Frequently Asked 3+1 Schedule Questions

What is a 3+1 schedule?

• As is typical for most residency programs, we used to have 4 week rotations, culminating into 13 block rotations for the year with clinic time taken out of the wards and consult time primarily.
• Given our focus on resident education and the need to train in a new and ever-changing healthcare environment, we decided it was time to make an innovative change in how we deliver education and training.
• Our core rotations- wards, ICU and consults, are now 3 weeks in duration, followed by a week-long clinic rotation.
• The week long clinic rotation contains both primary continuity clinics as well as other subspecialty clinics such as Dermatology, ENT, Musculoskeletal clinic, Central City Concern, Women’s Health, Med-Psych, Occupational Medicine, etc.  The second and third year residents also have a secondary continuity clinic of their choosing (usually focused on their post residency career plans).
• The week long clinic also has two half-day educational sessions which focus on a number of topics including pre-clinic curriculum, practice management/medical home curriculum, EBM, etc.
• The residents will always have the weekend off before beginning the clinic week. This allows for recovery time on a consistent basis, every 3 weeks.

Why change to a 3+1 schedule?

This is an innovative schedule design which allows many exciting educational opportunities to occur:

How are the wards different as a result of 3+1?

University and VA Wards-general concepts

• We have developed as much symmetry for both wards as possible in order to reduce transitions for residents and interns in each system.
• Both systems function in a drip model approach; our prior system was a bolus model which we felt was not as conducive to learning with the highs and lows of patient numbers.
  • The drip model approach also allows more consistent care of patients over time which is important in the new era of duty hour restrictions.
• Both systems have face to face sign out between the teams and night float with an attending present in the morning sign out. 
  • This face to face time decreases transitions of care and improves overall quality of transmitting information on hospitalized patients.
  • The attending present at sign out rounds in the am provides teaching for the night float team and feedback on admissions from the night.
• Both systems have two early call/day teams and two late call teams each day.  The numbers of admits vary between each system and are listed below.
• Both systems have night float teams.  These teams are a 1 resident, 1 intern team and work 6 nights (Sun night-Fri night).
• Both systems have a Saturday night that a resident will work overnight but is promptly released at 24 hours (to assure compliance with the ACGME duty hour regulations).  In both systems, not all residents will have a Saturday call given the duration of the rotations.
• Both systems work with a Clinical Hospitalist Service which functions as a pop off valve in different ways for each side.
• Benefits:
  • More consistent patient census
  • More consistent continuity of care for the patients and the team
  • Elimination of educational and emotional pull of clinic during wards
  • Restructuring of educational conferences to improve process and flow of care for the patients and the teams (see educational conference changes section).
  • Improved transitions of care with face to face sign out in a group process.
  • Increased opportunity for coordinated case management rounds with all members of the healthcare team (physical therapy, pharmacy, nutrition, social work, nursing)

University Wards

• 5 one resident, one intern teams (GM 1-5) and one night float team
• Team census of 10 patients
• Daily admit census
  • 2 patients to each early call team
  • 3 patients to each late call team
  • 4 patients to night float
• 2 medical students, one PA student, one dedicated teaching faculty member

VA Wards

• 5 one resident, two intern teams (GM 1-5) and one night float team
• Team census of 16 patients
• Daily admit census
  • 4 patients to each day team
  • 3 patients to each late call team
  • 6 patients to night float
• 2 medical students and one dedicated teaching faculty member

How does the ICU work?

VA ICU

• Comprised of a combined CCU and an MICU service
• 4 housestaff teams with one resident and one intern
  • 3 day time teams and one night team, each taking turns doing a week of nights
• The night team is staggered between the resident and intern in order to maintain continuity of care for the patients and the team
• The night team works for 5 nights and then has two days off before coming back as a day team
• The night team can admit up to 6 patients but it usually around 2-3
• Formal transition of care occurs at 6pm whereby the day teams sign out face to face with the night team.
• Admits are divided up by the fellow throughout the day based on team census and acuity rather than a strict number
• Most days the number of admits per team is usually 2 (total of ~4-6/day)
• Total census is 15 patients
• Formal didactic sessions each afternoon by either a cardiologist, pulmonologist or other special guest

University MICU

• 4 housestaff teams with one resident and one intern
  • 3 day teams and one night team with each team taking turns doing 5 days of nights
• A pulmonary CC fellow is present on site 24 hours a day and provides direct supervision, assistance with procedures and teaching
• The night team is staggered between the resident and intern in order to maintain continuity of care for the patients and the team
• The night team works for 5 nights and then has two days off before coming back as a day team
• The night team can admit up to 6 patients but it usually around 2-3
• Formal transition of care occurs at 6pm whereby the day teams sign out face to face with the night team.
• Admits are divided up by the fellow throughout the day based on team census and acuity rather than a strict number
• Most days the team admits ~2-3 patients (total of ~4-6 per day)
• Total census is 20 patients
• Formal didactic sessions occur at noon

How does the +1 clinic week work?

• The week long clinic rotation contains both primary continuity clinics as well as other subspecialty clinics such as Dermatology, ENT, Musculoskeletal clinic, Central City Concern, Women’s Health, Med-Psych, Occupational Medicine, etc.  The second and third year residents also have a secondary continuity clinic of their choosing (usually focused on their post residency career plans).

Intern +1 week

• Depending on the location of your primary clinic (VA or OHSU), the schedule will vary on a 3 month rotation basis.
  • You will attend 3 primary care continuity clinics, an interim clinic (VA), Propel Clinic (OHSU), Chronic Illness Management clinic (CIM), HIV clinic and a host of other clinics spread out over the year including dermatology, women’s health, psychiatry, and geriatrics.
  • You will also have time throughout the year dedicated to working on a chronic illness management project for your clinic.
  • There are two seminars (Tues and Fri) which go over numerous topics including screening, immunization, panel management, HTN, DM, occupational medicine, etc. 
  • All of these topics are framed in an Evidence Based Medicine approach.

Second and third year residents

• You will attend 3-4 primary care continuity clinics and a second clinic of your choosing (usually related to your specialty interest).
• There are every 3 month rotating clinic sessions located in a number of different locations:
  • Outside In-a clinic designated for the care of teens and young adults who are homeless
  • Central City Concern: This is where our social medicine curriculum is delivered in a variety of venues including the addiction treatment center, Hooper Detox, and other areas.
  • Multnomah County Clinic: You now have the opportunity to spend time at the County clinic both in their general medicine and HIV clinic.
  • Other clinics: You continue to have other experiences such as the Propel clinic, ENT, Occupational medicine, musculoskeletal, geriatrics, urology, and psychiatry.
    • Propel Clinic:  A clinic designed to help residents understand the multifaceted approach to chronic pain management while employing evidence based medicine treatment for chronic pain.

What consult services are available for residents?

All specialties are offered to residents

• Cardiology, Pulmonary, GI, Renal, ID, Rheumatology, Endocrinology, Hematology, Oncology
• Residents over three years will have had the opportunity to work in all but likely one specialty
• We strongly encourage residents to not focus on their specialty of interest but rather diversify his or her education by rotating in all specialties
• Most consult rotations are two weeks or three weeks in duration.  If they are 2 weeks in duration it is because the time is paired with a vacation request.
• There are no continuity clinics during consults so residents are now more fully present which has enhanced continuity of care, increased teaching and consistency of presence for the team.
• There has not been a decrease in consult time with the 3+1 schedule.
  • In the old system, the residents may have been assigned a month rotation; however, they were also assigned to two half days of clinic as well as a night coverage rotation for the wards.  This effectively led to the resident being on the consult service for ~14 days total despite 28 days on the calendar.
  • The clinics and night rotation have been eliminated in the system so that the residents are now fully present on the consult rotation.

How has the educational delivery changed in the new system?

• Healthcare has changed and so the way we learn and work needs to change.  We have noted for some time that much of the work of the wards, consult services and ICUs occurs in the morning yet we have for some time put many teaching conferences in the morning hours which directly conflicted with patient care.  It was time for a change.
• Noon report, formerly called morning report has been moved to 12pm.
  • This change is symmetric on both sides and moved morning report from 9am to 12pm to free up the morning time for teams
  • It is a mandatory conference and so all attendings (except in the ICU-separate didactic) ensure the teams are able to attend the report
  • This report occurs on Mon and Wed at noon and on Thurs at 1pm for residents only
    • The University report is run by the PD and the VA report is run by the chief residents.  Faculty attend both reports.
    • The Thurs report for residents is run by the Chair of Medicine and includes the division chiefs from Nephrology, ID, Pulmonary, Allergy Immunology and other divisions as well.
    • We also have a separate intern report on Fri at 1pm.
      • This session is run by a faculty member trained in the Stanford Faculty Development Teaching series
      • The goal is to more systematically work through a case and develop a set of skills in creating summary statements, differential diagnoses and critical assessment skills

Noon conference

• This conference is held on Tues, Thurs, and Friday
• Tues and Thurs are the core curriculum content offered throughout the year
• Friday conference includes QI/M&M, CPC, Senior talks (given by our third year residents), Fireside Chats with the PD, Jeopardy (the game!).

Grand Rounds

• Held every Tues at 8am

Other

Elective time

• You will receive two 3 week electives in the second and third year to plan other clinical activities suited to your needs
  • International electives can occur only once during the two year period because of institutional/risk management issues.
  • We do have a Global Health Center that we are linking with and figuring out new ways to partner with them.
  • Our residents have traveled to a number of locations including China, Africa, India, Brazil, etc and so many opportunities exist to find a location.