- How have the hospitals and the UH-CWRU IM residency approached the coronavirus pandemic?
We are fortunate that in the State of Ohio we have so far not seen surges that have significantly taxed our hospital resources or significantly impacted our trainees’ clinical exposures. Like many hospitals throughout the country, at the beginning of the pandemic it was not clear if Ohio would have a major surge, and residency leaders at both University Hospital and the VA Hospital were very intimately involved with surge plans – thankfully these have not been needed. At both sites our residents have been involved with COVID-19 patients, but we have worked hard to find the balance between our commitment to this patient population and the educational needs and clinical experience of our trainees. With our census of COVID-19 patients being relatively modest, achieving this goal has not been difficult. We have made some structural changes in our ICU teams, and have included non-teaching services in our COVID-19 care response to help balance resident experience. Our hospitals have been on the cutting edge of COVID-19 care with a very robust research program including early participation in Remdesivir trials, our own plasma trials, and currently a vaccine trial.
From the beginning of the pandemic we have been mindful of the emotional and psychological stress the pandemic has wrought. We have IM resident COVID-19 town halls to keep the residents informed about COVID-19 issues and get feedback about our COVID-19 plans. We created a COVID-19 dashboard with both clinical and provider support resources for the IM residents. Resident wellness is an important part of our program and we have paid particular attention to any impact of COVID-19 to resident well-being.
We have also been fortunate that we have not had PPE shortages. At the VA we use PAPRs for patient care of COVID-19 cases and at UH N95 masks.
Our COVID-19 leadership teams have been very responsive to quickly getting residents tested for COVID-19 should they have an illness that could be concerning for infection due to sars-cov-2. Thankfully the great majority of residents with ‘viral syndromes’ who have been tested have been negative. A small handful of residents have tested positive and none contracted the virus through care of COVID-19 patients. None have been seriously ill or required inpatient care. We have a robust jeopardy system and coverage for residents who have an illness that needs to be ‘ruled out’ and of course cover for acute issues not related to COVID.
The pandemic is always evolving- our residency leaders are very involved in the institutional response at both our sites and worked hard to find the appropriate balance between patient care and education.
We do expect the pandemic to be largely over by the time the incoming interns start in June 2021. All the early vaccine trials are promising.
Update September 18, 2023
Thankfully, the impact of the pandemic on medical education and training is a minimal issue, and while we may have future pandemics, COVID-19/SARS-CoV-2 is unlikely to flare up in a way that so profoundly affected the healthcare system and medical education from 2020 to 2022.
My reflection on the Covid-19 pandemic for current applicants to our training program is that our approach emphasized things we are proud of- being resident centered, and academic. From the very beginning we engaged residents in every aspect of how we would approach and plan for census surges and the impact on rotations. Our philosophy is to always view the training program in a collaborative way with significant resident input. Moreover, we always view trainees with respect and not as workers who can be moved around without consent and engagement. During our one-month census crisis in January 2022 when our GME office declared a “GME disaster”, we had to ask some fellows to attend on new teams- and we paid them for this effort. And we created paid moonlighting positions when we asked residents to fill in gaps due to increased ICU census. We prioritized resident vaccination in December of 2020 when the vaccines were first rolled out. UH and VA were on the cutting edge of COVID research. UH was one of the first sites in the world for remdesivir clinical trials. Both UH and VA had vaccine trials and a number of trials in anti-inflammatory interventions and therapies. The engagement in the research side of the pandemic reflects the strong cutting edge academic focus of CWRU/UH/VA, and the commitment to advance science and clinical care and serve the needs of the public.
- What are the unique aspects of the Internal Medicine Residency Program?
Internal Medicine residency at University Hospitals / Case Western Reserve University provides trainees with a strong foundation in clinical and academic medicine balanced with a supportive and collegial atmosphere. The Department of Medicine is top-ranked in NIH funding and clinical care in U.S. News & World Report rankings. Many of our faculty are academic leaders in their field with strong national reputation.
When we ask our housestaff, they say the camaraderie among the housestaff, relationship with faculty and program leadership and the supportive atmosphere are unmatched.
Our residents receive outstanding clinical training working with approachable faculty who love to teach in two nationally recognized institutions, UH Cleveland Medical Center, as well as the Louis Stokes VA Medical Center. We also have innovative programs in ambulatory care (the VA–based Center of Excellence), medical education (LME pathway), and International Health.
Our program offers a balanced approach to clinical education, training and mentorship in an atmosphere that allows the residents to achieve their best.
- What do most of the residents do after residency
A comprehensive list of our alumni with respect to future career plans is available on our website. A large portion of our residents successfully matriculate into subspecialty fellowships throughout the country, with the majority securing their first choice program. Our program also supports residents pursuing outpatient primary care or hospitalist positions.
- How do your residents do in obtaining fellowships
Our residents have done extremely well in matching to competitive fellowships, with greater than 95% getting one of their top choices. Our website and application materials list the fellowship matches of our residents over the past decade. Our residents have done quite well in the most competitive areas such as cardiology, hematology/oncology, and gastroenterology, and have successfully matched in all fellowships available. We had an exceptionally strong fellowship match for the class of 2020, with residents matching at Mayo Clinic, NIH, Harvard, University of Michigan, Cornell, UCSF, Mount Sinai, UCLA, among others.
- How Much Time do House Staff Spend at the Two Sites on the Inpatient Service?
House staff spend approximately two-thirds of their time at University Hospitals Cleveland Medical Center and one-third at the Louis Stokes Cleveland VA Medical Center.
- What Criteria are Used to Select House Staff?
We look for applicants who demonstrate a strong commitment to learning and professionalism, value teamwork and have academic potential. We hope to recruit residents who have an intrinsic desire to learn, value autonomy and who will become excellent teachers and can help our program thrive.
- Do You Have Subspecialty Teams?
Yes. A remarkable strength of our program is that we have subspecialty teams dedicated to each traditionally inpatient service. Staffed by subspecialists, these teams provide a rare opportunity to work closely with experts in each field. Moreover, residents who are interested in particular fields can have first-hand exposure from the beginning of training and gain additional mentorship. In addition, we have dedicated general medicine teams at UH Cleveland Medical Center and the Louis Stokes Cleveland VA Medical Center that provide an opportunity to care for undifferentiated patients.
- Are your rotations based on months or blocks?
We use a block schedule, which represents a 4-week period, although some rotations may be 0.5 block long. The intern schedule is based upon 13 blocks. A block schedule makes the switch days standard and facilitates days off and weekend coverage.
- How many people are on a team?
Most of our inpatient teams are one resident and two interns. For the first 4 blocks of the academic year, we double the resident coverage at UH to help with additional support for new interns and acting interns. Two of our subspecialty teams (renal and cardiology) are 2 resident, 4 intern teams throughout the year.
- What is the Professional Development Block?
All categorical interns spend two weeks on the Professional Development block, which focuses on establishing and developing procedural competency, resuscitation proficiency, communication skills, physician wellness and physician exam skills. The block also includes modules on cultural competence, patient safety, meditation and reflection, humanism in medicine and conflict resolution.
It is a yearly experience that all of our categorical medicine interns share near the end of the academic year. It is a curriculum designed to emphasize several tenets of post-graduate medical education outside direct patient care. Experiences range from instruction on communication skills, examination techniques, clinical decision making, procedural skills, quality improvement and events at local museums and playhouses. It is a diverse and fun rotation that helps to advance the training of our house staff.
- How does your program approach resident wellness?
Having been involved in graduate medical education since before the days of duty hours and limitations on resident workload, we believe that residents wellness starts with workload and work-life balance. In 2018, we did away with all 24-hour call in our program- sleep hygiene and rest are critical elements of resident wellness. We have made many modifications to rotations over the years based on resident and Chief Resident input. We pay close attention to resident workload and always ask for resident input to modify admitting schedules and workflow. There will always be times in some rotations where there is hard work and some stress - and an element of this is needed for physician growth and development. We are committed to graduating residents who are effective and efficient in clinical care (and we believe this is one reason why our residents do so well in obtaining competitive fellowships and clinical positions). However, at the same time, we are also committed to finding the right balance so periods of hard work that contribute to professional growth do not impact wellness. Our schedule provides a nice balance of busy and less buy rotations. Ambulatory blocks, vacations, electives and the Professional Development Block are spread out throughout the year- so busy rotations are interspersed with much less busy rotations. The Ambulatory Blocks have built-in ‘personal half-days’ for time off. We have a ‘no questions asked’ jeopardy system for any urgent time off- but the ‘personal half-days’ and elective time allows for easy, predictable time for scheduling appointments, etc. We support without question any need for mental health appointments at any time.
The Professional Development Block is in many ways part of our wellness program. A two-week break from any clinical duties with many fun bonding activities.
We have Chief Resident mentoring groups, and the Chief Residents and program leadership pay close attention to the residents' training experiences- debriefing after stressful events, etc. In addition, as part of our wellness initiatives, we started a Resident Coaching Program in 2016 that allows residents to develop a unique partnership with a faculty coach, who is separate from their mentor, to support their professional and personal wellness goals.
We have social events scattered throughout the year. Every year in February, we have “Morale Week.” February is traditionally a low point in the interns' year. The excitement of starting an internship is over, the end of the year seems a bit far off and the days are shorter. Morale week includes a special breakfast every day, fun activities at noon conference, and evening activities.
Finally, perhaps the most important element of resident wellness is support of your colleagues. Our program has a tradition of collegiality and support within each class. These social support networks around shared experiences provide a sense of community that really enhances the residency experience.
- What is the Primary Care Block?
All categorical interns spend four weeks on primary care blocks in the PGY1 year. Interns are introduced to their clinic preceptors and patients and have protected time for small group learning sessions focused on ambulatory and primary care issues. Clinical activities include a variety of medical subspecialty clinics, urgent care and continuity clinic. We are committed to having a balance between the inpatient and outpatient educational venues, and the primary care block for PGY1s reflects the commitment of the program and general medicine faculty to ambulatory education.
- Can You Tell Me More About the Ambulatory Curriculum?
As of 2015, no residents have continuity clinic when they are on ward or ICU rotations. All PGY2 and PGY3 residents have five to six two-week ambulatory blocks evenly spaced through the year. All PGY2 and PGY3 continuity clinics occur during these blocks. PGY1 residents also have ambulatory blocks scattered throughout the year.
Continuity clinics occur either at the VA or at the Douglas Moore Clinic, which is a resident-run outpatient clinic at University Hospitals. There are no outpatient clinics for residents while on inpatient rotations. Spreading the blocks throughout the year is our version of the "6+2" model and prevents residents from having long periods of time on inpatient services without seeing their clinic patients.
Ambulatory block activities include continuity clinic, medical subspecialty clinics, urgent care, primary care continuity clinic and clinic-based quality improvement. Beginning in 2015 we implemented a half-day each week devoted to didactics and small group learning. Residents interested in primary care can do additional ambulatory blocks and tailor their experience based upon career goals. There are also built in free half-days that allow residents to meet with potential mentors or explore other subspecialty clinics.
- What are My Options for Elective Time?
We are proud that despite limitations in duty hours, we have been able to preserve our culture of freedom and quantity of elective time. There are no strict regulations on what an elective can be, nor is there an available list of electives that can be chosen. Residents are welcome to design their own electives. Some examples include inpatient consult services, outpatient subspecialty clinic rotations, research or any combination. If new interns are having difficulty identifying a possible elective, our chief residents are experts in guiding and creating worthwhile opportunities for them.
- What is the IM residency doing to address health care and social inequities?
It starts with patient care- both of our sites are committed to serving an underserved population with the highest level of compassion, respect and clinical excellence. As an institution, UH has been a leader in diversity efforts and has responded to recent events with community engagement. Our institutional leaders have supported demonstrations around recent events and social justice. The IM residency strives to recruit a diverse housestaff and to foster an environment of support, openness and free exchange of ideas. In light of recent events we are reinforcing educational content on topics such health care disparities, implicit bias, unconscious bias, and macroaggression. In the past year our International Track has also focused on health care disparities.
- What Changes Have You Made to Support the Duty-Hour Reform?
We have limited the total number of patients on the teams and the number of admissions, and have continually expanded the number of non-teaching services. We have added night floats at both UH Cleveland Medical Center and the Louis Stokes Cleveland VA Medical Center for both acute care and critical care rotations, and have created robust non-teaching services at both UH and the VA. We limit interns on ward rotations to no more than eight patients. We have done away with all '24/4' call- the only 24 hour call in our program is a once a week call at the VA MICU for a PGy3- so during their residency each resident does this one-two times.
- Is there a required palliative care and geriatric rotation?
Interns spend four weeks on a rotation that combines geriatrics and palliative care. The geriatrics portion includes inpatient geriatrics, geriatric clinics, a home visit and nursing home care. The palliative care portion includes small group learning, and inpatient and outpatient palliative care clinical experiences.
- Are Global Experiences Available?
Case Western Reserve University has a long tradition of involvement in Global Health research, education and clinical training. Many of our residents pursue overseas experiences during training. Residents have spent time in Vientiane, Laos (where the Department of Medicine is engaged in an education project) and in Kampala, Uganda (where we have a long-standing, multifaceted research collaboration in infectious diseases, cardiology and hematology-oncology). The Department of Medicine has received funds to support international work by residents, and residents each year can apply for financial support for international projects.
- What is Your Approach to the Work-Hour Reform?
Our experience has taught us that only by decreasing the workload can we achieve duty hour compliance, and we have limited the number of admissions and number of patients an intern can follow. We continually monitor workload and duty hours and have made changes in the program structure annually-most recently doing away with all '24/4' call.
- How Many Admissions Can I get When I am on Call on Ward Rotations?
Interns are allowed to get three patients on call, including night float admissions and ICU transfers. Interns are not allowed to follow more than eight patients on any rotation. For the first several blocks of the year, interns at UH and the VA are paired with AIs and do not follow more than six patients. Interns do not take overnight call on the wards and take no new admissions after 7 p.m. on their call day. We have modified our night float system to ensure that on-call interns can sign out as early as 6 p.m.
- Do You Have Short Call?
Our general medicine wards and some subspecialty wards have one short call per four-day admitting cycle, which is limited to night floats and ICU transfers (no new admissions) at UH but may include new admissions at the VA. There is no short call on weekends and no short call if an intern has eight or more patients.
- Is There a Night Float System?
We have a night float system at both UH Cleveland Medical Center and the Louis Stokes Cleveland VA Medical Center. Under the new duty hours, all interns now rotate as part of the night float team, supervised by upper-level residents. We emphasize teamwork and mentoring of night float interns by upper-level residents who are part of the night float team. Interns on the night float team cover the teams not on call, and may admit one or two patients. Most admissions are done by PGY2 or PGY3 residents, or by the non-teaching services. We also have third-year medical students as part of the night float team, and interns enjoy teaching these students.
- How Do Days Off Work?
Typically, on inpatient rotations house staff get one Saturday, one Sunday and one Golden Weekend per four-week block. On some rotations including ICU rotations, residents get one day off per week that may fall on a Friday, Saturday, Sunday or Monday. Non-ward rotations have additional weekend days off. No matter the rotation, all house staff are ensured four days off per block.
- How Do You Handle Vacation Time?
Each resident has four weeks of vacation divided into two two-week blocks. Vacation requests are taken before the start of each academic year and most requests are fulfilled, especially for significant life events (weddings, family vacations, etc.) Every intern starts their academic year during the last week of June, as such when the new intern class arrives the following year the graduating interns have an additional week off (that is five weeks total). During this last week of vacation many classes take a vacation together as a group to one of many tropical destinations (Florida, Dominican Republic, Cancun, etc.).
- How Do You Educate House Staff About Patient Safety and Quality?
Both of our teaching hospitals have committed significant resources to patient safety and quality. UH Cleveland Medical Center ranks third in the 90-member university hospital consortium in quality measures, and has a large quality center that is involved in many initiatives, including educating our residents. In August 2012, UH Cleveland Medical Center received the American Hospital Association's McKesson Quest for Quality Prize, making our institution the top hospital in the nation for its leadership and innovation in quality improvement and safety - and the first urban academic center to win this award.
In 2011 the Ohio Patient Safety Institute awarded UH Cleveland Medical Center the Best Practice Award for our Resident EQUIPS (Externship in Quality and Patient Safety) program. The Resident EQUIPS program is a first-of-its-kind rotation where the residents participate in our hospitals quality initiatives. The Louis Stokes Cleveland VA Medical Center is a center for patient safety and quality scholarship and education and offers a fellowship in this area. We expect our residents to be leaders in patient safety and quality initiatives at the next step of their careers. We also include Patient Safety and Quality modules in the Professional Development block for interns and involve PGY2 residents in quality committees.
- What is the Patient Mix?
At UH Cleveland Medical Center we have about one-third tertiary or quaternary referral patients; one-third come from an underserved urban population; and one-third community-based internal medicine. UH Cleveland Medical Center is one of two major referral centers in Northeast Ohio and has a busy transfer center. The patient population at the Louis Stokes Cleveland VA Medical Center is both primary care and tertiary care and comes from the greater Cleveland area and surrounding counties.
- How are the Ancillary Services at the VA?
The ancillary services have improved significantly over the years. There are phlebotomy rounds eight times per day to ensure that patients can get their lab draws throughout the day; IV therapists are also available during the day to place IV lines. After midnight, the IV therapist is also available to do blood draws (blood cultures, etc.). Nurses in the ICU and telemetry floor do all admission ECGs, and all nurses will do ECGs for acute clinical changes in patients (e.g., chest pain). Phlebotomy will also draw labs on-demand for patients with a change in clinical status.
- Do You Have Non-Resident Covered Services?
We have continually expanded our non-teaching services in order to decrease the house staff workload and keep the focus on education. At UH Cleveland Medical Center we have non-teaching services in cardiology, oncology and general medicine; in addition, we have expanded our general medicine non-teaching service at the Louis Stokes Cleveland VA Medical Center, allowing us to cap interns at eight patients.
- Do You Have Hospitalist Services?
At UH Cleveland Medical Center, our academic hospitalists attend on our general medicine teams, and we have separate non-teaching hospitalist services. In 2009, we established one of the first non-teaching hospitalist services in an academic VA Hospital, which has since expanded.
- Where Will I Live?
Most residents live within a mile or two of the hospital in Cleveland or one of the inner ring suburbs (Cleveland Heights, Shaker Heights). Housing in these areas is safe, very inexpensive compared to other large metropolitan areas, and convenient to the hospital. University Circle is a great place to live in as there are always exciting things to do. An increasing number of our residents also live in downtown Cleveland, which is about a 15 to 20-minute commute. You can read the interviews with our residents to get a glimpse of where they live and places they like to go to. You can also visit our Life in Cleveland section for more detailed information.
- Are Meals Provided?
Lunch is served at noon conferences. At UH Cleveland Medical Center residents have swipe cards for on-call meals and at the Louis Stokes Cleveland VA Medical Center food is provided for on-call residents.
- Do You Have Residency Retreats?
- We hold three major retreats for our residents. At the end of the year we meet off-site with all the categorical interns to talk about the skill set needed to be a successful resident and teacher. Mid-year we have an evening retreat for current interns to discuss how the year is going and get their feedback on the training program. We also have an off-site retreat for the rising PGY3s, with the focus on system issues and the leadership role of PGY3s.
- Are There House Staff Social Events?
Our residents organize house staff social events on an ad hoc basis during the year with financial support from the program. The Department of Medicine organizes a holiday party in December and a graduation dinner in spring. Families and friends are invited to the graduation dinner, which also features awards and a skit spoofing the hospitals and faculty (primarily the program directors).
In addition, the rising chief residents organize a Morale Week in February packed with fun events. In spring there is an annual event known as Bronson's Day that involves all the interns having the day off to attend a Cleveland Guardians baseball game with their classmates and the chief residents. We also have a summer picnic (with coverage by attending and fellows) in June as part of our chief resident and PGY3 sendoff. Program directors and chief residents also organize ad hoc social events, including a series focused on arts that includes book clubs and a night at the art museum series. You can see photos from our past social events on our Facebook page.
- Can You Tell Me About Your ABIM Pass Rate?
Our three year board pass rate ( 2018, 2019 and 2020) is 96 percent. We believe in a holistic admissions process, which means we do take some residents in our program who have exceptional abilities in some areas, but are poor standardized test takers. The vast majority of our residents do quite well, with several in the highest decile each year. We have implemented a tiered board prep plan based on the in-training service exam (ITE), and we provide focused mentorship for residents with low in-training exam scores. We also offer financial support for external board review courses for at-risk residents.
- What is the Resident Coaching Program?
As part of our commitment to resident wellness, we started our Resident Coaching Program in 2016, led by Associate Program Directors, Dr. Simran Singh and Dr. Ronda Mourad. Categorical interns form a three-year longitudinal partnership with a trained faculty coach, distinct from their academic advisor, research or career mentor, to assist with self-reflection, goal-setting and professional identity development. Based on the principles of positive psychology, the coaching process helps residents maximize their growth and recognize their full potential. Coaches also provide support for residents as they face personal stressors or career-related challenges. Resident experiences are captured in these recent testimonials:
“My coach was an important resource and sounding board for my ideas… By serving first and foremost as a listener, he became both an advocate and an educator for me as a person and as a physician.”
“I appreciated being able to have candid conversations without a fear of being evaluated. I loved having a faculty member as part of my support system, especially during the uncertainties of COVID-19."
“My coach helped me self-reflect when I faced difficult challenges and choices. She was a third-party sounding board who knew the different professional questions facing residents. I am immensely grateful to my coach for helping me figure out what was important to think of when thinking about careers, how to prioritize these, helping me figure out what I wanted, and how to attain it.”