General Medicine Service Rules

Teams

• 5 medicine teams consisting of one resident, two interns, +/- sub-I, and medical student(s)
• 1 Night Float team consisting of one resident and one intern
• 2 bridge residents (1 bridge admitting resident, 1 bridge cross cover resident). Their day off is Tuesday.
• The gen med teams alternate call days (once every 5 days) with the call team taking cross-cover and signing out to the gen med night float team when they arrive at 8:00 pm. 
• On call days, the entire team will be present with interns typically taking alternating admissions. 
• Residents and interns have short call (SC) on day 4 of call cycle. They will receive 4 hold-over patients admitted by the night float team.
• Sub-I (if applicable) that takes call days and off days with the resident

General Medicine team cycle structure

Call Day Team (p4367)

• Call day senior signs into the gens admitting pager (4367).
• 7AM – 6PM: admit up to 6 patients (1 patient after 5PM)
  • Admission distribution to the 2 interns is left up to the discretion of the senior resident. In general, we advised alternating admissions while also being mindful of list distribution equity.
• On Tuesdays (Bridge residents’ day off), the call day team will need to take cross cover for Gen Med. Interns on the team can split the cross cover.
• Call day team should ideally listen to presentation from admitting bridge resident to their attending which will occur when the night float team arrives
• Residents have a census cap of 20 patients (including sub-I patients if applicable).
• Interns have a census cap of 10 patients.

Post-Call Day Team

• Post-Call day rounding time is up to the discretion of the senior resident and attending (no later than 8AM)
• The team is expected to pre-round on all patients (including bridge resident admissions from the prior day)
• The team will present the day admissions (up to 6), overnight events for the bridge admissions (up to 4), and any old patients
• The intern and resident will sign out to the cross cover bridge resident together once the work is complete. On Tuesdays, the teams will sign out to the call day resident.

Non-Call Day Team

• Rounding time is up to the discretion of the senior resident and attending (no later than 8:00am).
• The team is expected to pre-round on all patients
• Rounds are expected to end at 10AM
• Teams are expected to attend morning report
• The intern and resident will sign out to the cross cover bridge resident together once the work is complete. On Tuesdays, the teams will sign out to the call day resident.

Admitting Bridge Resident (p30250) 

• Admitting bridge resident signs into bridge admitting pager (30250)
• 2PM – 8PM: admit up to 4 patients (to a call day team cap of 20), discuss new admissions with the current call day attending and call day senior. They should sign out the new admissions to the night float team. 
• 8-10pm: tie up admits, H&Ps, sign out to NF. All admits and transfers should have a note written by the admitting bridge resident.
• It is expected that the bridge resident come to morning report
• Day off is Tuesday. On their day off, there will be no bridge admits.
• The 2 bridge residents should coordinate 1 week of each experience (1 week of admitting, 1 week of cross cover). They are encouraged to assist each other as needed to allow both bridge residents to leave the hospital by 10:30pm

Cross Cover Bridge Resident

• 2PM – 10PM: take cross cover non-call gen med teams OR teach the medical students / sub-I / interns until teams are ready to sign out. Will sign out to the night float team. Should prioritize the call day senior signing out before them.
• It is expected that the bridge resident attend morning report
• Day off is Tuesday. On their day off, the day call team will take general medicine cross cover. If a day off other than Tuesday is needed, it is expected that the bridge resident finds coverage by another resident. If unable to find coverage, the bridge resident should ask the call team on the affected day if the call team would be willing to take cross-cover on their call day; if all residents agree, then the bridge resident will make up the day off on one of the Tuesdays.
• The 2 bridge residents should coordinate 1 week of each experience (1 week of admitting, 1 week of cross cover). They are encouraged to assist each other as needed to allow both bridge residents to leave the hospital by 10:30pm

Night Float Resident/Intern (p7645)

• Upon arrival (no later than 8PM), the night float team will be expected to cross cover the day call team, the bridge admissions, and the gen med cross cover from the cross cover bridge resident
• 8PM – 5AM: admit up to 4 patients (to a short call team cap of 16) 
• On the NF intern’s day off (Sunday), no overnight short call admissions. This means there is no short call on Monday
• Night Float resident’s night off is Friday. Weekend Float resident will cover NF resident’s position and admit 4 patients with help of NF intern. 

Admitting Flow

• 7am – 6pm: Call day senior, intern, and medical students begin admitting (see admission caps above)
• 2pm – 8pm: Admitting Bridge resident admits to that day’s call team (see admission caps above)
• 8pm – 5am: Night Float team admits and presents to the next day’s short call team
• On the 4th day of the call cycle, the short call team will receive up to 4 admissions from the NF team on every day except Monday. The short call team caps at 16 including the NF admission. NF team stays to present these admissions on rounds to the short call team before leaving for the day.
• Short Call days begin rounding at 7AM. Attendings are expected to be there at 7AM on these days to ensure the Night team leaves in a timely manner.
  • Rounding times on other days (including post-call) are left to the discretion of the senior resident and Attending (no later than 8AM). ROUNDS MUST BE DONE BY 10AM.
• ALL admissions/ICU transfers/OSH transfers must come from 9100. Any admissions not from 9100 should be re-directed to page 9100 for admission.

Admitting/Cross Cover Table

MDR and Morning Report

• 10:00 -11:00 am (specific time assigned) – MDR rounds – at least one team member and the attending should attend to discuss plan of care, dispo planning etc with multi-disciplinary team.
• 11:45 – 12:30: Morning report conference in a700 (M-F)

Teaching, Conferences, and Feedback

• Residents are expected to attend morning report on all but the day off.
• The 1:00-2:00 pm time slots are open for teaching by the general medicine attending. They should be utilized on non-post call days as time permits.
• We encourage senior residents to give didactics to younger trainees. The cross cover bridge resident can consider using 2PM – 3PM as dedicated teaching time to give chalks talks, etc.
• The team attending is responsible for the education of the entire team. It is expected that teaching will take place in combined teaching/management rounds each day with additional education sessions outside of rounds on non-post call days.
• The team attending is expected to provide goals and expectations at the beginning of the rotation.
• The team attending is expected to provide structured feedback at the mid-way point of the rotation and at the end of the rotation.
• The attending is expected to provide a written evaluation on all members of the house staff team at the end of the month.

Pagers

• When the senior resident is on a scheduled day off, their pager should be covered by one of the interns on service.

Supervision

The team resident is responsible for ensuring the highest level of care to patients admitted to their resident team. This care is accomplished through regular supervision of the work completed by the interns and students on the team. The resident should see and evaluate all patients in a timely fashion on the night of admission. They should see and evaluate all patients on a daily basis throughout the entire admission. In both cases, the plan of care should be reviewed with the intern delivering appropriate feedback where necessary. 

The Bridge resident is responsible for ensuring the highest level of care to patients they cross cover and admit. The Bridge resident should be prepared to give brief presentations to the call attending for the patients they admit prior to leaving for the night.

The attending physician is responsible for ensuring the highest level of care to patients admitted to their resident team. This is accomplished through regular supervision of the work completed by the resident, intern and students on the team. The attending should see and evaluate all patients at admission. They should see and evaluate all patients on a daily basis throughout the entire admission. In both cases, the plan of care should be reviewed with the housestaff team delivering appropriate feedback where necessary. The attending should be available 24 hours a day to the housestaff team for questions or concerns arising in the course of patient care.

End of Service Signout

• Signout emails at the end of your service should always be sent to both the oncoming team member you are signing out to and the intern/resident remaining on service when you leave.

Updated 6/12/23