University of Maryland Medical Center - Internal Medicine Residency
The University of Maryland Medical Center, a private not-for-profit hospital, is a major tertiary and primary care facility with approximately 750 beds and over 38,000 admissions each year. The medical services consist of over 200 beds divided among a variety of general medicine and subspecialty services. In all units, doctors, students, nurses, clinical pharmacists and support staff work as a team to promote unified and comprehensive care for every patient.
Each medical service is a mixture of patients -- some admitted to the care of the teaching attending and others admitted by full-time faculty attendings. The residents provide the patients' primary care under the supervision of the teaching attending. We have robust non-teaching services where general medicine, oncology and intermediate care (IMC) patients are admitted. Community physicians transfer all the care of their patients to the resident teaching services. First year residents are responsible for the day to day evaluation and management of their patients. Upper level residents are the leaders of each team and hence have significant clinical, supervisory and teaching responsibilities.
Medical Inpatient Units
There are 10 medical teams at University Hospital, including 4 general medical services, an infectious disease service, 2 MICU Teams, 1 CCU/Telemetry Team, an Advanced Heart Failure Service, and a Cancer Center Service (leukemia and hematologic malignancies). Teams on the floors and intensive care units are structured in a similar fashion with the resident as team leader supervising interns, subinterns and third year medical students. Attending rounds are held seven days each week. Call on all services is every fourth day. Admissions taken by interns and subinterns are strictly capped with interns taking no more than 5 admissions per call, thereby providing the upper level residents with ample opportunity to supervise and lead the team.
We are compliant with all ACGME Duty Hour Requirements. We were excited to be a part of the national iCOMPARE trial and were randomized into the intervention (or FLEX) arm of the study. For the trial, the only change we made was for interns to do every 4th overnight call in the MICU and CCU at UMMC (28 hour shifts, rather than the previous 16 hour shifts). The remainder of the clinical schedule including night float, day float, team call at UMMC and all rotations at the VA and Mercy Medical Center remained unchanged. Resident feedback has been positive with enhanced continuity, less patient turn-over, more even work and rest schedules, and improved resident satisfaction in our UMMC ICU's during the iCOMPARE trial. We elected to continue 28-hour q4 call in the University MICU and CCU (only). We have a mandatory Fatigue Management Policy in the CCU and MICU requiring a 45 minutes nap during 28 hour calls.
A fully staffed 7-day/week Night Team System covers all the floor teams and ensures that interns and residents get ample rest and meet 100% of the RRC Duty Hour Requirements. Interns and residents on the general medicine and ID services take admissions using a "drip method" with their last admission at 6 pm. This pattern allows admissions to be staggered so that residents leave by 9 PM and have 8-10 hours off between duty shifts. Interns and residents only stay overnight while only while on MICU and CCU/telemetry at UMMC, and residents stay overnight on their Cancer Center rotations. Nocturnists and intensivists are present throughout the night shifts and assist with patient care and supervision.
The non-ICU services consist of 4 General Medicine services (Med 1-4) and an Infectious Disease service (Med-ID). The Med 1-4 services are organized in a Team Call system with the Med-ID team having individual call with close resident supervision. Med 1-4 consist of one resident and 2 interns who take call as a team every 4th day. Subspecialty faculty attend on Med 1, general internists on Med 2, and academic hospitalists on Med 3 and 4. The Med-ID service has ID faculty and fellow supervision, with 1 resident and 3 interns. Interns take their last admission at 6 PM (also with a "drip method" of staggered admissions) and sign out to the Night Team at 9 PM. Third and fourth year medical students are members of all teams. A resident moonlighter works from 5-9 PM Monday-Friday to address all the cross-cover issues.
The Medical Intensive Care Unit (MICU) and the Cardiac Care Units (CCU) along with the Advanced Heart Failure Service comprise the mainstay of the resident's training in critical care medicine at UMMC. Interns and residents take overnight call every 4th day for 28 hours (see information about iCOMPARE trial above). PGY-2 residents have a 2-week rotation on the Advanced Heart Failure Service where they work alongside fellows and nurse practitioners. There is no overnight call on this service.
The MICU consists of 2 teams, each with an intensivist, 1 fellow, 2 residents, 4 interns, 1 subintern and 1-2 nurse practitioners. Our state-of-the-art 29-bed MICU has 24/7 intensivists in the MICU at all times. Intensivists, the team resident and night float intern cover the MICU at night.
Patients with cardiac disease are admitted to CCU/Telemetry team (PCS - Primary Cardiology Service). This service focuses on caring for patients with ischemia heart disease, MI's, valvular heart disease and arrhythmias. The PCS team cares for patients in both the CCU and telemetry unit. The PCS team consists of a cardiology attending, 1 fellow, 4 residents, 4 interns and 1 subintern. A resident and intern cover the cardiology patients at night, with back-up from the cardiology fellow and attending.
The Advanced Heart Failure Service consists of a second year resident who rotates on this service for 2 weeks and works alongside fellows and nurse practitioners in the care of complex patients with CHF, pulmonary hypertension, and transplant needs. Each team consists of a cardiology attending, 2 fellows, 1 resident and several nurse practitioners. There is no overnight call for the resident during this 2-week rotation. Patients are covered by a nocturnist or fellow at night.
Upper level residents rotate through the Greenebaum Cancer Center, where 4 residents care for patients on the Leukemia Service. Overnight call is every 4th day with upper level residents working for no more than 28 hours/shift.
Non-teaching services care for our patients and help off-load the resident services. Med-6 is a non-teaching hospitalist service consisting of recent graduates from our program and PA's. Having this service provides a valuable buffer to ensure compliance with the number of admissions to the teaching service. The Intermediate Care Unit (IMC - Med 7) is run by hospitalists with an interest in more critically ill patients. This service helps to off-load both MICU and floor patients. These faculty are in-house 24/7 and available for middle of the might consultations and supervision of codes. Med 5 is the non-teaching services for the renal transplant service. All these non-teaching services have helped the Department of Medicine achieve an increase in admissions, enhance patient flow in and out of the hospital, and relieve the pressure on the teaching services. They have been essential to the success of our residency program and reflect the strong financial support we enjoy from the institution.
All teams are assisted in their daily work by an interdisciplinary team, including a case manager, physical and occupational therapists, social workers, phlebotomy and IV teams, substance abuse counselors and respiratory therapists. Discharge coordinators assist residents in preparing patients for discharge and improving efficiency. Residents use EPIC to quickly retrieve lab data, studies, discharge summaries and scanned records. Residents can also access EPIC from their smart phones, tablets and their home via a VPN system. The addition of Dragon has been wonderful to enhance efficiency and improve documentation.
Our Emergency Department is comprehensive and state-of-the-art clinical service, staffed 24/7 by outstanding faculty from the Department of Emergency Department. Approximately half the patients on the medical services are admitted through the UMMC Emergency Department, where over 50,000 patients are evaluated and treated annually. First year residents do a 2-week rotation in the ED functioning as primary physicians, caring for patients with diverse medical conditions under the supervision of full-time faculty. Maryland Express Care, an integrated consultation and critical care transport system for patients from all points within the state and region, adds diversity to the educational experience.