Family Medicine Service (FMS)

Rotation Title: Inpatient Medicine: Family Medicine Service and Team Health

Faculty Chair: John Andazola, MD

Additional Contacts:

Victoria Grasso, DO
Davena Norris, PharmD

ACGME Program Requirements (see IV.C.)

Residents must have at least 600 hours (or six months) and 750 patient encounters dedicated to the care of hospitalized adult patients with a broad range of ages and medical conditions.^(Core)

Residents must have at least 100 hours (or one month) or 15 encounters dedicated to the care of ICU patients.^(Detail)
Residents must provide care to hospitalized adults during all years of the program.^(Detail)

Goal:

By the end of the Family Medicine Service (FMS) and Team Health (TH) rotations residents will develop the knowledge and skills to appropriately evaluate and treat hospitalized adult patients. This will include the evaluation and treatment of the patients’ biomedical, behavioral, and social needs.

General Information:

FMS and TH are longitudinal experiences that take place during all three years of residency training. The level of resident independence and responsibility will gradually increase throughout their training. In general, residents will have the following number of rotations each year. This includes FMS (days/nights/float) and TH rotations.

PGY1 residents: 4-5 months
PGY2 residents: 3 months
PGY3 residents: 2 months

Admissions come from:

Family Medicine Center (FMC)

Established patients of the FMC are admitted to the FMS service either via the emergency department or direct admission. For direct admission from the clinic, the resident and attending in the clinic shall communicate with the FMS team. The FMS team is responsible for completing the H&P and writing orders unless other arrangements have been made. The resident who is the primary care physician of the patient shall aid in the management of his/her patient in the hospital. However, the primary management of the patient will be the responsibility of the residents assigned to the FMS service.

Community Physicians/Practices
1. FMS: La Clinica de Familia on Mondays, Tuesdays, Thursdays, and Fridays, Amador Health Center, Dr. Rene Guerrero, Dr. William Baker, and Dr. Arthur Berkson. The FMS team also covers for Dr. Francis Attiogbe upon request.
2. Team Health: An updated list of all providers covered by TH is located in their office. Patients of La Clinica de Familia are covered by TH on Wednesdays, Saturdays, and Sundays.
ER patients with no doctor (city call)

Patients who present to the ER who do not have a primary provider may be admitted to the FMS and/or TH services.

Expectations for Residents and Faculty (if beyond those outlined in resident manual):

The FMS team usually consists of two PGY1, one PGY1 float, and one senior (PGY2 or 3) resident. An additional PGY1 resident and senior resident (PGY2 or 3) rotate on the night float. Team Health usually has two PGY1 residents and one senior (PGY2 or 3) resident. If a resident calls out for either service, Jeopardy will be used to cover that resident.

Patient Numbers

To ensure adequate resident education, the minimum number of patients that each resident should care for on service is 5 patients per resident. Too many patients can also have a negative impact on resident education, thus an upper limit of 10 patients per resident will be placed on the service. Once the service numbers rise above or fall below the limits stated above the senior resident on service and the attending will take action to assure an appropriate number of patients. There may be deviations from these numbers based on patient acuity, and these adjustments must be agreed upon by the senior and attending on the service.

The PGY1 Resident

PGY1 residents have primary responsibility for the care of their patients. They must know the appropriate history, conditions, treatments, labs, medications, allergies, etc. of each of their patients. The PGY1 is required to:

Coordinate the patient’s care with consultants, nurses, physical, occupational, and speech therapists, case management, PCP, and others involved on the care team.
Answer phone calls regarding assigned FMS and Team Health patients.
Communicate with the senior resident when there is a new admission or question.
Discuss all admissions with the senior resident. See each admission first unless the patient is seriously ill.
Discuss with the senior resident what his/her needs and expectations are.
Contact the attending to discuss the treatment plan of any complicated patient or to inform the attending of any significant changes in a patient’s status.
Communicate with the patients’ nurses and other team members involved in the care.
Have seen and be prepared to present all assigned patients by 9:00am.
Place daily notes on the chart by the start of morning rounds. Notes must be signed by 1:00pm at the latest.
The PGY1 resident who completes a discharge shall complete the Discharge Summary on the day of discharge.
Complete an Interim Summary for patients hospitalized for 3 or more days when resident is transitioning off FMS or TH on the last day resident is on service.
Conduct one afternoon of continuity clinic per week.

The Senior Resident

The senior resident is the team leader and supervisor who is responsible for leading the team rounds. The senior resident will:

Attend to and coordinate all ward team functions.
See and discuss the patient care of EVERY admission with the interns for at least the first 6 months, as well as every ICU admission throughout the year. This maximizes intern supervision and patient safety.
Write an abbreviated Senior Resident Admit Note on each admission. S/he does not write daily progress notes on a regular basis, except during weekend coverage or when PGY1 residents are overwhelmed and the quality of patient care is affected.
Ensure that there are adequate numbers of admissions on the service (PGY1 residents should be managing a minimum of 5 and a maximum of 10 patients each).
Assume the role of junior attending for management decisions. When decision points arise in their management, the senior resident is actively encouraged to make clinical decisions about the patient’s care that may be posed by the intern involved in the case. These decisions should be reviewed with the attending in a timely manner depending on the complexity of the patient’s illness.
The senior resident will pick up any patients that exceed the daily number cap of the PGY1 residents and round and write notes on these patients daily.
Attend code blues, rapid responses, and sepsis alerts throughout the hospital except within the emergency department.
Participate in daily interdisciplinary discharge planning rounds.
Conduct one afternoon of continuity clinic per week.

The Family Medicine and Team Health Attending

A family medicine attending physician is assigned to FMS on a one-week rotation. For Team Health, the attending schedule will vary; residents will rotate with 2-3 attendings during the one-month block. His/her role is that of a teacher and an attending with direct patient care responsibility. He/she will go over all admissions with the senior resident and PGY1 resident performing the admission. The attending is expected to be present at daily work rounds, round daily on all the patients, and discuss management issues with the primary PGY1 resident involved. S/he should also be available to act as a liaison for conflict resolution between the ward team, other hospital personnel and medical staff.

The PharmD

The PharmD faculty member will provide medication consultations and collaborate with the FM attending and residents to ensure appropriate, effective, and safe use of medication therapy. Her/his primary role is that of a consultant/teacher. She/he is expected to round daily within the limits imposed by teaching, pharmacy, and hospital responsibilities. Consultations and education are provided regarding drug selection, drug dosing and administration, poly-pharmacy, drug interactions, and adverse drug reactions. If a pharmacy resident or student is doing a clinical rotation on FMS, he/she is expected to round daily with the team and assist with the aforementioned tasks under the supervision of the PharmD faculty.

The Psychologist

The Psychologist is a faculty member who will provide behavioral health consultations and collaborate with the FM attending and residents in providing direct patient behavioral health care. Her/his primary role is that of a consultant/teacher. She/he shall round with the FMS team when available and discuss the management of behavioral health issues impacting the patient’s care. When an FMS patient is referred to the psychologist for a consultation, the resident responsible for that patient’s care is expected to participate with the psychologist in the assessment and recommendation formulation.

Deliverables (if applicable): Anything a resident needs to produce during the rotation (journal entries, letter to editor, etc.)

Each resident and faculty will summarize within a minute 1 key point they learned in the past 24 hours related to their patients during morning brief.
Residents shall participate in weekly 5-minute teaching topics prior to rounds. At least one resident shall lead a teaching topic each week. The topic should be relevant to a current/recent patient case and should conclude with three take-away points.

Competency-Based Education

ACGME Program Requirements (see IV.B.)

Assessments

Objectives (Competencies)	Educational Strategies/Activities All of the following educational strategies will include some component of direction instruction, faculty role modeling, and bedside teaching.	Assessments
By the end of the FMS/TH-1 rotation PGY1 residents will be able to gather and interpret information relevant to disease processes for all patients. (PC, IPC)	Perform inpatient admissions and round on assigned patients daily.	Faculty observation, verbal feedback, and global assessment form.
By the end of subsequent FMS/TH rotations, PGY1 residents will be able to formulate treatment and monitoring plans for common inpatient conditions. (PC, MK)	Perform inpatient admissions and round on assigned patients daily. Locate and utilize medical and drug information resources.	Faculty observation, verbal feedback, and global assessment form.
By the end of the FMS/TH rotation, PGY2/3 residents will be able to consistently critique and modify treatment plans of junior residents. (PC, IPC, PBLI)	Supervise junior residents during admissions and daily rounds. See and evaluate patients who are new admissions, critically ill, have a change in status, and others as appropriate.	Faculty observation, verbal feedback, and global assessment form.
By the end of the PGY1 year, residents will be able to describe the indications for and perform common procedures with guidance from preceptor (PC). By the end of the FMS/TH rotation, PGY2/3 residents will be able to perform common procedures with minimal guidance and correction from preceptor. (PC)	Perform common procedures under direct faculty supervision (e.g. paracentesis, thoracentesis, I&D of abscesses, central venous catheters, etc.).	Faculty observation, verbal feedback, procedure competency checklist, and global assessment form.
By the end of the FMS/TH-1 rotation, PGY1 residents will be able to identify personal strengths and areas for improvement. (PBLI) By the end of the FMS/TH rotation, PGY2/3 residents will be able to set personal improvement goals and action steps. (PBLI)	Participate in weekly goal setting and debriefs with faculty on FMS. Each resident and faculty will summarize within a minute 1 key point they learned in the past 24 hours related to their patients during morning brief. Residents shall participate in weekly 5-minute teaching topics prior to rounds.	Faculty observation, verbal feedback, and global assessment form.
By the end of PGY1 year, residents will consistently be able to deliver organized and effective patient case presentations to the interprofessional team (ICS, SBP).	Present patients utilizing the scut sheet to the attending, senior resident, pharmacist, and other members of the FMS team.	Faculty observation, verbal feedback, and global assessment form.
By the end of the PGY1 year, residents will be able to effectively communicate care plans with patients, family members, and caregivers using appropriate language and demonstrating compassion and respect. (ICS, PROF).	PGY1 residents shall lead the team in communicating the care plan with the patient. S/he shall confirm understanding of information provided using teach-back methods. At the end the resident shall ask other team members if they have anything else to contribute.	Faculty observation, verbal feedback, and global assessment form.
By the end of the FMS/TH rotation, PGY2/3 residents will be able to effectively communicate and coordinate care within interprofessional team, including proactively addressing discharge needs with case management and other team members, (ICS, SBP)	Guide PGY1 residents in developing discharge plans. Participate in interdisciplinary discharge planning (IDT) rounds.	Faculty observation, verbal feedback, and global assessment form.
By the end of the PGY1 year, residents will be able to recognize how specific language may result in bias and patient harm. (SBP, IPC, SC)	Identify and discuss with team when specific language (e.g. “frequent flyer”, “drug abuser”, etc.) is utilized in oral presentations and chart documentation.	Faculty observation, verbal feedback, and global assessment form.
By the end of FMS/TH rotation, PGY2/3 residents will be able to identify and begin to address the social determinants of health that may have contributed to a patient’s admission to the hospital. (SBP, SC)	Collect thorough social histories including home/work environments, social support systems, socioeconomic barriers to health, etc. Refer to appropriate resources and team members and arrange for outpatient follow-up.	Faculty observation, verbal feedback, and global assessment form.

Resources: Links to any websites, articles, or other resources the resident will need for the rotation

Up-To-Date, LexiDrug (MMC Intranet)
Clinical Pharmacology (MMC Intranet)
American Academy of Family Physicians Journals: https://www.aafp.org/journals.html
Infectious Diseases Society of America: https://www.idsociety.org/
Standards of Medical Care in Diabetes: https://care.diabetesjournals.org/
American Heart Association: https://professional.heart.org/en/guidelines-and-statements
JNC 8 Hypertension Guidelines: https://jamanetwork.com/journals/jama/fullarticle/1791497
COVID Treatment Guidelines: https://www.covid19treatmentguidelines.nih.gov/
CHEST Guidelines: https://www.chestnet.org/Guidelines-and-Topic-Collections
GOLD Guidelines: https://goldcopd.org/
US Preventive Services Task Force (USPSTF) Guidelines: https://www.uspreventiveservicestaskforce.org/uspstf/
Calculators: https://www.mdcalc.com/, https://clincalc.com/
Opioid Dose Conversion: https://opioidcalculator.practicalpainmanagement.com/conversion.php