The inpatient clinical and teaching activities at Temple University are centered around rotations on the general medicine and subspecialty floor teams as well as the intensive care units. At Temple, residents take great pride in caring for and managing medically complex patients with a wide variety of conditions. Often, these conditions are "undifferentiated," giving residents the opportunity to develop their diagnostic reasoning skills. Many of these patients have additional barriers to optimal care, such as limited (or no) health insurance, low health literacy, or addiction to drugs or alcohol. Together, this combination of factors provides Temple residents and faculty with an opportunity to care for some of Philadelphia’s most vulnerable people. As a result, residents learn how to navigate the Increasingly complex health care system and work with interprofessional teams to provide the best possible treatment plan. It is within these patient encounters that some the best learning takes place, but there is more to the story than learning. Our residents are making a difference in patient’s lives each and every day.
Our program’s philosophy is one of graduated responsibility and independence paralleling professional growth. As an intern, we focus on skill building, clinical reasoning, and management. Time is spent predominantly on general medicine inpatient floors, with upper-year residents and dedicated teaching attendings coaching and guiding care and learning opportunities. In the second year, residents continue to gain experience with managing patients, but with more of a subspecialty focus. There are also ample opportunities to teach and lead a medical team during this time. As a third year resident, emphasis shifts further toward honing skills in leading and educating junior team members. All of this happens within the context of attending physician back-up and guidance.
The main structure of the general medicine floor teams is one second or third year resident, two interns, two medical students, and one attending. The overall patient cap on these teams is 16. Each team is supervised by full-time teaching attending physicians who conduct daily teaching rounds. Residents also spend time caring for patients on subspecialty teams, especially in the second year— Congestive Heart Failure, Nephrology/Hepatology, and Pulmonology— supervised by their respective subspecialist attendings.
In 2017, Temple successfully transitioned to a q5 call schedule for the general medicine floor teams. During the On Call day, one of the two interns admits patients in the evening with the upper year resident, and the other intern admits patients overnight with the guidance of a dedicated, nighttime senior resident, whose primary focus is to provide support and education to the intern in real time. Interns alternate the type of call so that overnight call occurs every 10 nights. Post call rounds begin early the next morning to provide ample time for discussion and a safe handoff. Short call 1 and 2 consist of a maximum of two redistributed patients in the morning (admitted by overnight teams) and up to 3 new admissions, all coming before 4pm. On the pre call day, teams do not take any new patients, allowing additional time for reflection and education. Thus, in a five-day cycle, a general medicine teaching team is able to admit and follow the majority of their own patients (around 80% of the time according to our data) from Day 1 to Discharge. Reviews of this system have been positive; it has been shown to help decrease hand-offs, improve continuity of care and increase resident ownership of their patients.
Attending physicians on the general medicine floors are primarily academic hospitalists, though primary care physicians and a handful of subspecialty attendings also attend on inpatient teams. These physicians do not have additional “private” patients while working with the teaching teams, which keeps the focus on education. There are additional, hospitalist-run “private” (or direct-care) services that care for patients without residents. These services have allowed our program to utilize admission caps, which can make the workday more predictable for residents, again keeping the focus on education and safe patient care. For instance, if a teaching team has 10 patients at noon on a short call day, the maximum number of patients the team can admit that day is still 3 (the admission cap), even though the overall census cap is 16.
Subspecialty floor teams and ICU teams have varying admitting cycles, depending on the team. Attending physicians on these teams are subspecialists in cardiology, nephrology, hepatology, and pulmonary/critical-care.
The physician who completes the Internal Medicine Residency Program at Temple University Hospital will have participated in a program that is at the forefront of contemporary medicine. While providing thoughtful, effective, and evidence-based care of sick patients, residents are taught to ask why and not simply what. Furthermore, residents become skilled in elements of systems based practice, such as interprofessional teamwork, patient safety, quality and high value care.