3+1 Schedule Overview

3+1 schedule defined
Benefits of a 3+1 schedule
Ward differences in a 3+1 model
ICU Operations
+1 Clinic Week
Social Medicine Block
Consult Services
Educational delivery in the 3+1 system
Elective time

3+1 schedule defined

Most residency programs 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 made an innovative change in how we deliver education and training.
  • Our core rotations – wards, ICU and some consults – are now 3 weeks in duration, followed by a week-long clinic rotation.
  • The week-long clinic rotation contains primary continuity clinics, as well as other subspecialty clinics such as Cardiology, Pulmonary, ID, GI, Renal, Hem/Onc, etc. 
  • The second and third year residents also have the option of choosing a secondary continuity clinic, usually focused on post-residency career plans.
  • The week-long clinic block also has two half-day educational sessions that focus on a number of topics, including pre-clinic curriculum, practice management/medical home curriculum, and EBM.
  • Residents always have the weekend off prior to starting a clinic week. This allows for recovery time on a consistent basis, every 3 weeks.

Benefits of a 3 + 1 schedule

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

  • Clinic is not inserted into rotations such as wards and consults; thus, it allows the time needed to learn on those rotations without being pulled elsewhere.
  • Clinic is a valued rotation and, since most physicians' lives are spent in the clinic (subspecialist and generalists), it is important to focus time in this area instead of inserting it into different rotations where the resident is unable to completely focus on the clinic experience.
  • The clinic week allows dedicated time to learning outpatient medicine in a consistent and focused manner.
  • The residents are divided into firms so the patients have consistent care by a group of physicians.  The firm system also allows the residents to know exactly which residents will be in clinic on the following + 1 week, which facilitates a more organized and patient focused transition of care.
  • Firms also allow residents to develop a true group practice model approach to outpatient care.
  • Three weeks of a rotation appear to be an ideal amount of time to spend on any given service.
  • Residents are not "pulled away" to clinic when on the wards and consult service; thus, improving continuity of care, transitions of care, and overall consistent learning from patients, the team, and faculty physicians.
  • There is now a guarantee of having a weekend off at the end of 3 week rotations and before beginning the clinic week which allows recovery time before beginning the clinic week.

Ward Differences in a 3+1 model

University and VA Wards-general concepts

  • We have developed as much symmetry as possible for wards in each system in order to reduce transitions for residents and interns.
  • 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 era of duty hour restrictions.
  • Both systems have face to face sign-out between the teams and night float with an attending present for 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 when a resident will work overnight but is promptly released at 24 hours (to assure compliance with the ACGME duty hour regulations).  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 release valve for patient care 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
  • Max 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

ICU Operations

VA ICU

  • Comprised of a combined CCU and an MICU service
  • 4 housestaff teams with one resident and one intern
    • 3 daytime teams and one night team, with each team rotating on a week of night shifts
  • 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 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 average number of admits per team is 2-3 (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 daytime teams and one night team, with each team rotating on a week (5 days) of nights
  • A Pulmonary/CC fellow and attending are present on site 24 hours a day and provide 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 2 days off before returning as a day team
  • The night team can admit up to 6 patients
  • 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 average number of admits per team is 2-3 (total of ~4-6 per day)
  • Total census is 20 patients
  • Formal didactic sessions occur at noon

+1 Clinic Week

Goals

  • Augment knowledge and skills of ambulatory medicine through clinical practice, and didactic and interactive learning experiences
  • Experience outpatient team based care while learning practice management
  • Enhance clinical competency with the goal to become an independent outpatient practitioner in Internal Medicine

Three Main Components of the +1 Week:

  • Continuity clinic at (designated) primary continuity clinic site
  • Other ambulatory clinical experiences
  • Tuesday/Friday educational seminars (including Evidence-Based Medicine)

Intern +1 Week

Depending on the location of your primary clinic (VA or OHSU/Old Town), the schedule will vary on a 3-month rotating basis.

  • There are a total of three "+1" rotations offered in the R1 year: each rotation is for 3 months (or 3 "+1" weeks). All weeks will include 3-5 half-days of primary care continuity clinics, some of these being VA Interim clinic or OHSU Propel clinic.
    • The VA general Ambulatory +1week rotation includes experiences in VA Derm, ENT, Geriatrics Assessment, and Optometry clinics + continuity and VA Interim or OHSU Propel clinics.
    • The OHSU general Ambulatory +1 week rotation includes OHSU Geriatrics Consult clinic, HIV, MedPsych, and Women's Health + continuity and VA Interim or OHSU Propel clinics.
    • The Chronic Illness Management (CIM) +1 week is a 6-month (or 6 "+1" weeks) long rotation which includes CIM at OHSU and VA, with dedicated didactic/project time + continuity and VA Interim or OHSU Propel clinics.
  • There are two seminars (Tues and Fri) that address numerous topics, including screening, immunization, panel management, HTN, DM, occupational medicine, etc.  All of these topics are framed in an Evidence-Based Medicine approach.

Resident +1 Week

  • Depending on the location of your primary clinic (VA or OHSU/Old Town), the schedule will vary on a 6-month rotating basis.
  • There are a total of ten "subspecialty +1" rotations offered in the R2/R3 year.
    • Residents will rotate on four "+1 subspecialty rotations" over 2 years
    • Each rotation is 6 months (or 6 "+1" weeks) long and relates to a specific subspecialty experience.
    • Subspecialty topics include – Allergy, Cardiology, CIM, Geriatrics, Gastroenterology/Hepatology, Hematology/Oncology, Infectious Disease/HIV, Palliative Care, Pulmonology, Nephrology, and Rheumatology clinics.
  • All weeks include 3-5 continuity clinics and may include a second continuity clinic experience if chosen over priority ranking of the subspecialty clinic rotation assignments.
  • There are two seminars (Tues and Fri) that 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.

Social Medicine Block

Goals

  • To increase knowledge of the nature and extent of health disparities and health system gaps in our community and country
  • To improve sociocultural awareness and to improve knowledge, skills and attitudes toward indigent health and health care through exposure to clinical practice and relationships in a safety net clinic
  • To provide learners with the skills and capacity to begin to address health care for indigent/unstably supported individuals and to address health system and social system gaps that these individuals encounter
  • To better understand addiction and addiction treatment options
  • To allow for additional continuity clinics on a weekly fashion

Main Components of the Social Medicine Rotation

Interns will rotate through a variety of sites throughout downtown Portland, including:

  • Outside In (a social service agency working to address the changing needs of homeless youth and other low-income and marginalized patients)
  • Central City Concern (a large nonprofit agency serving single adults and families in the Portland metro area who are impacted by homelessness, poverty and addictions)
  • CODA (the oldest opioid addiction treatment program in Oregon)

For some of these rotations interns will be an observer, and for others they will act as a provider.  Each opportunity has been individually selected to give a broad exposure to the care of the underserved in our community.

Consult Services

All IM subspecialties are offered to residents

  • Cardiology, Endocrinology, GI, Hematology, Infectious Diseases, Oncology, Pulmonary, Renal, and Rheumatology, in addition to Palliative Care and Pre-Operative Medicine
  • Over the course of training, residents will have the opportunity to work in most subspecialties.
  • We strongly encourage residents to diversify his/her education by rotating in all specialties and avoiding too much focus on one subspecialty of interest.
  • Most consult rotations are 1-3 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, which results in residents being more fully present, thereby enhancing continuity of care and increased teaching and consistency of presence for the team.

Educational Delivery in the 3+1 system

  • Healthcare has changed, and so the way we learn and work needs to change.  We noted for some time that much of the work of the wards, consult services, and ICUs occurred in the morning, yet we put many teaching conferences in the morning hours and that directly conflicted with patient care.
  • Noon Report, formerly called Morning Report, was moved to 12:00pm.
    • This change is symmetric on both sides and moved Report from 9:00am to 12:00pm to free up the morning time for teams.
    • It is a mandatory conference, and 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 1:00pm for residents only.
      • The University report is run by the PD, and the VA report is run by the Chief Residents.  Faculty, residents and interns attend both reports.
      • The Thurs report for residents is run by the Chair of Medicine and includes division chiefs and other invited guests.
      • We also have a separate intern report on Fri at 1:00pm.
        • This session is run by one of our Associate Program Directors, Andrea Cedfeldt, who has been trained in the Stanford Faculty Development Teaching series.
        • The goal of this session 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 Fri.
  • Tues and Thurs offer core curriculum content throughout the year.
  • Friday conference includes QI/M&M, CPC, Senior Talks (given by our third year residents), Fireside Chats with the Program Director, and other curricular offerings.

Grand Rounds

  • Held every Tuesday at 8:00am

Elective time

  • You will receive a 3-week elective, one in your second and one in your third year, to plan other clinical activities suited to your needs.
    • International electives can occur only once during the two-year period due to institutional/risk management issues.
    • Our current international site is Botswana in partnership with Beth Israel/Harvard

Back to Top of Page