The Medical Service at San Francisco General Hospital consists of eight medical ward teams and one critical care team providing comprehensive inpatient care to acutely ill medicine patients. Of the eight medical ward teams, four teams will admit medical ward patients as well as medical ICU patients, cooperating with the critical care team; four teams will admit medical ward patients as well as cardiac ICU and cardiac ward patients, cooperating with the critical care team.

A Medicine Nightfloat Intern assists in providing care for patients on the Medicine Service.

A Medicine Consult team (attending and resident) provides consultative care to patients admitted to surgical or other non-medical services within the hospital.

Medicine residents and interns also care for patients in the Emergency Department at San Francisco General Hospital.

I. EDUCATIONAL GOALS

A. Critical Care Resident (Third-year house officer (R3), or Second-year house officer (R2) with prior ICU experience)

At the completion of this rotation, the Critical Care Resident should be able to:

1. Function as an effective team manager, leader, and teacher.
2. Discuss the differential diagnosis and direct the evaluation of diverse inpatient medical problems.
3. Demonstrate baseline competency and improvement in physical diagnosis and medical interviewing skills.
4. Demonstrate baseline competency and improvement in knowledge and clinical skills in critical care medicine, specifically in the management of respiratory failure, circulatory collapse, and multi-organ-system disease. Residents are also expected to achieve an understanding of ventilator management and invasive hemodynamic monitoring, as well as competency in electrocardiogram interpretation.
5. Function as an effective consultant to R1, R2 and non-medicine colleagues.
6. Work effectively as a member of a health care team to ensure proper care and welfare of patients.
7. On completion of the Critical Care Rotation and the remaining rotations of the R3 year, housestaff will be able to provide a reasoned and concise assessment and plan for common clinical scenarios, as outlined in the Clinical Competencies section of Graduate Education in Clinical Medicine: a resource guide to curriculum development (Federated Council for Internal Medicine Task Force on the Internal Medicine Residency Curriculum. 1997. American College of Physicians, Philadelphia, PA).

B. General Medicine Ward Resident (R2 or R3)

At the completion of this rotation, the Medical Ward Resident should be able to:

1. Function as an effective team manager, leader, and teacher.
2. Discuss the differential diagnosis and direct the evaluation of diverse inpatient medical problems. Specifically, residents will learn to care for patients with diabetes mellitus, HIV/AIDS, respiratory diseases (including COPD, asthma, and pneumonia), renal failure, liver disease, complications of alcohol and other substance abuse, cancer, and other medical problems. Medicine residents will also follow patients admitted to the Medical ICU and will become familiar with caring for patients with respiratory failure, circulatory collapse, and multi-organ system disease.
3. Demonstrate baseline competency and improvement in physical diagnosis and medical interviewing skills.
4. Demonstrate baseline competency and improvement in managing the wide range of medical conditions seen in the inpatient setting utilizing an evidence-based and humanistic approach.
5. Demonstrate baseline competency and improvement in knowledge and clinical skills in critical care medicine.
6. Work effectively as a member of a health care team to ensure proper care and welfare of patients.

C. General Medicine Ward Intern (R1)

At the completion of this rotation, the R1 should be able to:

1. Formulate a differential diagnosis and outline a plan for evaluating and managing diverse inpatient medical problems.
2. Demonstrate organizational skills necessary for the care of medicine inpatients.
3. Efficiently and effectively chart in the medical record.
4. Anticipate and formulate comprehensive discharge plans.
5. Demonstrate leadership and teaching skills through interactions with members of the medical team.
6. Utilize consult services and diagnostic studies appropriately.
7. R1's should gain competence in performing venipuncture, arterial puncture, lumbar puncture, paracentesis, joint aspiration, thoracentesis, placement of nasogastric tubes, and placement of Foley catheters by the completion of the R1 year. They should also be capable of explaining the indications, contraindications, and risks of these procedures.

D. General Medicine/Cardiology Ward Resident (R2 or R3)

At the completion of this rotation, the General Medicine/Cardiology Resident should be able to:

1. Function as an effective team manager, leader, and teacher.
2. Discuss the differential diagnosis and direct the evaluation of diverse inpatient medical problems. Specifically, residents will learn to care for patients with diabetes mellitus, HIV/AIDS, respiratory diseases (including COPD, asthma, and pneumonia), renal failure, liver disease, complications of alcohol and other substance abuse, cancer and other medical problems.
3. Discuss the differential diagnosis and direct the evaluation of diverse inpatient cardiac problems. Specifically, residents will learn to care for patients with acute myocardial infarction, unstable angina, congestive heart failure, arrhythmias, pericardial disease and other cardiovascular problems. Residents will admit patients with severe cardiac illness into the intensive care unit are expected to achieve an understanding of ventilator management and invasive hemodynamic monitoring, as well as competency in electrocardiogram interpretation.
4. Demonstrate baseline competency and improvement in physical diagnosis and medical interviewing skills.
5. Demonstrate baseline competency and improvement in managing the wide range of medical conditions seen in the inpatient setting utilizing an evidence-based and humanistic approach.
6. Demonstrate baseline competency and improvement in knowledge and clinical skills in critical care medicine.
7. Work effectively as a member of a health care team to ensure proper care and welfare of patients.

E. General Medicine/Cardiology Ward Intern (R1)

At the completion of this rotation, the R1 should be able to:

1. Formulate a differential diagnosis and outline a plan for evaluating and managing diverse inpatient medical and cardiac problems.
2. Demonstrate organizational skills necessary for the care of medicine and cardiac inpatients.
3. Efficiently and effectively chart in the medical record.
4. Anticipate and formulate comprehensive discharge plans.
5. Demonstrate leadership and teaching skills through interactions with members of the medical team.
6. Utilize consult services and diagnostic studies appropriately.
7. R1's should gain competence in performing venipuncture, arterial puncture, lumbar puncture, paracentesis, joint aspiration, thoracentesis, placement of nasogastric tubes, and placement of Foley catheters by the completion of the R1 year. They should also be capable of explaining the indications, contraindications, and risks of these procedures.

F. Medicine Nightfloat Intern (R1)

At the completion of this rotation, the R1 should be able to:

1. Formulate a differential diagnosis and outline a plan for evaluating and managing diverse inpatient medical and cardiac problems.
2. Demonstrate organizational skills necessary for the care of medicine and cardiac inpatients.
3. Efficiently and effectively chart in the medical record.
4. Evaluate patients for acute changes in their medical status, triage patients appropriately, and call for assistance when it is needed.
5. Utilize consult services and diagnostic studies appropriately.
6. R1's should gain competence in performing venipuncture, arterial puncture, lumbar puncture, paracentesis, joint aspiration, thoracentesis, placement of nasogastric tubes, and placement of Foley catheters by the completion of the R1 year. They should also be capable of explaining the indications, contraindications, and risks of these procedures.

G. Medicine Consult Resident (R2 or R3)

At the completion of this rotation, the Medicine Consult Resident should be able to:

1. Formulate a differential diagnosis and outline a plan for evaluating and managing diverse medical problems occurring on non-medical services.
2. Evaluate patients preoperatively and provide an assessment of their surgical risk.
3. Demonstrate knowledge of perioperative management of chronic medical conditions including coronary artery disease, pulmonary disease (COPD and asthma), diabetes mellitus, hypertension, and other medical conditions.
4. Demonstrate knowledge of post-operative medical complications and their management.
5. Function as an effective consultant to non-medical services.

H. Emergency Department Resident (R2 or R3)

At the completion of this rotation, the Emergency Department Resident should be able to:

1. Function as an effective leader and teacher of interns and students rotating through the emergency department and as an effective manager of the "patient flow" through the ED.
2. Discuss the differential diagnosis and direct the evaluation and triage of diverse urgent care and emergency medical problems. Residents will learn to accurately and quickly identify problems that are emergencies and to prioritize those diagnostic and life supporting measures that are most urgent. Specifically, residents will learn the initial management for patients with diabetic ketoacidosis and hyperosmolar state, complications of HIV/AIDS, respiratory diseases (including COPD exacerbation, asthma, and pneumonia), altered mental status, sepsis, acute electrolyte disturbances, congestive heart failure, angina, acute myocardial infarction, cardiac tamponade, ingestions, gastrointestinal bleeding, complications of alcohol and other substance abuse, psychiatric emergencies, oncologic emergencies and other medical problems. Residents will improve emergency technical skills such as central line placement.
3. Demonstrate baseline competency and improvement in physical diagnosis and medical interviewing skills, including performing a focused history and physical examination for an emergency patient with undifferentiated medical illness.
4. Demonstrate baseline competency and improvement in managing the wide range of medical conditions seen in the Emergency Department setting utilizing an evidence-based and humanistic approach.
5. Demonstrate baseline competency and improvement in knowledge and clinical skills Emergency Medicine and Urgent Care.
6. Work effectively as a member of a health care team to ensure proper care and welfare of patients.
7. Demonstrate an ability to effectively and efficiently use consultants.
8. Learn to organize the care of multiple patients simultaneously.
9. Demonstrate appropriate use of body fluid substance precautions.
10. Learn to admit patients to the hospital appropriately and promptly.
11. Learn to organize and direct and medical resuscitation.

I. Emergency Department Intern (R1)

At the completion of this rotation, the Emergency Department Intern should be able to:

1. Formulate a differential diagnosis and outline a plan for evaluating and managing diverse urgent care and emergency medical and surgical problems. Specifically, interns will learn the initial management for patients with trauma, acute abdomen, diabetic ketoacidosis and hyperosmolar state, complications of HIV/AIDS, respiratory diseases (including COPD exacerbation, asthma, and pneumonia), altered mental status, sepsis, acute electrolyte disturbances, congestive heart failure, angina, acute myocardial infarction, cardiac tamponade, ingestions, gastrointestinal bleeding, complications of alcohol and other substance abuse, psychiatric emergencies, oncologic emergencies and other medical and surgical problems. Interns will improve emergency technical skills such as suturing, splinting, wound care, peripheral IV placement, central line placement, etc.
2. Demonstrate organizational skills necessary for the initial evaluation and management of patients in the Emergency Department and Urgent Care Area. Specifically, interns will begin to manage the care of multiple patients simultaneously.
3. Efficiently and effectively chart in the medical record.
4. Anticipate and formulate comprehensive discharge and admission plans.
5. Demonstrate professionalism in interactions with the Emergency Department staff and with consulting and admitting physicians.
6. Utilize consult services and diagnostic studies appropriately.
7. R1's should gain competence in performing venipuncture, arterial puncture, lumbar puncture, paracentesis, joint aspiration, thoracentesis, placement of nasogastric tubes, and placement of Foley catheters by the completion of the R1 year. They should also be capable of explaining the indications, contraindications, and risks of these procedures.
8. Begin to accurately and quickly identify problems as emergencies.
9. Learn to perform a focused history and physical examination for an emergency patient with undifferentiated medical illness.
10. Demonstrate appropriate use of body fluid substance precautions.

II. TEAM STRUCTURE AND RESPONSIBILITIES

A. Team Structure:

The Critical Care team consists of four residents and one attending.

The four General Medicine teams consist of one attending, one resident, two interns, and, at times, a sub-intern (MS4), one to two third year medical students (MS3), and/or one podiatry student. A social worker is assigned to each team to aid in identifying and meeting discharge needs.

The four General Medicine/Cardiology teams consist of one medicine attending, one cardiology attending, one resident, two interns, and, at times, a sub-intern (MS4), one to two third year medical students (MS3), and/or one podiatry student. A social worker is assigned to each team to aid in identifying and meeting discharge needs.

A. Nightfloat Intern assists the eight medical teams with patient care at night.

The Medicine Consult team consists of one attending and one resident.

Medicine Residents and Interns rotating in the Emergency Department are a part of a multi-disciplinary team made up of attending and training physicians from both medical and other departments at UCSF, as well as numerous residents and interns from training programs outside of UCSF. The housestaff schedule is determined by the Department of Emergency Medicine at SFGH and varies according to the time of day and the time of year. There is always at least one Emergency Department attending physician present for supervision of patient care.

B. Critical Care Attending Physician:

1. Holds appropriate clinical privileges at SFGH with an academic appointment at the University of California, San Francisco (UCSF) School of Medicine.
2. Supervises and assumes ultimate responsibility for the care of inpatients admitted to the medical ICU, including appropriate continuing care, discharge planning or planning for transfer from the ICU, and medical follow-up. To achieve this, the attending should conduct daily management rounds that include the following:
a) Interaction at regular intervals with ICU patients each day.
b) Effective and frequent communication with the resident staff regarding management.
3. Conducts daily teaching rounds:
a) Rounds must consist of both patient-based and didactic teaching. Points for discussion include interpretation of clinical data, pathophysiology, differential diagnosis, specific management of the patient, appropriate use of technology and disease prevention.
b) The attending should work with the resident physicians to establish and achieve didactic goals for teaching rounds.
c) Teaching rounds must include direct resident and attending interaction with the patient. The teaching sessions must include demonstrations and evaluation of each resident's interview and physical examination skills, i.e. teaching rounds must include bedside teaching.
4. Oversees order writing, but residents and interns routinely write all orders for patients under their care. In those unusual circumstances when the attending writes an order on the team's patient, the attending must communicate his or her action to the resident in a timely manner.
5. Is responsible for providing verbal feedback and written evaluation of the resident physicians participating in ICU care. Resident evaluations must include assessments of interview and physical examination skills, communication of treatment plans, and discharge planning.
6. Is responsible for dictating on-service and admission notes. Admission notes should be completed by the end of the day following admission. On-service notes should be completed daily.
7. Is responsible for co-signing and ensuring dictation of discharge summaries for each patient in a timely fashion. Is responsible for signing the Patient Discharge Plan for patients discharged or transferred to another facility directly from the ICU.
8. Responsible for signing orders relating to the withholding of resuscitative efforts (DNR orders).
9. The attending physician will be available by pager at all times.

C. Critical Care Resident (Third-year house officer (R3), or second-year house officer (R2) with prior ICU experience):

Under the guidance of the attending critical care physician, this resident directs the comprehensive ICU care of critically ill medicine patients. The Critical Care Resident also assists with the care of cardiology patients admitted to the ICU, under the guidance of the attending cardiology physician. Specific responsibilities include:

1. Responsible for coordinating the day-to-day function of the Critical Care Unit and directly supervising interns and sub-interns.
a) Responsible for determining the assignment of critically ill patients to monitored beds in the ICU and step-down care unit.
2. Directs the admission and initial evaluation of patients to the medical ICU:
a) The Critical Care Resident will oversee the initial history, physical examination and
review of the laboratory data and medical records for all patients admitted to the medical ICU. The resident will write an admission note for all patients admitted to the medical ICU.
b) The Critical Care Resident will be on-call every fourth night.
c) The Critical Care Resident will serve as the Medicine Consult Resident and Cardiology Consult Resident during weeknights, weekends, and holidays.
d) The Critical Care Resident will provide supervision for the Medicine Nightfloat Intern.
e) The Critical Care Resident will respond in person to "Code Blue" alarms and will function as the leading physician coordinating resuscitations. The Critical Care resident will also document the events that occur during the code.
f) Resident physicians will be responsible for ensuring that individual intern and sub-intern patient loads do not compromise patient care and educational goals.
3. The resident directs the interns and medical students in providing continuing intensive care to all of the patients in the medical ICU:
a) Oversee the daily interval history, focused physical examination, and new
laboratory data for each patient on his/her team.
b) Oversee the rational use of consultants and laboratory tests.
c) Oversee the discharge planning and transitional care of all patients.
d) Ensures compassionate communication with patients and families regarding
the ongoing status and care of patients.
4. Ensures adequate communication of patient care issues among members of the
team, including the attending physician, other Critical Care residents, and intern.
5. Assists the General Medicine/Cardiology Resident with the admission and initial evaluation of patients to the Cardiac ICU and with the ongoing care of cardiology ICU patients:
a) A member of the Critical Care Resident team will participate in taking the initial history, performing a physical examination, and reviewing of the laboratory data and medical records for all patients admitted to the Cardiac ICU.
b) The Critical Care Residents will assist with placement of central lines for hemodynamic monitoring.
c) One of the four Critical Care residents each day will participate in formal rounds with the four General Medicine/Cardiology teams and Cardiology attending.
d) Although the General Medicine/Cardiology Resident will have primary responsibility for making management decisions on Cardiology ICU patients, the Critical Care Resident team will assist as needed with bedside management and critical care decision-making. The Critical Care team will be responsible for ventilator management for intubated Cardiology ICU patients.
6. Responsible for attending conferences as required by the Medical Service and the national Internal Medicine Residency Review Committee. Attendance will be monitored with a sign-in sheet. Residents will need to demonstrate at least 60% attendance at each of the required conferences and will be expected to attend as many teaching conferences as allowed by patient care responsibilities. Required conferences are designated as:
a) Weekly Morbidity and Mortality conference.
b) Weekly Grand Rounds.
7. Responsible for providing feedback on the performance of interns.
8. Responsible for providing written evaluation of attending physicians.
9. Residents will not work in excess of an average of eighty hours per week during any inpatient ward month.
10. Residents will have at least one day off per week.

D. General Medicine Ward Attending (this position is the same for Medicine and Medicine/Cardiology teams):

1. Holds appropriate clinical privileges at SFGH with an academic appointment at the University of California, San Francisco (UCSF) School of Medicine.
2. Supervises and assumes ultimate responsibility for the care of medical inpatients admitted to the medical wards and step-down unit, including discharge/transfer planning and medical follow-up. To achieve this, the attending should conduct daily management rounds that include the following:
a) Interaction at regular intervals with medical ward patients.
b) Effective and frequent communication with the resident staff regarding management.
3. Conducts teaching rounds:
a) Rounds must consist of both patient-based and didactic teaching. Points for discussion include interpretation of clinical data, pathophysiology, differential diagnosis, specific management of the patient, appropriate use of technology and disease prevention.
b) The attending should work with the resident physician to establish and achieve didactic goals for teaching rounds.
c) Teaching rounds must include direct housestaff and attending interaction with the patient. The teaching sessions must include demonstrations and evaluation of each trainee's interview and physical examination skills, i.e. teaching rounds must include bedside teaching.
4. Oversees order writing, but housestaff routinely write all orders for patients under their care. In those unusual circumstances when the attending writes an order on the team's patient, the attending must communicate his or her action to the resident in a timely manner.
5. Is responsible for providing verbal feedback and written evaluations of the residents, interns, and students on the team. Evaluations of housestaff must include assessments of interview and physical examination skills, communication of treatment plans, and discharge planning.
6. Is responsible for writing on-service and admission notes. Admission notes should be completed by the end of the day following admission. On-service notes should be completed daily.
7. Is responsible for co-signing and ensuring dictation of discharge summaries for each patient in a timely fashion. Is responsible for signing the Patient Discharge Plan for patients discharged or transferred from the medical wards.
8. Is responsible for signing orders relating to the withholding of resuscitative efforts (DNR orders).
9. The attending physician will be available by pager at all times.

E. General Medicine Ward Resident (R2 or R3):

Under the guidance of the attending physician, the R2/R3 directs the comprehensive inpatient care of acutely ill medicine patients on the wards and in the step-down unit and assists with patients admitted to the MICU. The specific responsibilities include:

1. Responsible for coordinating the day-to-day function of the team and directly supervising interns and sub-interns.
2. Responsible for attending conferences as required by the Medical Service and the national Internal Medicine Residency Review Committee. Attendance will be monitored with a sign-in sheet. Residents will need to demonstrate at least 60% attendance at each of the required conferences and will be expected to attend as many teaching conferences as allowed by patient care responsibilities. Required conferences are designated as:
a) Weekly Morbidity and Mortality conference.
b) Weekly grand rounds.
3. Directs the admission and initial evaluation of patients to the medical service:
a) Will oversee the initial history, physical examination and review of the laboratory data and medical records for all patients admitted to the team.
b) Residents will be on-call every fourth night and will split medical ward and step-down admissions with the General Medicine/Cardiology Ward Resident.
c) Resident physicians will distribute admissions among members of their individual teams:
i) Interns will be responsible for no more than five admissions per twenty-four hour period and no more than eight admissions per forty-eight hours.
ii) Sub-interns will be responsible for no more than five admissions per twenty-four hours and no more than eight admissions per forty-eight hours.
iii) Resident physicians will be responsible for admitting patients and writing detailed admission notes in excess of five admissions per intern or sub-intern per twenty-four hour period up to a maximum of twelve new patients.
iv) Total admissions per medicine team will not exceed twelve per twenty-four hour call day; a Jeopardy resident will be activated for any admissions in excess of twelve per medicine team per twenty-four hour call day; it is the responsibility of the Emergency Department Resident to notify the Chief Medical Resident on call in order to activate the Jeopardy system.
v) Admissions in excess of five per intern or sub-intern (up to a total of eight patients per intern or sub-intern) will be re-distributed to the intern or sub-intern on the post-call day.
vi) Resident physicians will be responsible for ensuring that individual intern and sub-intern patient loads do not compromise patient care and educational goals.
4. R2's/R3's direct the interns and medical students in providing continuing hospital care to all of the patients to the his/her team:
a) Oversee the daily interval history, focused physical examination, and new laboratory data for each patient on his/her team.
b) Oversee the rational use of consultants and laboratory tests.
c) Oversee the discharge planning and transitional care of all patients.
d) Ensures compassionate communication with patients and families regarding the ongoing care of patients.
5. Ensures adequate communication of patient care issues among members of the team, including the attending physician.
6. Assumes primary responsibility for supervising sub-interns (MS4s) and will write admission notes for all patients admitted by sub-interns.
7. Responsible for providing feedback on the performance of the intern, MS4, and MS3.
8. Responsible for providing written evaluation of the attending physician, intern, MS4, and MS3.
10. Residents will not work in excess of an average of eighty hours per week during any inpatient ward month.
11. Residents will have at least one day off per week and will be covered by the attending physician or by a resident on an outpatient rotation.

F. General Medicine Ward Intern (R1):

1. All responsibilities and clinical privileges of the intern are under the guidance and supervision of the Attending and Resident physicians.
2. Is responsible for patient care in concert with other members of the team.
3. Is responsible for attending conferences as required by the Medical Service and the national Internal Medicine Residency Review Committee. Attendance will be monitored with a sign-in sheet. Interns will need to demonstrate at least 60% attendance at each of the required conferences and will be expected to attend as many additional teaching conferences as allowed by patient care responsibilities. Required conferences are designated as:
a) Weekly Morbidity and Mortality conference.
b) Weekly grand rounds.
4. Is responsible for up to five admissions per twenty-four hour period, or up to eight admissions per forty-eight hour period.
5. Is responsible for writing up to five admission notes; supervising residents will be responsible for admitting patients and writing admission notes in excess of five per twenty-four hour period.
6. Is responsible for writing or co-signing medical students' daily progress notes.
7. Has primary responsibility for supervising MS3s.
8. Is responsible for dictating discharge summaries for each patient within forty-eight hours of discharge.
9. Interns will not work in excess of an average of eighty hours per week during any inpatient ward month.
10. Interns will have at least one day off per week and will be covered by his/her supervising resident.
11. Has primary responsibility for writing orders in the medical record and will co-sign all medical student orders promptly. Verbal orders will be signed within 24 hours.

G. Cardiology Attending:

1. Holds appropriate clinical privileges at SFGH with an academic appointment at the University of California, San Francisco (UCSF) School of Medicine.
2. Supervises and assumes ultimate responsibility for the care of inpatients admitted to the Cardiac ICU, including appropriate continuing care, discharge planning or planning for transfer from the CCU, and medical follow-up. The cardiology attending also has primary responsibility for cardiology patients admitted to both the telemetry/step-down unit and the wards. The attending should conduct daily management rounds, which include the following:
a) Interaction at regular intervals with CCU, telemetry, and ward patients.
b) Effective and frequent communication with the resident staff regarding management.
c) Review of electrocardiograms and other cardiac testing with the housestaff.
3. Conducts daily teaching rounds:
a) Rounds must consist of both patient-based and didactic teaching. Points for discussion include interpretation of clinical data, pathophysiology, differential diagnosis, specific management of the patient, appropriate use of technology, and disease prevention.
b) The attending should work with the resident physician to establish and achieve didactic goals for teaching rounds.
c) Teaching rounds must include direct housestaff and attending interaction with the patient. The teaching sessions must include demonstrations and evaluation of each trainee's interviewing and physical examination skills, i.e. teaching rounds must include bedside teaching.
4. Oversees order writing, but housestaff routinely write all orders for patients under their care. In those unusual circumstances when the attending writes an order on the team's patient, the attending must communicate his or her action to the resident in a timely manner.
5. Is responsible for providing verbal feedback and written evaluation of the resident physicians and interns participating in the care of cardiology patients. Resident evaluations must include assessments of interview and physical examination skills, communication of treatment plans, and discharge planning.
6. Is responsible for dictating on-service and admission notes. Admission notes should be completed by the end of the day following admission. On-service notes should be completed daily.
7. Is responsible for co-signing and ensuring dictation of discharge summaries for each patient in a timely fashion. Is responsible for signing the Patient Discharge Plan for patients who are discharged or transferred to another facility.
8. Is responsible for signing orders relating to the withholding of resuscitative efforts (DNR orders).

[See above (D) for responsibilities of the Medical attending for General Medicine/Cardiology teams.]

H. General Medicine/Cardiology Ward Resident (R2 or R3):

Under the guidance of the attending Cardiology and Medicine physicians, the R2/R3 directs the comprehensive inpatient care of acutely ill medicine and cardiology patients on the wards, in the step-down unit, and in the CCU. The specific responsibilities include:

1. Responsible for coordinating the day-to-day function of the team and directly supervising interns and sub-interns.
2. Responsible for attending conferences as required by the Medical Service and the national Internal Medicine Residency Review Committee. Attendance will be monitored with a sign-in sheet. Residents will need to demonstrate at least 60% attendance at each of the required conferences and will be expected to attend as many teaching conferences as allowed by patient care responsibilities. Required conferences are designated as:
a) Weekly Morbidity and Mortality conference.
b) Weekly grand rounds.
3. Directs the admission and initial evaluation of patients to the medical and cardiology services:
a) Will oversee the initial history, physical examination and review of the laboratory data and medical records for all patients admitted to the team.
b) Residents will be on-call every fourth night and will split medical ward and step-down admissions with the General Medicine Ward Resident. The General Medicine/Cardiology Ward Resident will admit all patients with primary cardiology issues.
c) Will communicate frequently with the members of the Critical Care team, who will assist with the care of CCU patients.
d) Resident physicians will distribute admissions among members of their individual teams:
i) Interns will be responsible for no more than five admissions per twenty-four hour period and no more than eight admissions per forty-eight hours.
ii) Sub-interns will be responsible for no more than five admissions per twenty-four hours and no more than eight admissions per forty-eight hours.
iii) Resident physicians will be responsible for admitting patients and writing detailed admission notes in excess of five admissions per intern or sub-intern per twenty-four hour period up to a maximum of twelve new patients.
iv) Total admissions per medicine team will not exceed twelve per twenty-four hour call day; a Jeopardy resident will be activated for any admissions in excess of twelve per medicine team per twenty-four hour call day; it is the responsibility of the Emergency Department Resident to notify the Chief Medical Resident on call in order to activate the Jeopardy system.
v) Admissions in excess of five per intern or sub-intern (up to a total of eight patients per intern or sub-intern) will be re-distributed to the intern or sub-intern on the post-call day.
vi) Resident physicians will be responsible for ensuring that individual intern and sub-intern patient loads do not compromise patient care and educational goals.
4. R2's/R3's direct the interns and medical students in providing continuing hospital care to all of the patients to the his/her team:
a) Oversee the daily interval history, focused physical examination, and new laboratory data for each patient on his/her team.
b) Oversee the rational use of consultants and laboratory tests.
c) Oversee the discharge planning and transitional care of all patients.
d) Ensures compassionate communication with patients and families regarding the ongoing care of patients.
5. Ensures adequate communication of patient care issues among members of the team, including the attending physician.
6. Assumes primary responsibility for supervising sub-interns (MS4s) and will write an admission note for all patients admitted by sub-interns.
7. Responsible for providing feedback on the performance of the intern, MS4 and MS3.
8. Responsible for providing written evaluation of the attending physician, intern, MS4 and MS3.
10. Residents will not work in excess of an average of eighty hours per week during any inpatient ward month.
11. Residents will have at least one day off per week and will be covered by the attending cardiology and medicine physicians or by a resident on an outpatient rotation.
12. Will carry a "Code Blue" pager and respond to all codes; will assist the critical care resident in these situations but does not have primary responsibility for leading the code.

I. General Medicine/Cardiology Ward Intern (R1):

1. All responsibilities and clinical privileges of the intern are under the guidance and supervision of the Attending and Resident physicians.
2. Is responsible for patient care in concert with other members of the team.
3. Is responsible for attending conferences as required by the Medical Service and the national Internal Medicine Residency Review Committee. Attendance will be monitored with a sign-in sheet. Interns will need to demonstrate at least 60% attendance at each of the required conferences and will be expected to attend as many additional teaching conferences as allowed by patient care responsibilities. Required conferences are designated as:
a) Weekly Morbidity and Mortality conference.
b) Weekly grand rounds.
4. Is responsible for up to five admissions per twenty-four hour period, or up to eight admissions per forty-eight hour period.
5. Is responsible for writing up to five admission notes; supervising residents will be responsible for admitting patients and writing admission notes in excess of five per twenty-four hour period.
6. Is responsible for writing or co-signing medical students' daily progress notes.
7. Has primary responsibility for supervising MS3s.
8. Is responsible for dictating discharge summaries for each patient within forty-eight hours of discharge.
9. Interns will not work in excess of an average of eighty hours per week during any inpatient ward month.
10. Interns will have at least one day off per week and will be covered by his/her supervising resident.
11. Has primary responsibility for writing orders in the medical record and will co-sign all medical student orders promptly. Verbal orders will be signed within 24 hours.

J. Nightfloat Intern (R1):

1. Will arrive in the hospital at 8pm and leave at 8am.
2. No intern will serve as nightfloat for more than 7 consecutive days.
3. Is responsible for taking care of medicine and cardiology patients on the wards and in the step-down unit for the 6 ward teams that are not on call.
4. Will receive written sign-out on all patients.
5. Will check laboratory results, radiology results, monitor fluid status, etc. as specifically directed by the sign-out from the primary team.
6. Will respond to all nursing pages regarding patients under his/her care and will personally evaluate patients for whom there are any concerns.
7. If the nightfloat is called to evaluate any patient who has had a significant change in condition, the nightfloat will clearly document any procedures, interventions, and/or studies in the chart.
8. The Critical Care resident is responsible for supervising the Intern Nightfloat.
9. The Intern Nightfloat will personally sign-out patients to the ward teams between 7am 8am.

K. Medicine Consult Attending:

1. Holds appropriate clinical privileges at SFGH.
2. Supervises and assumes ultimate responsibility for General Medicine consultations on inpatients.
3. Conducts daily teaching rounds with the medical consult resident.
4. Is responsible for completing of initial consultation templates and follow-up consultations.
5. Is responsible for providing verbal feedback and a written evaluation of the medical consult resident.
6. The medicine consult attending physician will be available by pager at all times.

L. Medicine Consult Resident (R2 or R3):

1. Will see all medicine consult patients, 8 am to 5 pm weekdays
2. Will discuss each case with the medicine consult attending.
3. Will provide cross coverage for Ward residents when they are on-call in clinic.
4. Will write appropriate orders with agreement of primary team.
5. Will give written sign-out to the Critical Care resident nightly.
6. Will initiate transfers to the Medicine Service where appropriate.

M. Emergency Department Resident (R2 or R3):

1. Will work no more than 65 hours per week and will have at least one day per week off.
2. Is responsible for directing patient care on the medical side of the Emergency Department including:
a) Assisting the nursing staff with triage when appropriate.
b) Responding promptly when called to the "Trauma Rooms" to care for the most acute patients.
c) Managing patient flow through the Emergency Department and facilitating admissions and discharges.
3. Supervises and teaches interns and medical students who are working on the medical side of the Emergency Department. This includes overseeing the history, physical examination, review of laboratory data, and review of medical records for all patients evaluated.
4. Ensures that appropriate studies and necessary consultations are obtained quickly.
5. Discusses all patients with the Emergency Department attending.

N. Emergency Department Intern (R1):

1. Will work no more than 65 hours per week and will have at least one day per week off.
2. Will rotate through all parts of the Emergency Department, including the Medical ward, Surgical/Trauma ward, and Urgent Care area.
3. Will evaluate patients under the supervision of the resident and attending who are working in his/her area.
4. Will appropriately chart in the medical record.
5. Helps to supervise and teach medical students who are rotating in the Emergency Department.