Family Medicine Service

Faculty Chair: Peter Kuhn, MD

Sample R1 Schedule (can significantly vary):

· Weekday mornings typically start with sign-out from the night team to the day team at 6:30AM. Weekend morning sign-out is at 7:00AM. Depending on volume you should adjust your pre-rounding time accordingly before that.

· On Mondays and Wednesdays, there is a morning teaching conference from 7:30-8:15. Mondays-Thursdays there is a noon teaching conference from 12:00-12:30. See the separate Teaching Conference schedule for specifications.

· Attending rounds in mid-morning generally start around 9:00 AM and can considerably vary depending on volume; all patients on the FMS are discussed during attending rounds, with review of diagnoses and treatment plans. Short teaching topics are also presented here.

· Mid-day sign-out is generally at 12:30.

· Afternoon clinic start times vary by site.

· If you are the “FMS-day call” intern, your shift ends after the 7PM sign-out to the night team.

· If you are the “FMS-night call” intern, your shift begins with the 7PM sign-out from the day team, and ends after the sign-out the following morning.

· If you are not in clinic and not on-call, your afternoon can end when your patients are squared away for the day; the senior may ask that you stay to help with cross-cover for the interns in clinic, if the admitting R1 is busy with admissions. If you are done with your work and the call team does not need help you are strongly encouraged to leave the hospital and use it for personal time.

Rotation Goals

• The resident will provide comprehensive and safe inpatient care of pediatric, obstetric, and medicine patients while being able to

effectively communicate with patients, colleagues, and consults.

Rotation Objectives

Patient Care:

• Perform an accurate and complete medical history and physical exam on patients at admission (R1)

• Develop efficiency to allow management of up to 6-7 patients each day (R1)

• Understand the indications for, and perform bedside procedures including paracentesis, joint aspiration, I&D, lumbar puncture, and thoracentesis (R1, R2, R3)

• Attend and assist in patient resuscitation during Code Blues (R1, R2, R3)

Medical knowledge:

• Generate a broad differential diagnosis, and begin to use diagnostic testing to narrow and refine the differential. (R1, R2, R3)

Interpersonal and Communication Skills:

• Tailor case presentations to a variety of different situations: daily rounds, discussions with consultants, sign-out. (R1, R2, R3)

• Actively participate in family care conferences (R1, R2, R3)

• Effectively communicate care plans with hospital staff (nurses, technicians, consulting physicians) (R1, R2, R3)

• Work effectively with medical interpreters (R1, R2, R3)

Professionalism:

• Accept personal responsibility for the patients under your care, including timely and accurate documentation of exam findings and regular communication with family members and other members of the care team. (R1, R2, R3)

• Recognize the limits of your own knowledge, skills, and stamina; and ask for or accept assistance when needed (R1, R2, R3)

• Understand and respect the regulations regarding duty hour restrictions (R1, R2, R3)

Practice-based Learning and Improvement:

• Participate in regularly scheduled teaching conferences (R1, R2, R3)

• Provide constructive feedback to other members of the team, and seek out feedback for your own performance (R1, R2, R3)

• Begin to use point-of-care decision tools/resources to help guide diagnostic and treatment plans (R1, R2, R3)

Systems-based Practice:

• Provide accurate and appropriate information during sign-outs to assure patient safety (R1, R2, R3)

• Learn the role of quality variance reports (eQVRs) for improving systems of care within the hospital (R1, R2, R3)

Family Medicine Service Rotation Overview

Function of the Service

The Family Medicine Service (FMS) rotation comprises the major portion of the General Medicine inpatient curriculum. It functions independently of the hospitalist-run Internal Medicine service although they parallel each other in accepting adult general medicine admissions. FMS will also admit and manage pediatric and obstetrical cases, including medical complications of pregnancy.

The Family Medicine Green Team is staffed by the First Hill Family Medicine Residency and provides care for all of our clinic patients from the First Hill, Ballard and DFM clinics. The Family Medicine Red Team is staffed by the Cherry Hill Family Medicine Residents. These two teams function separately and independently, although we do provide cross-cover for each other twice a year during residency retreats.

Admissions to the FMS Green team come from:

Family Medicine Clinic attendings and residents:

All Family Medicine Clinic patients from our three residency clinics are initially admitted to the FMS, with the faculty physician on the FMS usually serving as the Attending. If the patient’s primary care provider (PCP) is another faculty physician, they may choose to attend during their patient’s hospital stay. If the patient’s clinic PCP is a resident, their role in the care of their hospitalized patient will vary depending on their other clinical obligations. However, they are expected to communicate regularly with the inpatient team, participate in key decisions and assist in discharge planning.

Neighborcare Clinics:

Our Family Medicine Service admits all patients from the 45^th Street, Neighborcare Meridian and Neighborcare Vashon Clinics. We also admit for certain providers from other Neighborcare Clinics. The Neighborcare attending attends on their patients during the weekdays, and rotate call with our faculty on weekends and holidays.

Swedish Central Seattle Clinic:

Admissions also come from the Swedish Central Seattle (SMG) clinic. Their attendings will rotate at various points in the year on FMS. If they are not attending for that week the FMS attending will cover for their patients.

ED patients with no doctor:

Patients who present to the Swedish emergency department but who do not have a primary provider may be admitted to the FMS if the census allows. The family medicine faculty will serve as the Attending for these patients.

Roles

The typical FMS team consists of 4 R1s, 3 R2s and 1 R3, with 5-6 residents on the day team. There is one R1 and a senior resident (R2 or R3) on night float who provide night coverage for the FMS patients, take any new admissions, and manage family medicine clinic or Neighborcare patients seen in OB triage. The senior resident on day (weekend) or night call will also manage laboring patients from Neighborcare or our family medicine clinics if the patient’s own PCP is not available.

R1 admits patients to the family medicine service, and rounds on their panel of patients daily. They are expected to become familiar with all aspects of their patient’s care. The R1 has primary responsibility for the day-to-day care of their patients, including: daily interviews and exams; reviewing any changes in symptoms and any new labs or test results; ordering any additional tests or treatments; communicating with specialist consultants; close communication with the nurses, social workers, discharge planners and other members of the patient’s care team; communicating with the patient’s family members; presenting the patient history and physical (new admissions) or progress report during daily attending rounds; writing a daily progress note in the patient’s medical record (before attending rounds); and contacting the patient's attending each day to discuss their assessment and proposed treatment plan. All of this is done with supervision and support from the senior residents. Remember: there is always back-up and help available!

The R1 takes day call approximately every 3 days, functioning under the supervision of the R2 or R3. When on call, the R1 will be responsible for all admissions to the FMS. Unless the new patient is seriously ill and unstable, the R1 will do the initial comprehensive interview and exam, and then develop the initial assessment and treatment plan with help from their senior resident (it is highly recommended that the R1 discuss with the senior resident what their needs and expectations are). The admitting history and physical should be in the patient’s chart before the intern leaves at the end of the day (or night). As much as possible, try to keep up with your admission notes through the day (or night) and don’t let these stack up; we need to respect duty hour restrictions and get you home shortly after your shift ends.

R1s are expected to attend all morning and mid-day sign-outs as well as the morning and noon teaching conferences, unless they are involved in an urgent patient care responsibility. The senior residents are there to help with time management so that the R1s can get to the conferences.

R1s have one afternoon clinic per week, except during the week of night float.

R2 works under the direction of the R3 FMS chief to triage and coordinate admissions of patients coming from the clinics or the emergency department. They provide direct supervision of the R1s on the FMS. The R2 manages patients in early labor and in OB triage, reporting to the on-call Family Medicine OB attending (nights and weekends). They will also manage and deliver laboring patients from the Neighborcare Clinic (nights and weekends). The R2 will write an abbreviated senior resident admission note for each admission when on call (first 6 months of academic year). They will also write a brief afternoon or evening progress note with updates on all patients with a significant change in status, diagnosis, or treatment plan.

At the beginning of the year when the R1s are less experienced, the supervising R2 should interview and examine (at least briefly) every patient, go over the orders and any pertinent labs with the R1, and work with the R1 to develop their diagnoses and treatment plan. R2s are not required to be present for the initial H&P, but should perform their own evaluation of each patient within an hour of their admission. As the year progresses, the R1 is expected to require less supervision, but they should still present every admission to the R2 and review the orders and treatment plan. R2 residents are required to read all admission H&Ps; amendments should be discussed with the R1. The R2 is also ultimately responsible for insuring that accurate and timely discharge summaries are posted in the medical record.

R2s are expected to attend all morning and mid-day sign-outs, and morning and noon conferences unless tied up with urgent or emergent patient care activities. They play an important teaching role on the FMS, including direct bedside teaching for the interns they supervise. They will also present brief didactic presentations during attending rounds.

The senior resident on-call (R2 or R3) is encouraged to go to any “Code Blues” and take the leadership role in running these codes. You do need to have current ACLS certification to run the code.

The nighttime FMS senior resident provides in-house coverage from 7 PM until 7:00 AM for new admissions and cross-cover of patients in house as well as for OB triage and labor and delivery (for FMS and Neighborcare patients). They supervise the R1 on night call and if time allows does some one-on-one teaching. They are responsible for updating the daily sign-out list each morning.

The R2 or R3 on call is responsible for phone triage during the evening or weekend, taking incoming phone calls from clinic patients or nursing homes and documenting these calls in the medical record.

R2s generally have 1 half-day of afternoon clinics per week.

R3 is the FMS chief and team leader. They oversee all patient care on the Family Medicine Service and supervise the activities of the R1s and R2s. They distribute and balance the interns’ patient panels, coordinate the teaching conferences and ensure that the R1s and R2s are able to attend these sessions, and provide constructive feedback to the rest of the team on a weekly basis.

The R3 meets with the faculty attending at the start of each day to review and discuss the list of the service patients. The R3 should assume the role of junior attending for management decisions regarding FMS service patients that come up throughout the day or night. These decisions should be reviewed with the attending in a timely manner depending on the complexity of the patient's illness.

The R3 conducts daily ward rounds focusing on new or unstable patients; this may include bedside rounds, radiology review, and chart rounds. They do not follow individual patients or write progress notes on a regular basis, except during weekend coverage. When on call, they are responsible for primary supervision of the R1 on call.

The R3 attends and coordinates all ward team functions. They supervise the sign-outs in the morning and the early afternoon. The R3 ensures that there are adequate numbers of admissions on the service

The R3 should foster an environment of teaching, bringing and encouraging others to teach when time allows. The R3 is also responsible for facilitating the interns’ attendance at all the morning and noon teaching conferences. They run the weekly 7:30AM Monday morning report.

The R3 generally has one afternoon clinic per week.

FM Attending is a faculty member assigned to the FMS for a one-week rotation. Their role is consultant/teacher for the FMS residents, as well as attending on record with ultimate responsibility for the FMS service patients under their care. They will review all new FMS Service admissions with the R3 as well as the admitting residents. They will round daily on all of the Service patients and discuss management issues with the primary R1 or R2 involved. The FMS attending will be present at daily attending rounds. They will also be available to act as a liaison for conflict resolution between the FMS team and private attendings.

The FMS attending is responsible for presenting a 20-30 minute didactic on a core inpatient medicine topic each week. They are also responsible for providing direct individual feedback to each resident once a week.

On weekends and holidays, other faculty members may rotate call responsibilities; this may include the physicians from the Neighborcare Clinics, as well as our obstetric and geriatric fellows.

Call

In-hospital call for the Family Medicine service is covered by an R1 and a senior resident (R2 or R3) working approximately 13-hour shifts. Daytime call, approximately every third day, begins at 6:30 am with sign-out rounds. Night call begins for the night float senior and R1 at 7 pm. Each R1 spends approximately 6 nights on night float during each FMS block. The senior resident covering night float is not always on the FMS rotation, but each senior resident covers approximately three weeks of night float in the R2 year and two weeks during the R3 year.

6:30 am sign-out rounds are attended by all FMS members Monday through Friday mornings. Overnight admissions are presented by the night float team and assigned to an R1 and R2 for continued management. Daytime admissions are presented at ward rounds each morning.

Senior resident day call responsibilities include accepting and supervising admissions to FMS, evaluation of resident patients who present to OB triage, labor management for Neighborcare Clinic patients and for our family medicine clinic patients whose PCP is unavailable, and fielding phone calls from the emergency department about clinic patients. After normal business hours and on weekends, the senior resident will also respond to phone calls from patients at all three clinics, as well as nursing home patients belonging to our clinic physicians.

Charts

All inpatient notes and orders are documented using Epic, the hospital EMR. Admission H&Ps must be completed by the end of the resident's shift. Discharge summaries will be the obligation of the resident who was primarily responsible for the patient during his/her hospital stay, with a copy to the outpatient PCP to manage follow-up care. Discharge summaries must be completed within 48 hours of discharge or prior to SNF discharge. Patients who identify a resident physician as their primary care provider should be admitted with the FMS attending listed as admitting physician.

Unstable Admissions to Swedish Hospital:

1. ICU: Family Medicine Clinic patients admitted to the ICU will be admitted by the resident to the ICU attending. The FMS team will round on the patients daily and manage the patient under the direction of the intensivist. Upon discharge from the unit, the patient continues to be followed by the FMS attending. We do not place orders on these patients but do write notes and round on them.

2. Term Obstetrical Patients: (37+ weeks gestation) are admitted by the senior resident unless other coverage has been arranged. Patients in active labor will be further managed by their primary resident. OB patients needing admission to antepartum will usually be admitted by the FMS team (see OB curriculum for details).

Codes

All residents are required to have ACLS certification. The on-call residents carry pagers which alert them to hospital-wide adult codes, which are often supervised by the adult hospitalists. Residents should attend all adult codes, especially at night, to offer assistance to the code team. Senior residents are encouraged to take the lead in running the code, under the supervision of the hospitalist/intensivist.

Weekends and Vacations

On weekends, the night float and day call residents round on the all of the patients on the FMS. Vacation is only permissible for interns during FMS blocks with 5+ interns.

Medical Student Participation

Medical students from the University of Washington or other medical schools will occasionally participate in clerkship electives on the Family Medicine Service. The medical students, depending on their year of medical school and degree of experience, will assume appropriate responsibilities in patient management, but it will always be under the direct supervision of faculty and residents. Requirements include:

1. Students will make it clear to patients that they are students and that they work directly with a supervising physician.

2. Students will be preferentially assigned Family Medicine Clinic patients, but non-clinic patients can be assigned with the approval of the private attending physician.

3. Students will co-manage patients with R1s with direct supervision of a senior resident.

4. Students will write an admission history and physical exam on patients they admit, which will be reviewed, critiqued, and co-signed by the senior resident. The supervising resident physician will be responsible for the official H&P and discharge summary.

5. Students will be scheduled to take call, teamed with an R1 and R2 pair.

6. Students will be responsible for arranging their own housing while in the Seattle area, as well as providing their own malpractice insurance and health insurance.

7. The number of patients followed by any student will be determined by the supervising R3 chief, based on the student's year of medical school and demonstrated ability.

8. The evaluation form for the student's performance will be completed by the family medicine faculty in charge of medical students, with input from all team members.

Reviewed and Updated: 7/27/2020, Peter Kuhn

Effective 6/25/2020 - 6/24/2021