Policies and Procedures

INTERN INTERVIEW, ELIGIBILITY AND SELECTION PROCESS
Department of Medicine
Medical University of South Carolina

In accordance with the policies set forth in the Medical University of South Carolina Resident Handbook, developed by the Office of Graduate Medical Education, residents are selected on a fair and equal basis without regard to race, color, religion, sex or national origin.  Selection is based upon aptitude, academic credentials, personal characteristics and ability to communicate verbally and in writing.

The Department of Medicine Residency Program interviews approximately 325 preliminary, categorical, Internal Medicine/Pediatrics and Internal Medicine/Psychiatry intern candidates per year.  The program participates in the Electronic Residency Application System (ERAS) for the screening and selection of qualified candidates to interview.  Candidates are screened based upon a variety of criteria including USMLE examination scores, medical school grades, letters of recommendation and Dean’s letters.

Once a candidate has been selected to interview and an invitation has been offered, the candidate and Program Coordinator communicate to arrange an interview date.  The program typically interviews between ten and fifteen candidates per interview date.  Candidates meet briefly with the Department Chairman and then attend Morning Report. After Morning Report, candidates will meet with the Program Director and Chief Residents.  Each candidate is interviewed individually by two faculty members in two separate thirty-minute interviews.  Additionally, candidates are given a tour of the campus and have lunch with the housestaff.

Faculty interviewers submit evaluations of each candidate to the Program Coordinator for inclusion in their application files.  Each candidate’s file is then evaluated by at least two members of the Resident Selection Committee.  The files are evaluated on the basis of school record, letters of recommendation and personal interviews with MUSC faculty.

The selection committee then gives each candidate a numeric ranking.  After careful review of the rank list, the Program Coordinator submits the listing to the National Residency Matching Program.

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

RESIDENT EVALUATION, PROMOTION AND DISMISSAL PROCEDURES
Department of Medicine
Medical University of South Carolina

EVALUATION

Each Internal Medicine resident is evaluated on a monthly basis after each rotation using the evaluation template set in place in E*Value system.  The attending physician will also discuss the resident’s performance with him or her at the conclusion of the rotation.  These evaluations are discussed every six months during six-month reviews with the Program Director and/or Associate Program Director and the resident.    Additionally, the Resident Evaluation Committee reviews the evaluations and discusses the performance of each resident on a biannual basis.  The resident is given an opportunity to comment on his or her evaluation and can place a note in his or her file if so desired.

PROMOTION

The promotion of residents is determined on the basis of their monthly clinical evaluations, along with the deliberation of the Program Director and the Resident Evaluation Committee.  Recommendations for promotion are made to the DIO in the Graduate Medical Education office, which offers final approval. 

In general, each resident must obtain an overall rating in the satisfactory or higher range (5 to 9) on their annual evaluations.  PGY 1 residents can be promoted to the PGY 2 level with an overall rating in the marginal range (4), but any future promotions would require a rating of 5 or higher.

If any significant deficiencies in a resident’s performance are identified, they are discussed with the resident during his or her biannual review.  Further, a plan for remediation will be set forth.  If the resident fails to make satisfactory progress during this remediation, the resident may be dismissed or his or her contract may not be renewed.

DISMISSAL

A resident may be dismissed for just cause.  Just causes include, but are not limited to the following:

1.  Inability to complete training due to physical or mental illness.
2.  Failure of the resident to abide by MUSC policies, GME policies, hospital by-laws, federal or state laws, or departmental policies.
3.  Failure to maintain satisfactory levels of academic and clinical performance as determined by  evaluations.
4.  Any actions which directly violate the terms of the resident contract.
5.  Any significant breach of professional conduct or behavior.

Recommendations for dismissal will be made to the Associate Dean for Graduate Medical Education based on the determination of the Program Director, Chairman of the Department, and the Resident Evaluation Committee.  The resident has the right to appeal dismissal based on the department and institutional grievance procedures for residents (see GME policies).

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

RESIDENT EVALUATION COMMITTEE
Department of Medicine
Medical University of South Carolina

This committee meets in July, October, January and May as well as when deemed necessary.  The Program Coordinator provides quarterly reports of residents’ standing with regards to their evaluation ratings which are reviewed by the Committee. 

COMMITTEE MEMBERS

Benjamin Clyburn, MD, Program Director
Sarah Allen, MD, Chief Resident
Walter Brzezinski, MD
Preston Church, MD
Kim Davis, MD
Ashley Duckett, MD, Associate Program Director
Donald Fox, MD
Blake Haren, MD
Joe John, MD
Brad Keith, MD, Associate Program Director
Eddie Kilb, MD, Chief Resident
Leonard Licthenstein, MD
Sarah Mennito, MD
Pam Pride, MD
Cassie Salgado, MD
Andrew Schreiner, MD, Chief Resident
Jane Senseney, MD
Tamara Wolfman, MD
Meredith Stafford, Education Coordinator
Missy Atwater, Program Coordinator

ADMISSIONS AND PATIENT LOAD
Department of Medicine
Medical University of South Carolina

First Year Residents (Interns) will be responsible for no more than five (5) new patient admissions in a 24 hour period and no more than eight (8) in a 48 hour period.  Further, the intern will be responsible for the ongoing care of ten (10) or less patients at all times.

The upper level resident will assign new patients to the interns and the extern.  When the on-call intern reaches 5 new patient admissions or the intern workload is overwhelming at any point, the upper level resident on call will notify the Chief Resident.  The Chief will assess the situation with the upper level resident and further admissions will be dealt with as follows:

            1.  The upper level resident on call will assist by performing the history, physical exam, and admission
                 orders for further admissions, or
            2.  Other interns and residents on call may be called upon to work up further admissions, or
            3.  The surge intern may be called in to assist with further admissions.

New patient admissions are defined as new admissions to the hospital requiring a history, physical exam, and admission orders.  Previously evaluated patients who transfer to the service are not considered new patient admissions.  Patients admitted to the service beyond the five patient cap should generally be assigned to the other intern on the service.

Upper Level Residents will be responsible for no more than ten (10) new patient admissions per 20 hour period and no more than sixteen (16) new patient admissions per 48 hour period.  Further, the upper level resident will be responsible for the ongoing care of no more than twenty (20) patients at any time.  This includes the patients under the care of the interns/externs that the resident is supervising.

When the upper level resident has reached ten (10) new patient admissions, he or she should notify the Chief Resident who will assess the situation with the resident.  The other on-call resident will work up subsequent admissions or the surge resident may be called in to assist with further admissions.

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

DOCUMENTATION BY RESIDENTS AND INTERNS
Department of Medicine
Medical University of South Carolina

Third year medical students should write H&Ps on their patients; however, these H&Ps cannot be placed in the chart.  H&Ps written by Externs are placed on the chart.
                                                            

A.  History and Physical

Interns are responsible for the initial H&P on all regular admissions to their service.  The H&P must conform to the following format:

            Identification (hospital stamp or hand-written)
            Chief Complaint
            History of Present Illness
            Past Medical/Surgical History
            Family/Social History
            Allergies
            Medications
            Review of Systems
            Physical Exam
            Laboratory Data
            Assessment and Plan

There must be information for each of the above sections of the H&P.  If no information is obtainable for a particular section, this should be documented, e.g., Family History-unable to obtain, patient adopted.

B.  Resident Admit Note (RAN)

Residents are responsible for writing an RAN on all regular admissions.  This should consist of a summary of the current problems and the immediate plan for addressing those problems.

C.  Interim Notes

Patients who have been admitted to a service for the same problem within 30 days may have an interim note written by either the intern or resident.  This is a summary of the recent hospitalization, patient’s chief complaint, history or present illness, past medical history, review of systems, current physical exam, and an assessment and plan.  This note should be clearly marked as Interim Note.  This replaces both the Intern H&P and the RAN.

D.  Orders

The intern on service, with routine input and review by the resident, completes orders for admission and daily orders.  The resident may write orders in the absence of the Intern.  The Attending Physician may write orders as well; but, this should be done only in an emergency situation and should be co-signed by the house officer responsible for the patient.  All orders must be dated and timed.  Medical students or acting Interns may write patient orders, but these will not be carried out unless co-signed by either an intern, resident, or attending physician.

E.  Transfer Notes/Orders

1.  Transfer of a patient to the ICU or another service:
If a patient needs, at any time during the hospital stay, to be transferred to Intensive Care or another Medicine service, it is the responsibility of the resident or intern to write a transfer note outlining the patient status, hospital course, and reason for transfer.  Full orders will be written either by the resident or the intern, with review by the resident, to admit the patient to the receiving service.  Transfers to other Medicine services or to one of the units will not be undertaken unless approved by the receiving resident (or attending on faculty services) and appropriate fellows, if required.

2.  Transfers to services other than Medicine:
These may be accomplished as above.  In some instances, the receiving team prefers to write their own orders and this can be done by mutual agreement of both the transferring and accepting teams.  Some services, e.g., Psychiatry, require that the patient by physically discharged from the hospital for readmission to their service.  In this case, a written discharge summary should be included, rather than a transfer note, and appropriate discharge paperwork should be completed.

3.  Transfer of patients from another service to Medicine:
If a patient needs to be transferred from another hospital service to Medicine, the transferring team should write the transfer note and orders.  This team can be either the Medicine Consult team or the non-Medicine transferring team.  It is the responsibility of the resident or fellow on the transferring team to call and arrange the admission; notify the accepting team resident of the transfer; and provide the patient’s current and future location, current problems, and plan of care.  The accepting Medicine team should notify the Medicine attending physician as soon as possible of the impending transfer.

F.  Acceptance Notes
Patients that are transferred from the Intensive Care Units to the floor or from another service need to be evaluated on arrival.  An acceptance note must be written and all orders must be cosigned by the accepting housestaff prior to the orders being carried out.  The evaluation of the patient and the writing of the acceptance note are to be completed by the resident or intern on the accepting service.  Acceptance notes should contain a summary of the hospital course; and evaluation of the patient’s current status; and the plan of subsequent care.  It is not necessary to duplicate the transfer not in its entirety. 

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

PHARMACEUTICAL REPRESENTATIVE PRESENTATIONS
Department of Medicine
Medical University of South Carolina

Any presentation by pharmaceutical representatives to Internal Medicine housestaff at the Medical University of South Carolina during Morning Report or any other conference must adhere to the following guidelines:

            1.  Presentations must be limited to no more than three minutes.
            2.  Only pre-printed company material may be used to present information.
            3.  Overheads, slides, and Powerpoint presentations are not allowed.
            4.  Articles from peer-reviewed journals may be brought to the attention of the audience, but data may
                 not be presented.  Reprints may be offered.  All articles offered may be reviewed in subsequent
                 meetings by the faculty in objective sessions without the representative present.
            5.  Pharmaceutical representatives may not provide food.

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

PHYSICIAN IMPAIRMENT
Department of Medicine
Medical University of South Carolina

The Internal Medicine Residency Program adheres to the following polices set forth in the Graduate Medical Education Resident Handbook:

            Physician Impairment
            Employee Assistance Program

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

PROFESSIONALISM/GRIEVANCE
Department of Medicine
Medical University of South Carolina

A.  ELEMENTS OF PROFESSIONALISM

            1.  Attitude:  Acceptable professional attitude conforms to the ethical standards of the medical profession.  For example, patient confidentiality is required, as is treating patients, colleagues, and other personnel with respect.  Appropriate attitude toward patients includes providing their care in a timely and careful manner.  Appropriate attitude towards colleagues includes being on time for rounds, teaching conferences, Morning Report and clinics.  Unacceptable professional attitude includes treating patients without due consideration and response to their needs and concerns.  It is unacceptable to be routinely late for assignments and other duties such as completing charts, returning pages, and dictating discharge summaries, etc.  Inappropriate dress or behavior indicates a distinct lack of respect for others.  Gross misinterpretation of fraud goes beyond attitude into the realm of criminal offense.

            2.  Competence:  Competence is provision of what is felt to be appropriate “standard of care” for each patient.  Incompetence is possession of fund of knowledge grossly below that which is required of a house officer at his/her level of training.  Evaluation is based on the performance as well as faculty evaluations on ward services, consult services, and clinics.  The Resident Evaluation Committee is responsible for identifying the house officer with competency problems.

B.  VIOLATION OF STANDARDS OF PROFESSIONALISM           

            1.  Disciplinary action will be initiated at the discretion of the Chairman, Program Director, Resident Evaluation Committee, or the Chief Residents.  Offenses will be broadly divided into those of attitude or competence.  The system is three-tiered and the Resident Evaluation Committee will assign the level of any given offense.

                        a.  LEVEL 1: CORRECTIVE ACTION:  The offending house officer will be notified by the Chairman/Program Director and details of the offense discussed.  Additional investigation will be performed by the Chief Residents and reported to the Program Director/Resident Evaluation Committee.  After appropriate discussion/investigation, if deemed necessary by the Resident Evaluation Committee, a Level 1 letter (detailing the offense) will be written and presented to the house officer.  It will require the house officer’s signature and will be placed in that house officer’s permanent file.  No further action will be taken at this point.  This letter will serve as warning.

                        b.  LEVEL 2:  CORRECTIVE ACTION:  Continued gross misconduct or repeated offenses with regard to conduct or attitude will warrant a Level 2 corrective action.  The Program Director, Chief Residents, and Resident Evaluation Committee will again hold investigation of the incident.  If deemed appropriate by the Resident Evaluation Committee, a Level 2 letter will be written, detailing the offense.  Again, this will be presented to the house officer for review and for his/her signature.  The letter will be placed in the resident’s permanent file and a copy of this letter will be forwarded to the Chairman.  No further action will be taken.  This will serve as a second warning.

                        c.  LEVEL 3:  DISMISSAL:  Repeated violations despite previous corrective actions described above will be conceded as a Level 3 offense.  A Level 3 offense usually will result in immediate dismissal from the residency training program.

            2.  At the discretion of the Program Director or  Chairman, any grossly negligent action by a house officer can be deemed as constituting a potential Level 3 offense even if not preceded by Level 1 and 2 warnings.  After an appropriate investigation by the Program Director and the Chief Residents, the offense will be presented by the Program Director or Chairman to the Resident Evaluation Committee for discussion and a broader concurrence that it is, indeed, a Level 3 offense.  If deemed so, the house officer will be issued a letter of dismissal.

C.  DEPARTMENT GRIEVANCE PROCEDURE

            1.  Grievances by the house officer involving policies and procedures of postgraduate education should be handled in the following manner:

                        a.  A complaint by a house officer shall be placed in writing and reviewed by the Chief Residents within 2 weeks after the problem becomes evident.  The Chief Residents will meet with the house officer in a timely manner after receipt of the complaint.  If no satisfactory solution results from the meeting,  the complaint will be brought to the attention of the Program Director.

                        b.  The Program Director will then meet with the house officer.  If no satisfactory solution results from the meeting, the complaint will be brought to the attention of the Department Chairman.

                        c.  The Department Chairman will meet with the house officer concerning the written complaint.  In matters pertaining to departmental policy, the decision of the Chairman will be final.  In matters pertaining to the institution at large, the house officer can appeal to the Associate Dean for Graduate Medical Education as outlined in the ACGME Resident Handbook.

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

REQUEST FOR VACATION/ADMINISTRATIVE LEAVE/CLINIC CANCELLATION
BY RESIDENTS AND INTERNS
Department of Medicine
Medical University of South Carolina

1.  Residents and interns must submit requests for vacation/administrative leave/clinic cancellation at least 8 weeks prior to the dates being requested in order to facilitate cancellation of outpatient clinics with minimal inconvenience to the affected patients.

2.  Requests are submitted to the Housestaff Coordinator on the Vacation Request/Clinic Cancellation form.

3.  The Housestaff Coordinator verifies the balance of vacation days available to the resident/intern  as well as the site of the clinic to be cancelled.  The request is then forwarded to the Program Director for approval.

4.  Following the Program Director’s approval, the appropriate clinic sites and schedulers are notified of the planned absence.

5.  Use of administrative leave to attend conferences, interviews, Board exams, etc. is at the discretion of the Program Director.

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

SCHEDULE DESIGN
Department of Medicine
Medical University of South Carolina

A.  Service Design

            1.  Cardiology:  3 teams each with 1 Resident, 2 Interns that follow patients on the floor and in CCU
            2.  Gastroenterology:  2 separate teams each with 1 Resident, 1 Intern (GI Luminal and GI Liver)
            3.  Pulmonary:  1 Resident, 1 Intern
            4.  Hematology:  1 Resident, 1 Intern
            5.  Oncology:  1 Resident, 1 Intern
            6.  Geriatrics:  usually 2 upper levels
            7.  MUH Wards:  4 teams each with 1 Resident, 2 Interns and 2 “Float” Interns
            8.  VA Wards:  3 teams each with 1 Resident, 2 Interns and 1 “Float” Resident
            9.  MICU:  5 residents, variable number of Interns (1-3)
            10.  VICU:  3 upper levels
            11.  Night Float:  5 night float Residents, 4 covering MUSC, 1 covering VA Wards

B.  Call

            1.  No call on non-ward services except occasional Surge call (back up)
            2.  Switching calls/services is allowable with appropriate notice to Chiefs and Housestaff Coordinator
            3.  VA:  Residents Q3 until 8:00 P.M. M-TH, overnight FRI-SAT, on until 5:00 P.M. on Sundays on
                 wards;
                        Q3 in VA ICU; no call on GEM; Interns q6, 16 hour shifts overnight
            4.  MUH:
                - MICU:  Residents Q4 daytime call until 8:00 P.M. with rotating night float system (6 nights each);
                      Interns, 1  weekend of nights
                -Gen Med:  Residents Q4 until 8:00 P.M. M-TH; overnight FRI-SAT, until 5:00 P.M. SUN
                -Gen Med Intern:  2 Interns Q4 day call until 8:00 P.M., rotating night float (up to 10 nights in a
                  month). Floaters rotate every 5 days; other Interns q4 until 8:00 P.M.  Intern A covers GM 1
                  and 2;Intern B  Covers GM 3 and 4; Interns A&B alternate covering Pulmonary
                 -Pulm:  No call overnight for Interns.  Residents have 1 to 2 overnight calls per month
                 -Resident Night Float:  Sun. through Thurs. (Sunday starting at 5:00 P.M.; MON-TH starting at 8:00
                  P.M.
            5.  ART:
                 -Cardiology Residents: Q3 until 8:00 P.M.  on weekdays; overnight on weekends.  NF coverage is
                   SUN-TH as with Gen Med, but with occasional weekend coverage
                 -Cardiology Interns:  on team call Q3 until 8:00 P.M.; 16 hour overnight shits on weekends
                 -Hem/Onc Residents:  Q4 until 8:00 P.M. on weekdays, overnight on weekends; NF coverage is
                  SUN-TH as with Gen Med but occasional weekend coverage
                 -Hem/Onc Interns:  Q4 a week until 8:00 P.M.; night float from 8:00 P.M.-8:00 A.M.

            *Interns on call should not accept patients.  The resident will be notified by the accepting physician/service. The resident will then notify the intern.

This design is subject to change due to manpower issues.

1.  Duty hours will be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-
     house call activities.
2.  One day (one continuous 24-hour period) in 7 will be free of all educational and clinical responsibilities,
     averaged over a four-week period, inclusive of call.
3.  Adequate time for rest and personal activities will be scheduled by allowing at least a 10 hour time period
     between daily shifts of duty and after in-house call.
4.  In-house call will occur no more frequently than every three days, averaged over a four-week period.
5.  Continuous on-site duty, including in-house call for upper level residents will not exceed 24 consecutive
     hours plus no more than an addition four hours to participate in didactic activities, transfer care of patient
     and maintain continuity of medical care, and conduct outpatient clinics.
6.  Continuous on-site duty for interns shall not exceed 16 hours, which is inclusive of the transfer of care and
     educational activities.
7.  No new patients will be accepted by a resident or intern after 24 hours of continuous on-site duty.
8.  See program policy, Admission and Patient Load, for information on the number of patients to be assigned
     to residents and interns.

Duty hours are defined as all clinic and academic activities related to the residency program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences.  Duty hours do not include reading and preparation time spent away from the duty site.

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

JOB RESPONSIBILITIES/SUPERVISION
Department of Medicine
Medical University of South Carolina

PGY 2 and 3 Residents

1.  Initial care plans for all patients admitted to the teaching services will be made by the resident and intern.

2.  Patients admitted to the team will be seen and examined by the resident, and a Resident Admit Note (RAN) will be completed for each new resident.

3.  The resident will review daily care plans for the patients with the Intern and will lead daily work rounds with the interns and students.

4.  The resident will assign patients to students and interns on admission days.

5.  The resident will directly supervise the work of interns and students, including all procedures.

6.  The resident will discuss all patient care plans with the attending physician on a daily basis during rounds.  On services with fellows, the resident will discuss all patient care plans with the fellow and the attending.  The presence of the fellow should not diminish the role of the resident.

7.  The resident will identify any educational needs of the team and convey these to the attending physician.

8.  The resident will immediately notify the attending physician of all problems, need for invasive procedures, questions on patient care, change in the level of patient care (i.e. transfer to the ICU), deaths, and risk-management issues.  The resident will make certain the attending physician or another approved supervisor is present for any procedures for which the resident has not been deemed competent to perform without direct supervision.  All procedures should be recorded in the E*Value system.

9.  Residents are expected to provide 1-2 teaching sessions with the students each week and should pull pertinent articles for the team.

10.  The resident will attend Noon Conferences, Grand Rounds and Morning Reports whenever possible.  The program requires that residents attend at least 60% of all Grand Rounds, Journal Club, Morning Report and Noon Conferences.

11.  Residents should assist interns to allow rapid completion of discharge dictations (write progress notes, orders, call consults, etc.).

12.  Residents assume patient care duties when an intern has the day off or is in clinic.

13.  After 5:00 P.M., the resident covering for General Medicine is responsible for all emergent Medicine consults.  The resident should call the Chief Resident and/or the attending physician to review the consult.

14.  Admissions arriving after 7:00 A.M. will be seen by the on-call team.  The patient must be examined and assessed.  If not acute, holding orders may be written.  The H&P and Resident Admit Note (RAN) do not need to be written.  The primary team MUST be notified of the patient as soon as possible.

15.  On ambulatory rotations and in continuity clinic, PGY 2 and 3 residents present all patients directly to the attending physician.  The resident is expected to develop the care plan.  The attending physician will directly see patients as needed.

Interns

1.  The intern will be responsible for all daily care of the patient.

2.  She/he will see all patients within a timely manner, once admitted to the floor, and will write comprehensive histories and physical exams on each admitted patient.

3.  The Intern will write all orders and will follow-up on all patient studies and consults.  Interns will review all laboratory results and medication regimens daily, making necessary adjustments.

4.  The intern will discuss all admissions with the Resident on the night of call.

5.  Interns will present their patients to the attending physician post-call and will assist students in preparing presentations.

6.  Interns will make lists of all patients under their care each night to checkout to colleagues.  The on-call interns will write notes on all patients seen on cross-cover and will expect the same from colleagues.

7.  Interns (or students under their direction) will write daily progress notes and discharge notes.

8.  Interns are expected to attend all Noon Conferences, Grand Rounds and Morning Reports.

9.  Interns will perform all procedures on the wards and Residents are expected to assist and supervise as needed.  All procedures are to be documented in the patient’s chart.  Informed Consent must be obtained prior to all non-emergent procedures.

10.  Interns will report all problems directly to the resident.

11.  Interns are responsible for appropriate off service notes on all their patients prior to switching services.

12.  Interns should only accept patients when contacted by the resident on-call for that service.  No admissions are to be accepted by the intern from fellows, attending physicians, or other services.  The resident should be notified of all ICU transfers.

13.  Check out time is 5:00 P.M.  Housestaff may check out earlier but must stay on pager, return all pages, and return to the hospital if any major patient care problems arise.  The primary housestaff team is responsible until 5:00 P.M.

14.  On ambulatory rotations and in continuity clinic, PGY 1 residents present all patients directly to the attending physician.  The intern is expected to begin developing the care plan.  The attending physician will directly see all patients initially.

Acting Interns (MS-IV)

The MS IV will carry the same role and responsibilities as the interns with the following modifications:

1.  All patients worked up by the MS IV will be presented to the resident the night of call, and all admission orders will be examined by the resident and co-signed before they are entered in the chart.

2.  The MS IV will discuss all patient care plans daily with the resident.

3.  All orders written by the MS IV must be co-signed by the resident or intern before they are entered into the chart.

4.  All invasive procedures done by the MS IV must be directly supervised by the resident and/or attending physician.

5.  MS IV call schedules will be assigned by the Medicine office.  Students are expected to adhere to these schedules.

Third Year Students

1.  Students will follow 3-5 patients assigned to them and will be responsible for adhering to the call schedules assigned to them by the Medicine office.

2.  Students will write at least one full history and physical exam, which will be handed in to the attending physician each week.  The H&Ps must include a problem list and discussion of differential diagnosis and plan.  The student will have read a medicine text on the subject before handing in the H&Ps.

3.  Students will follow the patients they have admitted on a daily basis and will present these patients in a concise manner (5-7 minutes) to the attending physician post-call. 

4.  Students will present their patients on work rounds to the team each day, including subjective, objective data and a daily plan.

5.  Students will attend all required conferences.

6.  Students will write daily progress notes on their patients.

7.  Students will identify their own educational needs and convey these to the resident and attending physician.

8.  Students are supervised by the interns, the resident, the fellow (when applicable), and the attending physician.  They are assigned to the intern following their patients for supervision in seeing the individual patient.

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

MOONLIGHTING
Department of Medicine
Medical University of South Carolina

The Internal Medicine Residency Program adheres to the following policy set forth in the Graduate Medical Education Resident Handbook:

http://academicdepartments.musc.edu/gmehandbook/policies/moonlighting.html

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

RESUSCITATION TEAM RESPONSIBILITIES
Department of Medicine
Medical University of South Carolina

1.  Code pagers are furnished to all on-call Internal Medicine housestaff who are scheduled to carry the code pager.  It is the responsibility of the post-call housestaff to hand off the code pager to the on-call resident.  However, if the on-call resident will be out of the hospital for any reason (conference, clinic, etc.) it will be there responsibility to inform the post-call resident still in possession of the pager.  This is to facilitate the post-call person being able to leave rather than waiting to pass off the code pager.  All housestaff carrying code pagers are required to remain in-house.

2.  A code leader (Medicine resident) is responsible for directing all other participants in the code.  The leader shall designate duties and direct all interventions.  Only personnel designated by the leader shall be involved in resuscitative efforts.

3.  The physician leader of the code will be the resident on-call in the MICU.  The team leader will be identified to the entire code team present.

4.  The anesthesiologist or Internal Medicine Resident will provide access to the airway and ventilation as assisted by the respiratory therapist.  It is NOT the responsibility of the anesthesiologist to run the code.

5.  The MICU resident will provide or assign personnel to perform cardiac massage, ECG rhythm interpretation, drug recommendations, and observation of vital signs.  The team leader will provide overall direction of the code, as per ACLS guidelines.  The other Medicine resident should perform procedures, such as attaining central access, as deemed necessary by the code team.

6.  The physician leader of the code, in cooperation with a physician representative of the patient’s primary care team (when available), will determine the extent to which unsuccessful resuscitative efforts should be continued.

7.  The resident representative of the service primarily responsible for the patient’s care is responsible for notification of the patient’s attending medical staff member (faculty person) and family.  If no physician service representative is available, the code leader should assume this responsibility.

8.  All medicine housestaff must be ACLS certified.

9.  Patients who survive resuscitative efforts and require transfer to the ICU are the responsibility of the code team and/or primary care team until transfer to the ICU team.  All members of the code team are responsible for the physical transfer of the patient to the ICU.  The physician code leader must write a detailed code note on all patients.

Declaration of Death/Death Notes/Autopsies

At the conclusion of an unsuccessful code or in the event of the death of a patient who did not wish to be resuscitated, the primary team physician or the on-call physician will be required to pronounce the patient dead.  The physician performing this service will have the following responsibilities:

            -Examination of the patient and confirmation of death
            -Completion of a Death Note in the chart which is dated, timed, and signed by the physician pronouncing
              death (example below)
            -Completion of the Death Certificate (available from the chaplain)
            -Informing the Charge Nurse of the death
            -Notification of the patient’s family and the Attending Physician of the primary team

Example of a Death Note
“Called to see patient for lack of respiration and pulse.  On examination, patient was found to have no spontaneous respiration.  No pulse could be palpated or auscultated.  Pupils were fixed mid-position without reaction to light.  There was no response to deep pain stimuli.  (If applicable) Patient had requested that no resuscitative efforts be undertaken given the terminal nature of his/her disease.  We have complied with these wishes.  Patient was pronounced dead at 2135 today, July 1, 2011.  Patient’s family, Attending Physician and chaplain notified.”

The signature of the pronouncing physician must follow the death note and must be legible.  The pager number should also be included with the signature.  Notes following an unsuccessful code will document the performance of the code by ACLS protocol, outlining the medications and maneuvers utilized during the code.  An autopsy on the deceased patient should be offered to family members.  If applicable, organ donation should be discussed with the family.  The chaplain assists the family with funeral arrangements.

Do Not Resuscitate/Withdrawal of Life Support

A competent patient may, at any time, verbally request or consent to an order for “Do Not Resuscitate” or “Withdrawal of Life Support.”  IF the patient later becomes incapacitated, the previously expressed wishes will be upheld.  Key points are listed below:

            1.  Used only for competent patients.
            2.  The Attending Physician must be contacted to take part in any decision-making after hours and during
                 on-call time.
            3.  If the patient or family members do not feel comfortable with the decision, the Attending Physician
                 must be contacted.
            4.  The Attending Physician must document within 24 hours in the medical record that the patient is
                  terminally ill and  that resuscitation would merely prolong dying.
            5.  Family may be consulted only with the patient’s permission and have no legal rights to intervene.  With
                 some  exceptions, it is inappropriate for the cross-cover teams to discuss “Do Not Resuscitate”
                 considerations other than when the family or patient specifically approaches the on-call team in that
                 regard.  If it is deemed necessary for the cross-cover team to address code status, the primary
                 attending should be contacted first.
            6.  All reasonable efforts must be made to contact the next of kin for incompetent patients.  If no
                 disagreement exists  between available family members, a decision may be made on that basis.
            7.  If no relatives exist for an incompetent patient or a family disagreement exists, a legal guardian should
                 be ought.   Ethics consults are available 24 hours/day and may be helpful in difficult situations.
            8.  Chart documentation should include notes by a faculty member and an order that resuscitative efforts
                 not e used in the event of a cardiopulmonary arrest.
            9.  In the case of “Withdrawal of Life Support,” a written statement in the medical record by the
                 attending physician is required.
            10.  Re-document the code status upon transferring a patient from one service to the next.
            11.  It is appropriate for the primary tram to discuss code status with patients when they first enter the
                   Hospital, especially in those cases when the prognosis is uncertain.
            12.  When documenting in the chart, “DNR” is not sufficient.  The words “Do Not Resuscitate” must be
                   written in full and be legible.

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

SURGE POLICY FOR RESIDENTS
Department of Medicine
Medical University of South Carolina

1.  Each upper level resident will take surge call in blocks of approximately 6-7 days at a time throughout the year.  Surge residents are residents currently on a non-call month.

2.  Since the surge assignments are made prior to vacation requests being submitted for the upcoming academic year, trades will be allowed and should be arranged amongst the residents.  Notify the Chief Residents and Housestaff Coordinator for any changes and submit necessary paperwork.

3.  Surge responsibilities are defined as covering the call nights as well as daytime and weekend responsibilities of residents on call months who are unable to report to work due to illness, family emergencies, etc.  The surged resident will cover for the entire amount of time that the absent resident is unable to assume his/her responsibilities, until that surged resident’s block of time has ended.  The next resident on the surge schedule will then be surged, if necessary.

4.  If at any point during the year a resident finds it necessary to surge a fellow resident, he/she will not be required to make up that time to the surged resident unless the behavior becomes habitual.

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

SURGE POLICY FOR INTERNS
Department of Medicine
Medical University of South Carolina

1.  The surge call schedule is designed to provide support for those interns performing ward duties who are unable to report to work due to illness, family emergencies, etc.

2.  The intern on surge call must be available 24 hours a day during the dates of his/her surge assignment.  If surged, the intern assumes the absent intern’s duties and responsibilities within one hour of notification or at the discretion of the Chief Resident.  The surged intern will cover for the entire amount of time that the absent intern is unable to assume his/her responsibilities, until that surged intern’s block of time has ended.  The next intern on the surge schedule will then be surged, if necessary.

3.  Interns on consult, ambulatory or ICU rotations are eligible for surge call.

4.  Switches of surge call assignments are permitted and should be arranged amongst the interns.  Notify the Chief Residents and Housestaff Coordinator of any changes and submit necessary paperwork.

5.  If at any point during the year an intern finds it necessary to surge a fellow Intern, he/she will not be required to make up that time to the surged intern unless the behavior becomes habitual.

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

DISASTER EMERGENCY PLAN
Department of Medicine
Medical University of South Carolina

1.  In the event of a disaster, the residents and interns who are scheduled to be on-call on the day of the disaster (Disaster Team 1) should come to work prepared to stay for up to 72 hours on their respective inpatient services.  This includes bringing food, water, clothes, and sleeping gear if aware of disaster prior to reporting to work that day.

2.  Disaster Team 2 will be the residents and interns originally scheduled to be on-call the following day.  These residents will arrive at the hospital the same day and time as Disaster Team 1.  Disaster Team 2’s responsibilities will be to assume on-call duties after Disaster Team 1 has fulfilled the first 24 hours.  If necessary, the two teams will alternate call until relief is available for coverage.

3.  Non-ward resident duties are as follows:

            a.  During working hours (8:00 AM to 5:00 PM) residents on non-ward services will be contacted by one of the Chief Residents and/or Program Director to report to a central “pool” area (Gazes Auditorium) where they will be dispersed to areas of most need.

            b.  After hours, the 3 surge residents (Residents A and B and Intern) will be notified by one of the Chief Residents and/or Program Director to report to a central “pool” area (Gazes Auditorium) where they will then be dispersed to areas of most need.

4.  Post-call residents preparing can check out to oncoming Disaster teams as early as 8:00 AM; however, prior to checking out, they are expected to have rounded on their patients, written daily progress notes and orders, and, if possible, discussed the patients with the on-service attending.  After checking out to the Disaster Teams, post-call residents, and all other residents currently on duty must report to the Chief Resident on duty of the Program Director (at a designated meeting place) for further instructions.

5.  All non-ward residents not initially contacted should continue regular duties until advised otherwise by the Chief Residents or Program Director.

6.  If any residents are permitted to evacuate, phone numbers and destination plans must be left with the Chief Residents and/or Program Director.

7.  Residents in the process of evacuating must keep their pagers turned on while in radius for any new information.

8.  Chief Residents will have a phone list of all residents for check-in and contact purposes if additional assistance is needed.

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

DISASTER EMERGENCY PLAN
Department of Medicine
Medical University of South Carolina

HURRICANE EMERGENCY PLAN
Department of Medicine
Medical University of South Carolina

1.  In the event of a hurricane, the residents and interns who are scheduled to be on-call on the day of predicted landfall (Team 1) should come to work prepared to stay for up to 72 hours.  This includes bringing food, water, clothes, and sleeping gear.

2.  Team 2 will be the residents and interns originally scheduled to be on-call the following day.  These residents will arrive at the hospital the same day and time as Team 1.  Team 2’s responsibilities  will be to assume on-call duties after Team 1 has fulfilled the first 24 hours.  If necessary, the two teams will alternate call until relief is available for coverage. 

3.  The day prior to call, all efforts should be made to ensure that Team 1 and 2 residents/interns can leave work early in the day to afford them time to prepare for extended on-call time, evacuate their families, etc.

4.  Residents on Team 1 and 2 should report to the hospital no later than 8:00 A.M. on the day of predicted landfall.

5.  Post-call residents preparing to leave the morning of landfall can check out to oncoming teams as early as 8:00 A.M.; however, prior to checking out, they are expected to have rounded on their patients, written daily progress notes and orders, and, if possible, discussed the patients with the on-service attending.

6.  All non-ward residents continue regular duties until mandatory evacuation is announced or as specified by Chief Residents.

7.  Prior to evacuating, phone numbers and destination plans must be left with the Chief Residents.

8.  Residents in the process of evacuating must keep their pagers turned on while in radius for any new information.

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011

ON CALL MEAL MONEY
Department of Medicine
Medical University of South Carolina

The Department of Medicine adheres to the GME Office policy for On Call Meal Money:

SALARY SCHEDULE
Department of Medicine
Medical University of South Carolina

The following resident stipends are set for the 2011-2012 academic year.  Stipends will be reevaluated in the fall of each year and any changes will be made effective October 1 each year.  All residents will be notified if there are changes to the established stipend levels.

2011-2012 PGY Salaries

PGY 1:  $45,932.00
PGY 2:  $47,571.00
PGY 3:  $49,056.00
PGY 4:  $50,445.00
PGY 5:  $52,154.00

_________________________
Benjamin Clyburn, MD
Program Director, Internal Medicine Residency Program

Updated July 2011