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The Virginia Mason Clinic Medicine Residency

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  1. 2006-2007 Seattle, WA The Virginia Mason ClinicMedicine Residency

  2. Virginia Mason Medical Center Virginia Mason is located here

  3. Past and Present

  4. Established 1920 Mason Clinic (physician group) Virginia Mason Hospital (80-beds) - modeled on Mayo Clinic “Virginia Mason” named after the daughters of James Tate Mason, M.D., and John M. Blackford, M.D., who co-founded the clinic with radiologist Maurice Dwyer, M.D. Virginia Mason Medical Center

  5. • Multi-Subspecialty Tertiary care hospital • 336 beds,>400 MD’s • Full Medical and Surgical ICU (34 beds) • Benaroya Research Institute • Nearly 200 researchers with a budget of more than $20 million a year Virginia Mason Medical Center

  6. Milestones 1927 First ECG west of Mississippi 1928 First Surgical residency in NW 1936 Dr. Mason president of AMA 1939 First Medicine residency in NW 1992 First SNF for AIDS patients 1995 1000th renal txp - leader in NW Virginia Mason Medical Center

  7. Virginia Mason Medical Center • Wide Ranging Case Mix - Referrals from Washington, Alaska, Idaho, Montana counterbalanced by patients from the local community • Outstanding Faculty • Innovative Environment • Strong sense of camaraderie

  8. Mentors & Faculty • Faculty choose VM because they want to teach and work with residents • 1:1 Resident to faculty ratio on subspecialty rotations • 24 hour attending coverage on both the wards and ICU services • Opportunity to build close relationships with mentors (for career counseling & research)

  9. Virginia Mason Medical Center • Random survey 5000 MD’s and 500 complementary providers • VM providers exceeded all other Seattle institutions. • More than half of Seattle’s top physicians in the medical specialties practice at VM (56%). 54 of the 96 “best Med docs in Seattle”

  10. Virginia Mason Medical Center Residencies: Internal Medicine General Surgery Radiology Anesthesiology Fellowships: Regional Anesthesia Esophageal Research Minimally Invasive Urology Pancreaticobiliary Research Internships: Medicine Categorical Primary Care Preliminary Surgery Categorical Preliminary Transitional Year

  11. Internship Year

  12. Internships: Graduate Medical Education 10/yrCategorical (up to 4) Primary Care 5/yrPreliminary 12/yrTransitional

  13. Internships:13 four-week rotations per year Categorical Prim Care Prelim T.Y. Wards 5 5 6 2 ICU 2 1 1 1 Night Float 1 1 1 1 ER 1 1 1 1 Electives 3 3 4 4 Primary Care 1 2 0 *4 Surg Vacation 3 Wks 3 Wks 3 Wks 3 Wks Graduate Medical Education “Quality of Life” rotations – weekends off, no call. *(varies with individual goals)

  14. Sample Categorical Intern Schedule

  15. Sample Primary Care Intern Schedule

  16. Sample Preliminary Intern Schedule

  17. Sample Transitional Year Intern Schedule

  18. Electives

  19. Elective Rotations • Outpatient services (e.g. nephrology) focus on outpatient management of patients • Absence of fellows means closer teaching relationship with attendings • Includes in-patient consults in attached hospital, reflecting real worldpatient mix

  20. Continuity Clinics • During internship, residents are mentored at the downtown campus outpatient clinic. • Downtown clinic includes a popular, resident run case-based didactic series. • Clinic didactics cover key primary care topics, serving as both practical curriculum and boards review tool.

  21. Continuity Clinics During the 2nd and 3rd years of training, residents may select from a variety of outpatient settings, tailored to individual goals. • Downtown Clinic (attached to hospital) - Collaborative Practice (expanded to Lynnwood) • Suburban Clinics - Federal Way, Lynnwood, Kirkland • Carolyn Downs (Indigent Care) • Pike Market (Indigent Care) • North District Public Health • HIV Clinic

  22. Wards

  23. Wards Structure:4 Ward teams 1 Hospitalist 1 Resident 2 Interns +/- Med Student Same as University “Ward Attending” (unlike other community programs)

  24. Wards Each team covers a geographic cell: 17: Nephrology 16: Pulmonary 15: Oncology 14: Geriatrics 10: Gastroenterology 9: Orthopedics 8: Telemetry 7: Telemetry/IMC Team A Team B Teams A/B and C/D accept admissions on alternating days Team C Team D

  25. Wards Admission system: • Teams admit 7AM-7PM every other day • Nightfloat covers 7PM-7AM Sun-Thurs nights • Teams admit overnight twice a month • Patients distributed in the AM A = Admission day O = Overnight call

  26. Wards Intern Caps: Wards: Sunday to Thursday: 8 patient contacts per day (includes new patients and f/u patients) 3 admission max. on admitting day • if an intern starts with 6 patients on a call day, he or she can admit a maximum of 2 new patient • if an intern admits 6 patients on a call day and discharges 5, only 2 new admissions are possible • if an intern starts with 8 patients, he or she will not admit, even on a call day

  27. Wards Intern Caps: Wards: Sunday to Thursday: 8 patient contacts per day (includes new patients and f/u patients) 3 admission max. on call day Friday and Saturday: 5 overnight admissions Night Float: (Sun-Thur) 4 admissions per night

  28. Mon-Thur 7:00-7:30 NF Sign-Out NF Sign-Out 7:30-8:00 Morning Report Grand Rounds 7:30-09:15 Pre-rounds “ 9:15-9:45 Multidisciplinary “ 9:45-12:00 Rounds “ 12:15-1:00 Noon Conference “ 1:00-1:45 Teaching Rounds Intern Report Virginia Mason Medical Center Night Float Sign Out 7:00-7:30 AM Time Fridays • Housestaff meet to discuss the events of the night shift and to hand-off overnight admissions

  29. Mon-Thur 7:00-7:30 NF Sign-Out NF Sign-Out 7:30-8:00 Morning Report Grand Rounds 7:30-09:15 Pre-rounds “ 9:15-9:45 Multidisciplinary “ 9:45-12:00 Rounds “ 12:15-1:00 Noon Conference “ 1:00-1:45 Teaching Rounds Intern Report Virginia Mason Medical Center Pre- Rounds 7:30-9:15 • Interns see their patients and review labs/overnight events. • Develop a skeleton note on the computer, edited during rounds • Residents available to help after 8am Time Fridays

  30. Mon-Thur 7:00-7:30 NF Sign-Out NF Sign-Out 7:30-8:00 Morning Report Grand Rounds 7:30-09:15 Pre-rounds “ 9:15-9:45 Multidisciplinary “ 9:45-12:00 Rounds “ 12:15-1:00 Noon Conference “ 1:00-1:45 Teaching Rounds Intern Report Virginia Mason Medical Center Multidiciplinary Rounds 9:15-9:45 Time Fridays • House staff “run the list” with RN’s, case managers, pharmacists, and social workers, focusing on issues of patient safety, disposition and services after discharge.

  31. Mon-Thur 7:00-7:30 NF Sign-Out NF Sign-Out 7:30-8:00 Morning Report Grand Rounds 7:30-09:15 Pre-rounds “ 9:15-9:45 Multidisciplinary “ 9:45-12:00 Rounds “ 12:15-1:00 Noon Conference “ 1:00-1:45 Teaching Rounds Intern Report Virginia Mason Medical Center Rounds 9:45-12:00 Time Fridays • Interns present to the resident & hospitalist • RN’s and other team members participate

  32. Mon-Thur 7:00-7:30 NF Sign-Out NF Sign-Out 7:30-8:00 Morning Report Grand Rounds 7:30-09:15 Pre-rounds “ 9:15-9:45 Multidisciplinary “ 9:45-12:00 Rounds “ 12:15-1:00 Noon Conference “ 1:00-1:45 Teaching Rounds Intern Report Virginia Mason Medical Center Noon Conference 12:15-13:00 Time Fridays

  33. Mon-Thur 7:00-7:30 NF Sign-Out NF Sign-Out 7:30-8:00 Morning Report Grand Rounds 7:30-09:15 Pre-rounds “ 9:15-9:45 Multidisciplinary “ 9:45-12:00 Rounds “ 12:15-1:00 Noon Conference “ 1:00-1:45 Teaching Rnds Intern Report Virginia Mason Medical Center Teaching Rounds 13:00-13:45 Time Fridays • Case-based discussion with a subspecialist (“chalk talk” + bedside)

  34. Wards Our resident admitting system: • Eliminates the “Boom & Bust” of a Q4 call system • Caps on patient load to meet educational goals • Daily census hovers at 5 to 6 patients per intern • Minimizes overnight call (10-12 for internship year) • Maintains compliance with the 80 hr work week • Balances betweenProfessional and Private life

  35. Wards Our inpatient goals: • Excellent Patient care and Safety • Diversity in Patient population • Time for Bedside Learning • Time for Conferences • Time for Reading • Time to spend on the rest of your personal life

  36. ICU

  37. ICU

  38. ICU

  39. ICU Closed ICU system (no ward team coverage) • 3 interns, 2 residents • 2 daytime intensivists, 1 nocturnist • 1 day off in 6 for interns • Shift schedule

  40. ICU • Short shift: rounds with ICU attending, leave early • Long shift: intern and resident working together, staff admissions with ICU attending • Night shift: intern and nocturnist working together

  41. ICU • “Nocturnist”: a dedicated ICU hospitalist (attending) who stays in the ICU overnight with the intern • Advantage: attending-to-intern one-on-one teaching during night shifts

  42. Rapid Response Team MD, Critical Care RN, & Resp. Therapist • Team responds to acute situations before they become critical • Opportunity for residents to gain experience in evaluating sick patients and initiating resuscitation Since the teams inception, there has been a decrease in CPR codes.

  43. Virginia Mason Medical Center Work Hours: • Fully compliant with 80 hour work week and 24 / 6 rule on wards and ICU • Ward Interns average 65 hours/week • ICU Interns average 72 hours/week

  44. eMedicine

  45. Virginia Mason Medical Center • Paperless wards charting - allnotes, orders, labs and vitalson-line via single software suite (Cerner) • Standard cut and paste word processing functionality • Digital radiology accessible on any computer monitor • Hospital wide wireless broadband network with mobile computers-on-wheels (COWS) • Approx. 1:1 computer-to-patient ratio on the wards • Approx. 2:1 computer-to-patient ratio in the ICU

  46. Virginia Mason Medical Center • Up-To-Date, OVID, Cochrane, MD Consult • Library – hundreds of full text online journals • Tracemaster – online patient ECG’s • Stentor – online patient imaging studies • Cerner – paperless medical record & order entry • Available24/7 at home through VPN tunnel (Citrix).

  47. Virginia Mason Medical Center All call rooms have telephoneandcomputer

  48. Virginia Mason Medical Center Library 24/7 access by magnetic card lock House-staff Lounge

  49. Career