Rotations

Categorical interns will spend one month with a dedicated chief resident and a staff physician learning procedural skills and elements of patient safety and quality improvement methodology. Two or three interns are assigned to this service and will become skilled in providing the following services for inpatients on a consultative basis: bedside ultrasound-guided paracentesis, arthrocentesis, thoracentesis, lumbar puncture, and central line placement.

Interns will also receive online didactic information on quality improvement and patient safety and will participate in local quality improvement activities, including hospital committees and “root cause analysis” of errors.

Two interns, one resident, medical students, pharmacy students, and a supervising attending physician comprise one team serving the general medicine patients at one of two inpatient training facilities (University Hospital (UH) or the Audie L. Murphy VA hospital).

At UH, there are 6 teams that rotate a “late call” day in which the upper level resident from the late team stays to help interns with their last admissions of the day. UH is on a “drip” schedule where every team admits new patients every day.

At the VA, a traditional call schedule is used with call days rotating every 5 days. The team on call admits new patients until 7pm.

Admissions are capped at or below the ACGME limits for both call teams and night float. The training goals for interns on the general ward services include: developing a cost- and time-efficient approach to the diagnosis and management of common medical disorders, becoming proficient at common procedures, and maintaining and refining caring, humanistic patient relationships. Finally, interns make the transition from student to teacher in their interactions with the medical students.

Two or three interns, two upper-level residents, and medical students comprise the cardiology team. One upper-level resident works during the day and assists the interns with admissions and general care of patients. The other resident works at night and completes all overnight admissions with the assistance of the in-house cardiology fellow.

We have a cardiology care unit (CCU) at both the Audie L. Murphy VA hospital and University Hospital (UH). The cardiology experience involves caring for all patients admitted to both general cardiology and cardiology ICU beds. Supervision and teaching are provided in daily rounds with the cardiology staff attendings and fellows.

Training goals for the cardiology service include: managing patients with myocardial infarction and its complications, treatment of unstable coronary syndromes, diagnosis of complex rhythm disturbances, advanced electrocardiographic interpretation, diagnosis and treatment of heart failure, and much more.

The critical care team is usually comprised of three interns, three residents (two during the day and one overnight), two pulmonary/critical care fellows (one during the day and one at night), a pharmacist, and an attending. We cover a medical ICU (MICU) at both the VA and University Hospital (UH).

The critical care experience involves covering all MICU admissions. Supervision and teaching are provided in daily rounds with the critical care staff attendings and fellows. Training goals for the critical care service include: managing complicated patients requiring interventions such as mechanical ventilation and vasoactive medications, competence in ICU procedures including central venous catheter placement and arterial line placement, and participation in code blue scenarios.

Common disease processes encountered include: the adult respiratory distress syndrome, septic shock, gastrointestinal hemorrhage, pancreatitis, severe community-acquired pneumonia, severe electrolyte disturbances, diabetic ketoacidosis and others. The ethical issues arising during the ICU experience involving end-of-life care are an integral part of our residents’ training.

Preliminary interns and second year internal medicine residents rotate through the Emergency Room at both the Audie L. Murphy VA hospital) and University Hospital (UH). The UH ER evaluates approximately 2500 patients each month, and thus trainees encounter a tremendous variety of diseases.

During the ER month, the resident works approximately 19 twelve-hour shifts with at least one full day off per week. In the ER setting, the resident has the first chance to evaluate patients after their arrival to the hospital. The resident presents the case to the ER attending, including his/her assessment and management plan, and will receive valuable feedback and insight. The resident will follow that patient throughout their ER course until patient discharge or admission to the hospital, and will be responsible for all orders, notes and consults.

Training goals of the ER service include: managing a broad range of medical emergencies, developing an understanding of criteria for admission versus outpatient management of non-emergent medical conditions, learning the judicious use of laboratory and radiologic studies in the initial assessment of patients, and the application of principles of advanced cardiac life support (ACLS).

An average of 2-4 residents per month rotate through this service, which occurs exclusively in the outpatient setting. This is completed at WellMed, one of the private medical groups in San Antonio. Principally, patients present to clinic with a medical problem requiring a focused history and physical examination.

The residents on this rotation will be supervised by general internists with special interest in teaching primary care and preventive medicine. Due to increased follow-up opportunities, the resident gets a better understanding of how a complicated medicine patient can be managed with frequent interim clinic visits. Because it is hosted by one of the private primary care clinics in San Antonio, it gives residents a unique insight into a non-academic site. There is no call, overnight or weekend duties while on this optional rotation.

Two residents per month and an infectious disease fellow are supervised by an infectious disease attending on this inpatient service, which specializes in the care of patients with acquired immunodeficiency syndrome and its complications.

The residents evaluate admissions to this service from the emergency room or outpatient HIV clinic and accept patients transferred from general medicine services. The residents also attend a bi-weekly clinic to become familiar with the preventive/ambulatory management of AIDS patients (i.e., PCP prophylaxis, anti-retroviral therapy, reducing HIV transmission risk, and treatment of opportunistic infection). This team is University Hospital based and participates in the “drip” system with the other general medicine teams, usually to only accept HIV-positive patients.

Second-year residents rotate on one or two of the following during their one month neurology block: neurology ward service, neurology stroke service and neurology consult service. Duties include providing consultation of patients with neurologic diseases in a variety of settings such as the emergency room and medical or surgical wards.

This rotation is based for two weeks at University Hospital and two weeks at the Audie L. Murphy VA hospital. The residents will attend weekly neurology grand rounds and other didactic teaching sessions given by the Department of Neurology.

Training goals for the neurology service include: perfecting the neurologic physical examination, reviewing neuroanatomy and the localization of neurologic lesions based on physical exam findings, appropriate use of neuroradiology imaging modalities, prevention and management of acute stroke, managing neurologic emergencies such as complicated seizure disorders, and appropriate referral strategies for patients with neurologic diseases.

The night service is a team composed of a triage hospitalist staff, one senior resident and one or two categorical interns for each hospital. Housestaff will rotate at each hospital for 2 weeks.

The senior residents admit new patients and provide urgent medical consultations to other services overnight. The intern is responsible for cross coverage of the established inpatients on the HIV and general medicine services. The senior residents supervise and provide back-up to the interns as they manage acute medical problems on these services.

A faculty attending physician provides onsite supervision and teaching each night at both hospitals. He/she is available to supervise procedures and code resuscitations, as well as provide immediate feedback and guidance on the new admissions. The night float admissions are then distributed as “short call” patients to the general medical or sub-specialty teams.

Two to three senior residents and an attending physician staff the medicine consult service each month. This team generally sees consultations between the hours of 7 AM and 7 PM daily, at which time the night service takes over such duties.

This team provides consultation and assists non-medicine services (surgical sub-specialties, obstetrics, psychiatry, etc.) in the management of medical disorders. They also perform inpatient pre- and peri-operative evaluations. They make decisions about appropriate transfers to medicine services from non-medicine services. The lessons learned in this month are valuable to the future internist, as they provide a background for assisting non-internists with the management of common medical problems.

This rotation is designed to expose senior internal medicine residents to the field of hospital medicine beyond the inpatient wards. During this rotation, residents will be responsible for triaging ER patients, assigning patients to the appropriate level of care/teams, performing consults in the ER, and reviewing literature relevant to hospital medicine.

Residents will learn the skills necessary to efficiently transition patients from the outpatient to the inpatient setting. Didactics will cover curricular competencies that introduce billing concepts, core measures, readmission rates and utilization.

Elective months provide the opportunity to individualize the training experience. They can be used to enhance primary care training, to concentrate on medical sub-specialties, or to do research.

We offer rotations in all medicine sub-specialties. The resident sees consultations and participates in outpatient clinics, conferences, and procedures. Primary care outpatient electives include women’s health, HIV management, dermatology, musculoskeletal medicine, nephrology, rheumatology and hepatology. Research electives are conducted with the guidance of a faculty advisor in the field of interest.

Residents have the opportunity to present their work at the annual South Texas American College of Physicians Associates Program held in San Antonio each spring. At each spring meeting, over 50 presentations of research and clinical vignettes are given by internal medicine residents from six participating South Texas teaching programs. Residents also present at our local Department of Medicine Research Day and may present at regional and national specialty conferences as well.

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In addition to numerous sub-specialty elective opportunities, we also offer the opportunity for residents to create their own elective. This often leads to the creation of new electives.

Examples of electives residents have helped create include Medical Spanish Interpretation & Translation, Clinical Informatics, and Global Health.