Curriculum

Chart of Clinical Experiences

This chart shows the distribution of time devoted to the various clinical experiences during PGY 1 year (note: this is a sample schedule and includes a range within each rotation type). Each year is divided into 26 blocks, each block two weeks in length.

The schedule of inpatient coverage is organized to minimize stress by reducing the weekly work hours and consecutive daily hours and by limiting the number of admissions. Ancillary services are readily accessible on a 24-hour basis. Accommodations are made for coverage during illness and for parental leave.

Transitional Year PGY1  Clinical Experiences	Number of weeks per year
Inpatient Medicine	10-12
Critical Care Medicine	4-6
General Surgery	4
Emergency Medicine	4
Pediatric Medicine	2-4
Ambulatory Medicine	4
Night Medicine and Night ICU	8-10
Elective	8
Vacation	4
Total Weeks	52

Patient care

Each medicine team has a resident and two interns and a designated hospitalist attending. Teams care for a diverse panel of patients. 24-hour interpreter services, excellent social work staff, engaged consult liaison psychiatrists, comprehensive outpatient services for special populations - immigrants, the frail elderly, the homeless, the chronically mentally ill, those struggling with addictions - make it possible to provide high quality comprehensive care for a socially complex group of patients. The breadth and depth of medical pathology provides an inexhaustibly rich environment for learning. Patient care teams are geographically staffed such that all resident team patients are on one ward. This enables closer collaboration between nurses, doctors and care-coordinators.

Daily schedule of work

Interns arrive 6:30 - 7 to preround on their patients and take signout from the night team. From 8:30 - 10:30, both teams do bedside patient care work rounds with their team's hospitalist attending.

At 3 p.m., the ward team meets again for afternoon rounds with the attending to review the patient care plan for the current day and prioritizing task list for remainder of the day. This is also an opportunity for ‘bring-backs’: clinical questions come up during routine care of patients during work rounds and are assigned to team members. Emphasis is placed on learning to manage common and “cannot miss” diagnosis, learning to generate clinical questions and applying available evidence to patient care decisions. Case discussions may also focus on issues related to cultural competence, ethics and health systems.

Learning conferences

Tuesday and Thursday have conferences with lunch provided by the training program.

On Thursday the conference is in Learning center C/D and is a different activity each week of the month. Sometimes it's a house officer meeting with the program directors or a meeting of the house officer union (CIR); sometimes it's a resident-led journal club or case presentation; sometimes it's a reflective session on the art of medicine - CHA's unique Food for the Soul series.

On Tuesdays, residents sign out their clinical work to the hospitalist service at noon and make their way to the Learning Center for Tuesday School Program a four-hour block of protected time for teaching and learning the core curriculum in inpatient medicine.

Manageable hours of work

Long before the ACGME mandated 80 hour work weeks, our residents were working manageable hours. We know that exhausted residents can't learn and can't take good care of others. Both teams admit every day, alternating between short-call and long-call days. On short-call day, the team takes morning signout and then takes new admissions and transfers until 2 p.m. At 6 p.m., they sign out to the night team. Having shorter days and longer days makes it possible to balance hard work with life outside the hospital. We share the work of caring for hospitalized patients with a third team that has different structure (one Hospitalist attending and one resident working alongside).

Night Rotations

One intern and resident pair work together on the wards to look after the patients on the resident teams; another intern and resident pair work together in the medical intensive care unit. The administrative hustle and bustle of the day quiets down and residents focus on managing emergent medical problems and admitting new patients. An overnight hospitalist is available in the hospital for consultation on patient care and the intensivist is only a phone call away.

In this setting, residents develop expertise in managing sepsis, respiratory failure, toxic overdoses and doing invasive procedures, and also in caring for families in crisis and negotiating goals of care in ethically and medically complex situations. Because there are no critical care fellows, residents assume a significant amount of autonomy in the care of patients and work directly with the attending physician to make decisions and execute plans of care.

The day begins at 7 a.m. with signout from the night ICU team to the day ICU team. Work rounds are led by the intensivist and begin at 8:30 a.m. At the conclusion of rounds, the tasks of patient care are undertaken by the day team, including any procedures, consults, transfers, and new admissions.

The Intern critical care experience is split between our two acute care hospital campuses. At Cambridge Hospital one resident and one intern (two interns during the first ¼ of the year) work together with critical care nurses, respiratory therapists and a pulmonary-critical care intensivist to provide care to critically ill patients in a 6-bed ICU. At Everett Hospital one intern works directly under the supervision of a pulmonary-critical care intensivist in a 6-bed ICU. Time each afternoon is carved out for dedicated resident teaching, led by the intensivist.

Goals

The educational purpose of this rotation is to teach residents the principles of management of surgical patients with a wide variety of acute, subacute and chronic surgical problems. Residents will diagnose, treat and care for men and women in the inpatient and outpatient setting, and assist senior members of surgical team in the operating room. They will evaluate and manage these patients under the direct supervision of an attending physician specialized in general surgery.

Through the rotation residents will gain the knowledge of the epidemiology and pathophysiology of diseases, as well as optimal approach to diagnosis, treatment and follow-up of these diseases. Residents will continue to learn the key role of humanistic and professional values in caring for the sick and injured.

Residents will develop interpersonal and communication skills which allow them to effectively collaborate with the other members of surgical team and effectively provide patient care. They will gather data from all relevant sources, including patient history, physical exam, laboratory data, imaging and other medical documents, consultants from other specialties. They will subject this data to the scientific method of problem solving using available sources of medical knowledge. Based on that, they will make informed patient care decision under the direct supervision of an attending surgeon.

The care they provide will be driven by the values of humanism and professionalism. They will learn to function as an integral part of the health care delivery system and will access and utilize health care resources in an efficient and optimal manner.

Objectives

1. Patient Care: Residents will provide surgical care to the patients who have a wide variety of acute, sub-acute and chronic problems. Residents will often be primary providers for patients they evaluate and treat. Patients will be undifferentiated and not pre-selected. Every patient encounter will be supervised by surgical attending physician. Residents will develop the skills to obtain a medical history, do a problem oriented physical examination, develop differential diagnoses, diagnostic testing strategies and treatment plan. They will learn the principles of postoperative management of surgical patients in both inpatient and ambulatory setting, the principles of assisting in the operating room including exposure retraction and wound closure. Residents will learn to perform basic surgical consultation for common problems in the emergency department and inpatient services, they will learn the principles of postoperative fluid administration in the management of surgical patients. They will also learn the principles of nutritional management in postoperative and surgical patients, the anatomic and pathophysiology principles behind diseases of the breast, appendix, colon, and biliary tree. These skills will develop in the context of the time critical management of patients who are both stable and unstable.Residents will learn to assess a patient’s medical status with attention to relevant cultural, socioeconomic, ethical, occupational, environmental and behavioral factors.
2. Medical Knowledge: Residents will acquire knowledge in the most common areas of General Surgery. Residents will learn to treat patients based on etiology, pathogenesis and clinical manifestations of various diseases, drawing from the clinical experience of the supervising surgical attending and evidence-based medicine.
3. Practice-based Learning and Improvement. Residents will give and receive feedback regarding processes of care and demonstrate willingness to learn from their own past experience. Residents will implement strategies based on this learning to continually improve the quality of patient care. Residents will develop presentation skills. They will have to present and discuss patients with senior surgical resident and surgical attending. Such a discussion includes presentation of history, physical findings, differential diagnosis, diagnostic testing and treatment plan. Residents will obtain experience with a wide range of surgical procedures, including thoracocentesis, thoracostomy, paracentesis, arthrocentesis, airway management, naso- and orogastric tube placement, central venous cannulation, arterial puncture for ABG analysis, incision and drainage of abscesses, and wound repair.
4. Interpersonal and Communication Skills: Residents will continue their professional development through interactions with patients and their families, surgical residents and attending physicians, nurses and other health care professionals. They will establish and maintain therapeutic and ethically sound professional relationship with patients, their families and other members of surgical team. Residents will use effective listening, nonverbal, questioning and narrative skills to communicate with patients and families. They will interact with consultants in a respectful, appropriate manner. Residents will maintain comprehensive, timely and legible medical records.
5. Professionalism: Resident will consistently demonstrate sensitivity, respect, compassion and altruism in relationships with patients, families and members of the surgical team. Residents will demonstrate sensitivity and responsiveness to the gender, culture, age, sexual preferences, socioeconomic status, beliefs, behaviors and disabilities of patients and colleagues. They will adhere to the highest ethical standards including principles of patient confidentiality, academic integrity and informed consent.
6. Systems-Based Practice: Residents will learn to analyze systems of care with the goal of perfecting individual patient care in an evidence-based, efficiency-conscious manner. They will learn to collaborate with other members of the health care system to assist patients in negotiating complex health care delivery systems. Residents will learn appropriate utilization of health care resources.

Learning Venues

Surgical rotation is scheduled as a 4 week rotation. Residents are directly supervised by senior surgical resident and/or surgical attending 7 days a week, 24 hours a day.

1. Case based teaching. Residents are expected to read and learn about pathophysiology, differential diagnosis and management of clinical problems they encounter on the surgical service. The supervising surgical attending should use every case as a teaching opportunity, utilizing his/her experience, textbooks, review articles and newest literature data. The supervising attending will encourage residents to read about the cases they present.
2. Bedside teaching. Residents will learn and improve their physical exam and procedures skills under the direct supervision and guidance of senior surgical resident and/or surgical attending.
3. Didactic conferences. Please see Department of Surgery Conference Schedule

Shift Hours

Please see surgical rotation schedule.

Feedback

The program supports the learning and use of feedback techniques as a way to contribute to professional development and improve professional relations among housestaff and other medical personnel. Resident will receive regular feedback from the academic liaison for the department of surgery, at least once midway through the rotation and once at the end of the rotation. During these one on one feedback sessions they will be encouraged to provide feedback to the academic liaison about their surgery rotation, including their assessment of learning values of the rotation, interaction with the other members of surgical team etc. The Department of Surgery encourages direct feedback between surgical attendings and residents.

This is seen as an important and necessary part of the professional development.

1. Attending to Resident feedback: Surgical attendings supervise every patient seen by residents on surgical service. They review every chart written by residents. Personal informal feedback is encouraged for every case.
2. Residents to attending feedback. The academic liaison for the department of surgery will solicit feedback from the residents on their experience in the department of surgery. The feedback is mostly focused on educational issues.

Method of Evaluation of Interns and Residents

1. Interns and residents are formally evaluated by every surgical attending physician once a month during monthly departmental staff meeting.
2. These evaluations are summarized in a written evaluation form signed by surgical academic liaison. The form reflects the quality of performance during surgical rotation with a focus on areas for improvement. It considers accomplishment in the following domains: patient care; medical knowledge; practice based learning; interpersonal and communication skills; professionalism; system based practice.
3. These forms are submitted TY Residency Director and placed in the residents’ folders.

Evaluation of Surgical Rotation

1. At the end of their rotation residents debrief in person with surgical academic liaison. The focus is on learning experience and individual faculty teaching skills.
2. At the end of their rotation residents fill out an evaluation form on every surgical attending with a focus on teaching and supervising qualities. These forms go to the TY Residency Director for further discussion with a focus on improvement of training.
3. Surgical academic liaison is a permanent member of Transitional Residency Educational Committee

Learning Resources

1. Department of Surgery Library at 10 Beacon Street
2. CHA library
3. On-line resources

The educational purpose of this rotation is to teach residents the principles of emergency management of patients who present with a wide variety of acute, subacute and chronic medical, psychiatric, surgical, orthopedic and obstetric and gynecological problems. Residents will diagnose, treat and care for men and women in the setting of the emergency department. They will evaluate and manage these patients under the direct supervision of an attending physician specialized in emergency medicine.

Through the rotation interns and residents will gain the knowledge of the epidemiology and pathophysiology of disease, as well as optimal approach to diagnosis, treatment and follow-up of these diseases. Interns and residents will continue to learn the key role of humanistic and professional values in caring for the sick and injured.

Interns and residents will develop interpersonal and communication skills which allow them to effectively collaborate with the other members of emergency medicine team and effectively provide emergency medical care. They will gather data from all relevant sources, including patient history, physical exam, laboratory data, imaging and other medical documents, consultants from other specialties. They will subject this data to the scientific method of problem solving using available sources of medical knowledge. Based on that, they will make informed patient care decisions under the direct supervision of an attending emergency medicine physician.

The care they provide will be driven by the values of humanism and professionalism. They will learn to function as an integral part of the health care delivery system and will access and utilize health care resources in an efficient and optimal manner.

Overall Goals of the Rotation

Cambridge Hospital ED portion

1. Gain comfort in managing multiple patients at once (goal of 1 patient per hour or 2-3 patients at one time)
2. Learn the principles of recognizing and stabilizing sick patients in the initial hours of their presentation
3. Become familiar with basic pediatric procedures
4. Develop an approach to common urgent/ emergent pediatric presentations

Outpatient portion (Cambridge Pediatrics/ Windsor Street Pediatrics/ Somerville Pediatrics)

1. Become familiar with management of basic pediatric problems in the outpatient setting

NBN portion

1. Review the basics of newborn care
2. Discuss/ observe delivery room management of the sick neonate

ED Nuts and Bolts

Schedule
You are expected to be in the ED during your scheduled shift time. If you need to step out to grab something to eat, let the attending know.

If you are sick or otherwise unable to make it, please contact your chief residents so they can arrange coverage. If there are other issues, please contact the academic liaison Andrey Moyko (anmoyko@challiance.org).

Getting set up
On your first day in the ED, the attending on shift will find 5-10 minutes to walk you through the department, show you where to sit, and introduce you to other staff. We are a large group, so you will likely be working with different people every day. When you come on shift, introduce yourself to the attendings and the physician assistants and let them know if you have any particular interest (e.g. doing more lacerations).

Patient Load and Resident Responsibilities
One of the key skills in emergency medicine is learning to juggle multiple patients at the same time. We expect you to try to see roughly a patient an hour. Obviously this is a ballpark estimate, and will vary depending on the complexity of the cases and how busy the department is.

You are welcome to see pediatric patients anywhere in the department. Be aware that during some shifts, there will be a pediatric resident from MGH, who is also interested in seeing pediatric patients. Please try to coordinate with them so that you both are getting to see an adequate number of pediatric patients. PA’s will also see pediatric patients and can be a great teaching resource. However, any patient you see needs to be staffed by one of the attendings as PAs cannot officially supervise you.

At times, there will be only a few or sometimes no pediatric patients in the department. During these times, you should try to see adult patients, especially those who require a procedure that you would like to get more practice doing. Examples include laceration repairs or I&Ds, or pelvic exams. It is definitely easier to learn to do these well on an adult before you attempt them on a screaming, squirming child! If there are no appropriate patients to see, use the time to read or catch up on notes.

You will also have the opportunity at times to work with medical students who are doing a rotation in the ED. This is a great chance to develop your skills as a teacher.

Please keep track of the patients you see on the provided patient log. This should be handed to the attending on at the end of your shift with the goal of giving you the opportunity to reflect on the cases seen, ask questions about anything you saw and get real time feedback on your performance.

Patient Presentation
You will be presenting to any of the ED attendings who are working during your shift. If a patient is sick or you have any concerns, please get the attending right away.

Otherwise, try to come up with a plan before you present the patient. ED doctors are notorious for having short attention spans. Therefore a good strategy is to present the patient leading with your assessment (to get us hooked) and then building your case from there.

You should write a full note on all patients that you see in the department. Be sure to assign your notes to the attending to cosign.

Procedures
Part of the fun of the ED is getting to do procedures. Try to get involved in or perform as many as you can. Even if it is a procedure you will never do in your ultimate profession, gaining comfort with cutting and sewing and manipulating is often useful. All procedures need to be supervised by an attending.

Venipuncture is an undervalued skill. If you haven’t yet mastered this, let us know and the nurses will be happy to have you place IVs on patients. When you’re on call on the floors at 2 am with a crumping patient who just lost access, you will be grateful for this skill!

Other procedures that may be useful to learn:

• Laceration repair
• Procedural sedation
• Splinting and reduction
• I and D of abscess
• Bedside ultrasound
• Lumbar puncture

Every Month (usually first Friday) there is a PA procedure lab that you are encouraged to attend. Please email me if you are interested.

Learning
Most of your learning will be from the cases you see. A good approach is to try to read something on each patient, even if it is just an Up To Date article or a page out of one of the EM textbooks in the department.

Don’t be shy about asking attendings to explain their rationale. We all have developed different approaches to sorting through the muck and it can be quite oblique unless you ask for a bit of explanation.

Outpatient Nuts and Bolts

Please plan on being in clinic from 8:30-5 on the days you are scheduled. Ideally you will get to see outpatient presentations of some common (or not so common!) pediatric illnesses. When you arrive in clinic, ask a staff member at the front desk to introduce you to the attending you will be working with (you will be emailed this information in advance). Your attending will have you see patients and present to them. Ideally, you will have already had your outpatient Epic computer training and will be able to document your findings in the medical record as well. If you have any particular interests or personal goals for these sessions, please let your attending know! With any questions or concerns please email Dr. Bianca Shagrin at bshagrin@challiance.org. If you do not have a car to get to the clinics, you should use a taxi voucher with the company we are contracted with. Call and give the taxi company the account number on the slip (67-900) and take an extra voucher for returning to Cambridge later. You must call the taxi company to send a car over to Somerville to pick you up.

Nursery Nuts and Bolts

Please arrive in the nursery on the 5th floor at Cambridge Hospital at 9 AM on the days of your scheduled newborn nursery shifts. You will most likely need to be buzzed into the nursery by the staff. Ask the unit administrative assistant or one of the nurses to introduce you to the neonatal hospitalist working that day (this information can also be found in Staffnet under ‘On-call --> Delivery Room’). You will round on newborns with the attending and get some one-on-one teaching. In the afternoon, you will have some time to catch up on reading while you wait for deliveries or procedures (circumcisions) taking place. Please give the newborn hospitalist and/ or nursery nurses your pager information so that you can be called to these events. Your day will end between 4 and 5. Again, please email Dr. Bianca Shagrin at bshagrin@challiance.org with questions or concerns.

Goals

The educational goal of this rotation is to teach Transitional Residents the principles for the evaluation and management of outpatients. Residents will acquire the knowledge and skills needed to care for patients in the ambulatory care setting. This will be accomplished through their exposure to acute, sub-acute and chronic medical problems and a broad range of ambulatory care settings including urgent care, ENT, GI, rheumatology, endocrine, ophthalmology, urology and other clinics.

Objectives

The objectives outlined below reflect the Department of Medicine’s intent to satisfy the general competencies as recently defined by the ACGME.

I. Patient Care

By the end of the ambulatory block rotation residents will be able to:

• provide patient care that is compassionate, appropriate, and effective for the treatment of common outpatient medical problems and the practice of preventive medicine as it relates to adults in the ambulatory care setting
• communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families in the outpatient setting
• obtain a complete and accurate medical history
• perform a complete physical examination
• formulate an impression (including a differential diagnosis) and plan for the management of common outpatient medical problems
• make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment
• counsel and educate patients and their families
• incorporate the psychosocial aspects of patient care
• use information technology to support patient care decisions and patient education
• work with health care professionals, including those from other disciplines (e.g. specialists, social work, physical therapy), to provide patient-focused care

These objectives will be accomplished by direct patient encounters and by working closely with the designated preceptor at each ambulatory care site. Through direct supervision, frequent feedback and a longitudinal working relationship throughout the block residents will be able to improve their skills in these areas.

II. Medical Knowledge

By the end of the ambulatory block rotation interns will be able to:

• expand their knowledge base of common outpatient medical problems and apply this to patient care
• demonstrate an investigatory and analytic thinking approach to clinical situations

These objectives will be accomplished by attending regularly scheduled educational conferences, self-study, through direct patient encounters and by working closely with the designated preceptor at each ambulatory care site. In addition to the usual resident conferences, during the ambulatory block rotation there will be one morning a week designated for ambulatory care conference (see schedule) and daily ambulatory morning report (starting in Block 2).

III. Practice-Based Learning and Improvement

By the end of the ambulatory block rotation residents will be able to:

• investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices
• analyze practice experience and perform practice-based improvement activities using a systematic methodology
• locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems
• obtain and use information about their own population of patients and the larger population from which their patients are drawn
• apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness
• use information technology to manage information, access on-line medical information; and support their own education
• facilitate the learning of students and other health care professionals

These objectives will be accomplished by working on a quality improvement project, through direct patient care, self-reflection, working closely with the preceptor at each ambulatory site, and a process of self-inquiry and investigation. Residents are encouraged to utilize the many resources available to them (see list of resources). There will be designated time in the schedule each week for self-study.

IV. Interpersonal and Communications Skills

By the end of the ambulatory block rotation residents will be able to:

• demonstrate interpersonal and communication skills that result in effective information exchange with patients, their patients' families, and professional associates (for example resident colleagues, specialists, consultants, nursing, social work, and physical therapy)
• create and sustain a therapeutic and ethically sound relationship with patients
• use effective listening skills
• elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills as demonstrated in the documentation of patient encounters and request for consultative services
• work effectively with others (for example nursing, medical assistants, administrative office staff) as a member or leader of a health care team or other professional group

These objectives will be accomplished by direct patient encounters and by working closely with the designated preceptor at each ambulatory care site. Through direct supervision, frequent feedback and a longitudinal working relationship throughout the block interns will be able to improve their skills in these areas.

V. Professionalism

By the end of the ambulatory block rotation residents will be able to:

• demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
• demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development
• demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices
• demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities

These objectives will be accomplished by direct patient encounters and by working closely with the designated preceptor at each ambulatory care site. Through direct supervision, frequent feedback and a longitudinal working relationship throughout the block interns will be able to improve their skills in these areas.

VI. System-Based Practice

By the end of the ambulatory block rotation residents will be able to:

• demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value
• understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice
• know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources
• practice cost-effective health care and resource allocation that does not compromise quality of care
• advocate for quality patient care and assist patients in dealing with system complexities
• know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance

These objectives will be accomplished through direct patient encounters and dialogue with the designated preceptor at each ambulatory care site. By exposure to different hospital resources, discussion of various health care insurers, and familiarity with Massachusetts-based resources for Free-Care, interns will gain a better understanding and appreciation for health care costs, the cost-effective practice of medicine, the impact of cost on the individual patient and on society in general.

Resident Feedback & Evaluation

Residents will be given feedback on their performance by their preceptors on an ongoing basis as they work together throughout the block rotation. A designated primary care center urgent care preceptor* will be responsible for gathering information from all other preceptors and giving formal feedback to the resident at midpoint and giving a summative performance evaluation at the end of the rotation. It is expected that this evaluation will be reviewed with the resident in person (see attached evaluation form).

*Please see AMB schedule to find which of these East Cambridge Health Center (ECHC) preceptors/evaluators are assigned to you:

Dr. Aparna Batlapenumarthy
Dr. Cassie Frank
Dr. Carolyn Koulouris
Dr. Robert Marlin
Dr. Leah Zallman

Program Evaluation

Residents will be expected to complete an anonymous on-line program evaluation form at the end of their ambulatory block rotation. See New Innovations at https://www.new-innov.com/login/

Recommended Educational Resources

There are many resources available to you in the hospital library and on-line that will be helpful to you in achieving your educational goals for the ambulatory block rotation. The following is a list of some of these resources. The on-line resources can be accessed by linking to CHA’s Staffnet. If you have any questions, please contact our hospital librarian Trish Reid at Cambridge Hospital (617-665-1439).

Books:

• Principles of Ambulatory Medicine (Barker)
• Ambulatory Medicine: the primary care of families (Mengel)
• Primary Care Medicine: Office Evaluation and Management of the Adult Patient (Goroll)

On-line Resources: Digital Library; OVID; MEDLINE 

Most interns and residents say they actually like working in the hospital overnight. Night rotations are a chance for residents to test their own wings and make independent clinical decisions. One intern and resident pair work together on the wards to look after the patients on the two day teams; another intern and resident pair work together in the ICU. The administrative hustle and bustle of the day quiets down and residents focus on managing emergent medical problems and admitting new patients. There is an in-house hospitalist attending available to supervision all night and the ICU attending is only a phone call away.

At morning report, the night team presents new patients to the day team including the hospitalist attending. Every morning, the night team chooses a focus case for more in-depth analysis and group problem solving. The group identifies clinical questions from the case; one person assumes responsibility for reviewing the literature and bringing the evidence back to the group the following day. The format ensures safe and complete transfers of care from the night to the day team and engages a group of clinicians and learners to think together and to make evidence-based medicine practical.

Description of Elective Clinical Rotations

Residents avail themselves of a myriad of opportunities at Cambridge Health Alliance, in the Greater Boston area, and in national and international settings during their elective time. Residents may chose to rotate to the tertiary care Harvard hospitals for inpatient or outpatient subspecialty experiences in areas such as infectious diseases, endocrinology, hematology-oncology, nephrology, cardiology, gastroenterology, and pulmonary medicine. Residents also use elective time to work on their scholarly projects, learning languages that could help them in their medical practice, going to develop countires to work in rural clinics, or preparing for the boards.

Specially designed elective experiences within CHA include:

Medical Subspecialty Consultation Elective: Residents may opt for 2 to 4 week immersion experiences in a number of medical specialties.

Hospital Medicine Elective: Residents work apprentice-style with a hospital preceptor, evaluating and managing inpatients, performing procedures, completing a hospital quality improvement project.

Occupational and Environmental Health Elective: Basic principles of recognizing and preventing occupational health diseases are integrated into a series of didactics and clinical experiences. Residents participate in work site evaluations and projects in this elective.

Resident-Designed Electives: Resident may select a faculty mentor and participate in design of an elective to meet their educational/research needs. Recent examples include medical education, international health, behavioral medicine, acupuncture, and adolescent medicine.

Psychiatry Elective: Residents have a chance to work side by side with psychiatrists in various settings: from in-patient psychiatric unit, to psychiatric emergency services, to consultation liaisons. This is a rotation that could be crafted individually to meet the needs of participants.

• Ambulatory Morning Report
• Tuesday School Program
• Wednesday EBM Boot-Camp
• Wednesday EBM Boot-Camp
• Thursday School
• Thursday Noon Conference

A weekly lunch conference sponsored by the training program. There is different conference every week of the month:

• House Officer's Meeting
• Food For the Soul
• House Officer's Union (CIR) Meeting
• IM Thursday Journal Club
• Friday Social Medicine Rounds