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Internal Medicine Residency Program
Naval Medical Center, Portsmouth, Virginia
The INTERN’S MANUAL
AY 2013-2014 Edition
CDR Joseph J. Sposato, MC, USN
Program Director
LCDR Justin Lafreniere, MC, USN
Associate Program Director
LCDR(sel) A. Brooke Hooper, MC, USN
Associate Program Director for Interns
LCDR Edward T. Stickle, MC, USN
Chief of Residents
Mrs. Delilah Roman
Program Coordinator
Mrs. Tami Sjostrom
Administrative Assistant
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Assistant
Table of Contents
Topic
Page
Introduction
Purpose of this Manual
A Little NMCP History
NMCP Today
The Six ACGME Core Competencies
Department of Internal Medicine
Curriculum
New Innovations
CALL SCHEDULE
Internal Medicine Wards
CCU
Essentris
Work Hours
Call Rooms
Continuity Clinic
Leave
TAD
Didactics
Training File
Evaluations and Feedback
CAC/ID Cards
Fitness Reports (FITREPS)
Procedure Logs
Mini-CEX
Male-CEX and Female GTA Exercises
Research
Navy Mandatory Training
Step 3 Exams and Licensure
Inpatient Documentation and Data Flow
E-mail; Internet Etiquette
Requirements for Graduation
Pointers for IM Residency Application
Important Dates for Academic Year 13-14
How To Get Into Trouble
How To Distinguish Yourself
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“At the outset it is necessary for you to bear in mind that your professional education
[on graduation] is by no means complete; you have, as it were, only laid the foundation,
and,…while it is to be hoped that a good and promising foundation has been laid under
the guidance and instruction of others, it rests with yourselves what the superstructure
shall be.”
Sir William Osler (1849-1919)
Valedictory Address to the graduates in Medicine and Surgery, McGill College.
From The Quotable Osler
INTRODUCTION
Welcome to your Internal Medicine internship at NMC Portsmouth! This occasion is a
benchmark for you as you embark not only on your career as a physician, but also as an
officer in the United States Navy. On behalf of the entire Internal Medicine Department,
let me say that we are excited to have each one of you join us as housestaff and
colleagues. This year you will advance in professionalism and maturity. You will be
challenged, and much will be expected. However, you will never be without support, and
that support begins with me as your Associate Program Director and Intern Coordinator.
I hope that as this year proceeds, you will find that the hospital lives up to its motto of
“First and Finest.”
PURPOSE OF THIS MANUAL
This manual is not intended to be a definitive reference for you this year. An allinclusive text would be nearly impossible since so many of the facets and nuances of
internship will be discovered along the way. But hopefully the information included will
assist you in getting oriented to the job. Several other references will be given to you
during orientation. The most important will be the Intern Survival Guide (ISG). Some of
the information contained herein will overlap with the ISG. However, in order to add
emphasis without being totally redundant, references will be made where applicable to
the ISG.
A LITTLE NMCP HISTORY
Naval Medical Center, Portsmouth, is the oldest continuously running hospital in the
Navy. 4,300 officers, sailors and civilians work in locations from Yorktown to
Chesapeake to deliver health care to the 420,000 active duty members, family members
and retirees living in Hampton Roads. These men and women carry on a tradition of
caring and service to their country that dates back to revolutionary times.
The site of this hospital is the approximate site of the circa-1776 Fort Nelson.
Built in the mid-1770's as a colonial defense, the fort was captured on May 9, 1779 by the
British. Fort Nelson was later abandoned by the British and lay unused until 1827, when
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the commissioners of the Naval Hospital Fund were granted their request to build the first
naval hospital on the site. The hospital admitted its first patients in 1830. In 1847, the
hospital treated its first war casualties as patients were brought in during the MexicanAmerican War. A massive Yellow Fever epidemic in 1855 led to the admission of nearly
600 patients between July and November that year. During the Civil War, Virginia’s
secession led to the hospital falling under Confederate control.
Nearly seventy years of history later, after playing important roles in support of
the Spanish-American War and two World Wars, the hospital embraced graduate medical
education. 1937 saw the establishment of the first internship program at NMCP and the
initiation of a grand tradition of medical training. In 1960, construction on the “highrise” portion (Bldg 3) was completed, and in 1999 the doors opened to the Charette
Health Care Center, the most modern Naval medical structure yet built. Naval history is
palpable in the Hampton Roads region, and scarcely is this more plainly visible than at
NMCP where the visage of Building 1 juxtaposed with the ultramodern Building 2
epitomizes Navy progress in the heart of Hampton Roads.
NMCP TODAY
NMCP has a total of 420,000 beneficiaries in its catchment area, the largest population
base in the Navy. The hospital has 360 beds with an average daily census of 268. In
addition to the hospital, numerous outlying TRICARE clinics serve as primary care sites
for area beneficiaries. We are staffed by over 200 physicians and dentists, 500 nurses,
and 3200 allied health personnel in the main hospital alone. Graduate medical education
encompasses residencies in 13 medical and surgical subspecialties. Each year,
approximately 75 officers complete internships at NMCP.
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THE SIX CORE COMPETENCIES
In February 1999, the Accreditation Council for Graduate Medical Education (ACGME)
formally endorsed 6 general competencies in which physicians (of any type) must
demonstrate proficiency prior to the end of their RESIDENCY training. Thus, mastery of
each competency is not expected. Nonetheless, on each rotation you will be evaluated
according to these six competencies, which are described below. Further information can
be gained from http://www.acgme.org.
a.
b.
c.
d.
e.
f.
Patient Care that is compassionate, appropriate, and effective for the treatment of health
problems and the promotion of health
Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g.
epidemiological and social-behavioral) sciences and the application of this knowledge to patient
care
Practice-Based Learning and Improvement that involves investigation and evaluation of their
own patient care, appraisal and assimilation of scientific evidence, and improvements in patient
care
Interpersonal and Communication Skills that result in effective information exchange and
teaming with patients, their families, and other health professionals
Professionalism, as manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
Systems-Based Practice, as manifested by actions that demonstrate an awareness of and
responsiveness to the larger context and system of health care and the ability to effectively call
on system resources to provide care that is of optimal value
DEPARTMENT OF INTERNAL MEDICINE
The Department of Internal Medicine exists within the Directorate of Medical Services
and encompasses the divisions of General Internal Medicine and each medical
subspecialty. The staff are based at their respective clinics and routinely devote time to
serve as attendings for inpatient ward teams. For training purposes, your staff is
comprised of general internists plus subspecialists in the fields of Allergy &
Immunology, Cardiology, Endocrinology, Gastroenterology, Geriatrics, Hematology &
Oncology, Infectious Diseases, Nephrology, Neurology, Pulmonary & Critical Care, and
Rheumatology.
The Division of General Internal Medicine (GIM) on the 2nd deck is your base of
operations. This is a vital area of your training for several reasons:
1. GIM Clinic houses the Inouye Internal Medicine Conference Room which
serves as the location for the academic sessions of Noon Report (daily) and
Academic Conferences.
2. The GIM Clinic is also the site of your continuity clinic each week (more on
this later) and the location of the academic support staff.
3. You have a mailbox in the department secretary’s office (Ms. Foster) –
DON’T FORGET TO CHECK THIS DAILY!!!
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CURRICULUM
Your internship is designed to provide broad-based training in preparation for a tour as a
general medical officer with the fleet or Marines as well as provide a solid foundation for
progression to many residency programs. There are 13 blocks, each lasting 4 weeks. For
Internal Medicine interns, there are a variety of IM-based and non-IM rotations as
follows:
- Internal Medicine Wards (20 weeks)
- CCU (4 weeks)
- ICU (4 weeks)
- Ambulatory Medicine (4 weeks)
- Emergency Department (4 weeks)
- Orthopedics (4 weeks) - MD’s only
- Psychiatry + OB (4 weeks) - MD’s only
- Psychiatry + Ortho (4 weeks) - DO’s only
- OB (4 weeks) - DO’s only
- Medicine Elective (4 weeks)
- General Elective (4 weeks)
The differences between requirements of the American Board of Internal Medicine and
American Osteopathic Association lead to slight differences in the schedules of MD’s
and DO’s.
NEW INNOVATIONS
Internal Medicine currently uses this program for logging duty hours, evaluations, and to
log procedures. It is YOUR RESPONSIBILITY to log your duty hours, read and sign
your evaluations and log any procedures. Residents are required to log all duty hours for
the previous work week by Wednesday at noon. The work week is defined from
Tuesday through Monday. These will be closely watched by the Program Coordinators as
well as the Program Directors.
Access information - The website address is www.new-innov.com. This will take you to
the opening page. You will need to click on “Client Log on” and then you need to type in
all caps, NMCP then hit the submit button.
Your user name has been set for your first name initial and last name. Example:
pshipley. It must be entered in all lower case letters with no spaces.
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Your password is the same for the first time you log on. Example: pshipley (all
lowercase and no spaces). Once in the program you can change your password to
anything you want but REMEMBER IT! However, if you forget it, let Mrs. Roman
know by email or phone and she will change it back to your first name initial and last
name again so you can sign on. Hit the Log in button.
You’ll then get to the welcome screen with your name and our department seal. At the
bottom of this page we will list any notifications, evaluations, etc. that you need to know
about. There will also be alert messages from the GME office about application dates for
the Selection Board, etc.
Changing your password - If you go to the top of this page, you’ll see under the NI
symbol, the word MAIN. If you click on it, it’ll bring you to a drop down box in blue.
Near the bottom of this box is a link to Change Your Password. Just follow the directions
to change your password.
THE CALL SCHEDULE
The intern call schedules can be found on the NMCP computers by a couple of methods:
1) Click on “My Computer”. Then click “DFFM54” server. Click on the folder
entitled “Internal Medicine Clinic”. Click on the folder “Intern Watchbills”.
Click on the folder “Intern Watchbills AY13-14” to find the rotation schedule or
2) Click on “My Computer”. Then click on “Public-NMCP” server. Click on folder
entitled “GME”. Click on folder “Schedules”. Click on folder “Internal Medicine
Rotation Schedules AY 13-14”.
3) The Intern Advisor works closely with you each block on your schedule and will
send you a personal copy of the schedule prior to each block as well.
INTERNAL MEDICINE WARDS
The schedule (aka: the watchbill) is days during the week with a separate Night Medicine
team that covers call Sunday through Thursday nights. The current system consists of 3
ward teams. The intern coordinator creates the schedule and a watch bill is published
prior to each block. The weekends will be covered by the ward team interns while
working in shifts.
Intern shifts will be one of the following:
“A” Shifts
Working Friday and Sunday: 0600 - 1800
“B” Shifts
Working Friday and Saturday: 0600-1800 Fri and 0600 – 2000 Sat
“C” Shifts
This is the night shift. The intern is on duty from 1800 - 1000 Fri, and 2000 –
1000 Sat.
No shift listed If there is no shift on your schedule, this does not equal a weekend off (Golden
Weekend). No shift on the schedule means when your work schedule is
determined by your team resident.
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Each ward team is usually comprised of 3-4 interns from various programs. The team
is managed by the resident and supervised by the attending. The above system was
created to ensure that there is adequate coverage of teams, and so all interns would stay
within their work hour restrictions, as mandated by the ACGME.
It is imperative that interns complete their shifts on time. If the schedule is not
allowing for adequate completion of all necessary ward responsibilities, it is imperative
that you bring this to the attention of the Intern Advisor or the Program Director. When
there are more interns on the team or if the team census is low, additional days off may
be granted at the discretion of the team resident.
We use a drip admission system, where each of the 3 teams takes every third admission.
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The usual working day will be from 0600-1700.
Morning turnover will occur at 0600 each morning.
Afternoon turnover will occur at 1700 Sunday through Thursday (to NF team) and
Friday will occur at noon, Saturday turnover will occur as each team finishes
rounds.
The Night Medicine team will present at Morning report on Friday morning at 0730.
You will continue to have continuity clinic while on the wards.
See the appendix for a sample IM call schedule.
CCU
The CCU is devoted to cardiac cases and has more of a critical care and procedural bend.
The Intern Coordinator also schedules CCU interns. The same shifts and turnover times
as for the ward schedule above will apply. You’re encouraged to soak up as many
cardiac procedures as you can. Be sure to document them in New Innovations.
The CCU team consists of 3 to 4 interns.
See the appendix for a sample CCU call schedule.
IN-PATIENT ELECTRONIC MEDICAL RECORD
The in-patient electronic medical record is called ESSENTRIS. You will get training on
this during your Command intern orientation and more guidance from your ward
residents on how to use this efficiently.
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WORK HOURS
In 2003, and revised in 2011, via its various Resident Review Committees (RRC), the
ACGME issued stringent work hours that MUST be obeyed by all interns and residents.
There is no leeway on this issue. The purpose is to simply promote patient safety by
ensuring adequate rest of trainees. As a result, it was a challenge to develop a call
schedule that promotes compliance with the RRC and several versions were tried. We
believe the current intern call structure is the best fit at this command. Likewise, rounds
and the other routine daily work MUST occur efficiently. Sign-outs become VITALLY
IMPORTANT to ensure patient safety. Miscommunications and inadequate sign-outs
can result in catastrophic events. Further info is available at www.acgme.org.
The following is the new ACGME duty hour standards for PGY-1 residents:
80 Hour Rule - MUST NOT work more than 80 hours per week averaged over a
4 week period. If residents exceed 320 hours over a four week period on the same
rotation, this will be a violation.
10 Hour Rule – MUST have at least 10 hours outside of the hospital between
shifts for those shifts to be counted as separate.
16 Hour Rule - MUST NOT spend more than 16 hours providing patient care,
rounding, turnover, etc. YOU MUST LEAVE THE ROTATION AFTER 16
HOURS!!!!
5 patient rule - MUST NOT admit more than 5 patients per intern in 16 hours.
(an additional 2 patients may be assigned if they are in-house transfers).
10 patient rule - MUST NOT follow more than 10 patients at a time.
1 in 7 rule - MUST BE provided with one day in seven free from all educational
and clinical responsibilities, averaged over a 4 week period.
All housestaff must use the New Innovations website to log work hours. Interns are
required to log their hours weekly. This is mandatory and part of your professional
responsibility as an intern. The Intern Coordinator will be policing your logs regularly,
and reminders will be sent for those delinquent in maintaining their logs. Failure to
comply will be reflect in fitness reports and PARs (ie your permanent record). If an
intern foresees a violation of any of the above work hours, they are to contact the
Intern Coordinator immediately so proper measures can be taken to ensure
compliance. Nationally, all training programs are required to send reports of work hour
compliance to the ACGME Internal Medicine RRC. This is a “high-radar” issue and
your compliance is appreciated. Hours are due by Wednesday at noon for the previous
work week. The work week is defined as Tuesday through Monday.
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CALL ROOMS
Intern's CCU Call room
1. Hallway next to PCU
ICU Intern
1. Two rooms between ICU and OR hallway
General Internal Medicine Intern's call rooms (4 total rooms)
1. Near 4H (It is a Midwives’ office in AM but intern IM call room by night): adjacent
and share bathroom with OB Call room. The code is "2 and 4 (together)" then "3" The
room located right outside 4H in the main hallway. It is the first door on the right after
taking a left after leaving 4H. The room number is 410220.
2. In GME space there are two rooms.
3. The first floor in the hallway behind admissions, there are two call rooms. One room is
dedicated for interns/medical student and the second one is marked as junior (which
interns can use) The code for the Junior room is "3", "1" and "4" sequentially (NOT
together).
NOTE: Though room-sharing is not prohibited (but is probably unnecessary), it must be
noted that it is prohibited for members of the opposite gender to share a call room
together.
CONTINUITY CLINIC
Each IM intern has continuity clinic one half-day per week except on EMD and ICU
rotations. You will be assigned a panel of patients and you will be listed as their
Primary Care Physician. This is not just in the eyes of your training program. Your
name will be in the global TRICARE system as your patients’ primary doctor.
First and foremost, you must understand that this is your clinic! You will take
ownership of your clinic. It is a constant, not a variable. It is a distinct honor to be a
patient’s primary doctor. However, many times clinic can fall prey to rotation schedules.
Since you will be rotating on non-IM services whose schedules are not always available
to IM clinic staff, you must be proactive in looking ahead to make sure you do not
have clinic on a post-call day. This should be done at the beginning of every
rotation as soon as your call schedule is known. Because of TRICARE access
standards, your clinic will already be scheduled by the time a watchbill is released.
Reminders will be sent along the way to make sure you are policing your schedule for
conflicts. However, there will be penalties if you neglect this very crucial aspect of
checking your clinic. Remember, this is your clinic, and its maintenance is an important
facet of your professional development. You are not authorized to cancel your clinic.
If you see a conflict with your clinic you must inform the Intern Advisor and the Internal
Medicine Clinic Manager, Tracy DiGennaro.
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AHLTA (Armed Forces Health Longitudinal Technology Application). NMCP has
phased in the DoD-mandated electronic health record system – called AHLTA. You will
have received directed training on this during your orientation. Use of AHLTA is
mandatory for all outpatient encounters including telephone consults. Use of AHLTA can
be frustrating and time consuming for the new user. AHLTA has been implemented DoD
wide. It is to your benefit to learn how to best use AHLTA as this skill will follow you
wherever you may be stationed in the future. My advice: Be as patient as you can.
PRECEPTOR. During the clinic, you will work with a staff preceptor with whom you
will discuss every patient you see. You must document that you discussed the case
with your preceptor on every clinic note. On AHLTA, there will be a mechanism for
including your preceptor’s name on the note. All notes in AHLTA are reviewed and
electronically signed by a staff preceptor.
TIMELINESS OF NOTE. All intern clinic notes Must Be Completed That Same
Working Day!! For any extenuating circumstances that interfere with this completion,
you must notify your clinic preceptor immediately. Your clinic preceptor will then
authorize additional time if they concur with the need for an extension. Under no
circumstances is a delay of greater than 24 hours authorized!
PROCEDURES: No patient procedures will be done in the Internal Medicine Clinic
unless you have discussed the procedure with your preceptor, and you have a supervising
physician observing you. NO EXCEPTIONS!
PATIENT LOAD. As for scheduling, you will begin with 1-2 patients/ clinic half day
and change to 3 patients in the fall and then to 4 patients later in the year.
TELEPHONE CONSULTS (TEL-CONS): Since you will be a primary care provider
for patients, patients will call you for medication refills and numerous other concerns or
issues. You will receive these messages in AHLTA as tel-cons. You must respond to
these telephone messages within 24 hours. If you try to contact that patient within 24
hours but are unable to reach them; then you must document that in your tel-con and
continue to try to contact them. Once you have completed the tel-con it should be
forwarded to your clinic preceptor for review.
NEW RESULTS: It is your responsibility to follow-up on results of all tests you order.
These will be located under the “New Results” tab in AHLTA and should be checked
regularly. Patients should be contacted about any abnormal results and a follow-up plan
should be discussed and documented.
LEAVE
The command directive indicates that PGY-1 residents cannot take more than 14 days of
leave during the academic year. Although each resident accrues 30 days by military
policy, the remaining 16 days will be placed on your leave balance to be taken at a later
date.
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Interns are strongly encouraged to take leave during elective and non-call months.
Leave requests for rotations in Internal Medicine requiring call (Internal Medicine wards,
Heme-Onc wards, CCU) are at the discretion of the Program and Assistant Program
Director. Any leave submitted during other months is subject to that specific
department’s approval and may be denied. Leave is approved by all departments on a
first come basis and is at the discretion of the home service. Please ensure you submit
your chits at least 3 months prior to your leave.
Leave policies:
1. You may take no more than 7 days of leave during any one rotation.
2. No leave may be taken during a 2 week rotation, except for unusual or emergent
situations.
3. No leave may be taken during a rotation that you have C4 scheduled.
4. You must designate a fellow intern as your surrogate while you are on leave. This
surrogate will be responsible for your new lab results and tel-cons.
5. Leave requests are now done electronically (NSIPS). However, prior to entering it into
the E-Leave system you must get the leave approved by the rotation you will be doing at
the time of your leave. This can be done be either starting to enter your request and then
print a copy and having your rotation sign on the top line approving it OR approval can
be obtained via email. See the residency program coordinator in that specialty for the
name of the individual who should sign this approval. Either way it is done, the approval
MUST be forwarded to the Intern Coordinator.
6. Then the leave must be entered into the Navy’s electronic leave system, NSIPS. Your
clinic surrogate MUST be noted in box #24 with his/her pager number. This will
automatically get routed to the Internal Medicine Program Director. Once approved, you
will be emailed your approval and leave control number. If you do not receive a leave
control number, check NSIPS to see if it has been approved.
The E-leave website is: https://nsips.nmci.navy.mil
7. You MUST leave an “Out of Office” email on Outlook advising the dates of leave and
who your surrogate will be and list their pager number.
8. Emergency leave is not subject to the above restrictions. It will be allowed at the
discretion of the Intern Coordinator and the involved rotation coordinator.
9. Maternity leave: 42 days is authorized. You will have to make up this time.
10. Paternity leave: Ten days of non-chargeable paternity leave is authorized. However,
this still must be approved by the rotation you are on and the Intern Program Director.
This may be used within 365 days of the birth of the child. However, you still will only
be allowed a total of 14 days leave during your intern year.
TAD (TEMPORARY ADDITIONAL DUTY)
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TAD involves time spent away from the command while on official business. This does
NOT count against your regular leave balance. During internship TAD is granted only in
the following special circumstances:
C-4: All PGY-1 residents, except USUHS graduates and civilian trainees, will be
scheduled to go to C-4 (Combat Casualty Care Course) in San Antonio, TX. This is a 10day course that includes ATLS training. The GME office coordinates the schedule. If
you have any extenuating circumstances you must contact the GME office. Leave
cannot be taken during the same rotation as your C4.
Upon your return, YOU MUST bring Mrs. Roman your ATLS card and they will make a
copy for your file. YOU MUST PASS YOUR ATLS CLASS IN ORDER TO
DETACH FROM THE COMMAND AND GO TO YOUR NEXT DUTY
STATION!!!
A Special Request chit must be completed one month before leaving and must have your
clinic surrogate noted. These should be routed through (1) the rotation you will be on at
the time you will be gone to C4 so they know when you will leave and be back; (2) Intern
Program Director – so he/she can note your absence on the IM Clinic schedule and know
who your surrogate will be; and lastly to Mrs. Roman to keep on file.
You MUST leave an “Out of Office” email on Outlook advising the dates of your C4
training and who your surrogate will be and list their pager number.
Step 3 Exams: You must submit a Special Request chit (different than a leave request)
for licensing exams (USMLE-3 and COMLEX-3). A Special Request chit must be
completed one week before leaving and must have your clinic surrogate noted. These
should be routed through (1) the rotation you will be on at the time you will be gone to
C4 so they know when you will leave and be back; (2) Chief of Residents – so he/she can
note your absence on the IM Clinic schedule and know who your surrogate will be; and
lastly to Mrs. Roman to keep on file.
You MUST leave an “Out of Office” email on Outlook advising the date(s) of your exam
and who your surrogate will be and list their pager number.
House hunting TAD: Toward the end of internship as you prepare to relocate to a new
duty station, house-hunting TAD (5-working days) can be taken as no cost TAD,
although not counted as leave. “No cost” signifies that the active duty member bears all
costs of the trip. All efforts will be made to accommodate house hunting TAD; however,
this is at the discretion of coordinator for the service you will be on at the time and
Internal Medicine Program and Assistant Program Director. A Special Request chit must
be completed one week before leaving and must have your clinic surrogate noted. These
should be routed through (1) the rotation you will be on at the time you will be gone to
C4 so they know when you will leave and be back; (2) Chief of Residents – so he/she can
note your absence on the IM Clinic schedule and know who your surrogate will be; and
lastly to Mrs. Roman to keep on file.
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You MUST leave an “Out of Office” email on Outlook advising the dates of house
hunting leave and who your surrogate will be and list their pager number.
Conferences: TAD to attend conferences (i.e. American College of Physicians
meetings) may be granted to only those interns that are giving research presentations at
those meetings. You will be directed to complete the necessary forms by the Program
Director, Chief of Residents or Mrs. Roman.
Any further TAD is approved upon discretion of the Program Director.
You MUST leave an “Out of Office” email on Outlook advising the dates of leave and
who your surrogate will be and list their pager number.
Your Intern Survival Guide has much more helpful information on Leave and TAD.
DIDACTICS
Noon Report
You will be required to attend Noon Report (NR) in the Internal Medicine Conference
room when you are on IM Wards, CCU, Ambulatory Medicine and any medicine
elective. You are not required to attend when on a non-IM rotation. Noon Report (NR)
is conducted by the Chief-of-Residents and usually centers on the discussion of a case.
The goals of NR are for not only increasing your medical knowledge of a particular topic,
but to illustrate how to approach a case and for assessment of the presenter.
Alternatively, certain NR sessions will involve a resident lecture, guest speaker, or
review sessions conducted by a specialty staff member. NR starts at 1200 every Monday
thru Thursday (excluding holidays) and lasts 45 min. Late arrivals to Noon report will
not be tolerated.
Intern Noon Report
Thursday afternoons are usually devoted to Intern Noon Report, which is tailored to
intern issues. An intern presents the case and the discussion focuses on more nuts-andbolts of patient management on the wards. Alternatively, some Intern NR sessions will
involve skills lectures centered on interpretation of electrocardiograms, radiological
studies, etc. Also, there will be a series of lectures covering “ward emergencies” and
how to respond if called for acute symptoms in the middle of the night.
Academic Lectures:
Academic Lectures are held the Internal Medicine conference room immediately after
Noon report. A series of department specific lectures, workshops and case presentations
will occur starting at 1245 and lasting for 60 min. Attendance is mandatory when on IM
Wards, CCU, Ambulatory Medicine and medicine electives.
Make sure you sign the attendance roster at each of these sessions!
TRAINING FILE
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Every intern has a training file maintained in the IM Residency Program Coordinator’s
office. The file contains the following items:
Rotation evaluations
Fitness Reports (FITREPS)
Mini-CEX records
Step 3 exam scores
Verification of any Navy mandatory training
Clinic evaluations
CEX-GTA evaluations
Research abstracts
Any certificates of merit
Procedure logs
You have the liberty to review these at any time. I would encourage checking on it
periodically to ensure all required items are there.
EVALUATIONS AND FEEDBACK
Evaluations and feedback will occur through the year and throughout each rotation in a
number of forms:
1) Informal – From time to time your staff or residents may give you informal
feedback on a variety of issues relating to patient care or your professional
development. It is strongly encouraged to seek feedback if it is not given to
you.
2) Formal – Formal evaluation and feedback take a variety of forms:
a. Monthly evaluations by the attending or resident of the rotation
b. Mid-month evaluation and feedback by the attending. If you do not
automatically receive a mid-month evaluation by your attending, you
are strongly encouraged to ask for one. This is so you have the
opportunity to address any areas for improvement in the middle as
opposed to the end of the rotation.
c. Quarterly Clinic Evaluations. These are formed from the combined
input of all those attendings who have precepted with you in the clinic.
d. Appointments with the Intern Advisor. These will occur quarterly
as follows:
i. AUG – initial session, discuss goals and objectives, plan a
course for the year
ii. JAN – second session, discuss progress and evals thus far,
discuss in-service training exam results
iii. MAY/JUN – exit interview, discuss your internship year and
items that helped or hindered along the way.
iv. Periodically as required – you are always welcome at the
Intern Advisor’s office
e. Fitness Reports – more below. These center on your achievements
and development as a Naval officer.
i. Brag sheet – You will be given an opportunity to fill out a
brag sheet to provide input into your fitness report.
3) Rotation Evaluations – Your chance to give your feedback to your rotations.
Many of these will be done on New Innovations. Please take these very
seriously, and be objective and timely with their completion.
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CAC/ID CARD
Recently various organizations have attempted give free gifts/products to military
members in exchange for scanning the CAC card. This is specifically prohibited and is a
gateway to identify theft and threatens operational security. Don’t use your CAC card in
this manner. If you need to have your password reset, this can be done at the quarterdeck
in Bldg 2, 2nd floor, across from the pharmacy.
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FITNESS REPORTS (FITREPS)
FITREPS are evaluations that focus on your achievement as a Naval Officer. Standard
Navy forms are utilized – see the appendix of this manual. Performance is evaluated
along six performance traits on a scale of 1 to 5 (1 = worst, 5 = best):
Professional expertise
Equal Opportunity
Military Bearing
Teamwork
Mission Accomplishment
Leadership
Descriptions of each of these traits are listed on the FITREP. A score of 3 indicates
performance at a level that is expected for a member of that rank and position. Scores of
4 or 5 indicate performance that exceeds expectations. Likewise, scores of 2 or 1 are
detrimental and indicate subpar or failing performance. Supporting comments are added
on the 2nd page of the FITREP. The average of the six scores becomes the “trait
average”. Based on how this compares to the Commanding Officer’s trait average, you
will be rated along a scale of “promotability”, receiving a rating of one of the following:
Promotable
Must Promote
Early Promote
Most will be listed as “Must Promote” or “Promotable”. Those that have distinguished
themselves with the most exceptional performance will be “Early Promote”. This does
not mean that you will get promoted to LCDR any earlier than your peers, but it signifies
a high-level of performance and is a very desirable rating in the eyes of the promotion
board.
FITREPS are used by the promotion boards that convene in Millington, TN at BUPERS
every year to decide who gets promoted to the next rank and who does not. In the
medical corps, the promotion rate from LT to LCDR has traditionally been 100% barring
any show-stopping adverse career events. You will receive 2 FITREPS as an intern –
first in January, second at the conclusion of internship. All O-3’s in the Navy receive
their “regular” FITREP in January. Additionally, any time you or your CO changes duty
stations in the Navy, you will receive a “special” FITREP. After spending the requisite 5
years as a LT/O-3, you will be up for promotion, and all of the FITREPS you have
amassed in that rank will be reviewed in Millington in consideration of your promotion.
LCDR’s operate on a different cycle; their regular FITREPS occur in October. Likewise,
CDR’s and CAPT’s each have fitreps on other months of the year.
The above description represents a simplistic illustration of how FITREPS work and how
promotion is decided. The actual process of determining your score, your ranking
amongst your peers, and what it all means is much more complex than the scope of this
manual.
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PROCEDURE LOGS
You will have the opportunity to participate in the performance of many different types
of procedures including: arterial puncture, central lines, LP’s, etc. However, NMCP –
like many teaching hospitals nationwide – has experienced a decline in available
procedures. Thus, priority is given first to senior residents, then juniors, then interns.
There have been recent changes in the procedure requirements for IM trainees specified
by the American Board of Internal Medicine (ABIM). As of June 2006, per the ABIM,
there are essentially no procedures required of interns.
As many of our interns will spend their initial assignment in the fleet as General Medical
Officers (GMOs), NMCP-IM has required one procedure since 2006: Pap Smears. You
will need 5 documented Paps for certification. These will be documented using the
New Innovations website. This is not negotiable and you will not graduate on time if this
is not completed. There are a variety of avenues to obtain this requirement to include
working with the internal medicine nurse practitioners, working with the nurse manager
and your preceptor in internal medicine to arrange for pap visits in your continuity clinic,
during your OB rotation (though don’t usually get all 5) and while on your ambulatory
rotation while working with Women’s Health clinic.
I encourage you to seek out as many procedures as you can get! Make sure they are all
logged into and signed off in New Innovations by the resident or attending that
supervised you!
MINI-CEX
The Mini-CEX’s (short for mini-clinical evaluation exercise) document your
performance in selected aspects of the patient encounter (i.e. data gathering, physical
exam skills, counseling, etc). They are designed by the ABIM to be performed in
minimum time (5 – 10 minutes) and serve as an effective method for giving feedback in
real-time. They may be done in the inpatient or outpatient setting. 8 mini-CEX records
will be required over the course of the year. 4 of these 8 needs to include Physical Exam
observation. These will all be placed in your training file. Again, you are required to
complete 8 mini-CEX’s to graduate internship.
MALE-CEX & FEMALE-GTA EXERCISES
These exercises fulfill the ABIM requirement for demonstration of a male and female
genital exam. The exams are conducted at Eastern Virginia Medical School (EVMS) on
two separate dates in the fall of the academic year. These involve standardized patients
employed by EVMS for academic purposes. The male-CEX involves a full history and
physical as well as submitting a written case presentation outlining your assessment and
plan. The female-CEX only involves a brief clinical interview, with the main focus on
the mechanics of the pelvic and breast exam. No write-up is required. Both sessions will
be videotaped for a feedback discussion later with your clinic preceptor.
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RESEARCH
You are highly encouraged to seek opportunities to get involved with research – either by
generating a case report on an interesting and unique patient or by getting involved with
an ongoing original research protocol. All activities are supervised by staff physicians.
This will definitely help you stand out – especially if you plan to apply for a PGY-2
position. If accepted for a conference presentation, it will also help you get some
government-funded travel time (TAD) during your internship! The point of contact is the
Associate Program Director for Research (Major Jessie Glasser, Infectious Disease).
NAVY MANDATORY TRAINING
From time to time, requirements will be passed along for various types of training –
usually in the form of online courses. “Healthstream” involves a regularly occurring set
of online courses that must be completed by all members at the command. Alerts are sent
out over email when these are due. There will be others, some perhaps on Navy
Knowledge Online (NKO). These are either Navy or NMCP requirements, and though
are not directed by the GME office, they are required when they come along. Certificates
verifying training need to be printed out and given to Ms. Roman for inclusion in your
file.
Along those lines, the Command Urinalysis Office conducts regular but unannounced
urinalysis drug screenings. They are not announced until the morning of the screening
date and you MUST comply by giving a urine sample prior to the stated cut-off time.
Those that are on away rotations, on TAD/leave, or post-call are exempt. Command UA
has nothing to do with your academic file, but is listed here only for your awareness.
Missing a command directed urinalysis is potentially damaging to your career and is
closely monitored by the GME office as well.
There are other Navy-specific tasks that will come along – mandatory dental screenings
and physical health assessments during your birth month, the biannual physical fitness
assessment (which involves both a body fat assessment and the physical readiness test),
and occasional fire or disaster drills – just to name a few. These originate outside of your
training chain of command, but as active duty members assigned to NMCP, they are
absolutely required.
Do not blow these off. You will find it to be a Navy truth that seemingly innocuous
things like these come with strong penalties if disregarded.
STEP 3 EXAMS AND LICENSURE
OFFICIAL GME RULES: All interns will be required to have applied for USMLE
Step 3 or COMLEX Level 3 by DEC 2013 (exact date TBA) and will be required to have
taken the examination by March 2014 (exact date TBA). Upon passing Step 3, you must
apply for licensure. The deadline for licensure application is APR 2014. This is also the
deadline that USMLE and COMLEX Scores (a copy of the letter) must be submitted to
Ms. Roman and to the GME office. You must either bring the original letter or print
your results from the website for either Ms. Roman or Ms. Bryant to site verify the
results. The GME Office Staff will be standing by to assist with the application process.
Get this done sooner rather than later – Don’t put this off.
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You must discuss your proposed dates for taking the exam with the intern program
director prior to scheduling your actual exam date. Once your actual date of exam is
obtained you must inform internal medicine intern coordinator, Ms. Roman, and your
affected rotation coordinator.
INTERNAL MEDICINE’S PREFERENCE: It is STRONGLY desired by the
Department of IM that all IM interns take their Step 3 exams prior to the end of
January. In the unfortunate event of failure, this will help ensure that plenty of time is
left in the year to retake the exam with minimal risk to post-internship plans.
There are NO exceptions to the official GME rules. You will not qualify
for your operational additional specialty pay ($15,000) unless you obtain
a medical license.
INPATIENT DOCUMENTATION & THE DATA FLOW OFFICE
DoD-wide inpatient electronic system, ESSENTRIS, is used at NMCP. You will receive
further training during your intern orientation.
The Copy Forward function on any computerized inpatient medical record is discouraged
but not banned. This can become a significant problem and an issue of professionalism
as well as poor patient care if abused.
Ensuring that you are up to date on your final charting is an issue that reflects your
Professionalism (an ACGME core competency). Establishing good habits now will serve
you well later at smaller hospitals when you are staff physicians. Leave, TAD, and
liberty may be denied if you are delinquent with your final charting in Data Flow. Keep
in mind delinquency reports are regularly submitted to Department Heads. This is
another very “high-radar” issue.
E-MAIL
Communication will frequently pass through email. You are required to check Outlook
at least TWICE EVERY DAY. Important messages will be otherwise missed.
All email is monitored by the command! Please remember with any email to keep
conversations professional and tasteful! 
SOCIAL NETWORKING/INTERNET GUIDANCE
The Department of Defense has recently released guidance regarding the use of the
internet, to include social networking sites such as Facebook and Twitter.
Limited use of Federal Government resources are authorized on a non-interference basis
(you can access these sites at work, but it must not interfere with your job or the
hospital’s mission).
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Sound operation security (OPSEC) measures should be employed at all times and one
should not represent statements as the policy or official position of the Department of
Defense.
The following information should not be posted to websites which are accessible to the
general public;
1.
2.
3.
4.
5.
6.
7.
Operational plans
Troop rotation schedules
Position and movement of U.S. Naval Craft
Description of overseas military bases
Vulnerability of weapon systems
Discussion of areas frequented by U.S. Personnel overseas.
INFORMATION REGARDING PATIENTS OR COLLEAGUES.
When using the internet to access these sites;
1. Limit participation in public communications as it most not interfere with
completion of duties.
2. Avoid communicating any material that violates the privacy or confidentiality of
fellow officers, co-workers, or patients at NMCP.
3. Avoid disclosing any sensitive, proprietary, confidential, private or protected
health or financial information about NMCP.
4. BLOGs or WEBLOGs posted to public websites or non-official chat sites may not
be created/maintained/accessed during normal duty hours and may not contain
information on military activities not normally available to the general public.
a. Comments on daily military activities and operations
b. Unit Morale
c. Results of operations
d. Status of equipment
e. Information beneficial to adversaries
5. Prohibited sites include gambling sites, pornography and those that promote hatecrime activities.
6. Refrain from posting material that is obscene, defamatory, profane, libelous,
threatening, harassing, abusive, hateful or embarrassing to another person or any
other person or entity.
7. Do not offer to buy or sell goods, operate a business or use NMCP
communication tools for personal financial gain.
8. Be aware you may be held responsible for any personal legal liability and/or
UCMJ violations imposed for any published content.
9. Consider using a disclaimer when personal opinions are expressed may be used
(e.g., “This statement is my own and does not constitute an endorsement by or
opinion of the Department of Defense”).
In general remember the following;
1. Share information about yourself smartly and be careful what you disclose about
your family and occupation. Use privacy settings to protect you personal
information.
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2. You and your family should be particularly careful not to share: spouse’s
deployment status, home address, telephone numbers, location information and
schedules. Your close friends and family should have this information, it does not
need to be shared online.
3. You can share pride and support for service, units, specialties and service
members, generalizations about service or duty, information known to the general
public or in the public domain.
4. You should only allow people that you actually know in real life into your social
circle online.
5. Use different screen names on different social networking sites.
6. Access to both the internet and intranet at NMCP is a privilege and not a right of
employment. Internet and intranet privileges may be denied in part or in its
entirety.
7. Remember that the system at work is subject to monitoring, interception,
accessing and recording and may be passed to law enforcement agencies. All
users of the internet on government computing systems should have no
expectation of privacy or confidentiality.
8. NMCP specifically allows the use of the internet and intranet for personal
purposes as follows;
a. Does not adversely affect the performance of official duties
b. Does not overburden NMCP computing resources or network
communication systems
c. Does not adversely reflect upon the DoD, DON, Navy medical department
of NMCP (to include viewing and transmitting pornographic materials;
racial, ethnic, sexist and indecent/obscene jokes and literature; chain
letters, unofficial advertising, and inappropriately handled classified
information.
Violations of NMCP communication standards may result in disciplinary or
administrative action.
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References –
1. Directive-Type Memorandum (DTM) 09-026 – Responsible and effective use of
internet-based capabilities.
2. NAVMEDCENPTSVAINST 5230.12A Use of the internet and intranet
3. NAVMEDCENPTSVAINST 5112.2H Medical staff policy procedures and
bylaws
4. DoD Instruction 5400.13 Public Affairs Operations
5. DoD 5500.7-R Joint Ethics Regulation
6. DoD Directive 8500.01E Information Assurance
7. DoD Instruction 8500.2 Information Assurance Implementation
8. DoD Directive 5400.11 DoD Privacy Program
9. DoD Directive 5230.09 Clearance of DoD Information for Public Release
10. DoD Manual 5205.02-M DoD Operations Security (OPSEC) Program Manual
11. DoD Directive 5015.2 DoD Records Management Program
12. DoD 5200.1-R Information Security Program
13. Dod 5240.1-R Procedures Governing the Activities of DoD Intelligence
Components that Affect United States Persons
14. Dod Instruction O-8530.2 Support to Computer Netwrok Defense (CND)
15. Unified Command Plan, Unified Command Plan 2008 (UCP)
16. U.S. Strategic Command (STRATCOM) – Social networking opsec training
http://www.stratcom.mil/snstraining/
17. Navy Information Operations Command website
http://www.slideshare.net/USNavySocialMedia/opsec-snapshot
18. CHINFO Social media resources page
http://www.chinfo.navy.mil/socialmedia.html
19. Naval OPSEC Support team on FACEBOOK
http://www.facebook.com/NavalOPSEC
20. Navy for MOMS OPSEC video http://www.navyformoms.com/video/opsecinternet-safety
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REQUIREMENTS FOR GRADUATION OF INTERNAL MEDICINE
INTERNSHIP:
1. Satisfactory completion of 13 rotations: 4 IM ward, night float, CCU, ICU,
ambulatory medicine, EMD, IM elective, other elective, Psych/OB, Orthopedics.
DO interns have specific rotational requirements which may change one of the
required rotations.
Note: At the discretion of the program director, one rotation may be
remediated in lieu of an elective. This is decided on a case by case basis.
2. Demonstration of progressive independence and autonomy in medical decisionmaking, clinical judgment, and patient management.
3. Satisfactory performance of the following:
A. CEX (Clinical Evaluation eXercise)
B. GTA (Genital Teaching Assistant)
C. Basic procedures
1) CEXs – 8 mini, directly observed and documented on appropriate form
2) Pap smears: 5-directly observed and documented in New Innovations
D. Attendance and participation in clinic curriculum and continuity clinic
E. Completion of the Inservice-Training Examination (ITE)
F. >60% attendance to required morning report, noon and other lectures, after
accounting for leave/TAD/night rotations/off-rotations. Off rotations will have
their own lecture attendance requirements.
G. Taking the USMLE Step III or COMLEX examination. (Passing is not
required for intern graduation but IS required to be a general medical officer
and to get a license).
H. Completion of all medical records dictations.
I. Completion of all required training such as GMT, JCAHO, and HIPAA, as
well as other military requirements for naval officers or naval personnel.
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POINTERS FOR IM RESIDENCY APPLICATION
From the desk of Captain Lisa Inouye, the former IM Program Director…
1.
2.
3.
4.
5.
6.
Do your job well.
Interview with the Program Director. Provide an updated CV.
Get letters of recommendation from at least one or two Internal Medicine
attendings.
Make sure all test scores that are available (USMLE and COMLEX steps 1, 2
and 3, if taken before the Selection Board) have been provided.
Keep up to date and meet requirements in a timely manner. Examples include
maintaining C-1 status, Johns Hopkins Modules, dictating discharge
summaries, urine drug screening and the weigh-in/PRT.
Do a case vignette abstract for the Navy ACP. It seems a lot to do early in the
year (usually they are due in late July/early August) but it will help your
application substantially.
For those applying to Flight Surgery or Undersea Medicine:
http://www.nomi.med.navy.mil/NAMI/index.htm also see the .pdf file on the
Public/Medicine Wards folder.
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IMPORTANT DATES FOR ACADEMIC YEAR 2013-2014
Jul/Aug TBA
Jul 1
Jul
Meet one-on-one with Intern Coordinator – 1st counseling session
GMESB Web Application Activated
Male CEX exercises at EVMS
Aug
Aug TBA
Aug TBA
Aug 16
Aug
Operational Day for all interns
Macklin Symposium
Deadline for Abstracts to the Navy ACP Meeting in Portsmouth
Open House for Medical Students
Female GTA exercise at EVMS
Sep 20
TBA
Sep 30
Open House for Medical Students
Flight Surgery/Undersea Medicine Applications deadline
GMESB Deadline to Submit Web Application for GME-2 training
Oct TBA
Oct TBA
Oct 15-18
Oct 12
Oct 25
Oct 26
Fall PHA (aka PRT)
Brag Sheets distributed in preparation for O-3 fitreps
In-Service Training Exam (ITE)
Deadline for application changes and supporting documents for GME-2 training
Navy Chapter ACP Meeting, Portsmouth, VA
Deadline for FS/UMO application
Nov 25
Joint Service GME Selection Board (JSGMESB)
Dec TBA
Dec 11
Dec 31
O-3 FITREPs due (for January finalization)
GMESB results are released
Apply for USMLE 3/COMLEX tests no later than this date
Jan 10, 2014
Jan
Deadline for Acceptance of training
Virginia ACP Associates Day, Richmond, VA
Feb TBA
Feb TBA
Intern Dining Out
Meet one-on-one with Intern Advisor – 2nd counseling session
Mar 1
Mar TBA
Mar
DEADLINE FOR TAKING USMLE 3/COMLEX 3
NMCP Research Competition
Virginia Chapter ACP Meeting, Richmond, VA
Apr TBA
Apr TBA
Apr 10-12
Apr 15
Spring PRT
Brag Sheets distributed in preparation for graduation fitreps
National ACP Meeting, Orlando, FL
DEADLINE FOR SUBMITTING USMLE/COMLEX SCORES AND
SUBMIT MEDICAL LICENSE APPLICATION TO GME
May TBA
May17
Graduation FITREPs due
Internal Medicine Department Faculty/Resident/Intern Dining Out
Jun TBA
Jun 19
Jun 27
Meet one-on-one with the Intern Coordinator – 3rd/last counseling session
Internal Medicine Resident Graduation
Command Intern Graduation
26
HOW TO GET INTO TROUBLE
(in no particular order, but not all-inclusive)
Conduct unbecoming of an officer
Lack of respect: subordinates and superiors
Appearance: uniforms, haircuts, facial hair, scrubs, piercings
Ignoring chain of command
Moonlighting
Pharmaceutical rep indiscretion
Fraternization and adultery
Computer trouble: Porn, piracy, etc
Fraud, waste, and abuse: Personal long-distance phone calls, stealing, etc
Sexual harassment, racial and other offensive behavior
Security, gate guards, quarterdeck
Getting arrested in town
DUI and other alcohol-related events
Command urinalysis: missing or failing
Prescribing meds to self, family, or other questionable circumstances
Not letting Program Director know about: board failures, academic failures
Not signing up for boards on time
Not submitting medical license application on time
Procrastination: pages, email, dictations
Plagiarism
Laziness on the job
Not getting adequate rest as provided by the work hour restrictions
Dishonesty
Poor time management
Lack of planning
Not checking Outlook email, CHCS email, and clinic mailbox (Stay connected!!!)
Not keeping up with clinic schedule
Not notifying Program Director about changes to rotation schedule
Placing more emphasis on work hours and days off than on good patient care and teamwork (despite
the ACGME restrictions). Compliance with ACGME standards is required. However, do not let the
restrictions affect the quality of patient care. HEALTHY TIP: Exceptional time-management skills
are required for proper balance.
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HOW TO DISTINGUISH YOURSELF
(GOING BEYOND THE EXPECTED)
Have a great attitude!
The quality of your experience is largely, largely determined by your attitude.
Attitude is a CHOICE.
Enjoy and show interest in whatever rotation you’re on.
Be an optimist, not a pessimist. A cheerful nature is contagious.
Be proactive
Get things done AHEAD of schedule.
Bring articles to your ward team without being asked.
Contribute to discussions (morning report, ward team, electives, etc).
Innovate: find a new and better way of doing something.
Know your limitations and ask assistance where needed.
Admit mistakes AND demonstrate that you’ve learned from them.
Seize research opportunities
Seek out projects.
Submit abstracts to competitions.
Committee participation
Intra-departmental committees.
Command level committees.
Teach, Teach, Teach
Students – Remember your roots.
Corpsmen – Many look up to you and dream of being where you are someday.
Nurses – Teamwork is essential to good patient care.
Keep a log of things you teach.
Pursue a healthy, balanced lifestyle
Manage time well and get rest when able.
Indulge in the arts.
Physical fitness.
Read a book for fun (not Harrisons).
Balance life in and out of the hospital.
Volunteerism
Be active in community.
Organizational membership.
Church, Synagogue, etc.
Have a great attitude!
“Diligence is the mother of good luck.” - Benjamin Franklin, Poor Richard’s Almanac
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