Patient Caps and PGY-2/3 expectations Internal Medicine

[BrainDead12]

ACGME Rules Regarding Patient Numbers per Intern and Resident
- Interns (PGY-1)
 Interns can follow no more than ten (10) patients at any one time.
No more than five (5) new patients + two (2) transfers can be assigned to an intern during a routine day of work.
 No more than eight (8) total patients (news + transfers) can be assigned to an intern over a 2-day period.

- Senior Residents (PGY-2/PGY-3)
 With one (1) intern on the team, the supervising resident can follow
no more than fourteen (14) patients at any one time (this means the intern can follow up to ten (10) patients and the resident, without the intern, can follow an additional four (4) patients).
• With one (1) intern on the team, the supervising resident can only have five (5) new patients + two (2) transfers assigned to the team during a routine work day.
• No more than eight (8) total patients (news + transfers) can be assigned to the team over a 2-day period.
 With two (2) interns on the team, the supervising resident can follow no more than twenty (20) patients at any one time.
• With two (2) interns on the team, the supervising resident can only have ten (10) new patients + four (4) transfers assigned to the team during a routine work day.
• No more than sixteen (16) total patients (news + transfers) can be assigned to the team over a 2-day period.

Is above still accurate?

Say intern is brand new, coming to team on Monday, all patients will be new to them. What is the max they can expect to cover that first day? Based on above I found, it would be 5 and 2 transfers. Does overnight admits count as transfers?

The max of 8 new over 2 days makes it look like not until day 3 should an intern be expected to be at a cap of 10?

In terms of expectations for a PGY-1 and a PGY-2/3, what do your programs expect?
PGY- 1 write all daily progress notes - sure
PGY-2/3 also write addendums to intern notes?
PGY-1 write all orders in EMR?
PGY-1 write all discharge summaries?
PGY 2/3- review discharge summaries only?
PGY-1 see all new patients and write the H and P and discuss with attending?
PGY 2/3 their for the discussion, they don't write their own note or addendum on new H and P unless no intern available?

PGY-1 handle medical students- assign them patients to see, review their notes, teach?
PGY-2/3 there for supervision?

PGY-1 presents all cases at morning report.
PGY-2/3 never do morning report? May/should attend.

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[Raryn]

ACGME Rules Regarding Patient Numbers per Intern and Resident
- Interns (PGY-1)
 Interns can follow no more than ten (10) patients at any one time.
No more than five (5) new patients + two (2) transfers can be assigned to an intern during a routine day of work.
 No more than eight (8) total patients (news + transfers) can be assigned to an intern over a 2-day period.

- Senior Residents (PGY-2/PGY-3)
 With one (1) intern on the team, the supervising resident can follow
no more than fourteen (14) patients at any one time (this means the intern can follow up to ten (10) patients and the resident, without the intern, can follow an additional four (4) patients).
• With one (1) intern on the team, the supervising resident can only have five (5) new patients + two (2) transfers assigned to the team during a routine work day.
• No more than eight (8) total patients (news + transfers) can be assigned to the team over a 2-day period.
 With two (2) interns on the team, the supervising resident can follow no more than twenty (20) patients at any one time.
• With two (2) interns on the team, the supervising resident can only have ten (10) new patients + four (4) transfers assigned to the team during a routine work day.
• No more than sixteen (16) total patients (news + transfers) can be assigned to the team over a 2-day period.

Is above still accurate?

Say intern is brand new, coming to team on Monday, all patients will be new to them. What is the max they can expect to cover that first day? Based on above I found, it would be 5 and 2 transfers. Does overnight admits count as transfers?

The max of 8 new over 2 days makes it look like not until day 3 should an intern be expected to be at a cap of 10?

Not new to them. New total.

That is, the intern can't be expected to do more than 5 History and Physicals. Followups count towards the cap of 10 immediately. Your intern can be assigned 10 patients the very first day.

In terms of expectations for a PGY-1 and a PGY-2/3, what do your programs expect?
PGY- 1 write all daily progress notes - sure
PGY-2/3 also write addendums to intern notes?
PGY-1 write all orders in EMR?
PGY-1 write all discharge summaries?
PGY 2/3- review discharge summaries only?
PGY-1 see all new patients and write the H and P and discuss with attending?
PGY 2/3 their for the discussion, they don't write their own note or addendum on new H and P unless no intern available?

PGY-1 handle medical students- assign them patients to see, review their notes, teach?
PGY-2/3 there for supervision?

PGY-1 presents all cases at morning report.
PGY-2/3 never do morning report? May/should attend.

It depends on the program and the rotation, but where I did residency:

PGY1 writes all daily progress notes (weekends excepted, because if a team had 14 patients on a day that one intern had a day off, the senior would write notes on 4-7 of them depending on how nice the senior was)
Senior resident writes addendums to H+Ps only (could be omitted occasionally if it was a simple patient and/or you were pressed for time, but some attendings insisted on it). If I ever addended an interns progress note, it's because it was deficient on some important point, and that happened exceedingly rarely.
Senior residents wrote all discharge summaries on patients who were in the hospital >48 hours. Interns only wrote discharge summaries on patients admitted <48 hours.

Admits were split up depending on how busy everyone was. Interns would get them preferentially, but I did a lot of admissions on my own and just handed it to the interns the next day for followup. For example, during the morning, if I got an early admit and the interns were busy with followups, I'd typically do it on my own. Or if we had a bolus of patients all come in at once, I might give each intern 1-2 and do the last 1-2 on my own. Or on night float, where we had one senior + one intern at all times, the intern would typically do all the cross-coverage and half the admits (supervised by the senior), while the senior would do the other half of the admits solo. As the year went on and interns became more efficient, the seniors would do fewer admits solo, but only the truly lazy ones in my program had the interns do 100% of the admits if there were 8 or 10 admissions over the course of the day.

Morning reports were split amongst residents of all three years.

 

[alternatecharacter]

I did an away rotation at a program where the seniors had to addend every note during the day with a little summarized attestation about the patient. To me that place would have been hell on earth, what a dumb idea. Hell most attendings here just have their dot phrase seen and agree paragraph and don't actually type anything.

For night admissions the cosigning type addendum I'm fine with it when the senior is sort of acting as the attending, but if I had to cosign the interns notes during the day for no good reason I'd be pissed.

As far as #of patients every program has points where you exceed your numbers at some point. I've done more than 10 admissions as a senior on ICU nights. But that's just the nature of medicine every once and a while the volumes are high and you need to pitch in. There were nights were I did only 1 so it all balances out.

 

[WheezyBaby]

It just depends on the program, for example our interns do all discharge summaries in patients they were responsible for. In general, you can expect interns to be responsible for most of the daily work and notes for patients. Seniors make sure work gets done, filling in as needed to take some load off interns. Seniors pair with subi. More of teaching falls on seniors, but interns should be teaching as possible as well. I don't remember what the official caps are, but my program is adherent to all of what you cited, so plausibly that's the case

 

[BrainDead12]

I completely understand it depends on the program but just trying to get a general feel of how some places do things. Agree some nights/days could be hell with caps and others perfect so it balances out. Agree as the year goes on expectations change for each level as well.

I think the senior (2/3) writing something at least some of the time keeps them more engaged in the case. Whether that's one time on all new patients (admits, transfers, and overnights) or just complicated ones or some combination. Having them never write something I think is too much of a pass. Having them involved in discharge summary also helps cover that goal as well.

Obviously everyone should be teaching but there's a difference between giving 5 minutes of pointers/clarifiying something as an intern to a student and the Senior taking the students and maybe has the students present topics to them only or teaches the students for 30 minutes or whatever while the intern does all their notes/call consults/etc/study on their own.

In terms of seniors jumping in to help I agree that should be occurring sort of freely/fluidly by the senior being self motivated to do that, like everything though if not clearly communicated then it may not be done/expected.

When does night float start at most of your programs?

 

[alternatecharacter]

Night float started day 1 of residency for us. I'm plenty engaged in the patient's it's my butt on the line if something goes south. Doing extra paperwork that nobody gets paid for is a waste of my life.

 

[WheezyBaby]

I completely understand it depends on the program but just trying to get a general feel of how some places do things. Agree some nights/days could be hell with caps and others perfect so it balances out. Agree as the year goes on expectations change for each level as well.

I think the senior (2/3) writing something at least some of the time keeps them more engaged in the case. Whether that's one time on all new patients (admits, transfers, and overnights) or just complicated ones or some combination. Having them never write something I think is too much of a pass. Having them involved in discharge summary also helps cover that goal as well.

Obviously everyone should be teaching but there's a difference between giving 5 minutes of pointers/clarifiying something as an intern to a student and the Senior taking the students and maybe has the students present topics to them only or teaches the students for 30 minutes or whatever while the intern does all their notes/call consults/etc/study on their own.

In terms of seniors jumping in to help I agree that should be occurring sort of freely/fluidly by the senior being self motivated to do that, like everything though if not clearly communicated then it may not be done/expected.

When does night float start at most of your programs?

I don't thinking writing notes is where I derive my sense of patient ownership, and I don't think being forced to write notes is going to instill a sense of patient ownership in anyone. Night float starts as soon as rotation 1, as late as never (though I imagine nearly all programs have some sort of night float given that interns just recently regained the ability to do long call)

 

[Raryn]

Oh, and for student management, we did it like this:

M3s followed patients along with the interns. Interns could wrangle them, though the seniors were typically in charge of teaching if there was time.

M4s followed patients with the senior residents only. The seniors wrote notes on all their patients. No interns involved (given they were supposed to be a "subi" anyway)

 

[WheezyBaby]

Oh, and for student management, we did it like this:

M3s followed patients along with the interns. Interns could wrangle them, though the seniors were typically in charge of teaching if there was time.

M4s followed patients with the senior residents only. The seniors wrote notes on all their patients. No interns involved (given they were supposed to be a "subi" anyway)

Ditto, I think this is fairly homogenous (though I could be wrong)

 

[ThoracicGuy]

There were days during my training when I would have loved to be "capped" on having more patients...

 

[akwho]

My cap on the hand surgery service my first rotation as an intern in July was... unlimited. However many people who wanted to blow their hands off with fireworks while drunk could get themselves admitted to my service. Turns out the number was about 40 at one time. That was a rough month.

 

[BrainDead12]

Sorry I wasn't clear.

When I asked when does night float start I meant what time does the shift start?
Start 6pm signout in the afternoon and then start morning signout at 7am? Start signout at 5pm and 7am? Start 8pm signout and 7am? Any program already adjusting hours/shifts so a 24hr call can be done on wards since the intern hour restriction is gone?

In terms of extra paperwork I understand addendums are viewed that way. Having seniors (2/3) write something I think is relevant simply b/c some point quickly in the future having 20-30 or more depending on your hospitalist group all at once is a shock once the trainee support is gone. Having senior write notes on those the subi covers would also achieve that goal. No one likes to write notes but end of day that's as apart of medicine as your stethoscope and it is a skill that needs to be developed and expanded like everything else. How does a (2/3) improve their medical/legal verbiage if again they never really write a note or possibly anything after intern year was my thought and concern.

 

[Ismet]

Many of these questions will vary slightly or greatly from program to program.

PGY- 1 write all daily progress notes - yes.
PGY-2/3 also write addendums to intern notes? - not in my program.
PGY-1 write all orders in EMR? - they should, with senior supervision either directly or indirectly. I always check my interns' orders.
PGY-1 write all discharge summaries? - in my program, yes.
PGY 2/3- review discharge summaries only? - attending reviews them. I'll review the first several and give feedback until they get the hang of it.
PGY-1 see all new patients and write the H and P and discuss with attending? - intern discusses patient with senior. Depending on time of day/availability of attending or complexity of patient, may or may not discuss with attending until next morning on rounds.
PGY 2/3 their for the discussion, they don't write their own note or addendum on new H and P unless no intern available? - intern writes the note.

PGY-1 handle medical students- assign them patients to see, review their notes, teach? - interns can certainly teach and review med student notes, but the senior is the one overseeing the students, teaching them, and assigning patients.
PGY-2/3 there for supervision? - yes

PGY-1 presents all cases at morning report. PGY-2/3 never do morning report? May/should attend. Residents of all levels do case presentations at my program.

Sorry I wasn't clear.

When I asked when does night float start I meant what time does the shift start?
Start 6pm signout in the afternoon and then start morning signout at 7am? Start signout at 5pm and 7am? Start 8pm signout and 7am? Any program already adjusting hours/shifts so a 24hr call can be done on wards since the intern hour restriction is gone?

In terms of extra paperwork I understand addendums are viewed that way. Having seniors (2/3) write something I think is relevant simply b/c some point quickly in the future having 20-30 or more depending on your hospitalist group all at once is a shock once the trainee support is gone. Having senior write notes on those the subi covers would also achieve that goal. No one likes to write notes but end of day that's as apart of medicine as your stethoscope and it is a skill that needs to be developed and expanded like everything else. How does a (2/3) improve their medical/legal verbiage if again they never really write a note or possibly anything after intern year was my thought and concern.

Our night float is 7-7. There's a senior and an intern doing a 24 every week that gives the night team their night off.

I still write plenty of notes as a senior. You're not always on wards and you don't always have an intern under you, especially on electives. For wards, I write addendums to the sub-I notes, I do a couple H&Ps on night float if we have a lot of admissions, I have my continuity clinic every week. You never stop writing notes.