Standards

For Internal Medicine Clinical Rotations

Educational Standards for Internal Medicine Clinical Rotations, University of Alberta, Department of Medicine, August 11, 2021

Background

The Department of Medicine has the responsibility to oversee the training of medical students and residents from various residency programs, in the principles and practice of internal medicine. These learners are grouped on clinical teaching units or preceptor-based teams in hospitals in Edmonton. Each of these learners has educational objectives and constraints defined by their parent program, the medical school, and by other organizations such as the professional association of resident physicians of Alberta (PARA). The existing hospital-based learning environments and, in future, other environments offer their own culture, resources, and practices to assist these learners and their programs in achieving the learning objectives. To aid educational and clinical leaders in optimizing learning, patient care, and learner wellness, while also respecting the realities of costs and professional obligations, the following educational standards have been established by the Department of Medicine to clarify minimum expectations. These standards will apply to all junior residents on clinical Rotations sponsored by our Department.

Purpose

Adherence to these standards will be important criteria in determining how to best allocate medical students and residents for their internal medicine rotations. These standards are intended to complement not replace the accreditation standards of training programs and care facilities. These standards also support and not replace the Supervision Policy and Assessment Policy of the Faculty of Medicine and Dentistry. The standards apply as well to sites as they do to individual teacher-learner interactions.

Availability

Attending physician supervisors must be present with the students and residents for at least half of the normal work day, and immediately available in person for the remainder of the day, five days per week. Typically this would mean a minimum of a three hour period that starts no earlier than 7am and extends no later than 5 pm. The morning is preferred for rounds. Attending physicians should be present at the end of the day for sign-over rounds. To achieve this, we anticipate that preceptors will reschedule some of their other obligations such as outpatient clinics or other meetings while on clinical service.

Residents and students should be present during the work day for a minimum of 60% of the normal work week, and 75% excluding post-call absenteeism. For up to 40% of the time, residents may be absent from the work-day clinical setting for approved leave, vacation and excused post call periods. For traditional rotations, these learners must be present for twenty four (24) half-days in a normal 40 half-day rotation. To achieve this, we strongly recommend that learners schedule their other obligations so that they can be present for clinical rounds each morning of the work-week.

When attending physicians oversee a “junior attending” physician, their collective availability to junior learners should adhere to the standards above. Even then, the attending physician must have daily face-to-face contact with each learner.

Continuity

Attending physician supervisors may work as a “preceptor” as the physician of record continuously throughout the year. More commonly, they may share their duties with other colleagues in a “clinical teaching unit (CTU)” model that rotates no more frequent than weekly. Less continuous models such as the CTU must ensure that there is no compromise in continuity of the learning and evaluation experiences of residents and students through appropriate handover from outgoing to incoming staff supervisors. More continuous models (ie. preceptor) must be cautious not to compromise their availability as described above. Exceptions to this model include rotations which change the preceptor daily such as ED Consults or ambulatory clinics.

Intensity

To help ensure that learners experience appropriate graduated responsibility with supervision, the following are minimum standards:

Daytime responsibility for patients. Students should take primary responsibility for a maximum of 6 patients. Junior residents should take primary responsibility for a maximum of 12 patients. A junior resident may provide shared responsibility for patients assigned to a medical student. However, in this scenario, the total number for whom the resident has responsibility should still not exceed 12 patients. If a resident colleague is post-call, the remaining resident may provide daytime coverage for their patients, but not to exceed a total number of 12 patients. The remainder default to the attending physician or their designate.
Evening and On-call responsibility for patients. Depending on the acuity of the patients, junior residents should have responsibility for no more than 60 hospitalized patients while on call. This includes the patients assigned to a medical student for whom the resident has overnight responsibility. If cross-coverage occurs, the patients should belong to a similar teaching service (Example. GIM patients on both services) or the resident must have prior training in both their primary and the cross-covered services. Residents should not provide overnight coverage for patients who are not under the daytime care of a teaching service.

Resources

Principal Teaching Physician, sufficiently qualified with adequate time.
MEP-C (Medical Education Program Coordinator) support
Adequate access to computers and facilities for information management
Physician teachers adequately supported to fulfill the dual responsibility of excellent patient care and excellent teaching. Physicians who cannot adhere to the standards described herein should not be assigned to work with medical students or junior residents.

Teaching & Assessment

It is the responsibility of the resident and student to take ownership of their own learning through active engagement in patient care.
It is the responsibility of staff preceptors to actively engage students and residents in bedside teaching and assessment daily. This includes direct and indirect observation (e.g. a minimum of one EPA observation documented per teaching day for all learners (not per learner) and appropriate individualized face-to-face feedback).
When a pattern of learner performance is deemed to be less than “progressing as expected”, the staff physician is obligated to communicate this verbally to the learner at a mid-point of their time working with them so that there is an opportunity for correction. All verbal midpoint feedback and endpoint feedback that is less than “progressing as expected” must be documented in writing and discussed in person with the learner.
Rotation ITERs should be completed within 7 days and must be completed within 28 days of the end of each rotation.

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