patients and with your Team, and that you will enjoy. You can immediately enact the plans that your team discussed (the solution to problem #6 of the old system) which improves patient care and efficiency. And since there is no clinic in the afternoon, both you and your resident will be available to help get the work done, decreasing the intensity of the day (the solution to problem #2 of the old system). Because the whole team will be around in the afternoon, you can count on some additional teaching from your resident  (the solution to problem #3 of the old system) prior to “Afternoon Delight.”

But the best part is that by eliminating fragmentation, the efficiency of the day improves, and your quality of life exponentially increases. Since there is no clinic in the afternoon, you obviously won’t be returning from clinic to complete unfinished ward business (the solution to problem #1 of the old system). Indeed, most residents leave the wards soon after Afternoon Delight, enabling them to enjoy their lives, further develop the “person inside the physician,” and spend time with their family and friends (the solution to and problem #2 of the old system). Since there are no clinics to avoid in scheduling days off, you will have your full complement of days off on each rotation. And since the 4-week blocks end on Friday, you’ll have a guaranteed Saturday and Sunday off (the golden weekend) prior to each +1 week. (The solution to problem #4 of the old system).

The benefits extend to electives too. Because you will not be plucked off of the elective to go to clinic, you can fully engage in the management of the subspecialty service’s patients, exacting greater fulfillment that comes with actively being a patient’s doctor instead of just “following along.” And if the subspecialty career is for you, count on the fact that your greater involvement in the service will lead to a stronger relationship with the subspecialty fellow and attending, and a stronger letter of recommendation (the solution to problem #6 of the old system).

 

The “+1” Week

In the fifth week of each block (i.e., every 28 days), you will rotate onto your “+1 clinic week.” It is during this time that your continuity clinics will occur.  As noted above, the week begins on Friday evening, which means that the first two days of the week (Saturday and Sunday) will be days off to catch up on your life and enjoy your family (and if you don’t have a significant other, well… every 28 days you’ll have a week to find one). Can you see it? At Tulane, you will have a golden weekend every 4 weeks! (…in addition to your other days off and the weekends that come with elective rotations).  The ten half days of this week (mornings and afternoons, Monday to Friday) are divided in the following proportions: 5 to 6 half days devoted to your general medicine continuity clinics, 1 to 2 half-days devoted to a longitudinal subspecialty clinic of your choice, and three half days of devoted education: Ambulatory School, Friday School, and CAS; see below). See the diagram below for a sample “+1” week. In this example, the week has been designed for an intern interested in cardiology…. But substitute in additional sessions for general medicine or any of the subspecialties (based upon what interests you) or a combination of all of them.

 

UNIQUE BENEFITS TO THE “4+1” SCHEDULE SYSTEM
In addition to the above, here are the unique benefits of the “4+1” system.

1. No distractions.
Because you will have absolutely no other requirements (no ward requirements, no jeopardy, no nightfloat, no anything!) during this week, you can truly focus upon your clinic patients (the solution to problem #1 of the old system)… enabling the true fulfillment of continuity clinic by having time to get to know your patients’s lives. No one will be paging you, and your mind will not be worried about what needs to get done on the wards.

2. Early career development
From day one at Tulane, you can begin tailoring your clinical experiences to meet your career goals. If you want to do infectious disease… or cardiology… or gastroenterology… or general internal medicine…. The option is yours. You can choose to position your two “at large” clinics in each “+1” week to receive a longitudinal experience in the specialty of your choice. This allows you to see the ambulatory aspect of the subspecialty (which is often missed in most systems where the subspecialty electives are exclusively inpatient-based), AND it allows you to develop a mentorship relationship with a faculty in the subspecialty field…. Since you’ll be seeing them every 4 weeks for the duration of your residency. If you change your mind as to your career, or if just want to exposure to multiple subspecialties, then you can change your “at large” clinics to a different subspecialty each year.

3. Greater accessibility to patients
Paradoxically, consolidating your continuity clinics into the “+1” week enables greater patient continuity, and greater flexibility for your patients. You patients no longer have to guess at when you will be in clinic (i.e., the old system had to cancel clinics on on-call/post-call days, and/or move your clinic around each week to avoid the on-call/post-call days). You can tell your patients, “Listen, I’m here every 4th week. If you can’t make Tuesday, that’s ok… choose Wednesday… or Thursday… or Friday… or Monday for that matter.”). Patients are blocked out of clinic while you do ICU or ER rotations (as is the case in most programs), since these rotations do not overlap with the “+1” weeks.

Continuity is preserved between your “+1” weeks…. Each firm has one resident (The Stardust) who will bridge the gap between the “+1” posts… enabling someone with whom you have a connection to provide urgent care to your continuity clinic patients between visits (med refills, blood pressure checks, drop-ins, etc.). It’s a team-based system, but guess what? That’s the way the “real world” works. If you someday find yourself in a community practice (regardless of specialty), it will be your practices’ team of doctors that will preserve continuity for your patients.

The old system had 108 clinic sessions in three years. The “4+1” system has thirty “+1” weeks, with 5 sessions per week, or 150 total clinic sessions. The 140% increase in continuity clinic (not counting your continuity clinics in the subspecialties) is what you get when you eliminate the fragmentation and waste in the old system!

4. Sleep recovery
Everyone’s big on the sleep literature when it comes to residency reform… but it’s interesting that they focus only on the parts of the literature that are convenient to them… ignoring other very important principles. One of these is universally ignored principles is the concept of “sleep debt:” when you go without optimal sleep for a period of time, the deficit accumulates (i.e., eight hours minus the hours you actually slept per night = sleep debt). A negative balance can’t be erased by just getting one or two really good nights of sleep. The longer you go without erasing your deficit, the greater the overall physical and mental fatigue. This is the reason that residents in most programs will start to become depressed, angry and/or disgruntled towards the middle or back half of the year. In most programs, there is a reasonable chance that you might be assigned “systole” months (i.e., months where you do call assignments) in succession…. Preventing you from paying off your sleep debt.

BUT NOT AT TULANE! The Tulane wards are protected from excessive fatigue by the Orion, the Moondog and the Knightrider. But even so, we do have call months, and there will be some accumulation of sleep debt during these months. But picture this! At Tulane, you will never go longer than 4 weeks without coming to your “+1” week… a week that always starts with two days off, and a week where you get to sleep in your own bed each and every night. It is 100% protected from jeopardy, call assignments, night shifts, etc. Most programs will leave your systole/diastole sequence to chance (if they even afford you true diastole) … but at Tulane, you can count on a restful week every 4th week of the year… routinely.


THE BENEFIT OF BEING FIRST TO THE TABLE

Like Friday School, you’ll now find many training programs that are following Tulane’s lead in converting to the “4+1” (or some permutation thereof) system. But unlike Tulane, these program’s will not have Tulane’s six-year experience in operating this system. Just like Friday School, changing a program’s platform is not as easy as “plug and play.” There are many hard lessons learned along the way, and many necessary tweaks to modify the system to make it optimal for patient-centered care and resident performance. At Tulane, you’ll benefit from our innovation and six-year experience with this model. The tweaks have been made, and the system is the most efficient, highly-functioning in the country. Tulane is a place were good people do even better things… you’ll be proud to be a part of the “original” 4+1 system! (and don’t be surprised, after you graduate from the Tulane Team, if people recruit you to build the system at their location!)



PROBLEMS WITH THE STANDARD METHOD OF TRAINING USED IN OTHER PROGRAMS

Problem #1: Discontinuity of Care on the Wards/ Lack of Focus in the Clinics

The first problem will become apparent during your first week on the wards (or electives for that matter)… just as you get into “the zone” of caring for your patients on the wards, you are plucked away to go to clinic. You round in the morning, making a big “to do” list, and just when you are ready to act on that “to do” list, you have to leave to go to clinic. Any patient-related task that is partly done will have to wait, and usually that means starting that task all over again. And as you waste thirty minutes to an hour traveling to clinic, your mind remains with your patients on the wards. Even as you sit before your first clinic patient, your mind is elsewhere… “What did Mr. Robert’s CT show?” What did ID say we should do with Mrs. Geauxz’s antibiotics?” “Does the resident  (who is covering ALL of the service while I’m in clinic) know to put the discharge orders in for Mrs. Barter? Oh no, here are the orders in my pocket. Damn! She won’t go home today, then.” And during subsequent clinic patients, your pager continues to go off…. It’s the ward nurses reminding you of all of the work that still needs to be done for your inpatients.  Your focus is broken, and your clinic patients know it. There is no time to truly get to know your clinic patients (the fulfillment that comes with clinic-based care) because you have to hurry… there is a lot of work that still remains on the wards. And as you waste the thirty minutes to an hour traveling back to the wards after clinic, you think about how much you hate continuity clinic. And that makes you sad… because you do enjoy the notion of getting to know your patients in the clinic, and the fulfillment that comes with doing so. You feel guilty that you feel this way… but you shouldn’t because it’s NOT YOUR FAULT. The system has been constructed to force you to choose between the work you need to do for your ward patients and the work you need to do for your clinic patients…. It’s a broken system. But it gets worse…

Problem #2: Inefficiency On the Wards

When you return to the wards after clinic, you realize that your resident has done all that he can to get things done, but a lot of work still remains. You have to start all over again to complete those half-completed tasks that you began in the morning. Worse yet, the radiologists and consultants have gone home by now… the window of opportunity in ordering tests and consults has closed. All of this work will have to wait until tomorrow… extending your patients’ length of stay, and making the next day even busier than it has to be. And once again the system paints you into a corner… forcing you to choose between going home to see your family/friends vs. doing more work on the wards (which will require calling your significant other to say that you’ll be home late again).

Problem #3: Intensity

And on that next day you discover the dirty little secret of the “new work hours regulations.” It looked good on paper…. Residents used to work 100 hours per week, now they work less than 80. But you quickly discover that while the hours may be less, the work product (what has to get done) has remained the same… increasing the work-intensity to an exhausting level. In specific, you discover that the only way that the program can ensure that someone stays on the wards to take care of patients is to alternate the resident’s and intern’s continuity clinics. If the program doesn’t alternate clinics, then multiply problems 1 and 2 by a thousand. The work on the wards just piles up (and like a credit card balance, accrues “interest”… causing even more work) while you are both in clinic!

Alternating clinics, of course, means that the day of the week for your “continuity” clinic has to change each week  (because you are on a q 4 call schedule and you can’t have clinic post-call), making a moving target that perplexes the clinic scheduling staff and confuses your patients… making the probability that you will actually see “continuity” patients exceedingly low.

But it also means that since you were in clinic yesterday, the resident will be in clinic today. You received no teaching or guidance from your resident yesterday (because you were in clinic), and you’ll receive no teaching or guidance from your resident today (because he is in clinic). That means you’ll be doing all of the ward work by yourself. After attending rounds ends, you are on your own: no guidance (so more mistakes, more inefficiency), no teaching (your resident’s in clinic) and no support (so the day’s intensity will be exceedingly high… and the day could go very, very long…. once again, call your significant other and tell him/her you won’t be home until late).

Problem #4: Call, Post-Call, Work Hours, and Days Off

But you’re probably thinking, well… that’s only for two days out of the week (one when you are in clinic, and one when the resident is in clinic).  Right? Wrong. Because of the 24-hours per shift regulations, clinic really can’t occur on post-call days (not to mention that you would be exhausted, sleeping through clinic). And really, it’s not good to have clinic scheduled on On-Call days… since that leaves a ton of work to be done when you return to the “call day” after being absent for clinic… that would multiply “Problem #1” by a thousand fold.

So here’s the math… If you take out on-call and post-call days as options for clinic, you reduce a 28-day rotation to 14 possible days in which both you and your resident have to fit in your clinics (50 percent of the days on a q 4 cycle are on-call or post-call). Four of these 14 days will be weekends, so those days won’t qualify as viable clinic days. So, you’re down to 10 possible days to fit in 8 clinic days (4 for you and 4 for your resident). That means that there are two remaining days for the two of you to share your days off…. One each. Of course you have those 4 weekend days to split… but even so, that only takes you each up to 3 days off on the rotation. Hmmm, not quite the four days off per month that the ACGME requires. And all of that, of course, hinges upon perfect planning on the part of your resident to ensure that you get your four days (you could only end up with one or two!). But it’s nobody’s fault… the system makes it mathematically impossible to meet all of these requirements.

Problem #5: Further Inefficiency on the Wards

If your program schedules clinics in the morning, you’ll miss out on the morning attending rounds: you’ll be left out of the discussions critical in managing your patients, and the ward rotation will regress to the “shadowing” you did as a first year medical student. You’ll also miss out on morning report, and likely, noon conference. Sounds like “service without education,” doesn’t it?
If your program schedules clinics in the afternoon (which most will because of the issues above), then it will mean that all of the curricular conferences (morning report, noon conference) will have to packed into the first half of the day, since half of the residents/interns will be in clinic in the afternoon. And here is what you can expect in those morning hours…. the antithesis of efficiency: FRAGMENTATION.

You’ll start the day with pre-rounds ... maybe even resident rounds (if the program let’s the residents make decisions…. If not, then substitute all of this for attending rounds where you will just follow along, doing what the attending tells you to do). Either way, you’ll be in the midst of rounds when the chief resident will start sending angry pages, telling you that you need to go to morning report. So you leave what you are doing (half done), and go to morning report. This will cost you some travel time, but the big loss in efficiency is that nothing gets done in the hour that follows, and you’ll likely have to start over on any half-completed task.

The nurses, of course, are focused on patient care, so they’ll continue to page you through morning report, asking “Where are the orders on Mr. Lapirusse?” And if it’s not you being paged, it will be someone else… a constant string of pagers going off, completely disrupting the conference. And your mind will be somewhere else… thinking about what needs to be done for your patients: it will be impossible to focus on the morning report discussion.

And after morning report, you waste more time traveling back to the wards for attending rounds. The fragmentation of the morning caused great inefficiency… and you will be less than prepared for attending rounds discussions. Attending rounds will drag out accordingly. And should your attending get into an “educational zone” of teaching, count on the fact that it will be cut short… it’s time to go to noon conference. More tasks half-completed (or not completed at all… a “to do” list with many empty boxes)… more wasted travel time to noon conference… more distractions in noon conference… more travel time back to the wards (or to clinic). 

But the biggest loss of all is the failure to recognize that the morning hours are very, very valuable. This is when it is easiest to get tasks accomplished, because the whole hospital system is working in the mornings (laboratories, radiology, consultants, social workers, clinic schedulers, etc.). Orders written in the morning get done that day. Orders written in the late afternoon get done the following day. Under this standard residency system, you’ve missed out on this premium time… because you have been rounding, traveling, sitting, traveling, rounding, traveling, sitting, traveling… making big “to do lists with many empty boxes… but not really getting at completing any of it. Your orders have to wait until the afternoon, which means a percentage of them (a discharge, an MRI, etc.) will just have to wait until tomorrow… making the next day even more compressed.

Problem #6: Electives

The problems of this “tightly wound” system are not limited to the wards. Even on elective months, where you have an opportunity to experience the subspecialties … perhaps even to choose your career…. The system sell’ you short. Because you are routinely leaving the service to attend clinic, the subspecialty attending and fellow fail to engage you in the management of their patients. And why would they? Just when they trust you to do the management, you have to leave for clinic. The result is a “shadowing: experience no better than the shadowing you did as first year medical student. And should you decide you want to this subspecialty as a career, the two to four weeks of time with the subspecialty attending and fellow is hardly enough time to develop the mentorship relationship requisite for the best letters of recommendation. Add on the fact that all you really did was just “follow along,” so how strong could the letter really be?

Whew… that’s a lot of problems. I’m glad they no longer exist at Tulane!!!