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The General Medicine Service in Massachusetts General Hospital’s Internal Medicine Residency Program consists of two inpatient teaching services as well as three intensive care units.
Because Massachusetts General Hospital is a major academic referral center in Boston, New England’s most populous city, it provides the residents with exposure to a patient population of enormous diversity. The Mass General Department of Medicine’s General Medical Teaching Service is called the Bigelow Service. In addition, there are three intensive care units: the Medical Intensive Care Unit (MICU), the Cardiac Intensive Care Unit (CICU) and the Cardiac Step Down Unit (SDU). Other inpatient rotations include the Emergency Department, the medical consultation service, oncology services and rotations at Newton-Wellesley Hospital.
The Bigelow Service, comprised of nine resident teams, is the core of the Department of Medicine’s clinical teaching experience. Working in teams led by junior residents, and supervised by attending physicians with a commitment to bedside teaching and direct observation, the Bigelow Service is where residents grow from interns with great potential into skilled clinicians.
As the general medical service for a leading academic medical center, residents care for patients of high complexity and acuity, seeing the pathology of every organ system, and delivering the best care to a socioeconomically and geographically diverse patient population.
Composition of a Bigelow Team
On the Bigelow there are two types of teams, Bigelow and Flex.
The six Bigelow teams are comprised of four interns and a junior resident who oversee the care of 16-18 patients. All interns share responsibility for all patients, and rotate through a four-day cycle of tasks. The “call” intern admits up to five patients in a 24 hour call period and cross-covers all patients on the floor at night, with night-time supervision and teaching provided by third-year residents. The “plan” intern leads team rounds on all previously admitted patients, creating the plan for the day and leading the daily follow-up bedside interview and exam. The “swing” intern takes the lead in communicating with consultants, coordinating and performing procedures, and managing key time-sensitive tasks that need to be completed before rounds. The junior resident supervises the care provided by the team and leads discussion in work rounds.
The three Flex teams, which consist of two interns and a junior resident, oversee the care of 13-16 patients on two different floors. These Flex teams only admit patients during the day. Flex teams are a traditional model in which each intern has primary responsibility for their own 6-8 patients. The Bigelow and Flex team structures complement one another: Interns will experience both a wide breadth of patients and the educational opportunities of team dialogue in caring for patients when on a Bigelow team, as well as the ability to provide all aspects of care for a patient from admission to discharge while on a Flex team.
Medical students are actively incorporated into both patient care and education.
View sample schedules of the Bigelow and Flex teams.
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The Medical Intensive Care Unit (MICU) is staffed by two teams covering 18 beds, serving critically ill patients. The case mix includes patients in severe septic shock, ARDS requiring mechanical ventilation, ECMO and patients requiring intensive physiologic monitoring. Each team has three interns who rotate through day and night rotations and are supervised by two juniors, who take 24-hour call every fourth night. The team is supervised by a senior resident, pulmonary/critical care fellow and attending. Overnight there is a teaching senior and overnight intensivist to help with the care of acutely ill patients. A lecture series is held every morning to provide additional education on critical care medicine.
Composition of a MICU Team
The Cardiac Intensive Care Unit (CICU) is staffed by two teams covering 18 beds, serving critically ill cardiac patients. The case mix includes patients suffering from acute coronary syndromes complicated by cardiogenic shock, acute decompensated heart failure requiring tailored therapy, advanced heart failure requiring transplant and patients requiring mechanical support. Each team has one intern who supports the team during the day and three juniors who take 24-hour call every third day. The team is supervised by a senior resident, a cardiology fellow and an attending cardiologist. Overnight, a teaching senior and an overnight intensivist are available to help with acutely ill patients. At all times, subspecialty services are involved in patient care, including Interventional and Structural Cardiology, Adult Congenital Cardiology and the Advanced Heart Failure/Transplant Service. A lecture series is held every morning to provide additional education on cardiac critical care topics.
Composition of a CICU Team
The Cardiac Step Down Unit (SDU) is staffed by two teams covering 30 beds, serving patients leaving the CICU, post-procedural from electrophysiology and interventional procedures and requiring cardiac monitoring for management of acute coronary syndromes and acute decompensated heart failure. Each team has two juniors who take 24-hour call every fourth night. The team is supervised by a senior resident, a cardiology fellow and an attending cardiologist. Interns can choose to do an elective in the SDU. A lecture series is held every morning to provide additional education on cardiac arrhythmias, acute coronary syndromes and post-procedural complications.
Composition of a SDU Team
Approximately 90% of Bigelow Service patients are admitted through the Emergency Department. The Emergency Department is staffed by residents from the medical, surgical and emergency departments. Medical residents spend two to four weeks in the Emergency Department during each year of residency.
Senior residents are responsible for providing teaching and supervision as well as triage decisions within the medical service. Seniors also provide urgent medical consultation to non-medical services in the Emergency Department.
During senior year, each resident spends two weeks as a general medical consultant for non-medicine services (e.g., psychiatry, orthopedics, surgery, OB/GYN, etc). A group of Core Educators with expertise in medical consultation serve as attending physicians and organize teaching rounds and a lecture series covering important aspects of medical consultation, including pre- and post-operative issues.
In addition, all residents have the opportunity for multiple electives with subspecialty inpatient consultants, in which they work closely with supervising subspecialty fellows and attending physicians.
Senior residents spend approximately four weeks as the “Senior On” for the entire hospital. In this defining role of the Mass General Internal Medicine Residency experience, the Senior On runs all codes and rapid responses throughout the hospital, triages all transfers from the floor to the intensive care units, and interfaces with all hospital departments and nursing leadership to manage patients at high risk of clinical decompensation.
The Lunder Oncology service consists of two teams – Solid Oncology (14 patients) and Bone Marrow Transplant/Leukemia (18 patients). Each team is staffed by two interns, who alternate daytime admitting responsibilities, and a supervising resident. Overnight the patients are managed by a junior resident. A teaching conference is held daily at 11:00 am-12:00 pm to provide additional education on the diagnosis and management of malignancy.
The Ellison Oncology service covers 16 patients, with a mix of “solid” and “liquid” oncology. The team practices a multidisciplinary approach to patient management, including two upper level residents (juniors or seniors) and three nurse practitioners. The residents alternate early and late shifts to allow for additional time spent in the outpatient oncology clinics with close mentorship by oncology faculty.
Residents receive a robust community medicine experience at Newton-Wellesley Hospital (NWH), located in the nearby suburb of Newton.
Interns rotate on one of the medical floor teams (telemetry unit, general medical or oncology teams) for one month. Each team is staffed by two interns, with one intern from Mass General and one from the NWH Transitional Year Program, and is supervised by a Mass General senior resident and a NWH hospitalist attending. Patients are covered overnight by NWH Transitional Year interns and a Mass General junior resident.
Residents spend 2-4 weeks at the NWH ICU, which is staffed by two NWH Transitional Year interns two Mass General junior residents, and a Mass General senior resident. The ICU is supervised by NWH intensivists. The NWH ICU experience provides the opportunity to care for a different patient mix than what is seen in the Mass General MICU and includes post-surgical patients. There are no fellows at NWH, allowing Mass General residents additional autonomy and the ability to perform procedures while in the ICU (i.e. bronchoscopy, intubation, and temporary wire placement).
Each year, five Mass General senior residents are selected as Newton-Wellesley Hospital (NWH) chief residents and spend 10-12 weeks of their senior year at NWH. NWH chief residents run the educational conferences at NWH, including daily morning report and noon conference, a simulation series and didactic lectures for rotating Tufts University School of Medicine medical students.
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