Sites, Rotations, and Continuity Clinic
The UC Davis Medical Center is a 600-bed hospital and the only academic medical center and Level 1 trauma center in the northern Central Valley of California. It is a major tertiary referral center, but also a key healthcare provider for its surrounding community. It is the primary training site, and residents spend approximately 70 % of their time on rotations at the Medical Center hospital or clinics.
The Sacramento Kaiser Permanente system is the largest healthcare system in the Sacramento Area, caring for more that 50% of the patients in our region! Our residents work at several sites at the North Kaiser and South Kaiser Hospitals, in clinics, inpatient wards and the ICU. Residents spend about 15 % of their time at Kaiser over their residency.
The Sacramento VA Medical Center is a new 50-bed state-of-the-art hospital. Its relative size makes it operate much like a small community hospital. Our residents work in the clinics, wards, and the ICU. Residents spend approximately 15 % of their time at the VA over their 3 years.
Several other outpatient sites help train our residents. The Sacramento County Clinics for the medically indigent and underserved houses the TEACH primary care clinic for our TEACH Track, and several categorical residents have their continuity clinic based here as well. Residents rotate through several subspecialty clinics here, including the County’s TB Clinic.
The Dignity Health System is a large hospital and clinic system in our area. Our residents rotate there for geriatrics, podiatry, allergy, and neurology clinics.
This is our flagship rotation, with an amazing patient population and disease mix. There are 4 teams, each comprised of an R2, R3, 2 interns, 1 attending, 2 third-year year medical students, and usually a fourth-year medical student. The 4-day cycle goes like this: Short Call à No Admit Day à Long Call à Post Call. Thus, teams take long call every 4th night (admit up to 7 patients), where one resident and 2 interns come in at 6 PM and admit overnight. Teams also take short call every 4th day, admitting up to 4 patients between 8 AM and 2 PM.
No shift is longer than 16 hours for any member of the team and there is always a senior resident (either the R2 or R3) to lead the team during the day. Discharge planners are assigned to each team, which is very helpful.
The majority of patients admitted on this service come through our very busy Emergency Department, but we also get tertiary referrals from other hospitals in the Central Valley and Northern California areas. The supervising faculty for this rotation are primarily hospitalists and general internists who are very experienced at inpatient care. They are wonderful clinical mentors and great role models of clinician-educators.
UC Davis is one of only 41 nationally recognized National Cancer Institute Comprehensive Cancer Centers. The inpatient Heme-Onc service cares for patients seen at the Cancer Center as well as those admitted through the ER with new cancer diagnoses or complications of cancer. For educational reasons, interns do not care for our bone marrow transplant patients or routine chemotherapy patients. These are handled by the fellows and faculty separately.
This service is staffed by 4 interns, 2 fellows, and 1 attending. The interns share admissions daily until 5 PM under the supervision of our outstanding Hematology-Oncology fellows. There is no overnight call, as patients are covered by the UC Night Float intern. There is a separate teaching attending that teaches a didactic curriculum through several seminar sessions each week.
UC Night Float:
All interns do 2 weeks of night float, where they cross-cover on UC floor patients on the medicine and hematology-oncology services. They have on-site backup from senior IM residents on ICU, Cardiology and General Medicine services, in addition to phone back-up from fellows and attendings.
North Kaiser Wards:
North Kaiser is a hybrid rotation, where residents spend half of their time on the floors and half of their time in the MICU. This is a large community hospital, and most of the patients are admitted by the large hospitalist and ICU services. Given the size of the Kaiser system in our area, the hospital admits an incredible variety of medical patients. Residents take a distinct minority of the admissions to medicine (the rest go to a non-teaching service) – so the admitting hospitalists cherry pick the best cases for the housestaff teams. The Academic Floor Team is staffed by a subset of hospitalists who are dedicated to resident education. The Academic ICU Team has ICU attendings who are dedicated, experienced intensivists that have a track record of winning teaching awards. Kaiser has a long history of supporting our residents so that they receive optimal educational experiences.
There are 4 teams at Kaiser at a given time: two teams of 1 resident, 1 intern, and 1 third–year medical student that manage the ICU, one daytime floor team of 1 resident, 2 interns, and 2 third-year medical students, and one night team comprised of 1 resident.
- The night resident cross-covers on the housestaff patients in the ICU and on the floors Monday through Friday. They admit patients overnight to the floor and ICU (maximum 3 per night). There is no night resident on weekends, when the hospitalists and ICU staff at Kaiser provide cross-coverage.
- The daytime floor team admits daily on Tuesday through Saturday (Sunday is the resident day off, and Monday is our Academic Conference day).
- The ICU teams take call during the daytime every other day. The night resident covers at night, except on Saturday and Sunday when the intensivist faculty cover the unit without residents.
There is a small Surgery Service at the VA, but for the most part this 50-bed hospital is run by the Medicine Service. This allows for our residents to see what it is really like to work in a community hospital and see virtually everything that comes their way. Add to this the wonderful VA patients, with their “bread and butter” medical problems and their great spirit, and this becomes a great rotation.
The floor at the VA is covered by four teams with 1 resident, 1 intern, and 1 third-year medical student. One of these teams is a Family Medicine team. The call schedule for these teams is Long Call à Post-Callà Short Call à No Admit Day. Residents take call overnight every 4th day, admitting to the floor over the 24 hour shift, and covering the VA ICU Team patients and admissions after 5 PM. The interns do not work overnight shifts. The team also takes short call every 4th day until 2 PM.
The VA ICU admits cardiology and ICU patients to the 10-bed unit. This is a 1-resident, 1-2 intern team that admits ICU and cardiology patients daily. There are cardiology and pulmonary fellows on the service as well. Night admissions and cross-cover are provided by the overnight floor medicine team. The team rounds with the ICU team at 8 AM and the CCU team (cardiology fellow and faculty) at 10 AM every day.
The attending for the ICU team is one of our UC Davis pulmonary faculty who rotates at the VA. The CCU attending is one of several outstanding VA cardiology faculty. The night ICU attending in-house helps housestaff with complicated patients and procedures after hours.
The MICU is probably the favorite rotation for most of our residents. This is because of the incredible medical pathology, the great fellows and attendings that supervise this service, and a true multidisciplinary care team of nurses, nutritionists, physical therapists, and respiratory therapists.
There are 2 “mega-teams” comprised of 2 R3s, 1 R2, 1 day intern and 1 night intern. Each mega-team takes call every other day. The R3s take overnight (24-hour) call every 4th night, admitting with the day intern during the day and the night intern during the night. Intern shifts are less than 16 hours. The R2, however, does most of the daytime admissions with the day intern. We devised this schedule to have junior residents have MICU experience during daylight hours, doing admissions and procedures with the pulmonary fellow and/or attending. By the time you are an R3 on an overnight MICU call, you are more than ready to run the ship.
Starting August 2012, there is now an in-house pulmonary fellow to help supervise the overnight intern and resident. This added supervision at night will only improve the learning experience and the already top-notch patient care.
UC Cardiology Inpatient Service:
This is a combined CCU and cardiology floor rotation. Residents will admit to the floor and the unit. There are 2 teams of 2 upper level residents, 2 interns, 1 fellow and 1 attending. Each resident takes overnight call (24 hours) every 4th night, going home after presenting the next morning. Interns take call with the resident for 16 hours and go home. There is a night intern that comes in to relieve the day intern, provide cross-cover and help with overnight admissions. There is an in-house cardiology attending every night to teach and assist with sick patients. We have an active and outstanding group of cardiologists practicing at the cutting edge.
General Medicine Consult Service:
Upper level residents (2 at a time) provide consultation to non-medical services under the supervision of the general medicine faculty. This team co-manages many of surgery patients, performs many preoperative evaluations, and helps manage many common post-operative problems. We have a set curriculum that all residents finish during their training. After this experience, residents are well-prepared to perform perioperative consultation and management.
Most of our electives are at the UC Davis Medical Center, though some electives send residents to subspecialty clinics at the VA, Kaiser, Dignity, or County clinics. We have electives in GI/Hepatology, Rheumatology/Allergy, Nephrology, Pulmonary, Cardiology, Hematology-Oncology, Infectious Diseases, Endocrinology, Palliative Care, and Hospitalist Medicine. Most are a mix of inpatient and outpatient experiences. Under our new 4+1+1 schedule this year, residents do electives in 2 to 4 week blocks.
Global Health Electives:
Starting in 2010, we have been sending 2-3 third-year residents (and 1-2 UCD faculty physicians) per year to Rwanda in central Africa. The Ruhengeri Regional Hospital graciously supports our residents and faculty, as they work alongside Rwandan doctors and residents for a month to learn from them and the patients of Rwanda. It is a wonderful experience to practice in a developing country--one that has dramatically different medical resources, yet provides universal healthcare to its people. The residents see an amazing range of conditions, including conditions not often seen in the U.S., such as active tuberculosis, malaria, and typhoid fever. In addition, residents participate in the UC Davis School of Medicine global health activities, including trips to Nicaragua and India.
UC Emergency Medicine:
Residents work for 2 weeks per year in the new, state-of-the-art emergency department. This is a very busy ED and residents play a key role as the first evaluator of many common and complex patient problems. During this rotation, residents have ample opportunities to perform procedures and get experience with bedside ultrasound with our ER faculty.
Residents and interns have eight weeks of Ambulatory Blocks each year. During these weeks residents have 3 continuity clinic sessions and go to subspecialty medicine and non-medicine specialty (e.g. dermatology, gynecology, urology, PM&R) clinic sites.
- Friday mornings are dedicated to a didactic session that includes evidence-based medicine presentations and journal clubs, led by two of our key faculty.
- Interns complete their Research Curriculum during these blocks.
- Interns videotape encounters early in their year and review them with faculty and a psychologist to hone their interviewing skills.
- Junior and senior residents spend parts of their Ambulatory weeks in geriatrics and neurology clinics.
- All residents are required to complete 6 directly-observed (by faculty) patient encounters each year during this rotation time, at which time they are given direct feedback.
All interns and residents get 4 weeks of vacation per year. These are taken in 1 to 2 week blocks over the course of the year. We do our best to meet the requests of our residents.
Of course, all residents get 1 day off per week on average, per ACGME guidelines. On electives, residents are not required to work weekends, except when they are covering night shifts or providing backup services to other residents who are unable to work.
All primary care, TEACH, IM-Psychiatry, and categorical residents have at least 130 half-day clinic sessions, as mandated by the ACGME. Our preliminary interns also have continuity clinic at the VA or Kaiser, but we are less stringent about the number of clinics that they attend.
Residency programs across the country, including ours, have always struggled with the tension of residents going to clinic while working on very busy inpatient services. In July 2012, we instituted a new schedule, which we call 4+1+1, to try to eliminate this tension. In 4+1+1, residents do 4 weeks of an inpatient rotation, followed by two weeks of elective, ambulatory block, or vacation (this is the 1+1 part). Residents no longer have their continuity clinic during their 4 weeks of inpatient work. During the 1+1 weeks, they have 2-3 continuity clinics where they can care for their primary care patients and give them their full attention. A sample schedule can be seen on the Categorical Track page.
Most residents have their continuity clinic at the UC Davis General Medicine Clinic. This clinic comprises 32 exam rooms and over 40 staff supporting 60+ residents in the residency clinic, our general medicine faculty practice, and endocrinology, infectious disease, rheumatology, anticoagulation, and allergy clinics. It is a full-service primary care clinic that sees patients of great ethnic and socioeconomic diversity.
Residents learn to practice with patients who have HMO, PPO, Medicare, and Medicaid insurances. Four to 12 residents work side-by-side each half-day with outstanding general medicine faculty. Residents work in small groups called Firms, and every resident has a dedicated Firm Attending who helps out at any time with any clinical questions about the resident’s patients. With the 4+1+1 schedule, residents now work even more as a team to provide care for their Firm’s patients, as there may be 4 weeks between clinic sessions for a given resident.
The General Medicine Clinic boasts wonderful support for a residency clinic. Many residency programs have poorly funded and under-supported continuity clinic sites. We have an outstanding telephone nurse triage system, pharmacist-run medication refill system, pharmacist-run hypertension and medication management clinics, and our own Psychiatry, Wound, and Pain Medicine clinics within our residency clinic walls. We also have excellent interpreting and social work services. This provides great access to needed services, and teaches residents to work in a multidisciplinary environment. In addition, the fully implemented and integrated EMR allows residents to easily care for their patients away from the clinic, and also allows great communication with staff, faculty (and patients though our email portal!). When you leave UC Davis, you will be ready to care for the sickest patients in any ambulatory setting.
Four residents from each class have their continuity clinic at Kaiser Clinics. Here, each resident sees patients with a single faculty doctor within that doctor’s practice, over their entire 3 years. Residents have universally praised this apprentice model due to its close mentoring and role modeling. Residents also like working in the highly efficient, patient-centered Kaiser closed-HMO model.
Two residents per class have their continuity clinic at the Sacramento County Clinics. This clinic cares for the medically indigent population of the county. Residents love caring for this very underserved population. We try to put interns who have an expressed desire to work with this population at the County Clinic. The five TEACH residents also have their continuity clinic here during their 3rd year, in the TEACH Clinic. They work as a group practice to care for their patients.