Rotation Overview

Our curriculum allows residents to develop top-quality skills in both the inpatient and outpatient setting. The curriculum is fine-tuned with ongoing resident involvement. Each subspecialty elective includes responsibility in the inpatient setting as well as outpatient experience in the subspecialists’ office. The curriculum integrates stimulating clinical experiences in a “real world” academic medical center and rigorous evidence based instruction by nationally recognized faculty. Residents are simultaneously challenged and supported – creating a vibrant learning environment.

Rotation

PGY-1
(# mo’s)

Combined
PGY-2&3
(# mo’s)

Inpatient teaching services

4.66

5.5 – 6.5

Night float

1.27

1.0 – 1.5

ICU

1.66

2.0 – 2.5

Outpatient block

1.2

1.0 – 1.5

Improving the Healthcare System

0.5

1.0

Procedure Rotation

0.5

-

Electives and Selectives*

3.0

12 – 13

*Includes Medical Specialties and 2-week blocks of Geriatrics and ER

Inpatient Medicine Teaching Service

Key Features

  • Progressive Responsibility
    • Unique team structures linked to resident development
    • Step-wise increase in patient census as PGY-2
  • Diversity of patients
    • Varied demographics
    • Wide range of diseases
  • Emphasis on autonomy
    • 1:1 linkage with hospitalist
  • Interactive teaching conferences
    • New dynamic congerence series
  • Night float system
    • No shifts longer than 16 hours at any PGY level
  • Superb ancillary support services

Each first-year house officer spends 4.5-5 rotations on the inpatient service. Team structures intentionally vary.  Specifically, interns work with upper-level residents in two different team structures.  First-year residents may either be paired alone with an upper-level resident or be part of a two intern, one resident team.  one of the senior housestaff is from Oregon Health & Science University (OHSU) and represents part of our formal affiliation with its medical school.  Our program also has a formal affiliation with the Providence Milwaukie Family Practice Program with each family medicine intern having an experience on one of our ward teams. Teams usually have either one junior medical student or a fourth year sub-intern for each intern on the team. Teams average six to eight patients for each intern on the team.

We believe that a teaching service team overwhelmed with too many patients serves neither the best interests of the resident nor of the patient. So, a teaching service is closed to admissions when a team accrues a predetermined number of patients. The round-the-clock availability of personnel doing IV catheters, EKGs, arterial blood gases, blood drawings and transport markedly enhances the resident's ability to manage teaching service patients efficiently.

In addition to daily teaching during work rounds, the dynamic and interactive noon-conference series occurs daily.

The teaching services are designed to ensure that house staff is responsible for patient management.  When attendings admit to the teaching service, the physicians agree that only house staff will write orders on those patients.  All physicians admitting to the teaching service must participate in medical education-sponsored faculty development. Patients on the teaching services have either a full-time hospitalist or a core medical education faculty as their attending.

Each teaching service also admits patients from our own faculty resident practice.  Residents follow their patients as the primary physician. A full-time faculty member supervises all hospitalized patients.

Interns on the five inpatient teams admit 75% of days. There is night float cover every night.

Second and third year residents.  Second-year residents in the beginning of the year start on a team with no intern and are paired 1:1 with a single hospitalist and a Medical Education faculty member who's focus is to provide meaningful observations and feedback to the resident.  This unique structure allows the new second-year resident to gain comfort with expanded responsibilities while intensely focusing on the continued development of excellent clinical skills and efficiency prior to assuming the added responsibility of managing teams with interns and medical students later in the fall of their second year.  Second-year residents then move on to lead teams with one intern.  Then as a PGY-3 resident skills naturally evolve and permit a purposeful progression of responsibility.  Team census and progression to bigger teams are matched to the individual development of our residents.

Second and third year residents supervise inpatient ward services at PPMC for a total of 5-6 months during the PGY-2/PGY-3 years. During inpatient rotations, they lead their teams on work rounds, coordinate patient care and teach both interns and students. Prior to the start of the PGY-2 year, house staff participate in a formal seminar series, “Becoming an R2” that focuses on the management and educational skills needed to optimally run a teaching service. The call schedule for residents on the wards is identical to that described for interns.  Upper-level residents may admit one patient when the intern on a single-intern team is off.  Residents have no call shifts longer than 16 hours.

Night Float

The night float team (one resident and one intern) evaluates medicine admissions coming to the hospital and cross-covers teaching service patients, between 7:00 p.m. and 7:00 a.m. Monday night through Saturday morning.  A float resident covers nighttime call and admits the other two nights. 

Interns have one month of night float. Residents have a total of 1.0 – 1.5 months of night float during their PGY-2/PGY-3 years.

Intensive Care Unit

Key Features

  • Combined medical-surgical ICU (24/7 on site support from board-certified intensivists) 
  • High census, high acuity, create a vibrant learning enviroment
  • Daily rounds with board-certified intensivist
  • Weekly ethics rounds

The Intensive Care Unit at PPMC is a combined medical-surgical ICU. The unit allows our residents to gain tremendous experience in the assessment and management of critically ill patients. Managing both medical patients and complicated post-operative patients gives residents experiences that will be invaluable in their future careers.

Daily, multidisciplinary rounds with an intensivist allow house staff to learn both the latest in ICU management techniques and how to lead a multidisciplinary team. These two hour rounds provide a strong foundation to house staff rotating in the ICU. Educational experiences in the ICU include:

  • Rounds with board-certified intensivist, daily
    • X-ray rounds, daily
    • ICU didactics, daily
    • Multidisciplinary, daily
  • Infectious disease rounds, daily
  • Ethics rounds, weekly

Two interns and a senior resident staff the unit each day.

Second year residents assigned to the ICU cover the unit five nights each week. A float resident covers the other night. Each intern takes overnight call once every other week.

Each intern spends 1.5 rotations in the ICU. Residents spend, on average, a total of 2.5 rotations in ICU during their PGY-2/PGY-3 years.

Outpatient Block

Key Features

  • Focus on resident autonomy 
  • Learn what is needed in a real general medicine practice
    • Efficiency
    • Procedures
    • Communication skills 
  • Formal self directed, on-line ambulatory curriculum
  • Diversity of experiences
    • Urgent care (acute chest pain, pyelonephritis)
    • Complicated psychosocial issues
    • Direct supervision by behavioral medicine specialist
    • Community education
    • Musculoskeletal Clinic
    • Derm Clinic
  • Behavioral Health Clinic
  • Mobile Van clinic experience with the Wallace Medical Concern Free Clinic
  • Work with multi-disciplinary team in Patient-Centered Medical Home model
  • Multi-disciplinary outpatient rounds to review complex cases

The Outpatient Block rotation, scheduled for one month during both the PGY-1 and PGY-2 year, is designed to familiarize house staff with general medicine outpatient practice. Formal didactics and observed patient interviews by general medicine and behavioral medicine faculty supplement the experience. Residents gain experience in the full gamut of outpatient experiences, including office orthopedics, women’s health, dermatology, and ENT.  The residency clinic is also a Patient-Centered Medical Home with a diverse group of staff including social work, behavioral medicine, clinical pharmacist, dietician and outreach worker.

Becoming a Physician

Understanding the Healthcare System

This half-block rotation is a supervised independent study rotation. It combines a variety of one-on-one sessions with faculty, structured reading, and a series of projects designed to familiarize residents with caring for a population of patients. By the end of the experience, residents will have learned the fundamentals of population-based health and be in a position to integrate them effectively into their own practice.

Interns collaborate to design and carry out a shared Quality Improvement project each year.

Evidence Based Medicine

All second-year residents receive a half-block rotation experience focusing on evidence-based medicine. The rotation emphasizes asking clinical questions, becoming adept at using electronic resources to answer questions, critically appraising the literature (with a focus on reading articles about therapy, diagnosis, and overviews/meta-analyses), and applying it to patient/population care.

The resident meets one-on-one with experienced and enthusiastic EBM faculty during the rotation for one-hour article sessions and personalized (tailored to meet your needs and level of skill) literature-searching sessions. In addition, during the rotation the resident completes and presents a research project. Some residents will present their EBM project at Grand Rounds.

Procedures Rotation

Key Features

This half-block experience is designed to give interns comfort and competence in a broad range of experiences.

High-volume, hands-on learning allows rapid acquistion of technical skills such as intubation, central lines and paracentesis.  Point-of-care ultrasound training is incorporated.

Work in the OR, IR creates mentored experiences to learn best techniques.

Electives and Selectives

Key Features

  • Full range of medical and surgical electives available
  • 1:1 with subspecialty faculty
    • personalized teaching
    • opportunity for procedures
  • Most rotations combine inpatient and outpatient experiences

We encourage house staff to tailor elective choices to meet their personal goals. The proportion of inpatient versus outpatient can be adjusted. Specific faculty can be requested. Every month of residency training is precious. We want to maximize every elective’s value to every resident. The associate program director works directly with each resident to maximize elective education.

International Elective

We feel that the perspective added by working in a developing country is a wonderful supplement to residency training. The resident gains several important benefits:
  • Increased confidence in physical exam 
  • Decreased reliance on diagnostic technology, along with a deeper understanding of the importance of cost-effective care
  • Exposure to a myriad of unusual tropical diseases
  • Most importantly, reinforcement of our need as physicians to improve the health care of the underserved. Seeing how much can be done with so few resources in a developing country strengthens our commitment to use the resources here in the United States to improve health care for everyone.

For more details see International Health 

Hospitalist Elective

The hospitalist consult elective allows residents intensive experience in the delivery of inpatient consultation and direct 1:1 patient care experiences with hospitalists.
  • Direct supervision by full-time hospitalists 
  • Formal curriculum in consultative medicine
  • Participation in Quality Improvement activities

Primary Care Elective

Residents on the primary care elective spend time with primary care physicians in a variety of settings.  They learn the pros and cons of individual practice, midsize physician-owned practices and large multilocation practices.  They also get opportunities to perform outpatient procedures of their choosing.