Insights for Success in Medical Residency at Summa Health System

Welcome to the Department of Medicine & Summa Health System David B. Sweet MD, FACP Program Director, Internal Medicine June 30, 2022

Disclaimer Past 2 years have been incredibly different and difficult, we are getting back closer to normal We did early start for the past 2 years and it seemed to work, so we are trying it again Biggest benefit seemed to be the individualized attention We re all just doing the best we can we know you will do that as well We are open to considering any suggestions

Welcome: 1 These slides are intended primarily as a reference These are just highlights Most of what is said at orientation isn t remembered. 3

Welcome: 2 When in doubt Go see the patient Always listen to the nurses Ask your senior resident 4

Welcome: 3 Treat the patients like they are your family they are someone s family. Treat your colleagues like family they will become your family. Whenever possible give others the benefit of the doubt. If something about the program doesn t sound or look right, ask someone we want to avoid any misunderstandings 5

Welcome: 4 Residency is Hard Work Average 6 days a week, 60-70 hours a week, 70-80/week during ICU & CCU One of our faculty recently gave some advice on how to do well in residency: o Show up 5 min early every day o Plan on staying an hour later than expected every day if you go home earlier than this it is a bonus Teamwork is critical to a great residency

Welcome: 5 a few pointers On Med Teams expect to be here until 5 pm unless you are overnight admitting or post overnight admitting o If patient care is completed check your IMC box and do MKSAP o We always make accommodations for health care appointments and do our best for occasional other issues that come up Complete your IMC notes on day of visit

Welcome: 6 Show up on time particularly for: o Morning sign-in o Night Call o IMC Have a To Do list on rounds Look over your patients at the end of the day

Welcome: 7 Keep up on stuff o IMC Charts complete notes by end of day o IMC electronic box Look at this daily Complete items each day o Health Stream o MKSAP o Surveys Answer pages from Mary, Val, Dawn and other secretaries

Welcome 8: Wellness Remember Residency is hard & a major commitment We do our best to help you Our system works but only if we all work together Everyone needs something sometime Do what you can to help yourself o To help yourself: Avoid exhaustion Avoid overextending yourself but ask for help when you need it Give others the benefit of the doubt Overlook slights and minor issues 10

A few words about COVID-19 Most important to be fully vaccinated oSee me if you have not had vaccine Presume every patient you see has COVID PPE requirements have changed somewhat Wear at least a KN95 or surgical mask & gloves for every patient encounter Hand-washing / sanitizer before & after every encounter Minimize exposure with high flow O2 and any aerosol procedures oAlways a FIT-tested N95 and goggles/face shield in these situations

COVID-19 Surge plans We have used several plans for COVID Surge All involved reassigning IM residents to work more closely with ICU and SHMG Covid hospitalists This plan worked to get patients the care they needed and extend that provided by ICU & Covid hospitalists Presently all services are admitting Covid patients as needed Goal is to make sure patients get the right care If uncertain, check with your senior, call your attending or call me

Who are the key individuals I need to know about? 13

Key Individuals: Brandon Rapier, Chief Resident for 22-23 Mike Rich, Chair, Department of Medicine; Director of Internal Medicine Center Ron Jones, Program Director, Transitional Program; Associate Program Director IM Joe Myers, Associate Program Director, IM Brad Moore, Core Residency Faculty & Medical Student Clerkship Director 14

Other Key Individuals Core Faculty Full Time Part Time Stephanie Zaugg Irene Chenowith Katie Tatar Julie Radwany (OP) Kamal Dayal Diana Stewart (OP) Joel Rayl Stephanie Tan (OP) Spike McCorcle Yoleetah Ilodi (OP) Jordan Groubert Junior Velez 15

Key Individuals Coordinators & Secretaries Mike Oravec, Administrative Program Director, IM Mary Yanik, Program Coordinator, IM Valecia Pickett, Program Coordinator, IM Megan Baugher, Program Coordinator, Transitional Dawn Jackson, Department Secretary Staci Westren, Medical Student Coordinator Rosie Saunders, Department Secretary Gabrielle Tebelak, Department Secretary 16

Key Individuals Fellowship Programs Jen Drost, Program Director, Geriatrics Medicine Fellowship Themos Politis, Program Director, Hospice & Palliative Medicine Fellowship Marc Penn, Program Director, Cardiovascular Disease Fellowship Justin Dunn, Program Director, Interventional Cardiology Ashley Desmett, Program Director, Critical Care Medicine Jessica Repko, Coordinator, Geriatrics; Hospice & Palliative Medicine Caitlin O Shell, Coordinator, Cardiovascular Disease Fellowship Deanna Laubis, Coordinator, Interventional Cardiology Fellowship and Critical Care Medicine Fellowship 17

How can I contact Dr. Sweet? 18

Dave Sweet Contact Info When in doubt about anything you can reach me at various numbers Office 53318 Home 330-334-1052 Summa Pager 330-971-3296 Cell 330-607-8490 Cell service inside my house is spotty but if I am not at home almost invariably I have my cell on. I turn it off overnight but there are occasional landline outages. Overnight if no answer at my house call my cell 19

Vacation Requests 1 All Requests go to the Chief Resident Brandon Rapier Not approved until signed by Brandon (including those sent with scheduling requests) Turn requests in early!! 20

Vacation Requests 2 No Vacation / Away conference time oJuly, Dec, June oICU, CCU, Night Float Exceptions in Very Special circumstances Transitional and Prelim can use 1 week vacation June 24-30 Early Start Transitional and Prelim will not automatically be able to have May 25-31 as vacation Turn requests in early!! 21

Wellness To do the best for your patients we have to be at our best ourselves Mayo Clinic Well Being Index app Download and take anonymous survey monthly Group info available to Med Ed & residency, no personal info available at all Akron Physicians Wellness Initiative available to all residents and I encourage each to use it

Akron Physicians Wellness Initiative Available to all residents Sponsored by Med Ed jointly with Akron Children s Hospital Spearheaded by Joe Varley, Chair of Psychiatry IM Champion is Ron Jones Essentially records-free counselling availability (unless very bad /dangerous info) Appointment availability with Christina Rowan, PhD Text or email for appt o Cell: 330-217-6331 o Email: rowanc@summahealth.org Will have 1 half day unscheduled during each IMC half month and encouraged to schedule appt during this time

Enroll: Compare Your Well-Being to Other Physicians. 100% Anonymously. The Well-Being Index is an online self- assessment tool that measures your wellness in just 9 questions. It allows users to compare well-being to their peers, track results over time, and receive customized learning - all 100% anonymously. QR code Help us build our culture of wellness; Join us by assessing yourself routinely. Use Invite Code Summa Health

Example of Well-Being Index Tracking

Rotation Schedules Requests for schedule change go to Mary Yanik See me after July 18 for: o Gaps in your schedule o Requests for schedule changes Unforeseen circumstances: o We try to accommodate whenever possible o I ll try to contact you with any significant rotation changes o Please accept such changes if at all possible 26

Educational Innovation Project (EIP) Developed by the Residency Review Committee (RRC) I.M. at the request of the Accreditation Council of Graduate Medical Education (ACGME) Goal: Improve resident education and patient care by applying innovative methods in both areas. 10 Year Initiative 2006-16 We are continuing and expanding the initiatives begun with EIP Many of the EIP innovations informed the current ACGME standards 27

EIP - 2 17 programs out of 400 in the country initially selected for this project o EIP began July 1, 2006 o 4 programs added July 2007 o 3 subsequently dropped Opportunity to positively impact your own education and that of future residents across the country Many of the EIP policies are now part of the ACGME accreditation policies 28

Main EIP Initiatives Use of a Team Approach (the Chronic Care Model) to enhance Inpatient Care Use of the Chronic Care Model to enhance Ambulatory Care Improve Patient and Resident Safety Improve Professionalism through a formalized curriculum 29

ACGME: Learning & Working Environment Extensive revisions July 1, 2017, and July 1, 2022 Section 6, page 50 of pdf at https:// www.acgme.org/globalassets/pfassets/programrequireme nts/140_internalmedicine_2022v3.pdf Focus on: o Safety & Quality of Care o Professionalism o Well being of all members of health care team Duty hours are 1 aspect of the Learning & Working Environment 30

Highlights of ACGME Duty Hours Rules -1 Following these Rules is YOUR Responsibility. 31

Highlights of RRC Duty Hours Rules 2 Minimum 4 days OFF per month (1 day = 24 hours) o Preferably 5 days OFF during most subspecialty months NEVER see New Patients after 24 hours on duty NEVER on duty in the hospital beyond 28 hours Maximum 80 hours per week averaged over rotation or month 32

Some Duty Hours standards that were changed by ACGME Minimum time out of hospital has been changed to: oSHOULD be out of the hospital a minimum of 8 hours Standards that were removed: o16 hour limit for PGY 1s oThe 6 consecutive night maximum oCall no more often than every third night (excluding Night Float) 33

Work Flow Redesign Call System Call System Redesigned further July 1, 2006, minor revisions July 2007, Dec 2010 Goal max call length 16 hours rather than the RRC mandated 28 hours Why? Rested residents can learn more, take better care of patients and are safer than tired residents. 34

Summa Internal Medicine response to 2017 Change in ACGME Duty Hours No Substantive Change in how we do things We have continued our current scheduling system rather than expanding the number of hours residents are on duty We are now less strict with insisting PGY 1s leave no later than 16 hours If your time on duty is approaching 19 hours I want to hear from you 35

Call Schedule Overview Day AR1 7A 7P Night 6:30P 7A* (10:30A**) 7:30P 7A* (11:00A**) 6:30P 7:30A 7 7:30A Signout 6:30 7P AI1 7A 7P 6:30 7P (to AR1) AR2, AI2, AI3 ICUR, ICUI 7A 7P 6:30 7P 5-5:30A&P 5A 5:30P 5P 5:30A CCUR,CCUI 6A 6:30P 6P 6:30A 6-6:30A&P *= end of admitting time; ** = expected end of shift 36

Call Schedule Days Off identified on individual schedules for Med Team, ICU, CCU Chief Resident also makes Neuro schedule Goal oAssure compliance with RRC rules oOptimize patient care PGY 1s must check with Mike Oravec, Brandon Rapier, or Dave Sweet before modifying Days Off 37

Unique Call Features 1 Night AR1 and AI1 o Round with the team from 8:30 10 am o AR1 leave by 10:30-11 am always by Noon o AI1 leave by 11 am always by Noon Cross Cover AR1 & AI1 (most Sat night, often on Fri night) o Round the next morning 8:30 10 am with the Team (and write notes) on the patients they admit overnight 1 Senior and 1 PGY 1 from the daytime admitting team (who came in for the day on the admitting day) o Round & write notes next day on old Med Team patients o Round with overnight cross cover on overnight admissions 38

Unique Call Features 2 AI2 / AI3 o Daytime 1 resident holds both o Overnight 2 residents o May get calls about some non-Med Team patients o See the patient if it seems urgent o If in doubt about seeing a patient, call your senior o Talk with your senior about every call o Write a note for every patient you see o Average 6-8 calls/night for each PGY 1 o Overnight supervision for non-Med Team patients is by senior & in house ICU attending or SHMG Nocturnist 39

Unique Call Features 3; Jeopardy Call Just implemented June 2022, need apparent due to Covid 1 senior per weekend / holiday Daytime Med Team, ICU, CCU backup All residents still have 2 weekends (4 days) off per month at a minimum Thus far have not needed Jeopardy system for PGY 1s any time or for weekday seniors or weeknight seniors We rely on teamwork to get everything done if a resident goes out

Unique Call Features 4; Raspid Response Rapid Response nursing goes to almost all calls on non-Med Team patients If you have to do anything with the patient (make an assessment beyond that of the Rapid RN, write orders) talk with the patient s attending and write a note If you have to write orders or a note on a non- Med Team patient there must be a consult to Med Team 41

Unique Call Features 5 Read an EKG If only a reading of EKG is needed the nurse should call the Cardiology fellow Neverjust read an EKG Always see the patient and make an evaluation based upon the entire clinical picture, including the EKG Presume the RN was concerned about a cardiac complaint which led to an EKG being obtained Talk with senior resident AND Cardiology fellow 42

On Duty Time Med Team Weekdays 7A 5P / completion of patient care / sign out Never leave before 5 pm without sign out to another member of your team this should be Rare 1 Senior & 1 PGY 1 from each team must stay on campus until 5 pm. Both cannot be in IMC Never leave before 4 pm without approval of Chief Resident. Must be available by pager Weekends/Holidays 7A end of rounds/completion of patient care AND verbal sign out to cross cover Admitting & post-Admitting days see details at https://www.summalearner.com/ 43

On Duty Time CCU Days 6A 6:30P Nights 6P 6:30A Day & Night hours same weekdays, weekends, holidays Daytime CCU never stays past 7 pm Overnight CCU never stays past 7 am Never leave before 6 pm without approval of Chief Resident More details at https://www.summalearner.com/ 44

On Duty Time ICU Days 5A 5:30P Nights 5P 5:30A Day & Night hours same weekdays, weekends, holidays Daytime ICU PGY 1s never stay past 6:30 pm, seniors never past 7 pm Overnight ICU never stays past 6 am Never leave before 5 pm without approval of Chief Resident More details at https://www.summalearner.com/ 45

On Duty Time Other Rotations Weekdays 7A 5P/completion of patient care Never leave before 5 pm without sign out to another member of your team or Day Pager Never leave before 4 pm without approval of Chief Resident. Call Chief Resident if attending OK s leaving before 4 pm. Must be available by pager until at least 5 pm Weekends/Holidays individualized by rotation Must have minimum 4 days off per month, often more Neuro follow schedule at https://www.summalearner.com/ 46

Duty Hours Tracking Must track everyone for at least one month simultaneously Mandatory tracking in July & probably Feb Must occur weekly (before 8 am Monday) Weekly tracking every month in ICU & CCU Mike Oravec, Mary Yanik & Valecia Pickett will work with me to track compliance with the RRC time restrictions. New Innovations for on-line duty hours tracking Weekly time cards for those for whom on-line tracking is not as convenient. CarePath & Parking Deck swipes may be used to confirm some info 47

IMC Month & Night Float Categorical oIMC usually half month increments usually attached to half month Night Float, HPM, or ER oIf 1 half month PGY 1 NF, second will be in July- Sept 2021 with AI2 or AI3 pager oTotal 3 IMC months during the 3 years Transitional / Prelim 1 calendar month IMC & 1 month NF Vacations no more than 1 week vacation / conf during IMC month 48

Transitional/Prelim & IMC One month rotation More half day sessions due to RRC rules for Transitional 1 Half Day IMC per week during Med Teams During Med Team IMC half days only follow up of your own Med Team patients with 3-4 patients per half day 49

Ambulatory requirements ACGME requirements mandate 1/3 ambulatory time Scheduling to address this includes: o Subspecialty Ambulatory experience may be block or intermittent o ER changed to month in PGY 1 o HPM month ambulatory during PGY 1 o Free electives now have some ambulatory requirement