Internal Medicine Residency Program
Frequently Asked Questions: Your ScheduleFor your convenience, we have prepared the following questions and answers frequently raised by applicants. Please click on a question to be presented with the answer.
- Is California Pacifc Medical Center's Internal Medicine Residency compliant with new ACGME work hours regulations of July 2011?
- What about R2s and R3s? Are they still working more than 24 hours or more at a time?
- Does an R2 or R3 ever work longer than 16 hours?
- How many patients does each intern follow?
- How much primary care is there?
- How much elective time is scheduled and what electives are available?
Is California Pacifc Medical Center's Internal Medicine Residency compliant with new ACGME work hours regulations of July 2011?
Yes. The new rules mainly center around maximum 16 hour shift lengths for R1s and demand the presence of supervisors in house for the interns at all times. We have always had superb availability of any needed supervision. There is always a senior resident working closely with interns and we are one of a limited number of American hospitals that have the 24 hour-7 day/week presence of Board Certified Pulmonary/Critical Care attending physicians. While these attending physicians are always available, they also understand the importance of “hanging back” and allowing house staff the decision-making autonomy necessary for professional development. We also have 24/7 in-house hospitalists (all excellent teachers.) Over a decade ago, CPMC was one of the first hospitals in the United States to break ground in this crucial area of patient safety and house staff education by instituting the important quality initiative of having in-house hospitalists and critical care physicians.
With regard to 16 hour intern duty limitations, the schedules were meticulously re-designed and introduced in July 2011 to comply with these new regulations. At the time of this writing, so far, so good though we continue to “tweak” any issues that arise based upon all-important house staff feedback to the program directors and chief medical residents.
Mekhala Chandra, MD, Kate Zietler (MS3), Duc-Uy Quang-Dang, MD, Neil Maluste, MD, Tim Chen, MD, and Derek Hsu (MS4)
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What about R2s and R3s? Are they still working more than 24 hours or more at a time?
Although the new regulations permit upper level residents to work 24 hour admitting shifts and to stay in the hospital for up to 4 additional hours to finish up work and sign out patients (the so called, “24 + 4 rule”), we have chosen to dispense with this paradigm of residency training.
Our reasons for eliminating traditional long shifts were multiple, but mainly boiled down to 3 things:
- The feedback from our senior residents during our brainstorming sessions with them indicated that having the senior residents work long shifts without their interns would be disruptive to the close knit team structure and collegiality that our program is known for. For many of our house staff, it is the team and the people on that team which make their experience so enriching, educational and fun. We truly care about what our residents think and this was the biggest factor in our decision to eliminate traditional 24 hour admitting cycles.
- As leaders of the program who are nationally involved in medical education, the Program Directors felt that the future trend of residency training would be to eventually eliminate these 24 + 4 duty lengths—so why wait? We decided to do it in 2011.
- While the medical literature is unclear about what the ideal duration of admitting shifts should be to provide optimal, safe patient care balanced with optimal medical education and training experience, the data available to date does support shorter shift lengths. Both experientially and intuitively, we also felt that eliminating long shifts made sense from both a patient safety standpoint and from a “burnout” standpoint.
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Does an R2 or R3 ever work longer than 16 hours?
Yes. There are still a few shifts where a senior resident may come in at 5pm on Friday (Cardiology Nights) and stay until noon (shift length 19 hours) on a Saturday. These shifts are very rare, however.
Mike Chew (MS4), Rachel Geffen, MD, Felix Lui, MD, and Don Zumwalt, MD, (Hospitalist)
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How many patients does each intern follow?
On most inpatient services, each intern will admit 2-5 patients per admitting day and will carry an average census of 8-10 patients.
However, census varies from service to service with the higher intensity services, such as Hematology/Oncology, having slightly fewer patients. Intern services are strictly "capped" at 10 patients and interns may admit no more than 5 new patients and accept 2 transfers in a 24 hour period.
2012 R2 Retreat
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How much primary care is there?
We have a very strong continuity clinic located at the California Campus which is a 7-minute shuttle ride from the main inpatient campus. The clinic offers exposure to a broad range of patients in a well-supervised setting. We believe that our outpatient clinic is one of the best available to train residents in outpatient primary care medicine. The patient base includes 50% HMO patients. Most of these patients work in the local community. Approximately 25% of our ambulatory patients are Medicare seniors (age>65), and twenty five percent age indigent (Medicaid).
All residents in the three year program spend one half-day every week in the outpatient continuity clinic beginning in the R-1 year. In addition, house staff in the three-year program have four mandatory rotations in the outpatient setting over the course of the three years (including one ER month, 2.5 ambulatory care months and one month of geriatrics). The ambulatory care rotations include exposure to the following activities: urgent care of the uninsured ("Free Clinic"), office orthopedics, dermatology, geriatrics, travel medicine, podiatry, rheumatology, among others.
Elective months can be devoted to further enhancing primary care exposure. Residents can choose to work for one month in the office of a group of primary care internists and/or care for indigent ambulatory patients.
Although we do not have primary care track, residents can select to spend up to 35-40% of their time during their second and third years in ambulatory training sites. We encouage house staff who are interested in a primary care career to use assigned rotations and electives to design a comprehensive ambulatory care training experience.
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How much elective time is scheduled and what electives are available?
Each first year resident (R-1) has over two months of elective time. Electives can be chosen in any subspecialty area. Commonly selected electives include: anesthesiology, cardiology, dermatology, gastroenterology, infectious diseases, nephrology, research, quality improvement (QI), and rheumatology. It should be noted that during one of those elective months the intern is "at risk", otherwise known as "On jeopardy call". At risk means that the intern may be called in from elective in the event that a colleague becomes ill or for other extenuating circumstances.
R-2 and R-3 schedules include over two months of elective time per year and several "selective" months. All second and third year residents also have "selective" rotations which include nephrology and geriatrics/palliative care during their 3 years at CPMC.
Residents take most of their electives at California Pacific. Electives can also be taken at Bay Area Hospitals including: UCSF hospitals (Moffitt-Long, the VA and SF General), Stanford, and Alameda County ("Highland") Medical Center.
Elective opportunities are available in all traditional subspecialties of internal medicine and in many related fields, including HIV medicine, complementary medicine, rehabilitation medicine, and end of life care/hospice medicine. Research electives are encouraged as part of the scholarly activity of our house officers. One month of research is allowed each year. Quality Improvement and Residency Program Improvement electives are readily available and have been popular, productive and successful.
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