Written Curriculum and Lines of Responsibility
for Required Rotations at the
San Francisco Veterans Affairs Medical Center

The Medicine Service

The Medical Service at the San Francisco Veterans Affairs Medical Center (SFVAMC) consists of seven teams providing comprehensive inpatient care to acutely ill medicine patients.

I. Educational Goals

A. Third-year house officer (R3)

1. Under the guidance of the attending physician, direct the comprehensive inpatient care of acutely ill medicine patients, including those admitted to the MICU, CCU, telemetry unit and regular medicine wards.
2. Refine leadership and teaching skills.
3. Refine skills in the differential diagnosis and evaluation of diverse inpatient medical problems.
4. Refine critical care knowledge.
5. Supervise interns in the performance of procedures for which the R3 is specifically certified.
6. On completion 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. Second-year house officer (R2)

1. Under the guidance of the attending physician and supervising resident, direct the comprehensive inpatient care of acutely ill medicine patients, including those admitted to the MICU, CCU, telemetry unit and regular medicine wards.
2. Refine leadership and teaching skills.
3. Refine skills in the differential diagnosis and evaluation of diverse inpatient medical problems.
4. Develop skills, including the performance of procedures, in the management of critical care patients.
5. Supervise interns in the performance of procedures.

C. First-year house officer (intern)

1. Develop skills in the differential diagnosis and evaluation of diverse inpatient medical problems
2. Refine organizational skills necessary for the care of medicine inpatients
3. Develop leadership and teaching skills through interactions with members of the medical team
4. Learn the appropriate utilization of consult services and diagnostic studies
5. Develop basic procedural competence, including venipuncture, arterial puncture, lumbar puncture, paracentesis, joint aspiration, thoracentesis, placement of nasogastric tubes, placement of Foley catheters

II. Team Structure and Responsibilities

A. Team structure

The Medical Service consists of seven teams, each comprised of an Attending physician, a medicine R2 or R3, an intern and, during many months of the year, a sub-intern (MS4) and a third-year medical student (MS3). A social worker is assigned to each team to aid in identifying and meeting discharge needs.

B. Attending physician responsibilities

1. Holds appropriate clinical privileges at the SFVAMC 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 his/her team, including appropriate discharge planning and medical follow-up.
3. Conducts daily teaching rounds:
a. Works with the resident physician to establish and achieve didactic goals for teaching rounds.
b. Reviews the history, diagnosis, daily clinical status, and plan for each patient on the team.
4. Responsible for providing verbal feedback and written evaluation of the resident physician, intern, sub-intern (MS4) and third-year medical student (MS3).
5. Responsible for writing electronic on-service and admission notes by the end of the day following admission.
6. Responsible for co-signing and ensuring dictation of discharge summaries for each patient in a timely fashion.

C. Second- (R2) or third-year (R3) house officer

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. Daily residents' report.
b. Weekly grand rounds.
3. Directs the admission and initial evaluation of patients to the medical service:
a. R3s will be on-call every fourth night and will determine the distribution of admissions between teams.
b. The R3 on call will serve as the Medicine Consult resident during weeknights, weekends and holidays.
c. R2s will be on-call every third night Monday through Friday, but will not take overnight call on Saturday or Sunday.
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.
iv. Total admissions per medicine team will not exceed ten per twenty-four hour call day; a Jeopardy resident will be activated for any admissions in excess of ten per medicine team per twenty-four hour call day; it is the responsibility of the medicine resident to notify the Chief Medical Resident on call (719-2626) in order to activate the Jeopardy system.
v. Resident physicians will be responsible for writing a brief admission summary for each patient admitted to the intern or sub-intern within twenty-four hours of the admission.
vi. 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.
vii. Resident physicians will be responsible for ensuring that individual intern and sub-intern patient loads do not compromise patient care and educational goals.
viii. Resident physicians will be responsible for notifying the chief residents if admissions exceed the maximal cap or if patient care is compromised; jeopardy or night float residents will be mobilized by the chief residents to cover any additional admissions to the medical service.
4. Ensures adequate communication of patient care issues among members of the team, including the attending physician.
5. Assumes primary responsibility for supervising sub-interns (MS4s).
6. Responsible for providing feedback on the performance of the intern, MS4 and MS3.
7. Responsible for providing written evaluation of the attending physician, intern, MS4 and MS3.
8. Responsible for dictating and co-signing discharge summaries for each patient within forty-eight hours of discharge.
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. During the week and on Saturdays, the Attending physician will cover the responsibilities of the resident on his/her day off. On Sundays, the resident will be covered by a licensed physician to be designated by the Medical Service; the Attending physician shall be available to discuss patient care issues.

D. First-year house officer (intern)

1. All responsibilities and clinical privileges of the intern are under the guidance and supervision of the Attending and Resident physicians.
2. Responsible for patient care in concert with other members of the team.
3. 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 interns' report.
b. Weekly grand rounds.
4. Responsible for up to five admissions per twenty-four hour period, or up to eight admissions per forty-eight hour period.
5. 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. Responsible for writing or co-signing medical students' daily progress notes on all patients assigned to them.
7. Primary responsibility for supervising MS3s.
8. Interns will not work in excess of an average of eighty hours per week during any inpatient ward month.
9. Interns will have at least one day off per week. The responsibilities of the intern will be covered by his/her resident during the designated day off.

The Medical Consultation Service

The Medical Consultation service at the San Francisco Veterans Affairs Medical Center (SFVAMC) is staffed by a second- or third-year medicine resident who is supervised by an attending physician. The consultation service provides problem-oriented guidance to non-medical clinical services at the SFVAMC which desire advice on management of medical issues or pre-operative assessment. Each resident will complete an average of two weeks in the R2 or R3 year.

I. Educational Goals

A. Third-year (R3) and second-year (R2) house officer

1. Learn the principles and problems of interface medicine, including development of professional and social skills necessary for effective interdisciplinary communication and patient care.
2. Provide problem-oriented, evidence-based recommendations for dealing with medical urgencies in non-medical patients.
3. Under the guidance of the attending physician, provide timely medical advice to inpatient non-medical services.
4. Refine diagnostic and management skills of medical problems in patients on non-medical wards.
5. Learn the principles of effective pre- and peri-operative risk assessment and differential diagnosis, including preoperative cardiac assessment and DVT prophylaxis.
6. Learn the principles and management of post-operative complications.
7. When students are present, refine leadership and teaching skills.

II. Team Structure and Responsibilities

A. Team structure

The Medicine Consultation Service consists of an attending physician and a second- or third-year medical resident.

B. Attending physician responsibilities

1. The Medicine Consultation Service is supervised by an assigned attending physician, who holds staff privileges on the Medical Service at the SFVAMC and a faculty appointment at the University of California, San Francisco.
2. When the assigned attending physician is unavailable, the chief medical residents or other staff physician designated by the assigned attending physician will serve as the attending physician
3. The attending physician will meet with the consult resident daily, Monday through Friday, to:
a. Discuss new and ongoing patients on the consultation service.
b. Work with the resident physician to establish didactic goals.
c. Provide educational materials and didactic lectures in consultation medicine.
4. The attending physician is responsible for writing initial consultation notes or addenda within 24 hours of each consultation, barring weekends and federal holidays.
5. The attending physician will be accessible by pager to the consultation resident 24 hours a day for issues of coverage for patients on the service.
6. The attending physician is responsible for providing written evaluation of the resident physician at the conclusion of the rotation.

C. Resident physician responsibilities

1. Responsible for prompt assessment of surgical and psychiatric patients in response to consultation pages.
2. Available for consultation to other services from 8 am until approximately 8 pm Monday through Friday, weekends and federal holidays excepted.
3. Responsible for seeing patients on a daily basis and writing electronic progress notes as dictated by the patients' clinical course and the needs of the consulting service.
4. Will sign out to the R3 Medicine resident on call in the evening and on weekends; the R3 Medicine resident on call will provide medical consultation on weekends, holidays, after 8 pm during the week, and on the consult resident's half-day of continuity clinic.
5. Residents will not work in excess of an average of eighty hours per week, averaged over the course of the rotation.
6. Responsible for keeping contact with inpatient medicine ward residents, and transferring appropriate patients to the Medical Service.
7. Residents may be responsible for providing coverage for the inpatient teams as needed to achieve patient care and educational goals of the program.

Categorical Ambulatory Care Block

The ambulatory block rotations are comprised of one one-month rotation in the internship year, one three-month rotation in the R2 year, and one two-month rotation in the R3 year. During each rotation, housestaff will attend didactic lectures and interactive seminars two mornings each week while devoting the remainder of time to clinical care in a variety of acute care, primary care, and specialty medical clinics.

I. Educational Goals

A. Third-year house officer (R3)

1. Increase competency in non-medical subspecialty areas through lectures and clinical experiences.
2. Learn fundamental principles in caring for adolescent patients through didactic and clinical experiences.
3. Refine skills in the diagnosis and management of office-based adult medicine through longitudinal and urgent care clinics.
4. Participate in community outreach work in shelters and adult skills centers.

B. Second-year house officer (R2)

1. Increase competency in medical subspecialty areas through lectures and clinical experiences.
2. Gain in depth, focused, and longitudinal clinical experiences in two core selective subspecialty areas.
3. Improve outpatient teaching skills through supervised lectures and case-based discussions by participating in a three-month teaching course:
a. Enhance medical knowledge through reading and preparation on an ambulatory medicine topic.
b. Focus attention on the process of teaching and prepare teaching goals and explore specific techniques in advance.
c. Receive feedback from faculty and colleagues on both positive aspects of teaching style and areas for improvement.
d. Discuss specific techniques that can be applied to address problem areas.
e. Practice techniques in the following teaching sessions as well as in other teaching arenas.
4. Learn advanced skills in evidence-based medicine through weekly journal club with areas of study including case-control studies, randomized controlled trials, cost-effectiveness analysis, meta analysis, decision analysis and practice guidelines.
5. Continue to increase proficiency in the diagnosis and management of office-based adult medicine through longitudinal and urgent care clinics.

C. First-year house officer (intern)

1. Increase proficiency in the diagnosis and management of office-based adult medicine, both in continuity clinic and urgent care settings.
2. Increase familiarity and facility in the assessment, evaluation and treatment of commonly seen diagnoses in the urgent care setting using an evidence-based medicine approach.
3. Learn fundamental principles in geriatric medicine through didactic and clinical experiences.
4. Learn techniques in medical interviewing and physical examination skills through core lecture series.
5. Develop skills in critical assessment of the medical literature, including
a. Principles of evidence-based medicine.
b. How to read studies about diagnostic tests, therapy, prognosis, and prevention.
c. How to perform self-evaluation and remain up-to-date.
6. Increase proficiency in the provision of longitudinal care, including issues relating to health care maintenance and disease prevention, national guidelines in preventive care, and time management skills.

II. Resident Responsibilities

A. Patient care

1. Comprehensive notes will be entered into the medical record on the day each patient is seen.
2. All patients seen will be discussed with a designated attending physician, who is responsible for co-signing chart notes.
3. Residents are expected to follow patients from their outpatient panels during any hospital admission, and to facilitate discharge planning and timely follow-up.

B. Attendance

1. Residents are excused from assigned clinical responsibilities only for previously-scheduled vacation, jury duty, acute illness or other major emergency. When an unscheduled absence is necessary, the resident is responsible for notifying each clinic affected as well as the Ambulatory Block Director in order to minimize inconvenience to patients.
2. Residents are not excused from clinical duties following a scheduled night float shift.

C. Conferences

Residents are required to maintain and document (by signing the attendance ledger) at least 60% attendance at the following required conferences:

1. Core Curriculum Seminars (Monday and Wednesday mornings for R1s, Tuesday and Friday mornings for R2s, and Wednesday mornings for R3s).
2. Residents Journal Club (R2 and R3s).

D. Work hours

Housestaff are expected to work weekdays from 8 am - 5 pm, or until their clinical work is completed. If an evening clinic is scheduled, the intern or resident will be given a compensatory morning off. Excepting those instances in which a night float or weekend coverage day is scheduled, residents will have Saturdays and Sundays as days off. In no circumstance are housestaff expected to work more than 80 hours per week.

III. Requirements of Academic/Administrative Time

A. Third-year house officer (R3)

1. Complete a research/academic project.
2. Continue contact with mentors and career decision making.

B. Second-year house officer (R2)

1. Lead 2 case-based discussions, drawn from selective modules.
2. Lead 1 didactic talk from list of common urgent care diagnoses.
3. Lead 1 journal club discussion.
4. Pursue research interests.
5. Continue contact with mentors and career decision making.

C. First-year house office (intern)

1. Identify and meet with mentors.
2. Increase reading in outpatient medicine topics.
3. Directed case-based reading to allow active participation in morning conferences.

PRIME Block

The PRIME Block rotation is staffed by eight second- or third-year medicine residents providing comprehensive outpatient medical care in primary care, medical subspecialty and surgical clinics while completing a required curriculum in clinical epidemiology/evidence-based medicine, behavioral medicine and scholarly research. Each resident will complete two 3-month long PRIME blocks per year during the R2 and R3 years.

I. Educational Goals

A. Third-year (R3) and second-year (R2) house officer

1. Provide comprehensive primary care for chronically ill SFVAMC patients in the multidisciplinary medical practice (2 sessions/week) and in Women's Clinic (1 session/week).
2. Refine diagnostic and management skills in specialty areas of medicine through 3-month duration, weekly rotations in specialty clinics (4/week) selected from the attached listing.
3. Learn the principles of evidence-based medicine through attendance at the weekly PRIME epidemiology seminar and through application of these skills in clinical practice.
4. Refine knowledge of psychosocial medicine principles and skills through attendance at weekly PRIME psychosocial medicine seminars and through application of these skills in clinical practice.
5. Refine teaching skills through assigned teaching responsibilities:
a. Researching and presenting lectures for PRIME epidemiology seminars.
b. Researching and preparing evidence-based reviews of common clinical problems at PRIME residents reports.
c. Elective opportunity to serve as clinical preceptor for first- and second-year medical students through Foundations of Patient Care course.
d. Preparing and presenting ongoing research projects twice annually at formal work in progress sessions.
e. Preparing and formally presenting results of their research project at a designated noon Medical Conference during their R3 year.
f. Presenting a well-researched analysis of a clinically interesting journal article at one PRIME Journal Club per year.
6. Improve administrative abilities through assignment as Administrative Chief Resident during one third-year block rotation.
7. Refine clinical research skills through completion of an evidence-based systematic literature review and/or primary epidemiologic investigation over two years; one session per week is set aside to facilitate meetings with faculty research mentors and advisors and to allow greater access to library or computer-based data sets.

II. Resident Responsibilities

A. Patient care

1. Comprehensive computer notes will be entered on the day each patient is seen.
2. All patients seen will be discussed with the designated attending physician, who will co-sign all chart notes via computer.
3. Residents are expected to follow patients from their outpatient panels during any hospital admission, and to facilitate discharge planning and timely follow-up.

B. Attendance

1. Residents are excused from assigned clinical responsibilities only for previously-scheduled vacation, jury duty, acute illness or other major emergency. When an unscheduled absence is necessary, the resident is responsible for notifying each clinic affected as well as the Program Director's office in order to minimize inconvenience to patients.
2. Residents are not excused from clinical duties following a scheduled night float shift.

C. Conferences

Residents are required to maintain and document (by signing the attendance ledger) at least 60% attendance at the following required conferences:

1. PRIME epidemiology seminar.
2. PRIME psychosocial medicine seminar.
3. PRIME residents' report (following principal continuity clinic).
4. Wednesday morning inpatient residents report.

D. Work hours

Residents are expected to work weekdays from 8 am - 5 or 6 pm, or until their clinical work is completed. Excepting those instances in which a night float or weekend coverage day is scheduled, residents will have Saturdays and Sundays as days off. It is expected that completion of the research requirement will require additional evening and weekend work, but in no circumstance are residents expected to work more than 80 hours per week.