Our fellows act as consultants at Michigan Medicine and the Veterans Affairs Ann Arbor Healthcare System (VAAAHS), but have no primary patient care for inpatients at either facility. Fellows perform an average of 70-120 consultations per month and may follow a service of 12-24 patients at a time for inpatient concurrent care. At the VAAAHS, fellows perform about 30-35 consultations per month and may follow from 10-20 patients at a time.
Clinical consultation blocks are scheduled during July - December during the first year and from January - June during the second year of training. Within these six month blocks, fellows alternate months of service at Michigan Medicine and the VAAAHS (i.e., a total of three months at Michigan Medicine and three months at the VAAAHS during each block). During these blocks, coverage for at least two full weekends will be supplied by fellows not on service to reduce fatigue and burnout. This schedule provides a largely uninterrupted year to (month seven to month 18) to pursue a significant research project and elective opportunities.
Rounds at both hospitals follow a similar format (see chart below).
Consult patients are seen and evaluated by the fellow and/or medical residents, medical students, and attending physicians in the morning. The morning hours are also used to conduct follow-up visits to previously evaluated patients. After the lunch hour, the fellow and the consult team meet with the attending physician to present the new consults and to discuss the progress of patients being followed by the team. Each new patient and selected follow-up patients are seen with the attending physician and a clinical note composed by the attending, fellow or resident describing the evaluation, diagnostic formulation, and management plan is added to the patient’s chart. In most cases, attending physicians write notes for patients seen by medical students. Patient-based teaching occurs during the case presentation and/or at the bedside. The fellow, attending (or an Internal Medicine Resident) writes a formal consultation report. The attending physicians review and sign all clinical notes placed in the electronic record, both on new and follow-up patients.
Clinical Microbiology rounds are incorporated into consult rounds on a daily basis (Monday - Friday). At Michigan Medicine, these rounds begin at 1:00 pm and last until 1:30 pm. At the VAAAHS, lab rounds occur at 3:00 pm. Laboratory rounds permit the team to learn about and to discuss new significant cultures from hospitalized patients. In addition, for teaching purposes, the Laboratory staff (under the direction of the staff doctoral trained microbiologist) at Michigan Medicine prepares daily demonstrations of culture and staining techniques or microscopy.
Consult patients seen at Michigan Medicine who require outpatient follow-up are scheduled in the fellow’s outpatient clinic. If the fellow’s clinic spots are filled, the attending on service will see the follow-up patients. If the attending on service does not have a University clinic, alternative arrangements will be made.
At the University Clinics, our fellows complete an average of 150 visits per year in the outpatient setting. The majority of these patients were initially seen by the fellow as inpatients, including many being treated with outpatient IV antibiotics. We think it is critical that fellows are involved in the entire episode of care. Some of these visits are with individual patients that a fellow may follow continuously for the two years of their fellowship.
The fellows have significant responsibility in these clinics. They are the first to see the patients, to assemble all of the necessary data, review it, and develop a management plan. The plan is then discussed with a faculty member, and the faculty member either approves or amends the plan. At both outpatient facilities, patients requiring continuing care are assigned to the fellow who performed the inpatient consultation. More than one faculty member may supervise a case on subsequent visits, however, a fixed group of attending physicians staff the fellow’s clinics to improve continuity of care. Patients are not transferred from fellow to fellow or from fellow to attending until one of the trainees graduates from the program. At that point, all of the patients assigned to a graduating fellow are transferred to an incoming fellow or faculty member.
Clinics are never held without the physical presence of an attending physician. After evaluating patients, fellows present all of the relevant clinical data to the attending faculty member, in the clinic staff room, while the patient is still present. The faculty member may use this opportunity to teach, to recommend reading or specific research relevant to the patient’s problems, and to supervise specific details of the management. The faculty member will review and confirm critical physical findings. Fellows will then dictate notes concerning the patients’ visits, which are reviewed by the faculty member before they are added to the medical record. The fellow’s note is always co-signed by the faculty member. Fellows will, with rare exception of emergency follow-up, be limited to two weekly clinics.
A Ryan White Funded HIV AIDS Treatment Program has been part of the division since 1997. The program has grown significantly and now cares for almost 900 active HIV positive individuals. In a typical year, we see over 100 new patients and a portion of these patients are assigned to fellows. Further, fellows care for HIV positive individuals seen at the VAAAHS.