Stephanie Seto, PharmD, was the first to volunteer. “It was hard to see our colleagues strained with the large influx of such high-acuity patients,” she says. “I wanted to help if I could.”
Internal Medicine Residency
The inpatient medicine structure is designed to provide stellar clinical training with dedicated teaching faculty, covering a wide diversity of pathology in a variety of regionalized care settings. Clinical education focuses around core experiences on the Inpatient General Medicine Teaching Service, with additional learning experiences in 3 inpatient subspeciality domains: pulmonary critical care, cardiology care and oncology care. Residents also gain diverse experiences in general medicine and critical care in both the emergency department and community hospital settings. The inpatient educational structure culminates in four senior year capstone roles focused around acute care management, hospital level triage, leadership, teaching and communication.
Inpatient General Medicine Care
The Inpatient General Medicine Teaching Service, comprised of ten 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 Inpatient General Medicine Teaching 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.
On Mass General’s Inpatient General Medicine Teaching Service 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 15-16 patients. Bigelow teams are regionalized to clinical care on a single floor, allowing close bonds with nursing staff and increased ability to care for high acuity patients. Interns on the team 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 period and cross-covers patients on the floor at night, with night-time supervision and teaching provided by senior residents (see "Night Teach" section below). ("Post-call" is second day of cycle)
- The “plan” intern leads team rounds on all established patients, creating the clinical plan for the day and leading the bedside interview and physical exam
- The “swing” intern takes the lead in communicating with consultants, addressing acute clinical issues at the bedside, managing key time-sensitive tasks and coordinating and performing procedures
The junior resident supervises the care provided by the team and leads discussion and teaching on rounds. Bigelow teams are staffed by two attendings, each carrying ½ the patient census, who are chosen and paired to optimize clinical learning for the team.
The four Flex teams are comprised of two interns and a junior resident who oversee the care of 11-12 patients. Flex teams are regionalized to clinical care on either 1 or 2 floors, allowing close bonds with nursing staff and increased ability to care for high acuity patients. Each Flex intern has primary responsibility for his/her own 6-7 patients, and admits to his/her own list during daytime hours, on an alternating day cycle with the Flex co-intern. The junior resident supervises the care provided by the team and leads discussion and teaching on rounds. Flex teams are staffed by a single attending, chosen to optimize clinical learning for the team.
The Bigelow and Flex team structures complement one another from a clinical growth and educational standpoint. Both have in-depth patient exposure and teaching, with the Bigelow experience highlighting a wide breadth of patients within a team dialogue atmosphere and the Flex experience highlighting a deep and singular ownership allowing oversight on all aspects of care from admission to discharge.
Medical students are actively incorporated into both patient care and education, with Bigelow teams having integrated sub-interns and Flex teams having integrated clerkship students.
A diverse group of attendings join on the Inpatient General Medicine Teaching Service, hailing from the Inpatient Core Educator Faculty, Hospital Medicine Unit, General Medicine and Subspecialty Core Visit Faculty, and Chief Residents.
Pulmonary Critical Care
The Medical Intensive Care Unit (MICU) at Mass General is home to an 18 bed unit, where critically ill patients are cared for by two resident teams. 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 roles and are supervised by two juniors, who, paired with the juniors from the other MICU hemi-team, take 24-hour call every fourth night. Each hemi-team is supervised by a senior resident, pulmonary/critical care fellow and pulmonary/critical care attending. Overnight there is a teaching senior (see "Night Teach" below) and pulmonary/critical care intensivist to help with the care of acutely ill patients, supervise procedures and staff all new admissions. A lecture series is held every morning to provide additional education on critical care medicine.
Heart Center ICU (HC-ICU)
The Heart Center ICU (HC-ICU) at Mass General is home to a 16-bed cardiac intensive care unit, where patients are cared for by a resident team (CCU Blue) and an advanced practice provider (APP) team (CCU Red). The HC-ICU serves as a destination for cutting edge and novel care for some of New England’s sickest patients and provides a robust experience in cardiology, critical care and their overlap. The CCU Blue team serves as a general cardiology ICU service, caring for patients with acute coronary syndromes (including complications of MI), new and decompensated heart failure, cor pulmonale, endocarditis, pericardial diseases, post-procedural patients, cardiogenic shock, severe valvulopathy, cardiac arrests and unstable dysrhythmias. The CCU Blue team is staffed by four junior residents, who share responsibility for all patients while rotating through a four-day cycle of tasks, taking a 24-hour call every fourth day. The team is supervised by a senior resident, a cardiology fellow and an attending cardiologist. A lecture series is held each day to provide additional education on cardiology critical care.
All residents rotate through the CCU Blue team; residents are able to rotate on the CCU Red team on an elective basis if they so choose. The CCU Red team serves as a mixed medical/surgical team, caring for patients with cardiogenic shock in need of mechanical support through devices such as Impella, pre- and post-VAD and pre- and post-heart transplant.
Cardiac Step Down Unit (SDU)
The Cardiac Step Down Unit (SDU) is home to a 36 bed cardiology unit where patients are cared for by two resident teams. Residents are exposed to a breadth and depth of pathology within inpatient cardiovascular medicine, including acute coronary syndromes, brady- and tachy-arrhythmias, severe/advanced decompensated heart failure, pericardial syndromes and post procedural cardiovascular care. Each team is comprised of two junior residents, one senior resident and an attending cardiologist. A cardiology fellow is dedicated to the floor for teaching, acute management and care coordination. The juniors work closely with their own attending, and also rotate with the juniors from the other SDU hemi-team through a four-day cycle, taking a 24-hour call every fourth day. There is also an additional night float junior resident that helps the on-call junior with overnight admissions and acute patient care issues. A lecture series is held each day to provide additional education on cardiac arrhythmias, acute coronary syndromes and post-procedural complications.
The Lunder Oncology service is home to two adjacent 32-bed oncology units, where patients are cared for by three resident-led teams and one advanced practice provider (APP) lead team. The three resident teams are each primarily focused around the care of patients within one inpatient oncology domain—leukemia; solid tumors; or lymphoma/myeloma. The teams are comprised of interns who have primary responsibility for his/her own 6-7 patients, and admit to his/her own list during daytime hours, with supervision from a senior resident and a disease-specific attending. Overnight the patients on the unit are managed by two junior residents.
Community Hospital Care at Newton-Wellesley Hospital
Residents receive a robust community medicine experience at Newton-Wellesley Hospital (NWH), located in the nearby Boston suburb of Newton.
Newton-Wellesley Hospital Inpatient General Medicine
Interns rotate on one of the inpatient general medicine teams for one month. Each team is comprised of two interns, with one intern from the Mass General IM program and the other from either the Tufts IM program or the NWH Transitional Year Program. Each intern has primary responsibility for his/her own 6-7 patients, and admits to his/her own list during daytime hours, on an alternating day cycle with the NWH co-intern. The teams are led by a Mass General senior resident and a NWH hospitalist teaching attending. Patients are covered overnight by NWH Transitional Year interns, supervised by Mass General junior residents.
Newton-Wellesley Hospital Intensive Care Unit (ICU)
Residents spend 2-4 weeks at the NWH ICU, which is staffed by two NWH Transitional Year interns, one Mass General junior resident, one Mass General senior resident and a NWH pulmonary/critical care attending. The NWH ICU experience provides an opportunity to practice critical care in the community setting with a varied patient population compared to what is seen in the Mass General MICU. There are no clinical subspecialty fellows at NWH, allowing Mass General residents additional opportunities to perform attending-supervised procedures while in the ICU (i.e. bronchoscopy, intubation, temporary wire placement, HD catheter placement, etc).
Emergency Department Care
The Mass General Emergency Department is a high volume, high acuity care center. In addition to ED residents and advanced practice provider (APP) staff, teams are staffed by residents from Mass General’s medical and surgical training programs. IM intern and junior residents each spend two weeks in the Emergency Department, rotating through the “fast track”, “urgent” and “acute” zones of the ED, allowing upstream exposure and triage decision-making around a broad range of pathology, ranging from acute ambulatory issues to critical care.
Capstone Inpatient Rotations
Senior On / Emergency Department Triage Senior
These are two of the defining clinical roles of the Mass General Internal Medicine Residency experience, combined into a single rotation with alternating shifts. These roles leverage our senior resident’s expertise not only in clinical care, but also the in-depth understanding of the care pathways, patterns and capabilities of our inpatient structure. These roles utilize all of the skills learned in residency up to that point, including acute care management, clinical reasoning, triage and communication.
The Senior On “for the house” runs codes and rapid responses throughout the hospital, triages transfers from general care floors to intensive care units and interfaces with hospital departments and nursing leadership to manage patients at high risk of clinical decompensation.
The ED Triage Senior helps facilitate the process of ED patients being admitted to the department of medicine, with a focus on “complex triage” (subspeciality vs general medicine; ICU vs floor), critical care management and consultative input on non-DOM patients.
In one of the defining teaching roles of the Mass General Internal Medicine Residency experience, each night, four senior residents oversee night-time clinical care across the inpatient residency units. The night teaches provide educational and admission support to the Bigelow interns on the general medicine units, collaborative input for the junior residents on the cardiac step-down and oncology units, and critical care procedural and acute care management supervision to the MICU and HC-ICU, in conjunction with the in-house overnight fellow/attending critical care structure.
Every weekday morning, the seniors that worked the night prior (Senior On; ED Triage SAR; Night Teaches) join for the beloved “AM Intake”, reviewing all dynamic and challenging cases from the night with the Chief Residents and a select teaching attending.
Medicine Consult Service
Each senior resident spends two weeks as a general medical consultant for non-medicine services (psychiatry, orthopedics, surgery, OB/GYN, etc.), managing a range of typical inpatient medicine issues, along with input on pre- and post-operative medical optimization. The Inpatient Core Educator Faculty serve as attending physicians, organizing teaching rounds and a daily lecture series covering important aspects of medical consultation.