Program Overview: Rotations and Clinics

• The ICUs
• The Wards
• The Cardiology Pavilion
• University of Pittsburgh Cancer Institute (UPCI)
• Electives and Subspecialty Consults
• Ambulatory Block
• Continuity Clinics

The ICUs

During their training, residents may rotate through the following intensive care units (ICUs): the Medical Intensive Care Unit (MICU) and the Coronary Care Unit (CCU) at the University of Pittsburgh Medical Center (UPMC) and the Veterans Administration Intensive Care Unit (VICU) at the Veterans Administration Medical Center (VAMC). All intensive care units are closed units and have a dedicated fellow assigned to assist the housestaff teams.

• The Medical Intensive Care Unit is a 24 bed unit located in Presbyterian Hospital. The MICU serves as tertiary center accepting patients from the tri-state area, locally, and from the Presbyterian emergency room. Housestaff in the MICU are grouped into four teams consisting of one intern and one resident. Two pulmonary attending physicians are on service along with two pulmonary or critical care fellows. This arrangement allows for two housestaff teams to round with one attending and one fellow. The housestaff take overnight call every fourth night with the assistance of an in-house fellow. This rotation continues to be a favorite among housestaff as the residents and interns develop technical skills in line placement and patient management. The housestaff truly enjoy learning from our esteemed faculty as they care for critically ill patients.
• The CCU comprises a closed 10-bed unit. This roatation utilizes an integrated team approach to learning and patient care. Six housestaff members comprising 3 residents and 3 interns, staff the unit during any given month. The call structure is a Q3 overnight system for each reisdent and intern pair. Interns usually admit about 3 patients during an overnight call, but they can admit up to a cap of 5 patients. Patients in the CCU are not assigned to be cared for by any particular intern/resident pair but instead are cared for collectively by CCU team.

• The VICU is located at the nearby VAMC and comprises a combined MICU and CCU. Four teams, each with 1 resident and 1 intern, staff the unit during a given month. The call structure is a Q4 overnight system. Interns admit up to a cap of 5 patients during on overnight call. The average census for a given team is 4-8 patients.
• Residents may also request to rotate through the MICU and CCU at Shadyside Hospital, a local community hospital affiliated with the University of Pittsburgh Medical Center.

The ICUs: Sample Schedules

	Daily	Monthly
UPMC MICU
VAMC VICU

The Wards

Residents rotate through general medicine wards at two different sites: the University of Pittsburgh Medical Center (UPMC) and the Veterans Administration Medical Center (VAMC). Both sites run a purely hospitalist-based system. Therefore, each housestaff team will have only one attending who serves as the attending of record for that team's patients as well as the team's teaching attending. This dramatically increases the efficiency of patient care, ensures that core departmental values for patient care are consistently implemented, and increases the time available for educational activities.

All patients admitted to the general medicine services are triaged so that services run by housestaff have patients admitted to them in a manner that maximizes learning. Residents are exposed to and learn to care for patients with medical problems spanning the fields of endocrinology, gastroenterology, pulmonology, rheumatology, nephrology, infectious diseases, and some hematology and neurology. The only exceptions are cardiology patients, who are admitted to a separate cardiology service staffed by residents (see below). All other patients with medical issues that have less educational value are admitted to a separate attending service to which housestaff coverage is not assigned.

• General medicine wards at UPMC operate under the direction of 6 teams. Five of the teams care for patients admitted to 5 attending-supervised, general medicine services, and each team consists of 1 resident and 2 interns. The sixth team cares for elderly patients admitted to an attending-supervised geriatrics service and also consists of 1 resident and 2 interns.
• Teams on the 5 MUH general medicine services operate on a Q5 call structure in which each intern on a given team alternates staying overnight every tenth night (i.e., Q10 overnight long-call). An intern on long-call will admit no more than 5 patients. The overall census cap for an intern is 12, though this rarely becomes an issue. There is a night-float system in place to care for patients from the other 4 MUH teams. This allows the overnight intern to cross cover only on his or her individual team's patients. The Q5 call structure maximizes work-related and didactic educational activities for the housestaff.
• The interns on the geriatrics service alternate admitting 3 patients every other day. Because the admission caps are lower, the overall census for a given intern tends to be lower than that of the other services. As a result, this service is an excellent educational opportunity.

The Wards: Sample Schedules

	Daily	Monthly
UPMC Wards
VAMC Wards

The Cardiology Pavilion

The Cardiology Pavilion, also known simply as the "Pavilion," is a special inpatient service at UPMC for patients who primarily have cardiology disorders. The service covers patients with electrophysiologic issues (arrhythmias and pacemakers), congestive heart failure, and general cardiology problems such as coronary artery disease and unstable angina.

• Four teams, each with 1 resident and 1 intern, staff the Pavilion during a given month. The call structure is a Q4 overnight system. There is always a dedicated Pavilion attending during the day and a cardiology fellow during the night to help housestaff with patient management issues. Interns admit up to a cap of 5 patients during on overnight call. The average census for a given team is 4-8 patients. The patient turnover is usually high on this service because of the focused nature of the patients' medical problems. This rotation has become one of the most popular within our program because of the focused nature of the problems, the call system, and the teaching that takes place in the form of daily didactic lectures as well as bedside teaching by the attendings.

The Cardiology Pavilion: Sample Schedules

	Daily	Monthly
Cardiology Pavilion

University of Pittsburgh Cancer Institute (UPCI)

The University of Pittsburgh Cancer Institute and the Division of Hematology/Oncology together provide the academic and research activities for cancer at the University of Pittsburgh. UPCI is the only National Cancer Institute–designated Comprehensive Cancer Center in western Pennsylvania. UPCI works in tandem with the UPMC Cancer Centers to offer patients the latest advances in cancer prevention, detection, diagnosis, and treatment.

The inpatient rotation is divided into 2 independent services: the malignant and nonmalignant hematology service and the medical oncology service. A separate attending and fellow cover each service and round with the resident teams on a daily basis.

The hematology service primarily cares for patients with acute leukemia and non-Hodgkin's lymphoma. Examples of patients with nonmalignant diseases admitted to this service include those with immune thrombocytopenia, thrombotic thrombocytopenic purpura, autoimmune hemolytic anemia, aplastic anemia, and hemophilia. Patients on the medical oncology service include those with cancers requiring inpatient chemotherapy (e.g., sarcomas), those with complications of their diseases (e.g., pain, gastrointestinal obstruction, and pleural effusion), and those in whom palliative or hospice care is being discussed. In addition, both services provide abundant resident experience in the management of neutropenic fever and transfusion medicine.

• Three teams, each with 1 resident and 2 interns, staff the hematology/oncology wards during a given month. The call structure is a Q6 overnight system for interns. The average number of admissions for an intern during an overnight call is 3-5 patients. The average census for a given intern is 4-8 patients.
• Teaching takes place during walk rounds performed daily by both a faculty medical oncologist and a hematologist who round with each of the 3 resident teams. In addition to the teaching provided during walk rounds, a series of didactic lectures is provided by the hematology/oncology staff. These 1-hour lectures occur 4 days each week and cover clinical situations or disease entities that the residents will encounter during their rotation on the inpatient service.
• A separate inpatient service, the Stem Cell Transplant Program that is normally covered by nurse practitioners and a fellow, offers an elective opportunity for residents interested in transplant hematology.

UPCI: Sample Schedules

	Daily	Monthly
UPCI

Electives and Subspecialty Consults

Each resident will have several months available each year for electives. Our program offers a plethora of elective opportunities from which residents may choose. Elective months may be spent doing research, working in a particular clinic of interest to the resident, or handling subspecialty consults. The consults allow housestaff to explore other fields in internal medicine and to experience the role of a medical consultant. There is no call during a consult month, and all weekends are free. Outpatient clinics in the medical subspecialties are also included as part of several consult rotations.

In addition, interns have the opportunity to explore medical subspecialties through exposure electives. These electives are 2 week blocks designed to provide interns with a broad experience in a subspecialty with the focus on non-inpatient aspects of care. The four week electives please make this the link for the four week electives) are designed to provide more indepth training in an area of medicine for both interns and residents.

Subspecialty Consults: Sample Schedules

	Daily	Monthly
Consults

Two-week Exposure Electives

Ambulatory Block

Residents have multiple venues in which to experience patient care in the ambulatory setting. In addition to their continuity clinics, residents rotate through the emergency department at the University of Pittsburgh Medical Center (UPMC), the Emergent Care Center at the Veterans Administration Medical Center (VAMC), and the ambulatory block.

The goals of the ambulatory block rotation are to obtain a broader and deeper knowledge of the diagnosis and management of common problems seen in outpatient general medicine, to become familiar with "real world" office experiences as practiced in community-based general internal medicine (including aspects of billing, scheduling, and personnel management), and to apply evidence-based medicine principles as learned in the academic setting to management of patients in a community practice.

The ambulatory block rotation consists mostly of experiences in individually scheduled clinics with practicing community internists. Also included in the rotation are outpatient office experiences with specialists in various medical subspecialties, such as hematology/oncology, cardiology, and pulmonary medicine. Interns and second-year residents also participate in a mini-clinical evaluation exercise (mini-CEX), a tool used to assess the clinical skills, attitudes, and behaviors that are essential in providing high-quality patient care. Each week ends with an ambulatory care conference during which various topics and evidence-based medicine concepts are reviewed.

Continuity Clinics

The goal of the continuity clinic is to develop the skill sets involved in providing excellent longitudinal patient care. These skill sets not only include differential diagnosis and management skills but also include how to prioritize management decisions and how to coordinate care across time and among subspecialists. To best achieve this goal, all continuity clinic attending preceptors are general medicine clinician-educators who precept the same residents throughout their residencies. This allows for continuity in patient care, feedback, skill development, and mentoring. We recognize that the skills of longitudinal care are as important for those going into subspecialties as they are for those going into primary care.

All housestaff enrolled in one of the 3-year programs participate in a continuity clinic one-half day per week, either at the Veterans Administration Medical Center or the University of Pittsburgh Medical Center. Each resident serves as the sole primary care physician for his or her own panel of patients under the supervision of a teaching attending. A well-trained ancillary staff helps the resident manage complex medical problems, make referrals, follow up on labs and studies, and respond to patient phone calls. A housestaff call system is in place for after-hours phone coverage to closely simulate "real world" patient care. Clinics focused on women's health and geriatrics are available as part of the individual training tracks. A weekly, one-half-hour pre-clinic conference reviews important topics in outpatient medicine. Continuity clinics take place weekly, year-round for all residents in one of the 3-year programs except on holidays or when the resident is on an ICU rotation.