Oncology Scheduling

Team Structure

  • 4 disease-specific teams (2 solid and 2 liquid teams).
  • Solid (Onc A1): 1 resident (BWH) and 2 interns (1 BWH and 1 BIDMC)
  • Solid (Onc A2): 1 resident (BIDMC) and 1 intern (BWH)
  • Liquid/Heme Malignancy (Onc B and Onc C): 1 resident (BWH) and 2 interns (BWH/BIDMC) per team.
  • Weekday nights: 1 flex resident, 1 float resident; 1 flex (admitting) intern, 1 float (admitting) intern, 1 cross cover intern
  • Saturday night: 1 flex resident, 1 float resident; 1 cross-cover/admitting intern
  • Sunday night: 1 flex resident, 1 float resident; 1 cross-cover/admitting intern
  • Evening and night team help the day teams leave on-time, take care of patients overnight, and admit patients when the day teams cap and at night.
  • 1 attending per team (except when a liquid patient is on a solid team, and vice versa in which case there should be a single “overflow” attending).
  • Daily admitting: Teams admit until 5 pm, with only 1 admission from 4 – 5 pm. Pass-off to the cross cover intern at 5 pm. Residents on all services admit daily. Interns on Onc A1/B/C alternate admitting days (daily admitting for Onc A2); resident supervises interns.

Day Team Members

Oncology A1, B, and C Team Interns

  • On long call days work from 7 am – 6 pm (11 hrs + pre-rounding).
    • Pass-off occurs at 8 am on the weekends.
    • No admissions after 5 pm (1 admission between 4 – 5 pm).
    • Meets with night team at 5 pm to sign-out patients to cross-cover intern and any admissions received after cap was reached to the admitting interns. Can stay until 8 pm to complete work as needed.
    • If an admission page is received before 5 pm and the patient is located in BWH/ED then it is the day team’s responsibility. If the patient is an OSH transfer or direct admit (from outside clinic/home/DFCI) then the note can be prepped and patient passed off to flex intern. In this case the admission will be passed back to the same team the next morning. Teams can receive only 1 admission from 4 – 5 pm.
  • On non-admitting days work from 7 am to 5 pm (10 hrs + prerounding). Non-admitting interns may sign-out to the Nightfloat cross-cover intern intern at 5 pm.
  • If an intern has clinic on an admitting day then the interns should internally trade their call days. If they are issues please discuss them with the CMR. Changing clinic days is strongly discouraged.
  • One intern on Onc A1 for the whole year will be a BIDMC intern; during the first half of the year, one intern on Onc B will be a BIDMC intern.

Oncology A1, B, and C Team Residents (BWH resident)

  • Works 7 am – 6 pm x 6 days per week (11 hrs).
  • Pass-off occurs at 8 am on the weekends.
  • Supervises interns, covers intern list when in clinic.
  • Meets with night team at 5 pm to sign-out patients to Nightfloat cross-cover intern and any admissions received after cap was reached to the admitting interns.

Oncology A2 Team Interns

  • Daily admitting work from 7 am – 6 pm (11 hrs + pre-rounding).
    • No admissions after 5 pm (1 admission between 4 – 5 pm).
    • Meets with night team at 5 pm to sign-out patients to Nightfloat cross-cover intern and any admissions received after cap was reached to the admitting interns. Can stay until 8 pm to complete work as needed.
    • If an admission page is received before 5 pm and the patient is located in BWH/ED/DFCI then it is the day team’s responsibility. If the patient is an OSH transfer or direct admit (from outside clinic/home) then the note can be prepped and patient passed off to flex intern. In this case the admission will be passed back to the same team the next morning. Teams can receive only 1 admission from 4 – 5 pm.
  • If an intern has clinic on an admitting day then the resident will admit.

Oncology A2 Team Resident (BIDMC resident)

  • Works 7 am – 6 pm x 6 days per week (11 hrs).
  • Supervises intern, covers intern list when in clinic.
  • Meets with night team at 5 pm to sign-out patients to cross-cover intern and any admissions received after cap was reached to the admitting interns.

Night Team Members

Night Interns (Flex Intern, Nightfloat Intern and Cross-cover intern)

  • Flex intern: Admits to ONC A1-C/BMT from 4 pm – 2 am (last admission at 12 am). Fills the nightfloat cross-cover intern role on Sunday.
  • Nightfloat admitting intern (admitter shift): Admits to ONC A1-C/BMT from 7 pm – 7 am (or 8 am on the weekends)
    • Nightfloat admitting intern helps flex Intern with late admissions so they can finish by 2 am.
  • Nightfloat cross-cover intern (cross cover shift, daily): Cross-covers ONC A1-C/BMT from 5 pm – 7 am weekdays (and until 8 am weekends) and when able will help with overnight admissions.
  • Days off: Please see amion. 3 days per 2 week block for night float interns (Saturdays and Sundays), 1 day per week for flex intern (Saturday). On Sunday evening, the Flex intern fills the Nightfloat cross-cover intern role.
  • Note: All admissions admitted by the flex intern will be signed out to the nightfloat cross-cover intern for the remainder of the evening.

Flex Resident (covering ONC A1-C)

  • 4 pm – Midnight (8 hrs) x 6 nights (covered by weekend rounding shift on Fri).
    • From 4 pm – 10 pm, supervises admissions done by the Flex intern or Nightfloat admitting intern. (Day teams cap at 5 pm, but are only allowed one admission between 4 – 5 pm). Admits on own only when necessary and both interns very busy.
    • No admissions after 10 pm.
    • There is no cap for the number of admissions that the night team can be assigned. If you and your interns feel overwhelmed you should first ask the Nightfloat resident to help with the admissions and if he/she is too busy, discuss with the phys who can help redistribute to other night teams.
    • There is only 1 intern on Saturday and Sunday nights. On Saturday and Sunday nights the Flex resident will admit on their own until the Nightfloat cross-cover intern is compensated with cross-cover and able to admit.
    • All admissions done independently by the Flex resident will be passed off to the Nightfloat resident for the remainder of the evening.

Nightfloat Resident (covering ONC A1-C and BMT)

  • 10 pm – 7:30 am (9.5 hrs) x 6 nights (covered by extra shift on Sat).
    • Pass-off occurs at 8:00 am on weekends (so shift ends at 8:30 am)
    • Supervises admissions done by the Flex intern and the Nightfloat interns. And if both interns are very busy then can help do admissions on their own.
    • Helps the Flex resident get out at midnight by helping to supervise the admitting flex intern and the admitting float intern.
    • Will supervise admissions starting at 10 pm.
    • All admissions by the Flex resident will be passed off to the Nightfloat resident.

BIDMC Interns/residents

  • One BIDMC Resident: Onc A2
  • Two BIDMC Interns:
    • First half of year: 1 intern on Onc A1 and 1 intern on Onc B.
    • Second half of year: 1 intern on Onc A1 and one intern is the flex intern (they alternate with each other to do 2 weeks Onc A and 2 weeks flex).

Supervision of Interns

  • Team resident supervises team interns and may ask the Flex resident to assist with supervision.
  • Flex resident supervises Flex intern and Nightfloat cross-cover and admitting interns from 4 pm to 12 am.
  • Nightfloat resident supervises Flex intern and Nightfloat cross-cover and admitting interns from 10 pm to 8 am.

Admitting Structure

Census Caps

  • Team cap:
    • 14 for Oncology A1.
    • 8 for Oncology A2 (8th patient can only be assigned if all other solid tumor oncology teams are full)
    • 16 for Oncology B and C (Oncology B and C will uncap for acute leukemic patients).
  • Intern Cap:
    • Maximum 9 patients per intern for Oncology B and C; maximum 8 for Oncology A1 and A2

Extreme Census

  • Extreme census for oncology is only activated Mon-Fri when total oncology census is above 135.
    • There is NO change to the team caps in Extreme Census.
    • Teams affected: Short call will be initiated on oncology A1/B/C
      • Non-call intern on A1 can take up to 1 holdover.
      • Non-call intern on B/C can take up to 2 holdovers.
  • If oncology teams and PA oncology teams have capped, plan as per DFCI leadership, Joel Katz, and CMRs.

Intern Daily Caps

  • Oncology A1, B, and C
    • The admitting intern can admit up to 3 total (no distinction between holdover, ICU callout, new admission or inter-service transfer) patients per day every other day (Q2). In extreme census (Monday-Friday), the non-admitting intern on A1 can take 1 holdover, non-admitting intern on B and C can take 2 holdovers.
  • Oncology A2
    • The admitting intern can admit up to 3 total daily (no distinction between holdover, ICU callout, new admission or inter-service transfer). No extreme census modifications.
  • If teams cap early in the day, patients will be distributed to other oncology teams. If all oncology teams are capped, additional measures will be taken by CMR.

Days Off

  • Day Interns
    • Oncology A1, B, C, and BMT interns – Interns have 1 day off per week when their non-admitting day falls on a Saturday or Sunday.
    • Oncology A2 intern – Intern has Saturday off
  • Day Residents
    • Oncology A1 and B residents have every Saturday off (covered by weekend rounder).
    • Oncology A2 and C residents have every Sunday off (covered by weekend rounder).
  • Night Teams
    • Flex resident – Friday night off (covered by weekend rounder).
    • Nightfloat resident – Saturday night off (covered by weekend rounder).
    • Nightfloat interns – Days off are per Amion

Daily Structure

  • Morning Report: 730 – 830 am M-Th Residents at Morning Report; interns pre-round or Morning Report. (FRIDAY: 7:30 am Team breakfast; Medicine Grand Rounds – 8 – 9 am; residents and interns expected to attend)
  • Rounds: 830 – 1100 am Rounds MUST be done by 11 am. Rounds should start at 9am on Fridays to allow for attendance at Grand Rounds.
    • 8:30-10:30 am – Bedside walk rounds
    • 1030-11 am – Card-flip on remaining patients
  • Care Coordination and Work Time: 11 am – 12 pm
    • Residents attend care coordination rounds; intern work time prioritizing discharges and critical tasks.
  • Resident Noon Conference: 12 – 1 pm Residents and interns expected to attend.
  • Work Time: 1 pm – 4 pm
  • Teaching: 4 – 4:30 pm (3-4 pm on Wednesdays):
    • Monday and Tuesday: 1 resident-led and 1 attending-led session per week based on clinical schedules (each team should determine teaching schedule at beginning of block).
    • Wednesday: 15 minute slide rounds, by team, starting at 3PM at the microscope in the hematology lab, led by Dr. Aric Parnes. Submit patients to the CMRs on Tuesdays or review teaching slides.
    • Thursday: Oncology teaching for all teams, usually in Eppinger. Look out for an email on Thursday morning with the location and teacher.
    • Friday: Feedback is an essential part of training; individual feedback between all team members should occur each Friday during teaching time.
    • All teams are expected to attend slide rounds and group oncology teaching, barring clinical emergencies
  • Sign Out Prep: Beginning at 5 pm

Key Oncology Rounding Strategies

  • Discuss goals and expectations early: Attending and residents should discuss format, goals, and strategy of rounds at the beginning of each rotation. Individual roles should be clarified and expectations for presentations communicated.
  • Resident as leader: The resident should lead rounds.
  • Bedside rounding: Should be prioritized. The resident should determine the bedside rounding order prioritizing new admissions, high acuity patients, and efficiency. Actively manage the time in the room by establishing goals for the encounter before entering. Intern should lead encounter with help from resident and attending. Avoid lengthy goals of care conversations on rounds; establish need for team to return if necessary.
  • Orders: Only housestaff should enter patient orders.
  • Presentations: It’s helpful for the team to have read admission notes in advance to allow succinct presentations. Focus on active issues. Avoid repeating and summarizing.
  • Teaching: In addition to daily dedicated teaching sessions, residents and attendings should focus on integrating teaching into daily rounds, especially when it is busy. Think out-loud (“Why?”) in clinical discussions. Teaching should be practical, concise, and relevant to the patients on service. “Bread and butter” topics are welcome and appropriate (and can include outpatient management topics and screening).
  • Feedback: The attending should provide confidential, individualized feedback to each team member at least weekly (“Feedback Friday”). Brief (5 min), daily attending feedback to the resident on their team leadership and teaching style is recommended at the conclusion of rounds.