Resident Training Program - Internal Medicine Residency
The education and clinical training of Internal Medicine residents is a central focus in the Department of Medicine. We provide comprehensive training in general internal medicine for all residents seeking career in a subspecialty fellowship, primary care and hospital medicine.
Combined training programs in Medicine-Pediatrics and Internal Medicine-Emergency Medicine (including a 6th year for EMIM-Critical Care certification) offer unique opportunities to individuals interested in dual or triple certification. Preliminary interns participate in a curriculum similar to the categorical interns and develop a solid clinical base in internal medicine before entering their specialty residency.
The broad and flexible curriculum allows residents to put together a well-rounded program suitable for their individual educational needs. Residents participate in a comprehensive core curriculum that emphasizes the breadth and depth of internal medicine and a broad choice of electives that allow them to explore areas of clinical and research interest.
Goals of the Residency Education Program
Through their clinical training, residents:
- Learn the principles and knowledge necessary for the practice of general internal medicine balanced with a comprehensive exposure to the medical subspecialties.
- Gain clinical knowledge in diverse ambulatory and inpatient settings by caring for patients with a variety of illnesses and from many socioeconomic backgrounds.
- Receive a balanced exposure to patients with acute or life threatening illnesses and to those with chronic or subacute problems.
- Are immersed in a clinical learning environment that promotes wellness and supports a healthy work-life balance.
To meet these goals, residents gain clinical experience at three teaching hospitals and numerous ambulatory sites. Residency training is conducted at the University of Maryland Medical Center, at the modern and adjacent Veterans Affairs Medical Center, and at Mercy Medical Center -- a private community hospital within five minutes from University Center. Training in ambulatory care takes place at these sites as well as in clinics and private practices in Baltimore City and surrounding counties. Residents may also choose to do rotations at Area Health Education Centers (AHEC) in rural Western Maryland and on Maryland's Eastern Shore.
Individualized and group mentoring workshops provide our residents with career guidance for their careers in subspecialty medicine, primary care, hospital medicine and global health.
Structure of the Curriculum
Inpatient and ambulatory rotations are structured using an X+Y format. All inpatient rotations are part of the X component with spaced 2-week ambulatory blocks during the Y component.
- Interns have two Y blocks -- Academic General Internal Medicine -- where they attend their continuity clinics in the afternoon and dedicated learning sessions in the mornings. During the fall Academic GIM session, the morning sessions include simulations, ultrasound curriculum, literature in medicine, interprofessionalism experiences (working with nurses in the MICU or Cancer Center), and wellness activities. During their spring session, the interns attend selected subspecialty clinics to broaden their clinical exposure.
- Upper level residents have six Y blocks that are strategically placed throughout the year. They attend their continuity clinic in the afternoons and selected subspecialty clinics in the mornings. Since the timing of the Y blocks is flexible and can be moved depending on the resident's personal needs -- family or personal events, fellowship interviews, etc. -- we call our structure FleX+Y. It consolidates inpatient and ambulatory training while providing residents with flexibility in setting their schedule for the year.
Residents have inpatient rotations on a variety of services, including general medicine, subspecialty services (e.g., cardiology, ID, and oncology), MICU, CCU and night/day floats. The rotation schedule is carefully arranged so that each resident has exposure to general medicine, subspecialties, clinical floors and intensive care units, while not allowing any one area to dominate. The remainder of their time is spent on clinical or research electives, including subspecialty outpatient experiences during the mornings of their Y blocks. A summary of the clinical rotations by year of training can be found in Curriculum in Internal Medicine.
Mentoring and Career Pathways
A comprehensive mentoring program provides individual and group mentoring. Residents are paired with faculty with similar interests provide guidance as they develop and solidify their career goals. They attend a series of workshops that include how to apply for fellowships, the fellowship interview process, creating your CV, securing a primary care or hospitalist position, among others. Faculty enthusiastically welcome residents to engage in research and take an active role in ensuring residents achieve success.
Residents planning a subspecialty fellowship engage in research during their training and receive close mentoring by faculty who have diverse clinical and research interests. The Department provides financial support for residents whose research is accepted for presentation at regional or national meetings. The spring meeting of the Maryland Chapter of the American College of Physicians is an annual showcase of the residents' research and clinical case reports. At each year's May meeting, over 50 residents present their research or clinical vignettes.
Several workshops are held throughout the year where residents learn principles of research design, IRB submission and basic statistics, and process workshops on strategies for applying to fellowships, creating an academic CV, and having a successful fellowship interview. During 2017-2018, our residents published 25 peer-reviewed papers and presented 23 national or international abstracts, 49 regional abstracts, and 8 institutional abstracts! See our Resident Bibliography for the full listing.
For those planning a career in primary care, residents take rotations in geriatrics, women's health, orthopedics, neurology, endocrinology or rheumatology. They have their continuity clinic in the Faculty Practice Offices and work alongside general medicine faculty in a private practice setting. Residents spend time in private practices in the community where they experience "real life" primary care and reach a deeper understanding of the business of medicine. Our Primary Care Chief Resident oversees the primary care content of the core curriculum, conferences and ambulatory rotations.
For residents seeking a career in hospital medicine we offer an expanded curriculum in Patient Safety and Quality Improvement (PSQI), including the IHI modules (Institute for Healthcare Improvement), longitudinal individual and group projects, and conferences on PSQI principles. Whether residents will be hospitalists as a life-long career or only for a year or two as they transition to a fellowship, they benefit from these offerings. They take electives that emphasize inpatient medicine, such as general medical consultation, cardiology, infectious diseases, GI and pulmonary medicine.
We offer an Elective in Hospital Medicine that exposes residents to medical consultation, quality assurance, utilization management, hospital administration and finance, and delivery of evidence based care in the inpatient setting. Under the guidance of our academic hospitalists and dedicated PSQI chief resident, our extensive curriculum in Patient Safety and Quality Improvement (PSQI) is incorporated into our Morbidity and Mortality Conference and core curriculum, with all residents participating in collaborative longitudinal QI projects.
Residents with an interest in international health attend lectures and conferences in other departments and institutes on campus, including the Institute for Human Virology and the Center for Vaccine Development. They focus their Journal Club presentations and Senior Manuscript on international health, choose research projects in international or global health, and can participate in international rotations. Recently residents have traveled to Zambia, Haiti, Kenya and India. Limited funds are available through a special endowment to support resident travel abroad.
The Clinical Learning Environment
We are deeply committed to ensuring our residents learn in a supportive environment that emphasizes clinical medicine, individualized mentoring and resident wellness. Our efforts have resulted in a wonderful camaraderie among our residents and an outstanding review from the RRC with a full 11-year accreditation from the RRC -- their highest level! Some examples of recent changes include dedicated educational time, healthier food options at conference lunches, a new resident lounge, an X+Y format for scheduling rotations, comprehensive wellness curriculum, annual educational retreats with a fall retreat for the interns, and ongoing social events. The GME leadership at UMMC has been phenomenally supportive of our residents, including funding for hospitalists, moonlighting shifts and ancillary support.
Here are some highlights of our clinical curriculum and structure:
- At the UMMC and the VA, we have 4 general medicine teams (1 senior resident + 2 interns) in a team call structure. A Day Float resident helps the residents with admissions and cross cover to ensure they leave on time.
- At both UMMC and the VA, we have a Team Call System for the general medicine services with the Night Team arriving at 9 PM, and the long call team taking their last admission at 6 PM. The "drip method" limits admissions from 4-6 PM so everyone leaves at the end of their shift. A moonlighter handles all cross-cover issues from 6-9 PM. With a Night Team covering 7 nights/week, interns and residents do not stay overnight on general medicine and Med-ID.
- The team attending is the physician of record for all patients on all services. Hence, private practitioners and consultants may admit to our services, but the team attending, resident and intern assume primary responsibility for the patient.
- Patient coverage in the ICU's is done by residents, hospitalists and intensivists. At UMMC, an intensivist is present in the MICU 24/7/365. At night the intensivist and pulmonary-critical care fellow work with the senior resident and 2 interns in admitting and cross-covering patients. In the CCU, the senior resident and 2 interns admit and cross cover patients at night, with a cardiology fellow available for immediate assistance. At the VA, the MICU and CCU services are covered at night by the ICU resident and interns on a night float rotation. Interns on VA ICU rotations do not stay overnight.
- Call on all services at all sites - including floor teams and ICU's at all sites - is every fourth night.
- We track resident duty hours through a self-reporting method to ensure compliance with all RRC Duty Hour Requirements.
- Interns are strictly capped at 5 admissions per long call or night float shift with upper level residents capped at 10 supervisory admissions.
- Interdisciplinary teams and discharge planners facilitate patient care. Broad ancillary services at all sites make patient care efficient and effective.
- All sites have full electronic medical records, with EPIC at UMMC and Mercy, and CPRS at the VA.
- Non-teaching services admit patients at all sites to help patient flow and ensure we meet all ACGME rules. At UMMC, we have non-teaching services for general medicine, step-down intermediate care unit (IMC), BMT, renal transplant services and bone marrow transplant unit. The VA and Mercy have general medicine nonteaching services.
Wellness in Residency Training
We are committed to ensuring residents have a balance between their training and their personal life. Our extensive wellness curriculum includes many components -- from monthly conferences on topics such as nutrition, stress management, exercise, meditation, chair yoga and fatigue management -- to reading essays and books, educational retreats, baseball games (go O's) and evening social events. One of our favorites is when the service dogs visit us and provide some quiet time for the residents.
So that residents have time for doctor's appointments, errands and other personal issues, they have four wellness 1/2-days off (in addition to regularly scheduled days off and vacation time). The RISE Program - Resilience in Stressful Events - helps teams and individual residents cope with adverse patient events. The GME Office orchestrates events through the House Staff Association with four big events throughout the year. The highlight of the year is the annual Valentine's Day Ball at the B&O Museum.
Leadership and Teaching Skills
The development of leadership and teaching skills is an important part of residency training. Throughout their rotations, residents develop the necessary skills to be clinical supervisors and teachers of the medical teams. By taking on progressive responsibilities, residents become comfortable dealing with a wide variety of clinical situations, including patient care, interpersonal situations and teaching.
Residents attend an annual educational retreat where they improve their skills in giving feedback, teaching in small groups, managing conflict, and team building. An annual educational retreat for interns in the fall helps to boost their skills early in the year and provides a dinner social event to enjoy time with their classmates. A best resident-teacher award is given to a senior resident each year -- reaffirming the importance placed on excellence in teaching as part of each resident's core responsibilities.
Our residents consistently receive the majority of the teaching awards given by the medical students, including AOA Honor Society and the Gold Humanism Honor Society.
Resident Evaluation and Curriculum Development
Ongoing communication between residents and faculty is highly valued and considered critical to our success. We have developed a comprehensive core curriculum that is delivered through our noon conference series. Residents review monthly feedback on their clinical milestones through our web-based evaluation system (E*Value). Similarly, residents evaluate attending teaching and the educational value of the rotations, providing real-time feedback to the education leadership.
Through our Peer Evaluation System, residents evaluate their interns and interns evaluate their supervising residents. Students evaluate residents on their clinical, teaching and leadership skills, and residents provide valuable evaluations of their medical students. This comprehensive multi-source feedback system ensures that residents are continually striving to improve their skills in a positive and nurturing environment. Residents meet with Dr. Wolfsthal in a formal semi-annual mentoring and feedback session where we review the resident's clinical performance, career interests, and educational goals for the coming year.
Through the Postgraduate Education Committee, resident representatives from each class review feedback about the program, and contribute to the educational process. An Annual Needs Assessment gives residents another way to evaluate the overall residency and its components. Residents and faculty from all the divisions actively participate in this review process to continuously improve the curriculum and meet the needs of our residents.
Our core curriculum is delivered during our dedicated noon conferences series, which include case conferences, didactic lectures, journal club, board review and pre-clinic conference. Each of these conferences has a different format and provides residents with diverse learning environments.
Workshops in procedures, ultrasound and simulations are held throughout to improve residents' skills with procedures and ACLS.
Medical Grand Rounds is our premier didactic conference of the week. The Acute Medicine Series is held early in the year to provide residents with a foundation of the evaluation and management of acute illnesses. Along with our Patient Safety and Quality Improvement curriculum, our Morbidity, Mortality and Improvement Conference includes a comprehensive curriculum in patient safety and quality improvement. Ethics Seminars are held throughout the year.
Residents have online access to all our major conferences through our web site. It is a marvelous compendium for our residents and provides a valuable educational resource throughout the year.