Rotations

All interns have approximately 6-8 weeks of ambulatory medicine, including a 2- week introduction to outpatient medicine at the beginning of the academic year. Continuity practice sessions provide an opportunity for growth of your own practice. Our intern ambulatory curriculum is focused on common medical problems in primary care. We also provide teaching on resources in our practice that help you to provide care to complex patients. 

Junior and Senior residents have 15-16 ambulatory practice weeks per year, during which they work in their continuity practice and attend ambulatory curriculum didactics in the morning. Ambulatory electives are incorporated into the overall elective options available and are scheduled during dedicated elective weeks. 

The internal medicine residency provides opportunities to work directly with cardiology attendings and fellows on the inpatient cardiology wards (Zoll rotation) and in the cardiac care unit (CCU) with a focus on management of patients with cardiovascular issues. The cardiology educational experience includes caring for patients on the general cardiology, heart failure, electrophysiology, structural and interventional cardiology services. Residents and interns have the opportunity to work with numerous experts in cardiology who are fantastic teachers such that the CCU rotation is one of the residents' most highly ranked rotations. The cardiology rotations are all staffed by residents, interns and fellows. 

ZOLL: 

The Zoll service is our inpatient cardiology service. Dr. Paul Zoll was a Beth Israel Cardiologist who pioneered the development of heart monitors, pacemakers and defibrillators in a career that spanned the 1950s until his retirement in 1993.The cardiology service is located next to the cardiac catheterization lab and cardiac ICU. Patients with unstable angina/NSTEMI, advanced heart failure, significant valvular diseases, electrical disturbances, or patients requiring higher level of cardiac care are admitted to this service. 

The cardiology service is staffed by four teams of 1 resident and 1-2 interns. A supervising fellow and attending help care for the patients and oversee clinical management. A separate interventional cardiology, heart failure and electrophysiology service exist within the Zoll service which have associated supervising attendings and fellows that work closely with housestaff. Cardiology admitting call is every 4thnight with an individual team census cap of 7-10 patients per intern depending on resident oversight. A general cardiology service lecture series occurs throughout the rotation directed for housestaff. 

CCU:

The CCU team cares for 14 patients in the cardiac intensive care unit.  It is staffed by a cardiology attending, fellow, 3 residents and 3 interns. This rotation is typically one of the highest rated rotations for several reasons including the notable teaching opportunities and complex physiology. Patients are admitted to the CCU for complications of MI, cardiogenic shock, significant valvular disease (acute MR, critical AS), large territory ST elevation myocardial infarctions, arrhythmias and high-grade conduction disturbances. It provides an opportunity to experience first-hand hemodynamics using Swan-Ganz catheters and a range of mechanical support. Residents take overnight call every third night while they are in the CCU and interns rotate through a day-night schedule. The average census is 10-12 CCU patients. The CCU team attends morning curriculum with cardiology faculty feared towards the housestaff.  

All categorical interns will have a continuity clinic at Healthcare Associates, the Jamaica Plain and West Roxbury VA Hospitals, Dimock Community Health Center, or Fenway Community Health (Center). Preliminary interns may request but are not required to do continuity clinic. Primary care residents add a second practice in their junior year and can choose to add any of these sites or can choose amongst a wide range of additional sites depending upon their interests. In the past, residents have participated in clinics at a local prison, an alternative medicine clinic and other local specialty or private practices. 

The BIDMC internship and residency places great emphasis on evaluating and treating critically ill patients. There are several different ICU experiences at BIDMC, including MICU Red (residents & interns), Finard ICU (residents & interns), MICU Blue (residents only) and the Cardiac ICU. 

Each intern completes, on average, two critical care months per year (e.g., one month in the medical ICU and one in the cardiac ICU). Critical care rotations expose house staff to a breadth of common disease processes, including sepsis and septic shock, respiratory failure requiring mechanical ventilation, cardiogenic shock, and life-threatening gastrointestinal bleeding. The MICU Red and MICU Blue teams are located on BIDMC's West Campus. The Finard ICU is located on BIDMC's East Campus (also the location of our Oncology and several surgical services) and exposes trainees to critically ill patients with oncologic, obstetric, and surgical pathologies. Surgical patients are generally co-managed, allowing for a unique, collaborative learning experience. 

Highlights of Critical Care at BIDMC: 

Procedures: While in the ICU, interns have opportunities to place central venous lines and arterial lines and to perform other common ICU procedures such as arterial puncture, paracentesis, thoracentesis, and lumbar punctures. These procedures are always done with supervision by an attending or resident, but the intern is expected and encouraged to be the primary operator. 

Attendings: In addition to the critical care attendings who round with ICU teams each day, there is a dedicated critical care attending available and present overnight on both campuses. 

Nurses and Respiratory Therapists: ICU nurses and respiratory therapists at BIDMC frequently have > 10 years ICU experience and are willing to teach interns and residents in their areas of expertise! 

Teaching: There is dedicated teaching in the ICU every weekday morning before rounds. This is typically a 30-45 minute lecture on various ICU related topics, including management of hypotension, optimizing vasopressors and IV fluids, renal replacement therapies, ACLS protocols, and mechanical ventilation. On Friday mornings, each intern and resident provides a brief chalk-talk to the group on an ICU topic of their choosing. 

Schedule: Residents rotate on call every 3 days (24-28 hour shifts) in MICU Blue and FICU. Residents on MICU Red and interns across all ICU’s work in 12-hour shifts (long day, short day, night).  

EDFLEX /NightFLEX are unique rotations that primarily provide care to patients who are boarding in the ED awaiting a bed. This includes both general medicine and medicine subspeciality patients. Residents on this service have the opportunity to practice evaluation and triage of patients early in their presentations and help progress vital care as patients await admission. Depending on the number of boarding patients, ED/NightFLEXmay also help with other duties including admissions, medicine consults, etc.  This is a JAR/SAR only rotation and lasts for one week. 

ED/NightFLEX exist as two separate 12-hour rotations, with shifts lasting 7AM-7PM and 7PM-7AM.  

Emergency Department rotations provide the vital experience of initial patient assessment, triage, and management while building cooperative ties with our colleagues in the ED. Interns rotating through the Emergency Department will interview, assess, and evaluate new patients presenting to the ED. Interns and residents in Internal Medicine, like ED interns and residents, work directly with a senior ED resident and an ED attending. In addition, Emergency Department rotations provide an opportunity to perform procedures which would otherwise be done by the procedure service on the general medicine and cardiology floors. Interns and residents working in the ED have the opportunity to perform lumbar punctures, paracenteses, arthrocentesis, and central line placements under the supervision of a senior ED resident or attending. In addition, the ED provides a unique opportunity to perform procedures done less commonly on the inpatient floors including incision and drainage, suturing, and stapling. 

The Liver-Kidney service, referred to as the "Epstein-Trey" service, is so named for two famous BIDMC physicians: Dr. Charles Trey, a gastroenterologist/ hepatologist, and Dr. Franklin Epstein, a nephrologist. On this rotation, house staff manage patients with end-stage liver disease and patients with liver transplants, under the guidance of an attending transplant hepatologist. Residents also care for patients with kidney transplants, under the guidance of an attending transplant nephrologist. Commonly encountered diagnoses include acute and chronic graft rejection, acute renal failure, hepatic encephalopathy, spontaneous bacterial peritonitis and refractory ascites.  

There is dedicated and attending-led teaching in the mornings before rounds. Additionally, interns will gain experience initiating workup for organ transplantation and performing diagnostic and therapeutic paracenteses (under supervision by the Hepatology fellow). 

There are 3 ET teams, each caring for up to 10 patients. Each team is composed of one senior resident and one intern. Teams rotate call (admitting patients) every 3 days. Team members work 6 days a week and have either Friday, Saturday or Sunday off. 

MEDED consists of 3 resident/intern teams that arrive at staggered start times throughout the day to admit the majority of our patients between 7AM and 11:30 PM.  

Nightfloat is an overnight rotation admitting new medical patients overnight. 

MEDED (Staggered shifts starting at 7AM) 

MEDED teams are responsible for admitting general medicine and medicine subspecialty patients from the ED as well as other intra-and inter-hospital transfers. There are 3 MEDED teams that are responsible for the majority of medicine admissions throughout the day:  

MEDED1: 1 resident and 1 intern team that admits from 7AM-5:30PM. The team will also help take care of boarding ED patients if the EDFLEX team is capped, as admission load tends to be lightest in the mornings.  

MEDED2: 1 resident and 2 intern team that admits from ~11AM - 9:30PM.  

MEDED3: 1 resident and 2 intern team that admits from 3PM – 11:30PM 

Typically, about 1-2 hours are required after the last admission to wrap up plans and orders.  

Intern Night Float (5:30 p.m. - 7:30 a.m.): 

Interns are responsible for cross-covering all floor-level inpatients overnight on the West Campus. At the end of each day shift, the inpatient interns sign out the ward patients to a night float intern. The night float's primary responsibility is to manage acute issues overnight as well as follow up on labs and studies that are pending at the time of the day team's sign-out. Each night float intern covers approximately 80-100 patients. Interns at BIDMC are supervised by the Intern Supervisor resident whose primary responsibility is intern support overnight.  Typically, this is a 1-2 week rotation with one night off per week. 

Resident Night Float  

Night Admitters (9:30PM-7:00AM)  

Two junior/senior residents are responsible for all overnight admissions to the medical, cardiology, and liver/kidney services WITHOUT cross-coverage responsibilities. Residents admit in a geographic format and usually admit approx. 5-6 patients/ night. NightFLEX may help on busier admission nights. This rotation allows for significant resident autonomy and co-resident collaboration — a strength of BIDMC residents! This is a one-week rotation and residents typically have two-night float rotations per year. Residents also may rotate as night float at the VA hospital, with similar responsibilities as the BIDMC night float rotation.

Intern Supervisor (5:30-PM-7:00AM) 

One junior or senior resident serves as intern supervisor, with the primary responsibility of overseeing the two interns who are cross covering all the resident-team medicine patients on the West Campus. This role allows residents autonomy to practice and teach their rapid triage and management skills. Residents typically rotate on this rotation for 1 week per year.  

BMT 

The BIDMC "BMT" rotation is named for “Bone Marrow Transplant” and refers to the inpatient hematologic malignancies service on East Campus.  Patients on this service often require chemotherapy and/or bone marrow transplants for a hematologic malignancy such as leukemia, lymphoma, or multiple myeloma. House staff will also manage various oncologic emergencies (e.g., Tumor Lysis Syndrome, Cast Nephropathy etc), complications of either allogeneic or autologous stem-cell transplantation, infectious complications of chemotherapy, and palliative care issues.  

In addition to the teaching provided by attendings on rounds, there is a teaching conference each weekday at noon for all our oncologic teams (BMT and OMED). This is led by a member of the Heme/Onc faculty. Food is provided. 

 The BMT service consists of two resident teams, each caring for up to 10 patients. Teams are each composed of a senior resident and an intern. There is also a second- or third-year BIDMC Heme/Onc fellow, two Heme/Onc attendings and a dedicated pharmacist. Interns rotate call about every other day, and work Monday through Saturday (day off on Sunday). 

OMED 

The OMED rotation is named for “Oncologic Medicine” and refers to the inpatient solid organ oncology service on East Campus. On this rotation, house staff manage a variety of solid organ malignancies as well as their disease and/or therapy related complications. There is also a focus on pain management and palliative care, as these issues are commonly intertwined with oncologic disease. 

In addition to the teaching provided by attendings on rounds, there is a teaching conference each weekday at noon for all our oncologic teams (BMT and OMED). This is led by a member of the Heme/Onc faculty. Food is provided. 

The OMED service consists of one resident team that can care for up to 14 patients. The team is composed of one senior resident, two interns, and a dedicated BIDMC oncologist attending.  Interns take call (admitting patients) 4 days a week, always with support from either the OMED or BMT resident. Interns work 6 days a week and receive either Saturday or Sunday off.

DFCI Oncology

This rotation gives house staff comprehensive exposure to inpatient management of both solid and liquid (hematologic) oncology, including oncologic emergencies, disease-related complications, pain management, and palliative care. This is similar to our OMED and BMT rotations. The rotation is run through the Dana-Farber Cancer Institute (DFCI) and takes place on the oncology wards at the Brigham & Women's Hospital (BWH).  

Each block, 1 resident and 1 intern from BIDMC rotates on the solid malignancy team (Onc A), which is composed of 1 resident and 2 interns (1 intern from BWH). Another BIDMC intern rotates on the liquid malignancy team (Onc B), which is also composed of 1 resident and 2 interns (the resident and 1 intern are from BWH). 

While at DFCI, interns rotate through two shifts: a day shift (7AM-4PM) and a twilight shift (4PM-2AM). Interns will spend 2 weeks on each, during their time on the Onc A or Onc B teams. 

Interns work 6 days a week on this service and have either Saturday or Sunday off.  

The Sub-Intern Resident Service (SIRS) is a dedicated resident-sub-intern rotation on a general medical floor. This is a highly rewarding rotation for both residents and students and allows senior residents the opportunity to build upon their teaching skills while working closely with a supervising hospitalist attending and two sub-interns. There are no intern residents on SIRS, which allows sub-interns to assume the intern role and take ownership as they perform initial assessments, write all medical orders, respond to all pages, and prepare all discharge paperwork (under resident supervision). Each sub-intern also spends time admitting patients on MED ED. 

There are 3 SIRS teams each caring for up to 10 patients. Each team is composed of one resident and two medical students. The service is geographically based on one of our floors in the Farr tower. Team members work 6 days a week and have either Friday, Saturday or Sunday off.  

The BIDMC medicine program is fortunate to be affiliated with the West Roxbury VA (West Rox), a large tertiary inpatient medical center that serves veterans throughout New England. West Rox serves as a regional referral center for interventional cardiology, specialized surgery (including open heart, plastics, vascular, and hand surgery), and spinal cord care. It has a MICU, CCU, SICU and progressive care unit. 

The VA is a strength of our program, as it allows residents the opportunity to care for a unique patient population and to work with other residents in the Boston area. Residents at West Rox work on the general medical wards and on nightfloat with housestaff from BIDMC, Boston Medical Center, and Brigham and Women's Hospital, providing them the opportunity to learn different practice styles and meet new people. Most interns and residents are at the VA for one ward rotation every year. Residents may also spend 1-2 weeks annually admitting patients on VA nightfloat. 

The General Medicine rotation is a great mix of both bread-and-butter cases (COPD, renal failure, end-stage liver disease, GI bleeds) and many obscure/advanced presentations of disease! Based on the comorbidities of the veteran population, residents will have the opportunity to manage patients with spinal cord injury, new oncologic diagnoses, and many other service-connected disabilities. There are VA-specific and non-VA specific teaching opportunities offered with the daily morning report and noon conference series, as well as opportunities to enjoy some delicious food on weekly Waffle Wednesdays and BBQ Fridays. Morning report and noon conference occur daily, and chief residents even put together weekly waffle Wednesdays as well as summer barbecues.  

BIDMC junior and senior residents will rotate through nightfloat at the VA for one to two weeks at a time. The nightfloat resident will work on a team with a Brigham and Women's resident to admit patients to the medical and cardiology services. For half of the rotation, the resident will also cross-cover patients in the CCU. An attending nocturnist is in the house overnight to cross-cover all general medical wards patients and supervise residents if needed. 

Altogether, the West Roxbury VA offers much to our training program. The patients are grateful for their care, and the learning opportunities are abundant. 

General medicine ward rotations comprise the core experience of the internal medicine residency. Interns admit, diagnose, and manage patients with a broad range of internal medicine problems, while serving as the primary caregiver for their patients. Residents lead teams of two interns and oversee management decisions, teach interns and medical students, and guide their team through clinical decision making. 

During ward rotations, each team of interns and residents has their own clinical attending and two additional dedicated general internal medicine or subspecialist attendings who lead teaching conferences throughout the week with a particular focus on current medical dilemmas on the wards. 

Geographic Admitting  

We strive to adhere to a geographic admission scheme that aligns workflow in a manner that maximizes efficiency, facilitates multidisciplinary rounds, enhances teamwork and improves patient care. While medicine patients are admitted across our medicine tower, our resident teams are structured to see patients primarily on 1-2 floors to allow for continuity and teamwork with our nursing, case management, and social work colleagues. We’ve received great feedback from our residents about this system and the relationships they develop with staff over their time rotating on the wards!  

Quick Facts about Wards at BIDMC 

• Day teams work from approximately 7 a.m. - 5:30 p.m., six days per week with one weekend day off per week.

• Interns typically have three to four wards months per year, and residents have one to two wards blocks per year. 

• More than 95 percent of the patients are cared for by our academic hospitalist group, usually resulting in one attending per team of patients to enhance teaching, feedback and patient care. 

• An intern’s average census is between six to seven patients on any given day. 

• Multiple educational opportunities are provided through conferences, formal and informal daily rounds, and afternoon teaching sessions.