Scheduling Residents in an X+Y Schedule Minimizing Road Blocks, Maximizing the Resident Experience Who we are! Boston University Christiana Care Health System University of Colorado
Disclosures Craig Assistant Professor Boston University Katie Assistant Professor University of Colorado John Clinical Assistant Professor Thomas Jefferson University Julia Wishes she had something to disclose
Intro Questions Who is thinking about changing to X+Y or is transitioning to X+Y next year? Who has an X+Y system? 4+1, 3+1, 4+2, 6+2, other How long? Why did you change to X+Y? Anyone considering dropping their X+Y system or changing to a different X or Y? What is your biggest question/challenge right now? Objectives Define the components of an X+Y Scheduling System Review the pros and cons of an X+Y schedule Identify potential structures of the ambulatory portion of the X+Y schedule Identify potential barriers and creative answers to the X+Y Schedule DJ1
Slide 6 DJ1 These are the objectives from the workshop proposal. I think we will need to adjust on the fly depending on what experience people have with the schedule. I still think it could be helpful to talk about what we each include in X and Y, but we might be pretty brief on the pros and cons. Donnelly, John, 2/27/2015
4+1 Katie Suddarth, Julia Clemons University of Colorado
University of Colorado 4+1 174 Interns and Residents including 18 prelims 3 Tracks: categorical, primary care, hospitalist 4 Hospital Sites University of Colorado Hospital Denver VA Medical Center Denver Health (county hospital) Presbyterian St. Lukes (private) 7 Continuity Sites In the 4 weeks All grouped into 4 large groups of rotations: Ward Rotations CCU/ICU Rotations Electives Geriatrics Emergency Medicine Vacation 1 2 weeks Research International Electives
What It Looks Like Cohorts Weeks 1 2 3 4 5 6 7 8 9 10 1 C Group 1 C Group 2 2 Group 1 C Group 2 C Group 3 3 Group 2 C Group 3 C Group 4 4 Group 3 C Group 4 C Group 1 5 Group 4 C Group 1 C Inpatient Rotations Interns and residents rotate on the same Monday every four weeks Warm Handoff: On transition day, out going team rounds at bedside to provide in person handoff to in coming team (late clinic start) Improves Continuity of care Attendings rotate every two weeks either the Friday before or the Tuesday after the resident transition day Medical students on own schedule
Sample + 1 Week AM PM Monday Tuesday Wednesday Thursday Friday Quality Continuity Clinic Education Time Continuity Clinic Continuity Clinic Improvement Subspeciaty Continuity Clinic Continuity Clinic Personal Time Continuity Clinic Clinic (R2/R3) Clinic Experience Residents are scheduled 7 clinic sessions every 5 weeks. Up to 2 Vacation weeks allowed during clinic weeks Different faculty preceptor for each half day
Academic Half Day Content Includes: Journal Club Classics Professionalism Curriculum Evidence Based Medicine Health Disparities High Value Cost Conscious Care Burnout Prevention Need to repeat content five times Smaller cohorts allows for team building
The 4+2 Schedule John Donnelly Christiana Care Health System Christiana Care Health System 2 Hospitals 913 bed tertiary care hospital 250 bed safety net hospital Site of resident continuity clinic Thomas Jefferson University branch campus
4+2 schedule since 2009 for categorical residents only 36 Categorical 16 Med Peds 15 EM/IM 9 Transitional 6 Preliminary Each resident will have 25 two week ambulatory Sample blocks over 3 Categorical years Schedule 3 Cohorts of residents PGY-1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 micu micu amb NF vaca amb Floor Floor amb Wilm Wilm amb Floor Floor amb Elec Elec amb ccu ccu amb Elec Elec amb Floor Floor ccu ccu amb Wilm Wilm amb micu micu amb Elec Elec amb Floor Floor amb NF vaca amb Floor Floor amb Elec Elec amb Floor Floor Floor Floor amb vaca NF amb ccu ccu amb Elec Elec amb micu micu amb Wilm Wilm amb Floor Floor amb Elec Elec amb Floor Floor Floor Floor amb Elec Elec amb Floor Floor amb NF vaca amb ccu ccu amb Elec Elec amb micu micu amb Wilm Wilm amb Floor Floor micu micu vaca amb Floor Floor amb Elec Elec amb Floor Floor amb Wilm Wilm amb ccu ccu amb Elec Elec amb Floor Floor amb NF Floor Floor vaca amb ccu ccu amb NF Wilm amb micu micu amb Elec Elec amb Floor Floor amb Wilm Elec amb Floor Floor amb Elec micu micu Wilm amb Floor Floor amb Wilm NF amb ccu ccu amb Elec Elec amb Floor Floor amb vaca Elec amb Floor Floor amb Elec Floor Floor micu micu amb NF Vaca amb Floor Floor amb Elec Elec amb ccu ccu amb Wilm Wilm amb Floor Floor amb Elec Elec amb Floor Floor ccu ccu amb Wilm Wilm amb micu micu amb NF vaca amb Floor Floor amb Elec Elec amb Floor Floor amb Elec Elec amb ccu ccu Floor Floor amb Elec Elec amb Floor Floor amb Wilm Wilm amb micu micu amb Elec Elec amb Floor Floor amb NF vaca amb PGY-2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 amb Wilm FloorNF amb ccu ccu amb Vaca CSDU amb micu micu amb Wilm MNF amb Floor Floor amb CNF elec amb Floor Floor amb Elec amb Elec Elec amb micu micu amb CSDU CNF amb ccu ccu amb FloorNF Wilm amb Floor Floor amb MNF vaca amb Floor Floor amb wilm amb CNF CSDU amb Floor Floor amb FloorNF Wilm amb Floor Floor amb Elec Elec amb micu micu amb Wilm vaca amb ccu ccu amb MNF amb CSDU CNF amb Floor Floor amb MNF Wilm amb Floor Floor amb Elec Elec amb ccu ccu amb Floor NF vaca amb micu micu amb wilm Wilm amb ccu ccu amb CNF CSDU amb micu micu amb MNF vaca amb Floor Floor amb Elec Elec amb Floor Floor amb Floor NF wilm amb CNF amb micu micu amb CSDU FloorNF amb ccu ccu amb Wilm MNF amb Floor Floor amb Wilm vaca amb Floor Floor amb Elec Elec amb CSDU amb Floor Floor amb Vaca MNF amb Floor Floor amb FloorNF Wilm amb ccu ccu amb CNF Wilm amb micu micu amb Elec Elec amb ccu ccu amb CSDU CNF amb micu micu amb FloorNF Wilm amb Floor Floor amb MNF wilm amb Elec Elec amb Elec vaca amb Floor Floor micu micu amb Wilm Wilm amb ccu ccu amb CNF CSDU amb FloorNF vaca amb Elec Elec amb Floor Floor amb MNF Elec amb Floor Floor Floor Floor amb CNF CSDU amb Floor Floor amb Wilm MNF amb ccu ccu amb vaca CNF amb micu micu amb wilm Elec amb Elec Elec PGY-3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Elec amb micu micu amb Wilm CS wilm CS amb Floor Floor amb Wilm Wilm amb Floor NF Elec amb MNF vaca amb Floor Floor amb Elec Elec Elec Wilm amb Floor Floor amb FloorNF Wilm amb micu micu amb Elec Elec amb Floor Floor amb Elec Elec amb MNF wilm CS amb wilm CS Elec Elec FloorNF amb Floor Floor amb MNF Wilm amb Floor Floor amb Wilm CS Wilm CS amb micu micu amb Wilm vaca amb Elec Elec amb Elec Elec Elec MNF amb Wilm Wilm amb Elec Elec amb Floor Floor amb CNF Vaca amb Floor Floor amb Elec Elec amb micu micu amb Wilm CS Wilm CS Elec micu micu amb MNF Wilm amb Floor Floor amb Wilm CS FloorNF amb Floor Floor amb wilm Wilm CS amb Elec Elec amb Elec Elec amb Elec Vaca Elec Elec amb FloorNF Wilm CS amb micu micu amb MNF Wilm amb Floor Floor amb Wilm CS vaca amb Floor Floor amb wilm Elec amb Elec Elec Floor Floor amb Wilm CS MNF amb Floor Floor amb Wilm CNF amb micu micu amb Elec Elec amb Wilm CS vaca amb Elec Elec amb wilm Elec amb Wilm MNF amb micu micu amb CNF Wilm amb Floor Floor amb Elec Elec amb Floor Floor amb wilm CS wilm CS amb Elec Elec amb vaca amb FloorNF Wilm amb Floor Floor amb Wilm MNF amb micu micu amb Elec Elec amb vaca Wilm CS amb Elec Elec amb Floor Floor amb wilm CS amb MNF Elec amb FloorNF Wilm amb Wilm Elec amb Floor Floor amb Wilm CS Wilm CS amb micu micu amb Elec Elec amb Floor Floor amb Vaca
Sample In the 4 weeks PGY-1 Block Schedule MICU/CICU Floors Night Float Vacation 2 weeks per year Electives inpatient based electives International electives Block 1 Block 2 Block 3 Block 4 Block 5 Block 6 Block 7 Block 8 Block 9 Block 10 Block 11 Block 12 Block 13 MICU NF/ Elec CH Floor Wilm Floor CH Floor Elective CCU Elective CH Floor Inpatient Rotations ICU teams always intact for 4 weeks Floor rotations can be 2 or 4 weeks Attendings change every 2 weeks Night float Start on Saturday or Sunday before the first Monday of the block Electives can be split into 2 weeks Prefer 4 weeks Can carry over into ambulatory blocks Med Students on their own schedule
On the +2 ambulatory blocks 2 days each week resident clinic practice 3 days per week dedicated to other activities Geriatrics ER (4 days per week) Private office GIM Vacation/conference 2 weeks per year Electives Prefer outpatient based electives Monday Tuesday Wed Thurs Friday Clinic Conference Grand Rounds clinic clinic elective conference elective conference elective clinic clinic Clinic Experience Residents spend full days in clinic No back up will pull them off a clinic session Residents are arranged in coverage firms 2 residents per ambulatory block 1 attending firm chief for each team Attendings work with all resident cohort
3+1 Model Craig Noronha MD Boston University School of Medicine
Boston University 3+1 Model Residents rotate through inpatient rotations at Boston Medical Center and West Roxbury VA Boston Medical Center is 496 bed Safety Net Hospital ~150 internal medicine residents including preliminary interns 96 residents have clinic on main campus 30 categorical residents have continuity clinic at 6 community health centers or VA clinic 50+ clinic preceptors What happens in the 3 Weeks Ward Rotations CCU/ICU Rotations Vacation 1 2 weeks Nightfloat 1 2 weeks Medicine Consult Jeopardy Elective Elective Research Abroad Electives Emergency Medicine
3+1 Schedule POD WEEK 1 2 3 4 5 6 7 8 A WARD AMB WARD AMB B WARD AMB WARD AMB WARD C WAR D AMB WARD AMB WARD D AMB WARD AMB WARD Inpatient Experience Attendings and residents start and end on the same week during WARD rotations Same groupings of interns and residents work together Medical Students on own schedule Continuity of patient care not felt to be impacted Team building, but NOT sick of this team sensation Enough time for attending to grasp strengths and weakness of team members
Sample Ambulatory week Monday Tuesday Wednesday Thursday Friday AM Continuity Clinic Continuity Clinic Continuity Clinic Continuity Clinic Academic Half Day PM Subspeciality Clinic Subspeciality Clinic Subspeciality Clinic Subspeciality Clinic Administrative Time Continuity Clinic Experience Residents are scheduled 4 clinic sessions every 4 weeks. Cannot cancel clinic unless there is a special exceptionfellowship interview One preceptor is linked with one intern, one junior, and one senior resident Preceptor precepts all 4 sessions for each resident ie their precepting week falls on same ambulatory week as there residents
Academic Half Day 4 Hours of time with captured resident audience Inserted into Academic half day No Clinical duties Ability to guarantee that 100% of categorical residents experience a topic Mix of topics NOT just ambulatory Disagreement about what topics fall into Academic category Academic Half Day Sub specialty conferences Ambulatory Morning Report Wellness Curriculum Teach the teacher series QI Curriculum Communication skills High Value care Simulation based procedure training EBM and Research curriculum Professional development Finances for MDs, Negotiations,
8 9 AM Ambulatory Morning Report 9:10 10:30 Intro to EBM AM 10:40 11:50 PM PGY1 PGY2 PGY3 Communicatio n skills 12 1 PM Medicine Grand Rounds 1:15 PM 2 PM Sub specialty conference Sim Lab Mock codes QI curriculum Medicine Grand Rounds Sub specialty conference Sim Labprocedures High Value Care Medicine Grand Rounds Chiefs Lunch Chiefs Lunch Chiefs Lunch Small Group Break Out Small groups Groups of 4 5 Those who already have X+Y Those who are still developing their X+Y
Discussions for Small Groups Already Have an X+Y Schedule How do you handle scheduling templates vs individualized schedule? Do your residents have enough elective time? How is jeopardy coverage handled? How do you handle job and fellowship interviews? How are vacations scheduled? How do you handle transitions to clinic week ie night float What are pros of the system? What are cons of the system? What does your Y week look like? Transitioning to X+Y or Thinking about it Why are you changing to an X+Y system? Are you changing number of teams, types of ward teams etc? What barriers are you finding in the transition? How are vacations scheduled Do you have enough elective time? How is jeopardy coverage handled? How will you handle fellowship/job interviews?
Obstacles Programs Faced During Transition Subspecialty rotations became unbalanced could have 0 2 residents at a time Needed to change floor team structure to 1 resident, 2 interns Residents were skeptical of motives Faculty didn t like residents switching at different times Needed to have morning continuity clinic Needed more clinic faculty 39 Some of Our Obstacles More time commitment needed from chiefs to manage the schedule Block schedule did not always comply with the no more than 4 weeks away from clinic rule Reduced clinic continuity Reduced inpatient experience 40
Some of Our Obstacles Getting other Departments to schedule early Ambulatory residents needed to cover weekends and nights to give inpatient teams breaks 6+2, need to send residents to clinic during the 6 Scheduling vacations Uneven cohorts 41 Some of Our Obstacles Residency staff was overwhelmed with scheduling 2 week blocks Resident scheduling software and evaluation system couldn t follow the schedule, had to break the year up into all 2 week blocks. Subspecialists did not want to create ambulatory electives 42
Take Home Points
Benefits of Smaller Cohorts Team Building Happy hours Journal Clubs Mentorship Opportunities Transitions Need to think about how call cycles will impact clinic week Night float and then clinic week Golden weekend before or after clinic week Do residents and interns rotate on the same day?
Increasing Flexibility Split 4 week rotations into 2 two week blocks Ways to add elective time Add to the clinic week 2 week blocks of electives Combine inpatient and outpatient elective time Vacation Options All in the clinic week? Need to ensure adequate ambulatory time One week blocks versus two week blocks Ensure everyone gets time off during holiday?
Things to consider when creating the schedule Ultimate vacation requests People that need to coordinate schedules (couples) Even distribution amongst clinics How will you plan jeopardy? Maternity leave? Interview season? Need To Protect Ambulatory Time May not gain huge amounts of ambulatory time with block schedules Many changes will potentially take away ambulatory time Every resident needs 130 clinic to graduate
Coordinating Schedules Attendings: How are they currently scheduled? (2 vs 3 vs 4 weeks) Medical students: Are you going to be in charge of trying to align their schedules Off service interns: Are they also on a block schedule? Can they provide continuous coverage? Finally The first year is always the hardest year There is hidden flexibility in the schedule Use opportunities to build new experiences Academic half day Time for PI/QI New ways to get subspecialty experiences Devise a study You have the power to make changes
Contact Us Katie Suddarth: kathleen.suddarth@ucdenver.edu Craig Noronha: Craig.noronha@bmc.org John Donnelly: Jdonnelly@christianacare.org Julia Clemons: Julia.clemons@ucdenver.edu
5 Resident Teams: Lessons Learned Social events, team dinners, journal club Makes bigger program feel smaller Allows for improved mentorship Impact on Continuity in Clinic: Decreased visit continuity from patient perspective Improved visit continuity from resident perspective Significantly improved continuity from a lab follow up perspective
Lessons Learned Clinic schedules more predictable Decreased conflicting patient care responsibilities Decreased elective time (adding back subspecialty clinic time) Needed to adjust scheduling over interview season Benefit of golden weekend every 5 th weekend Educational Half Days Be Creative! Topics to think about Journal Club Classics Subspecialty Care Teach the Teacher Quality Improvement Professionalism Curriculum Evidence Based Medicine Health Disparities High Value Cost Conscious Care Wellness Burnout Prevention Simulation based procedure training Need to consider how often faculty will have to repeat content (5 times in the 4+1)
Warm Handoff One way to improve continuity Interns and residents rotate on the same day Team rotating off comes in to round, give bedside hand off to incoming team Pros Regularly interspersed diastole of clinic with weekends off during ambulatory block Allows patient centered morning & evening clinics Works with commonly used 13 block system to allow for scheduling compatibility with other residency programs Allows for four integrated resident cohorts who may cover for each other when away from clinic and may form tight bonds with other residents on same ambulatory block Easily knowable schedule allows for easier return to clinic recommendations by residents (e.g 1 week for close follow up or 2/4/6/12 months intervals for chronic management) Allows better use of resident clinic room space by making it easier to schedule a consistent number of residents Allows for scheduling of related ambulatory elective half days Permits flexibility for recurring didactic, quality improvement and panel management sessions Increased appreciation for clinic by residents Cons Perception of more limited elective time (if ambulatory clinic electives not counted) Weekend night float/medicine/call transition from wards can limit Monday clinics and electives Decreased ability of residents to swap rotations with other residents Splits residency effectively into integrated cohorts, which may limit interaction on wards/in clinic, coverage issues, unforeseen schedule adjustments Limited patient access (acute visits, non face to face interactions, completion of forms) for X week periods between ambulatory blocks Increased scheduling difficulty related to scheduling ambulatory electives during half days not in clinic (with students and residents alike) May require programs to find high quality half day experiences for residents, which may lack continuity or rigorous training experience Requires programs to staff and support supervision of half day didactics, quality improvement and panel management sessions Increased stress on clinic staff in management of patients between ambulatory blocks
Lessons Learned Boston University Increased community within groups of residents ie each pod that shares an ambulatory week *pot luck dinners, dinners, movie nights* Decreased interactions between residents from different pods/preliminary residents Residents have ~6 more hours a week during an inpatient rotation to focus on inpatient care Residents appreciate clinic more *Unclear if change in % of residents choosing PC* Increased connection between preceptors and residents Increase in dedicated ambulatory teaching Academic Half day Lessons learned Boston University continued Clinic schedules more predictable Continuity clinics have difficulty with scheduling especially health centers Difficult to track all residents in sub specialty clinicresidents skip sub specialty clinics Association between residents and preceptors stronger Short intense periods of clinics but then long periods between clinic time Is this Continuity??? Residents guaranteed 2 personal days per year have to be in clinic week Increased preceptor demands 25% of weeks dedicated to precepting
Thoughts Allow 2 weeks of vacation from +4 and 2 weeks from +2 Protect weekends when on ambulatory ER Starting night float on the weekend before the block starts Allow more 2 week rotations Mixes up the cohorts Allows flexibility in the schedule With a cost Get attendings to change on the same schedule Start electives on the +4 and finish them on the +2 Allow some decrease in clinic time to improve subspecialty experience Only need 130 clinic sessions over 3 years Pass everything you learn on to the next set of chiefs Challenges Logistical challenges 26 blocks to schedule instead of 13 blocks for each resident More difficult to make schedule changes Conflict with combined program using ½ day clinic per week schedule Combined program residents need other residents to cover on floors Trying to add combined residents into ½ day clinic session creates crowding Decreased Floor rotations Eliminated one month of floor from Pgy 2 and 3 year Reduced floor staffing by one resident at the smaller hospital Choppier Schedule Some floor blocks and many electives are only 2 weeks at a time Subspecialty time on Ambulatory blocks lacks daily continuity Reduced number of teaching beds in the hospital
Unforeseen Consequences Residents like 2 week floor rotations and electives Clinic Continuity improved slightly Combined residents are jealous of the schedule Subspecialists wanted more time with the residents Clinic faculty feel that the residents are more invested in clinic Some rotations intended for ambulatory clinics end up on inpatient consult service Full day clinic sessions are very well received Wins Less Stress Not rushed to get to clinic or back to hospital No longer doing back to back intense rotations Better Focus No longer split in two directions Fewer distractions Better focus on rotation and clinic Better Clinic Experience More ownership of clinic responsibilities More investment in PI projects Improved Continuity Easier to schedule outpatients with more availability Fewer handoffs and sparse coverage on inpatient rotations