Clinical Rotations and Continuity Clinic
This is our flagship rotation, with an amazing patient population and disease mix. There are 4 teams, each comprised of an R3, 2 interns, 1 attending, 2 third-year year medical students, and usually a fourth-year medical student. The interns and residents work days only on this rotation, and take Day Call every 4th day – admitting up to 4 patients before 4 pm.
A team of 2 R2s admit patients overnight and do after-hours general medicine consultations. These R2s present the new admissions to their team in the morning during bedside rounds, before they go home. So there is built in bedside teaching for the teams and the night residents get excellent teaching after their long night’s work.
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 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 Heme-Onc fellows, 1 hospitalist attending and 1 Hematology-Oncology attending. The interns share admissions daily until 5 PM. 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 seminar sessions each week.
UC Night Float:
All interns do 1-2 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 more senior IM residents on ICU, Cardiology and General Medicine services, in addition to phone back-up from fellows and attendings.
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. Even so, there is an in-house pulmonary fellow to help supervise the overnight intern and resident.
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.
We recently added a non-teaching cardiology service to offload the resident teams and improve the education opportunities and workload.
UC 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.
All residents do 2 weeks on our inpatient Neurology Services. Here they learn the basics of acute inpatient stroke care, secondary prevention measures, and neurologic examination skills.
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: 2 teams of 1 resident, 1 intern, and 1 third–year medical student that manage the ICU, 1 daytime floor team of 1 resident, 2 interns, and 2 third-year medical students, and 1 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 4 teams with 1 resident, 1 intern, and 1 third-year medical student. One of these teams is a Family Medicine team, who have medicine attendings. The call schedule for these teams is Long Call/Post-Call/Short Call/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.
There is an in-house hospitalist 24-7 to assist the residents when needed.
The VA ICU admits cardiology and ICU patients to the 10-bed unit, as well as cardiology patients to telemetry. This is a 1-resident, 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 (Pulmonary faculty and fellow)at 8 AM and the CCU team (Cardiology fellow and faculty) at 10 AM every day.
The attending for the ICU team is o1 of our UC Davis pulmonary faculty who rotates at the VA. The CCU attending is one of several outstanding VA cardiology faculty.
Most of our electives are at the UC Davis Medical Center. We have electives in GI/Hepatology, Rheumatology/Allergy, Nephrology, Pulmonary/Critical Care, Cardiology, Hematology-Oncology, Infectious Diseases, Endocrinology, Palliative Care, Toxicology, Psychosomatic Medicine (psychiatry), Master Clinician-Educator, and Research. Most are a mix of inpatient and outpatient experiences. Under the 4+1+1 schedule, residents mostly do electives in 2 week blocks. Residents are allowed to create “custom” electives in conjunction with the program director to gain experiences in other areas of interest. Residents do their continuity clinic 2 times per week on electives.
Residents and interns have 8-13 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 twice during the year and review them with faculty to improve their medical interviewing skills.
- 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.
- Time is given during ambulatory to complete quality improvement work and complete an online curriculum for ambulatory medicine (created by Johns Hopkins at peac.org).
- 4 weeks of the year are dedicated to our CORE AMBULATORY rotation (in two 2-week blocks). During these weeks, Thursday and Friday mornings are dedicated to core topics, including evidence based medicine, clinical reasoning, EKG reading, musculoskeletal exams, medical error reduction, quality improvement, and high value care provision.
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. 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 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 2 weeks of elective, ambulatory block, or vacation (this is the 1+1 part). Residents no longer have their continuity clinic during their 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 Program 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, Procedure, Musculoskeletal, 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.
We have 8-10 residents in our program with 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 love 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.
About 2-4 residents per class have their continuity clinic at the Sacramento County Clinics. This clinic cares for the medically underserved population of the county and will be expanding this year. Starting in January 2016, this clinic will also begin to provide primary care to undocumented immigrants in a pilot program for the County. Residents love caring for this very underserved population at the County that also has tremendous ethnic and language diversity. We try to put interns who have an expressed desire to work with this population at the County Clinic. The 5 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.