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Frequently Asked 3+1 Schedule Questions Share This OHSU Content

3+1 Schedule Frequently Asked Questions

What is a 3+1 schedule?
Why change to a 3+1 schedule?
How are wards different as a result of 3+1?
How does the ICU work?
How does the +1 clinic week work?
What consult services are available for residents?
How has the educational delivery changed in the new system?
Other

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 primarily out of wards and consult time.
  • Given our focus on resident education and the need to train in a new and ever-changing healthcare environment, we decided 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 (+1) clinic rotation.
  • The +1 week contains both primary continuity clinics as well as other subspecialty clinics such as Dermatology, ENT, Musculoskeletal clinic, , 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 +1 week also includes two half-day educational sessions that focus on a number of topics including, pre-clinic curriculum, practice management/medical home curriculum, EBM,  and others.
  • 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:

  • Clinic is no longer inserted into rotations such as wards and consults; thus allowing the time needed to learn on those rotations without being pulled elsewhere.
  • Clinic is a valued rotation, and since most physician 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, facilitating more organized and patient-focused transition of care.
  • Firms also allow residents to develop a true group practice model approach to outpatient care.
  • Three-week rotations appear to be an ideal amount of time to spend on any given service.  According to the residents, two weeks would be too short and four weeks is sometimes just too long.
  • Residents are not “pulled away” to clinic when on the wards and consult services; 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 prior to beginning the clinic week, which allows recovery time before beginning the clinic week.

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

University and VA Wards-general concepts

  • We have developed as much symmetry as possible for wards at both the University and VA Hospitals 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, an important factor 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 the overnight admissions.

  • Both systems have two early call/day teams and two late call teams each day.  The number of admits varies 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 per week (Sun night-Fri night).
  • Both systems have a Saturday night shift when 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 that 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 MICU service
  • 4 housestaff teams with one resident and one intern
    • 3 day teams and 1 night team, with 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 2 days off before  returning as a day team
  • The night team can admit up to 6 patients Formal transition of care occurs at 6:00pm 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 1 night team, with each team taking turns doing 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 coming back as a day team
  • The night team can admit up to 6 patients
  • Formal transition of care occurs at 6:00pm 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 primary continuity clinics and a variety of specialty 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, but not limited to, screening, immunization, panel management, HTN, DM, and occupational medicine. 
  • 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
    • CODA Clinic:  Opportunity to spend time at a drug treatment facility
    • 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.
    • Multnomah County Clinic:  Residents now have the opportunity to spend time at the County clinic, both in their general medicine and HIV clinics.
    • Other clinics:  Residents continue to have other experiences such as the Propel clinic, ENT, Occupational Medicine, Musculoskeletal, Geriatrics, Urology, and Psychiatry.

What consult services are available for residents?

All specialties are offered to residents

  • Cardiology, Pulmonary, GI, Renal, ID, Rheumatology, Endocrinology, Hematology, Oncology. Palliative Care, Preoperative Medicine Consults
  • Over the course of three years, residents have the opportunity to work in most of the specialties.
  • We strongly encourage residents not to overly 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 two 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,and this has enhanced continuity of care and 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 one-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. 
  • Noon report, formerly called morning report, has been moved to 12:00pm.
    • This change is symmetric on both sides and moved morning 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 the 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 beentrained 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 cover the core curriculum content offered throughout the year
  • Friday conferences include QI/M&M, CPC, Senior talks (given by our third year residents), Fireside Chats with the PD, and other curricular offerings.

Grand Rounds

  • Held every Tues at 8:00am

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  due to institutional/risk management issues.
    • OHSU  has a Global Health Center, and our Program is working with  the GHC to figure out new ways to partner with them.
    • Our residents have traveled to a number of locations including China, Africa, India, Brazil, etc., and many opportunities exist to find a location.

Intern Ambulatory Block

  • The intern Ambulatory block includes several unique educational experiences, including 3 full days  in the OHSU HIV clinic, 6 half-days  in the VA Dermatology clinic,  and  social medicine training through Central City Concern. All of our interns get an in-depth exposure to underserved medicine in order to gain an understanding social determinants of health by rotating through the Old Town Clinic in downtown Portland, Hooper Detox Center and the Recovery center, as well as the Community Engagement Program with clinical outreach workers. This is a very highly rated block and serves as a foundation for our residents who elect to pursue additional training in underserved medicine in the second and third years.

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