Curriculum

Intimate daily face-to-face resident-faculty and junior-senior resident teaching is critical to excellent patient care and successful residency education. All of our faculty are engaged in resident teaching. Faulty across all three Mayo campuses are also readily available by pager, telephone and mobile apps. Mayo’s unique electronic infrastructure provides ready connection to experts and best practices on all three Mayo campuses. Residents not only benefit from robust clinical experiences but also the opportunity to learn processes and systems of care within a national model of team care committed to safety and quality.

Just over half of the three year residency takes place on required inpatient rotations (general medicine, critical care, cardiology and oncology) leaving ample time to explore medical specialties, take time for research projects, rotate to another Mayo campus or sample various elective opportunities. Thirteen of 36 months are spent on the Page and Fleming general medicine services. Non-teaching hospitalist teams allow the residency to be driven by education and not service. ACGME’s mandated 2011 shifts for interns did not increase number of our inpatient rotations to meet service demands.

Typical Yearly Schedule

The categorical intern year includes two elective months for subspecialty rotation or research. The year includes six months on Page and Fleming general medicine teaching services, one month on intensive care unit, one month in the emergency department and two months on Ambulatory Block. The ambulatory experience includes a variety of one-week or less required and elective experiences including diabetes clinic, university student health clinic, hospice, multidisciplinary breast clinic and others.

Rounds and Conferences

Bedside attending teaching rounds are conducted on all inpatient services every day of the week. Chair’s Rounds takes place at the bedside every month on the inpatient general medicine service.

Conferences include daily Morning Report, Morbidity and Mortality Conference, Core Competency Series, Ambulatory Block conferences (see below), and a host of subspecialty conferences and journal clubs. The new academic year starts with an Intern Survival Skills Series. Journal Club includes a statistician.

The simulation center is the site for Tuesday Morning Report and Wednesday Ambulatory Block half-day sessions. Every month, one Morning Report is devoted to advanced physical examination skills modeled after The Stanford 25 project.

• Mayo Three-Campus Integrated Multidisciplinary Simulation Center

Handouts and PowerPoint presentations are archived on the Mayo intranet and are readily accessible through a search box on the residency internal home page.

Weekly Medical Grand Rounds frequently invites visiting professors from around the country. Grand Rounds is available by webcast for future viewing.

Handover training involves didactic training with Mayo Quality and Hospitalist Chairs, simulation center exercises and structured observed handover evaluations by seniors. Handovers make use of Mayo electronic data systems and protocols.

Rising PGY-2 residents take part in a retreat titled Becoming Seniors to facilitate their transition to senior teaching and management responsibilities.

Quality and Patient Safety Training

Mayo Clinic is a national leader in quality and patient safety, and Mayo Florida. All of our residents become Bronze-certified in the Mayo Quality Academy. Many residents, especially those going into hospital medicine and primary care, elect quality as their area of research. As a group, residents engage in class quality class projects, with the full support of world-class Mayo quality and patient safety infrastructure and methodologies. Finally, residents serve on key institutional quality and safety committees.

Inpatient Rotations

Two medical teams provide patients with 24/7 care by physician members of their primary team. Our system is uniquely designed to provide interns with senior teaching, supervision and assistance. Progressive responsibility, developmental milestones and readiness for practice are addressed by differentiating second and third year resident roles through creating the PGY-3 sub-attending role. Also, we have two chief residents, each assigned to one of the two teams, providing extra teaching as well as helping to troubleshoot any problems.

Night float rotations have been replaced by 5-day runs of consecutive night shift within the two primary teams. Days off before and after night shift runs are designed to help residents reset their biologic clocks. There are multiple non-resident hospitalist services that allow the teaching teams to be defined by education and not service. Our program currently sets a senior admission cap of 7 new patients and a team cap of 15 patients, below RRC-IM defined caps.

Handover training begins early in residency, using standardized handover protocols, electronic handover tools, and structured senior observation and feedback of intern handover performance. All handovers take place within either Fleming or Page services, since members of each team are present on every shift. Handover training is a high institutional priority, bringing simulation and other training resources to the residency.

Inpatient Resident Roles and Responsibilities

PGY-1

1. Primarily responsible for obtaining complete history and physical examination, developing plan and placing orders on new admissions, under supervision of on-call PGY-2.
2. Responsible for cross cover within the team.
3. Focus on developing skills assessing patients, initiating workup and cross-covering.
4. Move towards developing a complete plan for the patient.
5. Directly admit night duty bouncebacks to team with other team PGY-2 if not on-call.
6. Focus on developing skills assessing patients, initiating work up and cross-covering.
7. Move towards developing a complete plan for the patient.
8. Observe and develop your skills for concise, efficient patient presentations.
9. When not on call Arrive at 6 AM, Pre-round on patients, Attend morning report, rounds, noon conference, Clinic in afternoon or help finish floor work OR day off.
10. When on short call Arrive 6 AM, Pre-round on patients, Attend morning report, rounds, noon conference, Admit patients 8 AM-3PM, Finish work from 3 PM - 5 PM, Leave no later than 5 PM.
11. When on long call Arrive 6 AM, Pre-round on patients, Attend morning report, rounds, noon conference, Admit patients from 8 AM-6PM, Hand-off code and team pagers and check-out to night intern at 6 PM, Finish work from 6 PM-8 PM, Leave no later than 8 PM.
12. When on nights Arrive at 6 PM, Get code pager, team pager and sign-out from long-call intern at 6 PM, Help long-call intern with admissions/finish work at evening crunch time.
13. When team on-call, admit from 6 PM to 8 AM with on-call PGY-2.
14. When team not on-call, cross-cover on team's patients overnight and admit boucebacks to your team with other team PGY-2 (tell your team about important calls and admissions before morning report) Leave at 8:00 AM before morning report (you will not present your night duty admission to the attending. You will work with your team in transition until you leave at 8:00)

PGY-2 (Admitting Senior Resident)

1. When on-call, arrive at 0800 supervise admitting interns from 0800 to 0800 the following day and present patients to team post-call day. Leave no later than 1100 the post-call day.
2. When not on-call, arrive at 0700, conduct work rounds and provide general support to interns or post-call PGY-2.
3. Interview and examine all patients evaluated by the admitting interns. It is not necessary to repeat the entire history and physical. The admitting resident’s evaluation typically concentrates on the history of present illness and pertinent physical findings.
4. Focus on evaluating, stabilizing and working up patients.
5. Review with the intern his or her impression and plan. The admitting resident should avoid “micromanaging” but instead provide guidance and consultation for the intern.
6. The admitting resident note, which is typically one page or less, summarizes the pertinent history, positive physical findings, diagnosis, differential diagnosis and plan and can be added on to the intern’s note as an addendum.
7. Review all orders written by the interns or medical students. Co-sign medical student orders, if not already done by intern.
8. Be present at 1800 checkout by interns. Hold intern pager, answer calls and provide urgent patient care during checkout.
9. When on-call, receive checkout at 1800 from other team’s third year resident, particularly with regard to sick patients and anticipated overnight events.
10. Provide back-up for interns on overnight crosscover.
11. Attend morning report from 0800 to 830 on both on-call day and post-call day.
12. Present patients to the team on the post-call day.
13. Enrich education of interns, third and fourth year medical students.
14. Subinterns (fourth year medical students) may be assigned to general medicine hospital services and will be closely supervised by the admitting senior resident. The subintern will have increased responsibilities and over third year students. They will work up the first two admissions to the service.
15. Attend all conferences listed as mandatory by the Program Director.
16. Notify Mayo operator of any situation that affects communication (e.g. pager malfunction, emergency leave).
17. Supervise procedures that are done by interns and medical students in which you are certified competent to perform independently.
18. Perform procedures after discussion with attending physician and document them in ISES.
19. The PGY-2 or PGY-3 will notify the attending physician of the admission of all critically ill patients or the change in status of any patient from stable to unstable. Notify the attending physician of all deaths.
20. Review results of laboratory studies, x-rays and consultations each afternoon and discuss these and the ongoing plans with the junior resident during afternoon rounds.
21. Review all year-appropriate and rotation specific material in curriculum linked to the Internal Medicine website.
22. Complete a monthly Medicare Hours Tracking Form (which documents resident work hours) and submit it to the Program Coordinator in a timely fashion.
23. Notify Chief Resident so that back-up may be called-in if strategic nap needed to maintain excellent patient care, particularly during the 24+3 shift.

PGY-3 (Subconsultant)

1. Primarily responsible for the overall care of each patient and the primary source of continuity on the team. The “go-to” team member for the attending.
2. Supervise all patient care activities on the team.
3. Round in-person or over-the-phone (based on Attending’s preference) with Attending every afternoon.
4. Responsible for providing a 20-30 minute group didactic to the team once weekly. This should include a handout to each team member about a particular topic, recent journal article, literature review etc.
5. Arrive daily at 0700 to assist team as needed during pre-rounds and help post-call PGY-2 wrap up work if post-call. If on-call, discuss morning admissions with PGY-2.
6. Attend morning report from 0800 to 0830.
7. Attend morning teaching rounds daily from 830 to 1100 and additional rounding with the attending as needed.
8. PGY-3 will give one morning report per month based on an interesting patient seen by the team that month.
9. Assist interns with floor work as needed.
10. Assist admitting PGY-2 resident in supervising admitting interns if multiple admissions come in short time period. If this occurs, PGY-3 will then assume all responsibilities that the admitting PGY-2 would have otherwise had with regards to this admission. For details, see “PGY-2 Admitting Senior Resident Responsibilities” below but these include:
    • Interview and examine the patient concentrating on the history of present illness and pertinent physical findings
    • Review with the intern his or her impression and plan
    • Provide a senior resident note.
    • Review all orders written by the intern or medical student and co-sign medical student orders.
11. Work with interns to improve their presentation and documentation skills.
12. Ensure team’s compliance with duty hour rules, as well as team and individual caps and to notify Chief Resident(s) of problems.
13. Anticipate potential duty hour and cap violations by reviewing daily and notify Chief Resident(s) so that action may be taken to prevent violation from occurring.
14. Leave hospital between 1600 and 1800.
15. When team not on-call, sign-out service to other team’s Admitting Senior Resident (PGY-2) at 1800.
16. Attend all conferences listed as mandatory by the Program Director.
17. Notify the Mayo operator of any situation that affects communication (e.g. pager malfunction, emergency leave).
18. Supervise procedures that are done by the Admitting Senior Residents (PGY-2s) and interns in which you are certified competent o perform independently.
19. Review all year-appropriate and rotation-specific material in curriculum linked to the Internal Medicine website
20. Complete a monthly Medicare Hours Tracking Form (which documents resident work hours) and submit it to the Program Coordinator in a timely fashion.

Ambulatory Medicine and Geriatric Medicine Rotations

Ambulatory Block rotation is designed to give residents a broad overview of the office practice of internal medicine. This experience is designed to demonstrate outpatient primary care in the office setting but is also an opportunity for residents who ultimately will choose specialty or subspecialty practices to learn about any office practice of medicine.

During the 4-5 week block, residents will spend about 2 weeks seeing community internal medicine patients for acute illnesses or continuity of care. An additional 2-3 weeks is spent in ambulatory/office based brief experiences selected from student health clinic, breast clinic, medical orthopedics, ophthalmology, otorhinolaryngology, outpatient diabetes management and others.

The didactic sessions include a Disease-of-the-Month series in which the multidisciplinary outpatient management options for conditions such as congestive heart failure, diabetes, COPD and back pain are explored.  Presenters in this series include a pharmacist, home health agencies, chiropractor, nurse educators and physical therapists.  Additional instructional settings include small group sessions with attending, time in simulation center, online educational modules and peer-to-peer teaching.

Geriatric Block is a rotation intended to expose residents to non-hospital care of elderly patients.  While evaluation and treatment of elderly patients in CIM clinic is a key feature of the rotation, other experiences in the rotation are intended to familiarize residents with non-physician providers of care for elderly patients.

Opportunities include outpatient physical therapy and rehabilitation, out of hospital hospice care, neuropsychological testing and treatment for dementia, review of medications (deliberate or accidental polypharmacy) in the elderly.  Didactic sessions include one-on-one time with a geriatrician, online learning modules and peer-to-peer teaching.

Mayo International Health Program

Residents and fellows pursue elective rotations in underserved international communities through the Mayo International Health Program (MIHP). Participants stress the lasting and positive impact of their experiences. Serving the needs of the underserved is an important element in training future generations of leaders in academic and clinical medicine. Mayo International Health Program rotation settings are well planned and mentored. MIHP provides up to $2,000 in financial support to help defray travel and basic living expenses for those selected to participate.

• Mayo International Health Program

Quality and Patient Safety Training

Mayo Clinic Hospital in Jacksonville was among only 65 of 1200 national teaching, children’s and community hospitals awarded by the Leapfrog Group in 2011, recognizing investment in infrastructure for patient safety as well as adoption of the processes that we know save lives in hospitals.

All residents receive training in the Mayo Quality Academy and become Bronze-Certified. Many residents elect to pursue quality projects as their area research interest, especially if interested in hospitalist or primary care internal medicine careers.

Residents participate in an annual residency quality project, choosing their own subject and design, with interdisciplinary involvement. Residents receive the full support of the Mayo Quality Committee and projects follow established national quality methods. There are lectures by faculty with significant quality experience. The goal of each project is to publish results.

Curriculum in Clinical Teaching

Residents as Teachers Workshop serves internal medicine, IM fellows and family medicine residents. Mayo Medical School has complementary intranet resources for use. At the beginning of the second year, residents participate in Becoming Seniors workshops. Also, there are Faculty Development Workshops that include resident planners and facilitators.

Rotations to Other Mayo Sites

Mayo pays for transportation and housing for rotations on Mayo Arizona and Rochester campuses. Requests must be six months in advance and should focus on unique educational experiences not offered on the Jacksonville campus.

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