Hospitalist Resident Rotator Elective
The Hospitalist service at Johns Hopkins Hospital is pleased to announce the continuation of its highly rated Hospitalist elective. The goal of the elective is to expose residents who are considering a career in Hospital Medicine to our Hospitalist model, which differs substantially from most resident-training inpatient care models. It is also an excellent opportunity for residents, who are considering a general internal medicine fellowship or other sub-specialty fellowships, to experience training at Johns Hopkins Hospital. Throughout this elective, residents will work one-on-one with Hospitalist faculty, taking care of patients on a service that is organized to run without a resident team—a patient care model similar to what most practicing Hospitalists will experience following residency.
As hospitalized patients are increasingly being cared for by hospitalists rather than by outpatient primary physicians, the hospitalist movement continues to expand. The Society of Hospital Medicine (SHM) currently comprises more than 5,000 members, and trends in hiring and practice patterns suggest that the number of practicing Hospitalists will climb to approximately 30,000 over the next decade.
During residency, Internal Medicine trainees develop the ability to care for medical inpatients in a team environment. However, most Hospitalists practice without a resident team and are responsible for all elements of patient care. This difference between the typical teaching environment in residency and the actual practice of Hospital Medicine may leave some new Hospitalists unprepared for real-world practice. The goals of this elective are to:
- Expose residents who are considering careers as Hospitalists to a model of clinical care in which attending level care is provided directly to patients without a Housestaff team;
- Help residents develop skills in system-based practice that Hospitalists are expected to master, particularly those that revolve around patient throughput and efficiency of care. These include:
- appropriate triage of patients for the Hospitalist service
- judicious use of inpatient diagnostics and consultation
- determining the goals of hospitalization, and determining which medical issues can be safely deferred to the outpatient setting
- communicating the specific goals of hospitalization to patients, caregivers, and nursing staff, with early implementation of discharge planning
- leading an interdisciplinary approach through utilization of physical therapy, occupational therapy, nutritionists, speech therapy, palliative care, social work, and discharge planners
- optimal medical documentation and billing
- safely transitioning the patient back to the care of the primary care physician
Duration: 4 weeks
Weekday hours: Alternating weeks of 7:00 AM to 5:00 PM shifts with 1:00 PM to 10:00 shifts
Overnight call: None
Weekend hours: One weekend during the 4 week rotation (or 1 weekend day during two separate weekends)
- A telephone interview with Dr. Padmini Ranasinghe, Director, Hospitalist Education Programs
- At least 1 recommendation letter from a faculty member who has worked with the resident in the inpatient setting, or from the residency program director
- Credentialing (see: Required forms):
a. Maryland visiting residents who are US graduates: completed paperwork should begin to be processed by Johns Hopkins no later than 30 days prior to the anticipated start date.
b. Maryland visiting residents who are foreign graduates: completed paperwork
should begin to be processed by Johns Hopkins no later than 60 days prior to the anticipated start date.
c. Visiting residents from outside of the state of Maryland: completed paperwork should begin to be processed by Johns Hopkins no later than 90 days prior to the anticipated start date.
d. A primary source ECFMG is required for all foreign medical graduate visiting residents.
e. Contact April Blotkamp, [email protected], to help with the credentialing process.
- Prior to starting the rotation, the resident will need to train on our computer systems. THIS WILL REQUIRE AT LEAST ONE HALF-DAY AT JOHNS HOPKINS HOSPITAL PRECEEDING THE ACTUAL ROTATION. Contact Lisa Willams, [email protected], to schedule the training.
a. Patient Order Entry (POE)
b. Electronic Patient Record (EPR)
c. Compliance-Plus documentation system
*To be completed only by residents practicing outside of Maryland
Time Event 7am Sign-in rounds on Halsted 6 7am-10am Work rounds 10am-11am Integrated rounds with social worker, nurses, and NCIII 11am-Noon Present patients to the attending hospitalist, admit patients, continue patient care Noon-1pm Noon conference,M-Th (lunch provided) 3pm (on Monday) Didactic session with hospitalist 3pm (on Friday) 1pm ( on Tuesdays) Resident report 1pm (on Thursday) 5pm-5:30pm Group sign-out to afternoon/evening attending Weekends on call (8am-8pm) Perform routine duties on patients as during the week 1pm-10pm shifts
Admit 2-4 patients;
Take sign-out at around 5pm
Cross-cover floor patients while admitting
Conference and Time Location Department of Medicine Grand Rounds (Fridays, 8am-9am) Hurd Hall (1st floor) General Internal Medicine Grand Rounds (scheduled Fridays, 9:10am-10am) Cader Room (5th floor) Resident Report (see above) Lilienthal Library (4th floor) Noon Conference (M-Th, Noon-1pm) Cader Room (5th floor)
Visiting residents will be paired (one-to-one) with a Hospitalist faculty preceptor, and will be expected to provide independent care, under the supervision of the preceptor, for a subset of the patients admitted to the Hospitalist service. The degree of autonomy will depend upon each resident’s clinical confidence and abilities. Daily clinical activities will include the following:
- Residents will be expected to follow between 4-8 patients daily
- On the 1-10pm shifts, residents will admit 2-4 patients daily
- Discussing possible admissions with referring physicians (including ED physicians, outpatient physicians, and physicians from outside institutions) to determine the appropriateness of each admission and the goals of hospitalization
- Assessing new admissions, implementing a clinical plan of care under the guidance of the preceptor, and performing appropriate computer-based documentation and order entry
- Defining realistic goals of inpatient care for individual patients
- Communicating the goals and endpoints of care with patients, families, nurses and case managers
- Morning sign-in and afternoon sign-out rounds with the physicians covering during the evening, with use of a computerized sign-out system to facilitate concise, yet adequate, information transfer between caregivers
- Reassessing existing patients daily and developing personal time-management strategies to maintain a short length-of-stay and discharge patients early in the day whenever possible to facilitate hospital throughput
- Implementing evidence-based practices that apply to hospitalized patients, including: thromboembolic prophylaxis, optimal glycemic control, and inpatient pain management
- Recognizing when subspecialty consultation will improve patient care and communicating effectively with consultants.
- Daily review of the specific plan of care with the patient and the interdisciplinary team
- Providing regular updates to referring physicians as appropriate
- Ensuring that appropriate discharge plans are in place for each patient, and communicating these plans with the patient and the primary physician
- Appropriately billing and documenting the care of medical inpatients
While on the Hospitalist service, visiting residents will be expected to participate in at least one on-going quality improvement and hospital throughput research projects designed to evaluate and improve patient safety and bed utilization on the unit. Opportunities for continued participation in these projects following completion of the elective will be considered on a case-by-case basis for visiting residents who are interested in gaining additional research experience. At the end of the month, the visiting resident is expected to give a brief presentation to the Hospitalist group on the rationale and current status of this project. We recognize that one month is insufficient time to become a study investigator. It ensures, however, that residents are briefly exposed to the types of research and quality improvement initiatives that Hospitalists are expected to participate in and direct at their institutions.
Specific evidence-based conferences will be provided on the following topics:
- Thromboembolic disease prevention and assessment in medical inpatients
- Prevention and management of delirium in the hospitalized patient
- Optimal maintenance of mobility in hospitalized patients
- Managing glycemia in the hospitalized patient
Other specific clinical topics in Hospital Medicine and consultative medicine that may be covered (by request) include:
- Evidence-based management of acute inpatient cardiac diagnoses:
i. New-onset atrial fibrillation
ii. Medical management of acute myocardial infarction
iii. Evidence-based inpatient treatment of congestive heart failure
iv. Management of incidental dysrhythmias detected on inpatient monitoring (nonsustained ventricular tachycardia, frequent ventricular ectopy)
v. Hypertensive crisis
vi. Cocaine-induced chest pain
- Inpatient evaluation of syncope
- Pre-operative cardiac risk assessment
- Inpatient management of decompensated cirrhosis
- Pancreatitis management
- Inpatient management of alcoholic hepatitis
- Ischemic bowel syndromes (ischemic colitis, acute and chronic mesenteric ischemia)
- Evidence-based approach to gastrointestinal bleeding
- Anemia in the hospitalized patient
- Heparin-induced thrombocytopenia
- Evidence-based approach to neuroimaging prior to lumbar puncture
- Use of steroids in meningitis and suspected meningitis
- Beta-adrenergic blockade in patients with chronic lung disease
- Approach to pleural effusions
- Thyroid tests in the inpatient setting (the euthyroid sick syndrome)
- Portopulmonary hypertension
- Evidence-based use of urinary electrolytes
- Approach to acute renal failure
- Evidence-based approach to rhabdomyolysis
- Electrolyte disarray in the hospitalized patient (diagnostic and therapeutic approaches to hyperkalemia, hypokalemia, hypercalcemia, hyponatremia, hypernatriemia)
Visiting residents will be invited to attend other Johns Hopkins conferences, including:
- Department of Medicine Grand Rounds
- Osler Resident Noon Conferences (4 times/week)
- Osler Resident Afternoon Report (2 times/week)
- Division of General Internal Medicine Grand Rounds
- Hospitalist Sub-Intern lectures
All visiting residents will be evaluated by their preceptors and will have the opportunity to evaluate their preceptors using standardized evaluation forms addressing the core competencies. Consistent attendance, effort and participation are expected. The evaluation forms used can either be provided by the resident’s program or by the Johns Hopkins Hospitalist Program. Verbal feedback will occur mid-month.