On Inpatient Services, our residents not only experience the unique patient care within a state-of-the-art tertiary care center like the Michigan Medicine Hospital, but will also spend time in the Ann Arbor Veterans Affairs (VA) Hospital which complements the clinical experience tremendously.
- Michigan Medicine Hospital
- Major tertiary care referral center for Michigan, Northern Ohio, and Indiana, but also a community hospital for Ann Arbor and surrounding areas
- Focused subspecialty services combined with broad general medicine exposure
- Ann Arbor Veterans Affairs (VA) Hospital
- VA referral center for the entire region, but also serves the local veteran community
- Broad general medicine exposure (including ICU)
Inpatient Service Model
Guiding Principle: The optimal inpatient experience includes specialty experiences balanced with general medicine and critical care exposure.
Maximize Time for Education
- Resident Assistant Program - Designed to help teams with non-medical patient care tasks. At the University Hospital, each service has a resident assistant that performs clerical and other support tasks for the team. At the Ann Arbor Veterans Affairs Hospital, a care coordinator rounds with each team to assist with similar support tasks with a focus on optimizing transitions of care to the outpatient setting.
- Inpatient service caps designed around education - Each intern’s census is capped at a maximum of eight patients at the University Hospital and VA. Intern admissions are capped at five per long admitting day or night shift. Senior admission and team census caps are in place as well.
- Subspecialty services - In addition to General Medicine services, residents at the University Hospital rotate on the Cardiology, Gastroenterology/Hepatology, and Hematology/Oncology inpatient services, which offer opportunities to work directly with fellows and attendings in these fields daily.
- Duty hours – There is an excellent culture of sign out at the hospital, allowing residents to leave when their work for the day is completed and the late call team can appropriately cross-cover the patients. Services are carefully monitored to ensure that ACGME work hours are met, though most residents tend to be well under the limit.
- Overnight coverage – Apart from a single 24 hour call on Saturday at the VA MICU, all services have dedicated night float coverage. The night float teams are themselves relieved once per week by residents on consult or ambulatory rotations (which account for about four weekend nights per year per resident).
Inpatient Rotation Overviews
There are three separate resident-based general medicine teaching services. The vast majority of these are staffed by attending faculty who at other times of the year provide direct patient care in their role as hospitalists at Michigan or the Ann Arbor VA. This structure provides residents with teaching by faculty who are accustomed to the daily experience of being the first contact caring for complex inpatients.
- UH General Medicine (Dock, Francis, Hewlett, Sturgis): These are the traditional general medicine services that care for a broad variety of patients and medical conditions. Teams are comprised of an attending as well as one senior resident, two interns, and zero to two medical students. Teams are on call every other day, alternating between early call (admit 6 total) and late call (admit four total). Teams can sign out to the late call team once their work is done in the mid-afternoon. In addition, the late call team carries the code pager for the hospital. Two night float senior residents split the cross cover for the four teams overnight from 7pm to 7am and admit two to five patients each night.
- VA General Medicine (Gold, Silver, Emerald, Ruby): There are no medicine subspecialty primary services at the VA; as such, the VA general medicine services manage a broad variety of inpatients and conditions. This is a highly teaching-oriented service aimed at providing a smaller hospital experience to the trainees. Teams are comprised of an attending as well as one senior resident, two to three interns, and three to four medical students. Teams are on call every other day, alternating between early call (admit six total) and late call (admit five total). Faculty who round at the VA tend to work at both the University and the VA. The call cycle is similar to UH General Medicine. There is a faculty nocturnist and a senior resident who split the cross cover of the four teams overnight from 7pm to 7am.
- UH Hospitalist (Newburgh): This is a two-week rotation where senior residents can work in a role that is similar to a future career as a hospitalist. During the “inpatient” week, a senior resident is paired with a hospitalist and manages a list of up to 10 patients each for a week at a time. There are no interns or medical students on this rotation, and the residents do not perform admissions during this week. On the “admitting” week, the residents have afternoon admitting shifts, continuity clinic, and ample time off. There are two Newburgh teams working at any given time which allows for the teams to sign out to one another every other day. The service is covered by an advanced practice provider overnight with on-site nocturnist faculty supervision.
Residents rotate on the General Cardiology service as both interns and senior residents. These are busy services with a high degree of turnover, designed to maximize the educational experience for both general internists and those interested in pursuing a career in Cardiology. Residents manage conditions such as acute coronary syndrome, decompensated heart failure, atrial and ventricular arrhythmias, pulmonary hypertension, valvular disease, adult congenital heart disease, endocarditis, and much more. There is ample teaching, ranging from interpreting EKGs, echocardiography, and coronary angiograms to understanding the evidence behind major guidelines. The General Cardiology service is divided into four teams that each consist of an attending cardiologist, 1 senior residents, 2 interns, and 0-2 medical students. Teams are on call every other day, alternating between early call (admit 8 total) and early call (admit 6 total). Teams can sign out to the late call team once their work is done in the mid-afternoon. In addition, the late call team carries the code pager for the hospital (in conjunction with the late call General Medicine team). Three residents (2 seniors and 1 intern) cover the four teams overnight from 8pm to 7am and admit up to 10 patients collectively.
Residents rotate on the Gastroenterology/Liver (“GIL”) service as an intern and have the option to do so as a senior resident. These complex subspecialty services have two attendings: (1) a gastroenterologist who is the attending of record for patients with pancreatic disease, inflammatory bowel disease, and complex biliary disease as well as (2) a transplant hepatologist who is the attending of record for patients with advanced liver disease/cirrhosis and patients admitted following a liver transplant. Residents are exposed to a broad variety of care, including modern biologic therapy for IBD, transplant-related complications, immunosuppression, infection, decompensated cirrhosis, gastrointestinal bleeds, and much more. Two teams, each composed of one senior resident, two interns, and zero to two medical students, round with both attending faculty daily and admit new patients every other day, although only the senior resident and one of the interns stays all day. A senior resident and an intern cover the two teams overnight from 8pm to 7am and admit up to five patients.
Residents rotate on the Heme/Onc service as interns and have the option to do so as a senior resident. The Hematology portion of the service primarily cares for patients with acute leukemias and other liquid malignancies as they undergo induction chemotherapy, though a variety of other conditions are managed, including aplastic anemia, neutropenic fever, and patients admitted for complications of chemotherapy. The Oncology portion of the service cares for patients with solid tumors who are admitted with complications of their malignancy or treatment that would be best suited to having an oncologist as the inpatient attending of record. Teaching on this service is focused on appropriate diagnostic workup for malignancy, interval staging and screening, principles of cancer treatment, complications of chemotherapy and immunotherapy, and management of oncologic emergencies (tumor lysis syndrome, spinal cord compression, hypercalcemia). Two teams, each composed of one senior resident, two interns, and zero to two medical students, round with both the Hematology and Oncology faculty members, along with a Hematology fellow and a dedicated pharmacist for each service. The teams each admit new patients every other day, although only the senior resident and one of the interns stays all day. A senior resident and an intern cover the two teams overnight from 7pm to 7am and admit up to five patients.
Critical Care Medicine
The Critical Care Medical Unit (CCMU) is the University’s name for the medical intensive care unit. It is a 20-bed closed unit divided into four teams (Blue 1, Blue 2, Maize 3, and Maize 4), each composed of a senior resident and an intern. Both Family Medicine and Emergency Medicine residents also rotate through the CCMU. Blue and Maize each have a dedicated faculty intensivist and pulmonary/critical care fellow. Residents take care of the some of the sickest patients in the hospital, and daily teaching sessions are focused on the conditions that we commonly see and manage, including circulatory shock, respiratory failure and mechanical ventilation, kidney failure, and all other aspects of critical care. Residents perform commonly needed bedside procedures for their patients, including but not limited to arterial line placement, central venous catheterization, acute hemodialysis catheter placement, paracentesis, and thoracentesis Dedicated procedural supervision is provided by faculty, fellows, and senior residents. Residents are also responsible for leading family meetings and coordinating complex goals of care discussions. Two teams stay until 8pm daily when the night team arrives; the other two teams sign out to the team they rounded with, allowing for appropriate continuity of care. Two seniors and two interns along with an in-house pulmonary critical care fellow cover the service overnight from 8pm to 7am.
Cardiac Critical Care
The Cardiac ICU (CCU) is a 10-bed closed unit divided into two teams, each composed of a senior resident and an intern, along with a dedicated faculty cardiologist (typically either an Interventional Cardiologist or Heart Failure/Transplant subspecialist) and cardiology fellow. Conditions commonly seen in the CCU include cardiogenic shock, ST-segment elevation myocardial infarction, cardiac tamponade, ventricular tachycardia, and high-grade heart block. Residents gain exposure to advanced mechanical circulatory support and electrophysiologic procedures. Residents perform arterial line placement and central venous catheterization routinely. Teams alternate staying until 8pm daily. One senior resident along with an in-house cardiology fellow covers the service overnight from 8pm to 7am.
VA Medical ICU
Residents rotate through the MICU at the VA only as second- and third-year residents. There are three residents who round daily along with a faculty intensivist and pulmonary/critical care fellow. The VA MICU is a smaller unit than the CCMU; as there is no cardiology ICU at the VA, residents will take care of both medicine and cardiology critical care patients. Residents do all procedures at the VA in the same fashion that they would at the University. One of the three residents stays until 8pm daily. One senior resident covers the service overnight from 8pm to 7am, except on Saturdays when a day resident stays for a 24-hour call.
Patient Care Technology
- Michigan Medicine Hospital
- MiChart: EPIC based with mobile access
- Shared best practices in templates
- MiChart: EPIC based with mobile access
- Ann Arbor VA Hospital
- CPRS - Nationwide integrated system (labs, notes, etc.) with online order entry. Digital radiology accessible from any computer
- Inpatient teams carry phones to help coordinate care
- Online resources and mobile apps (UpToDate, DynaMed)