1. science
2. medicine

The Resident’s Manual
2013-2014
Internal Medicine Residency Program
Naval Medical Center
Portsmouth, Virginia
CDR Joseph Sposato
Program Director
LCDR Justin Lafreniere
Associate Program Director
LT A. Brooke Hooper
Associate Program Director, Intern Advisor
LCDR Edward Stickle
Chief of Residents, AY 13-14
Mrs. Delilah Roman
Program Coordinator
Ms. Tami Sjostrom
Administrative Assistant
1
TABLE OF CONTENTS
Introduction
Educational Program
Performance Expectations
Patient Care
Medical Knowledge
Practice-based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Systems-based Practice
Educational Plan
ABIM Requirements
Procedure Requirements
Optional Procedures for Certification
Policy on ACGME Guidelines: ambulatory assignments and patient loads
Ambulatory Medicine
Inpatient Medicine
Subspecialty Experience
Policy on ACGME Guidelines: Duty Hours
Maximum Hours of Work per Week
Mandatory Time Free of Duty
Maximum Duty Period Length
Minimum Time Off between Scheduled Duty Periods
Maximum Frequency of In-House Night Float
Maximum In-House On-Call Frequency
Evaluation
Monthly Rotation Evaluations
ABIM Mini-CEX
Academic Presentations
Program Director Meetings
Internal Medicine Education Committee (IMEC)
Conferences/Curriculum
Noon Report
Core Curriculum Conference
Grand Rounds
Resident Lectures
Resident Peer Review Conference
Clinical Pathology/Autopsy Conference
House Staff Meetings
Journal Club
Division Conferences
Joint Conferences
Attendance
Johns Hopkins Modules
Directed Reading
Scholarly Activity
Electives
Research
Outside Internal Medicine Electives
Procedures
Grievance Procedure
Three Year Overview Curriculum
Academic & Professional Requirements for Promotion and Graduation
2
3
3
8
9
13
15
16
18
21
22
22
23
23
30
Squads
Internal Medicine Clinic
Grand Rounds/Resident Lecture Evaluation forms
Resident Journal Club Evaluation Form
Rolling Admistions or “The Drip”
The Watch (aka “Call”)
Sign Out (Standardized Form)
Past COR Messages
31
33
38
40
41
42
43
44
I. Introduction
June 2013
Welcome to the new academic year! This year will see several very significant
changes to our program. First, we are evolving our patient centered medical
homeport to improve access for our patients, as well as improve continuity among
providers; enabling us to deliver more personalized, effective care while
improving your educational experience. Second, our evaluation system will be
changing to provide better feedback while meeting the upcoming new ACGME
requirements. Third, to improve our critical care curriculum, we are expanding the
SNGH ICU experience to incorporate both years of residency. The experience of
working with other professionals outside our military based system will also be
invaluable. Lastly, the Directed Reading program and Johns Hopkins Modules will
formally be incorporated into the curriculum. As in the past, this manual serves to
lay out requirements for residency as well as provide guidance on conducting our
day to day business. I look forward to an exciting, vibrant upcoming academic
year and look forward to working with you on ideas to further strengthen our
residency!
Thomas Stickle, Chief of Residents 2013-2014
Welcome to the Department of Medicine at Naval Medical Center Portsmouth. As a
member of the training program here, you are joining the unique experience of academic
and military training in medicine.
The training program utilizes three training sites: The Naval Medical Center Portsmouth
is the principal training site, and additional rotations occur at Sentara Norfolk General
Intensive Care Unit and Lake Taylor Transitional Care Hospital. The educational
rationale for presence at each training site is carefully considered. Clinical experience at
the Naval Medical Center Portsmouth is the cornerstone of our residency training
program because of its opportunities for residents to learn under the mentorship of core
military faculty dedicated to medical education and clinical investigation while caring for
a diverse population of beneficiaries from Navy Medicine East. The Sentara Norfolk
General Hospital Intensive Care Unit experience is designed specifically to expose
residents to the higher acuity of critical care seen at a tertiary care facility. Residents
also spend one month in their third year of training in conjunction with the EVMS
Glennan Center for Geriatrics primarily at Beth Sholom Village and Kempsville
Health and Rehab Center, designed to expose them to a geriatric population at a longterm and transitional care hospital not represented at NMCP.
II. Educational Program
3
As a physician in a residency program, you will receive post-doctoral training focused on
the development of clinical competencies and professional skills in an environment that
fosters the acquirement of a strong fund of knowledge in Internal Medicine. Our goal is
to prepare you for the independent practice of Internal Medicine with an emphasis on
professionalism not only as a physician, but also as a Naval Officer, and an appreciation
for the lifelong learning process that is critical for maintaining professional growth and
competency.
A. Performance Expectations
The Department of Internal Medicine utilizes performance criteria for the
advancement/promotion of its residents based on the educational milestones set forth by
the American Board of Internal Medicine (ABIM). These milestones are graduated
based on level of training and create educational goals, performance expectations and
evaluations of residents. They are available for review by residents and faculty online at
any time.
Utilizing an electronic evaluation format, each resident is evaluated monthly in the
American College of Graduate Medical Education (ACGME) six core competencies
(Patient Care, Medical Knowledge, Practice-based Learning and Improvement,
Interpersonal and Communication Skills, Professionalism, and Systems-based
Practice) by his/her attending physician. Additionally, the House Staff officer is required
to evaluate his/her attending. Similarly, residents evaluate interns and medical students
each month and then are evaluated by each intern. This system, in addition to frequent
self-evaluation critical to professional growth, provides multisource appraisal of the
resident's work and communication skills.
The Program Director and Associate Program Director serve as the program advisors for
the duration of the resident’s training. The program encourages the attending and
resident to speak directly about his/her evaluation not only at the completion of each
rotation but also in a mid-term evaluation. Evaluations play a large role resident
advancement to the next level of training. Residents meet quarterly with their faculty
mentor and receive feedback and guidance on career path and progress. Residents
receive direct feedback on a semiannual basis by way of a formal, documented meeting
with the Program Director to discuss not only the content of these evaluations, but other
performance measures crucial to residency training.
The final decision of whether to promote or graduate a resident is determined by the
Residency Program Director, taking into consideration input received from the Internal
Medicine Education Committee (IMEC) as well as the faculty of the Department.
The successful achievement of the core competencies as outlined by the American
College of Graduate Medical Education (ACGME) comprises the criteria for
advancement and final matriculation from the residency program. The competencies, as
well as the evaluation tools used to measure a resident’s progress in each area, are
listed below:
ACGME Competencies
(ref: ACGME Program Requirements for Graduate Medical Education in Internal
Medicine, IV.A.5)
4
(http://www.acgme.org/acWebsite/downloads/RRC_progReq/140_internal_medicine_07
012009.pdf for detailed program requirements)
1. Patient Care
Residents must be able to provide patient care that is compassionate,
appropriate, and effective for the treatment of health problems and the promotion
of health.
Residents:
1. Are expected to demonstrate the ability to manage patients:
a. In a variety of roles within a health system with progressive responsibility
to include serving as the direct provider, the leader or member of a
multidisciplinary team of providers, a consultant to other physicians, and a
teacher to the patient and other physicians
b. In the prevention, counseling, detection, and diagnosis and treatment of
gender-specific diseases
c. In a variety of health care settings to include the inpatient ward, the
critical care units, the emergency setting and the ambulatory setting
d. Across the spectrum of clinical disorders seen in the practice of general
internal medicine including the subspecialties of internal medicine and
non-internal medicine specialties in both inpatient and ambulatory
settings
e. Using clinical skills of interviewing and physical examination
f. Using the laboratory and imaging techniques appropriately
g. By demonstrating competence in the performance of procedures
mandated by the ABIM
h. By caring for a sufficient number of undifferentiated acutely and severely
ill patients.
2. Must treat their patient’s conditions with practices that are safe, scientifically
based, effective, efficient, timely, and cost effective. The program must integrate
patient centered care and resident education. On all assignments, residents and
faculty interactions must be patient-centered.
Evaluation tools: 360 degree evaluation, chart reviews, direct observation tool including
mini-clinical evaluation exercise (mini-CEX), observed clinical evaluation skills
(standardized patient encounter, SIM center scenarios), procedure log review during
semiannual review
2. Medical Knowledge
Residents must demonstrate knowledge of established and evolving biomedical,
clinical, epidemiological and social-behavioral sciences, as well as the application
of this knowledge to patient care.
Residents are expected to:
1. Demonstrate a level of expertise in the knowledge of those areas appropriate for
an internal medicine specialist, specifically
5
a. Knowledge of the broad spectrum of clinical disorders seen in the practice
of general internal medicine
b. Knowledge of the core content of general internal medicine which
includes the internal medicine subspecialties, non-internal medicine
specialties, and relevant non-clinical topics at a level sufficient to practice
internal medicine.
2. Demonstrate sufficient knowledge to
a. Evaluate patients with an undiagnosed and undifferentiated presentation
b. Treat medical conditions commonly managed by internists
c. Provide basic preventive care
d. Interpret basic clinical tests and images
e. Recognize and provide initial management of emergency medical
problems
f. Use common pharmacotherapy
g. Appropriately use and perform diagnostic and therapeutic procedures.
Evaluation tools: In-service Training Examination (ITE), chart stimulated recall, direct
observation, conference attendance (noon report and academics)
3. Practice-based Learning and Improvement
Residents must demonstrate the ability to investigate and evaluate their care of
patients, to appraise and assimilate scientific evidence, and to continuously
improve patient care based on constant self-evaluation and life-long learning.
Residents are expected to develop skills and habits to be able to meet the
following goals:
1.
2.
3.
4.
5.
6.
7.
8.
Identify strengths, deficiencies, and limits in one’s knowledge and expertise
Set learning and improvement goals
Identify and perform appropriate learning activities
Systematically analyze practice using quality improvement methods, and
implement changes with the goal of practice improvement
Incorporate formative evaluation feedback into daily practice
Locate, appraise, and assimilate evidence from scientific studies related to their
patients’ health problems
Use information technology to optimize learning
Participate in the education of patients, families, students, residents and other
health professionals.
Evaluation Tools: 360 degree evaluations, continuity clinic Process Improvement (PI)
projects, practice based learning and improvement initiatives, Resident Peer Review
Conference (RPRC) attendance, direct observation and use of EMR, reflective exercises
4. Interpersonal and Communication Skills
Residents must demonstrate interpersonal and communication skills that result in
the effective exchange of information and collaboration with patients, their
families, and health professionals.
Residents are expected to:
6
1. Communicate effectively with patients, families, and the public, as appropriate,
across a broad range of socioeconomic and cultural backgrounds
2. Communicate effectively with physicians, other health professionals, and health
related agencies
3. Work effectively as a member or leader of a health care team or other
professional group
4. Act in a consultative role to other physicians and health professionals
5. Maintain comprehensive, timely, and legible medical records, if applicable
Evaluation Tools: 360 degree evaluations, standardized patient encounter/SIM center
scenarios with faculty feedback, mini-CEX, mentored self reflection during semi-annual
evaluation, chart review
5. Professionalism
Residents must demonstrate a commitment to carrying out professional
responsibilities and an adherence to ethical principles.
Residents are expected to demonstrate:
1.
2.
3.
4.
5.
Compassion, integrity, and respect for others
Responsiveness to patient needs that supersedes self-interest
Respect for patient privacy and autonomy
Accountability to patients, society and the profession
Sensitivity and responsiveness to a diverse patient population, including but not
limited to diversity in gender, age, culture, race, religion, disabilities, and sexual
orientation.
Evaluation Tools: 360 degree evaluations, standardized patient encounters/SIM center
encounters with faculty feedback, presentation skills evaluation and feedback, mentored
self reflection (reflective exercises), conference attendance tracking (noon report, Friday
morning report and core curriculum conference), medical record compliance (AHLTA
notes on time, telephone consults completed on time, monitoring for scheduling conflicts
in advance)
6. Systems-based Practice
Residents must demonstrate an awareness of and responsiveness to the larger
context and system of health care, as well as the ability to call effectively on other
resources in the system to provide optimal health care.
Residents are expected:
1. Work effectively in various health care delivery settings and systems relevant to
their clinical specialty
2. Coordinate patient care within the health care system relevant to their clinical
specialty
3. Incorporate considerations of cost awareness and risk-benefit analysis in patient
and/or population-based care as appropriate
4. Advocate for quality patient care and optimal patient care systems
7
5. Work in interprofessional teams to enhance patient safety and improve patient
care quality
6. Participate in identifying system errors and implementing potential systems
solutions
7. Work in teams and effectively transmit necessary clinical information to ensure
safe and proper care of patients including the transition of care between settings
8. Recognize and function effectively in high-quality care systems
Evaluation Tools: 360 degree evaluations, individual and squad PI projects, chart
review
The NMCP Internal Medicine Program also evaluates residents’ competency to
supervise others, to practice with limited autonomy, and to pass the Internal Medicine
Board examinations. To assess the development of residents’ knowledge base as they
progress through training, a yearly in-service examination is given not only to simulate
the ABIM exam, but also to assist in early identification of areas requiring additional
attention. The in-service exam can provide residents with early insight into strengths and
weaknesses.
In order to graduate, residents must have achieved the competencies, demonstrated the
ability to act independently as an internist, and interact with other members of the health
care team. At the successful completion of training, residents will be strong leaders,
skillful patient care managers, courteous professionals, and proud members of the
community in which Naval physicians practice medicine.
The American Board of Internal Medicine has developmental milestones for Internal
Medicine Residency Training (Appendix A) and this provides a basis for our educational
plan and curriculum. Importantly, it distinguishes between basic and advanced levels of
performance for both ward, clinic, and subspecialty rotations and emphasizes growth
and development of the Internal Medicine resident through all levels of training. *
B. Educational Plan
A written curriculum (rotational goals and objectives) for all aspects of education and
training is distributed electronically to residents and faculty on a monthly basis via New
Innovations. These same goals and objectives are available to the residents and faculty
for review on the Internal Medicine drive (dffm54), and is anticipated to transition to
SharePoint. Additionally, the curriculum contains objectives for each level of training
(the minimum achieved while on each service) as well as teaching methods, educational
materials, procedures, and conferences specific to the subspecialty division.
All residents are expected to be familiar with the American Board of Internal Medicine
(ABIM) requirements for subspecialties in Internal Medicine, as well as areas required by
the Residency Review Committee (RRC).
Per Internal Medicine RRC guidelines, our education venues and strategies
include (ref: ACGME Program Requirements for Graduate Medical Education in
Internal Medicine, IV.A.2.c)
(http://www.acgme.org/acWebsite/downloads/RRC_progReq/140_internal_medicine_07
012009.pdf for detailed program requirements):
8
1. Required critical care rotations (e.g., medical or respiratory intensive care units,
cardiac care units) which cannot be fewer than three months and more than six
months over the 36 months of training
2. Exposure to each of the internal medicine subspecialties and neurology
3. An assignment in geriatric medicine
4. Opportunities for experience in psychiatry, allergy/immunology, dermatology,
medical ophthalmology, office gynecology, otorhinolaryngology, non-operative
orthopedics, palliative medicine, sleep medicine, and rehabilitation medicine
5. Opportunities to demonstrate competence in the performance of procedures
listed by the ABIM as requiring only knowledge and interpretation
6. A clinical experience in outpatient chronic disease management, preventive
health, patient counseling, and common acute ambulatory problems.
7. A longitudinal continuity experience in which residents develop a continuous,
long-term therapeutic relationship with a panel of general internal medicine
patients
8. An emergency medicine assignment for at least four weeks of direct experience
in blocks of not less than two weeks. Total required emergency medicine
experience must not exceed two months in three years of training
The curriculum composition (percentage and emphasis determined by ABIM and RRC
requirements and recommendations) is balanced between inpatient and outpatient
requirements, acute and chronic care, problems of the young adult, middle-age, and
elderly (geriatrics). At least one-third of residents’ time is spent in the ambulatory setting
(Internal Medicine clinic, specialty/elective, neurology, and ER rotations) and at least
one-third in the inpatient setting. Continuity clinic consists of 130 clinic sessions (halfdays). All rotations include an academic and teaching rounds component.
Core academic conferences occur Monday through Wednesday after Noon Report.
Friday Morning Report consists of a mix of Night Medicine case presentations, Resident
Lectures, Resident Grand Rounds and chart review. These conferences prepare
residents for certification examinations and meet the Residency Review Committee in
Internal Medicine requirements for education in both Internal Medicine and non-Internal
Medicine specialties. Augmenting daily conferences are monthly Resident Lectures,
Resident Grand Rounds, Resident Peer Review Conferences, and Journal Clubs.
Attendance is required at >60% of these mandatory Internal Medicine conferences and
10 journal clubs per year. There is a board review series designed for residents in their
final stages of training occurring throughout second and third year during/following Noon
Report.
Typically, most subspecialties will have scheduled conferences and are to be attended
by the resident(s) rotating on that service provided they do not conflict with the
aforementioned required educational experiences. Each Internal Medicine subspecialty
is responsible for orienting and training residents rotating in their division in interpretive
skills and procedures unique to their service (please see ABIM section below for
procedure documentation processes).
C. ABIM Requirements
NMCP Internal Medicine must focus academic activities on assuring residents are
eligible to sit for the certifying examination of the American Board of Internal Medicine.
Please reference the ABIM website for the specific and general terms of this. (ref:
9
http://www.abim.org/certification/policies/imss/im.aspx#eligibility, click link to
PDF document of Policies and Procedures for Certification, Jan 2013; pp 2-6.
Document is also available on dffm54).
PROCEDURAL REQUIREMENTS FOR GRADUATION FROM THE INTERNAL
MEDICINE RESIDENCY PROGRAM*
Procedure
BLS
ACLS
ATLS
Venous Blood Sampling
Papanicolau smear
Arterial Blood Gas
Arterial Line Placement1
Lumbar Puncture
Paracentesis
Arthrocentesis
Thoracentesis
Central Line Placement
Treadmill exercise testing2
CXR interpretation3
ECG interpretation3
Urinalysis interpretation3
Peripheral smear interpretation3
Gram stain interpretation3
PFTs/Spirometry Interpretation3
CEX/GTA
Requirement
Maintain certification
Maintain Certification
Completion
During R1 (need 5)
During R1 (need 3)
5
5
5
5
5
5
5
20
NA
NA
NA
NA
NA
NA
R2
R3
*Requirements per ACGME and ABIM for credentialing and privileging. Some
program specific requirements go beyond those of ACGME and ABIM due to the
high demands placed on Internist in Navy Medicine (e.g., operational medicine
and practicing in an austere environment). These numbers represent the
minimum number of procedures in which the resident actively participates and is
directly observed by senior resident or staff who is certified or credentialed in a
particular procedure.
1
5 arterial line placements can substitute for and be counted toward 5 arterial
blood sampling.
2
5 directly supervised, 15 indirectly supervised
3
Competency established by successful completion of clinical skills evaluation.
10
OPTIONAL PROCEDURES FOR CERTIFICATION FOR INTERNAL MEDICINE
RESIDENTS
Procedure
Administration of local anesthesia
for wound infiltration and suturing
of minor laceration not involving
nerves, tendons, vessels
Method of Certification
5
5
Cardioversion; elective
20
Holter monitoring
Incision and drainage of
thrombosed hemorrhoids, cysts
and minor abscesses
5
5
Intestinal intubation
Temporary pacemaker insertion
conscious
5
Swan-Ganz catheter placement
5
5
Tensilon test
5
Tzanck smear
3
Skin biopsy
3
Punch biopsy
3
Shave biopsy and excision
5
Moderate sedation
11
Residents are required to document the type and number of each procedure that has
been accomplished in New Innovations. Each resident’s training file contains an updated
list of these procedures and, as required by ABIM, serves as verification of competence
in procedural medicine. As Navy doctors, we are often in austere environments that will
require us to be the expert in completion of procedures; as the minimum standard of
quality accepted by the ABIM is reflected in the Policy and Procedures document, NMCP
Internal Medicine must exceed these requirements in order to properly prepare our
internists for practice in Navy Medicine.
The written examination is an essential portion of attaining board certification, however,
it also requires ongoing evaluation of the resident’s performance by an accredited
residency program.
Requirements outlined by the ABIM for the 36 month period of full-time internal medicine
residency education must include: thirty months of rotations in general internal medicine,
subspecialty internal medicine, critical care medicine, geriatric medicine, and emergency
medicine which may include a maximum of four months of non-internal medicine primary
skill areas (e.g. neurology, dermatology, office gynecology, or pediatrics); up to three
months of other electives approved by the Internal Medicine Program Director.
From ref: ABIM Policies and Procedures for Certification: “Up to one month per
academic year is permitted for time away from training, which includes vacation, illness,
parental or family leave, or pregnancy-related disabilities. Training must be extended to
make up any absences exceeding one month per year of training. Vacation leave is
essential and should not be forfeited or postponed in any year of training and cannot be
used to reduce the total required training period. - ABIM recognizes that leave policies
vary from institution to institution and expects the program director to apply his/her local
requirements within these guidelines to ensure trainees have completed the requisite
period of training.” ABIM gives each institution’s program director license to apply these
guidelines within the context of institution specific requirements.
ABIM requires that the residency must contain twenty-four months of direct patient
responsibility, occurring in either inpatient or ambulatory settings. A minimum of six
months of this direct patient responsibility on internal medicine rotations must occur
during the R-1 year.
The ABIM encourages documentation of direct observation of residents by faculty, chief
residents, or supervising residents in the provision of patient care. Our program requires
each resident to have a faculty member complete 12 mini-CEXs (Clinical Evaluation
Exercises) per year, six involving a component of the physical examination and six
involving a component of history taking or patient counseling. Completion of this
requirement will be documented on each resident’s ABIM tracking form, submitted
annually by the program.
As aforementioned, the ABIM in-service examination is required to be taken by all
residents each year and results are confidentially shared with the Program Director and
the Internal Medicine Education Committee. At the semi-annual meeting with the
Program Director, a computer print-out is given to the resident and performance is
detailed and reviewed at that time.
12
D. Policy on ACGME Guidelines: ambulatory assignments and patient loads
We require all trainees to follow the ACGME program requirements for residency
education.
The following is taken directly from the ACGME guidelines. Please go to the following
link for additional details:
http://www.acgme.org/acWebsite/downloads/RRC_progReq/140_internal_medicine_070
12009.pdf
1. Ambulatory Medicine: At least 1/3 of the residency training is in an
ambulatory care setting [IV.A.1.c)].
a. Longitudinal Continuity Experience [ref: IV.A.2.c).(1).(g).(ii)]
i. Must include the resident serving as the primary physician for
a panel of patients, with responsibility for chronic disease
management, management of acute health problems, and
preventive health care for their patients.
ii. Should not be interrupted by more than a month, not inclusive
of vacation.
iii. Must include a minimum of 130 distinct half-day outpatient
sessions, extending at least over a 30-month period, devoted
to longitudinal care of the residents’ panel of patients.
iv. Must include evaluation of performance data for each
resident’s continuity panel of patients relating to both chronic
disease management and preventive health care. Residents
must receive faculty guidance for developing a data-based
action plan and evaluate this plan at least twice a year.
v. Must include resident participation in coordination of care
across health care settings. Residents should be accessible to
participate in the management of their continuity panel of
patients between outpatient visits. There must be systems of
care to provide coverage of urgent problems when a resident
is not readily available.
vi. Must include supervision by faculty who develop a longitudinal
relationship with residents throughout the duration of their
continuity experience.
vii. Must maintain a ratio of residents or other learners to faculty
preceptors not to exceed 4:1.
viii. Must have sufficient supervision and teaching:
1. Faculty must not have other patient care duties while
supervising more than two residents or other learners
2. Other faculty responsibilities must not detract from the
supervision and teaching of residents.
ix. During the continuity experience, arrangements are made to
minimize interruptions of the experience by residents' duties
on inpatient and consultation services.
b. Emergency Medicine [ref: IV.A.2.c).(1).(h)]
i. Internal medicine residents must be assigned to emergency
medicine for at least four weeks of direct experience in blocks
13
of not less than two weeks.
ii. Internal medicine residents assigned to emergency medicine
must have first-contact responsibility for a sufficient number of
unselected patients to meet the educational needs of internal
medicine residents. Triage by other physicians prior to this
contact is unacceptable.
iii. Total required emergency medicine experience must not
exceed two months in three years of training.
2. Inpatient Medicine
a. On Inpatient Rotations [ref: I.A.2.m).(7), I.A.2.m).(8)]
i. A first-year resident is not assigned more than five new
patients per admitting day; an additional 2 patients may be
assigned if they are in-house transfers from the medical
services.
ii. A first-year resident is not assigned more than eight new
patients in a 48-hour period.
iii. A first-year resident is not responsible for the ongoing care of
more than 10 patients.
iv. When supervising more than one first-year resident, the
supervising resident is not responsible for the supervision or
admission of more than 10 new patients and 4 transfer
patients per admitting day or more than 16 new patients in a
48-hour period.
v. When supervising one first-year resident, the supervising
resident is not responsible for the ongoing care of more than
14 patients.
vi. When supervising more than one first-year resident, the
supervising resident is not responsible for the ongoing care of
more than 20 patients.
vii. Residents must write all orders for patients under their care,
with appropriate supervision by the attending physician. In
those unusual circumstances when an attending physician or
subspecialty resident writes an order on a resident’s patient,
the attending or subspecialty resident must communicate his
or her action to the resident in a timely manner.
viii. Second- or third-year internal medicine residents or other
appropriate supervisory physicians (e.g., subspecialty
residents or attendings) with documented experience
appropriate to the acuity, complexity, and severity of patient
illness are available at all times on-site to supervise first-year
residents.
ix. Residents from other specialties do not supervise internal
medicine residents on any internal medicine inpatient rotation.
x. There is a minimum of 6 months of inpatient internal medicine
teaching service assignments in the first year [ref: ABIM
Requirements for Certification in Internal Medicine]
xi. Residents are not assigned more than two months of night
float during any year of training, or more than four months of
night float over three years of residency.
14
b. Critical Care [ref: IV.A.2.c).(1).(a)]
i. Required critical care rotations (e.g., medical or respiratory
intensive care units, cardiac care units) cannot be fewer than
three months and more than six months over the 36 months of
training
ii. Consultations from other clinical services must be available in
a timely manner in all care settings where the residents work.
All consultations should be performed by or under the
supervision of a qualified specialist. [ref: II.D.8]
3. Subspecialty Experience [ref: IV.A.2.b)]
a. The curriculum must ensure that each resident has sufficient clinical
exposure to the diagnostic and therapeutic methods of each of the
recognized internal medicine subspecialties and neurology. Each
resident through the curriculum design has sufficient clinical exposure
of each of the recognized internal medicine subspecialties as a
dedicated rotation in each is not required.
b. An assignment to geriatric medicine, as directed by ABIM, is
incorporated into the curriculum during PGY3 year with the EVMS
Glennan Center for Geriatrics primarily at Beth Sholom Village and
Kempsville Health and Rehab Center under the direction of board
certified geriatricians.
E. Policy on ACGME Guidelines – Duty Hours
This information is taken directly from the ACGME website, Common Program
Requirements. For additional information, please reference:
http://www.acgme.org/acWebsite/dutyHours/dh_index.asp
1. Maximum Hours of Work per Week [Ref: VI.G.1.]
a. Duty Hours must be limited to 80 hours per week, averaged over a fourweek period, inclusive of all in-house call activities.
2. Mandatory Time Free of Duty [Ref: VI.G.3.]
a. Residents must be scheduled for a minimum of one day free of duty every
week (when averaged over four weeks). At-home call cannot be assigned
on these free days.
3. Maximum Duty Period Length [Ref: VI.G.4.]
a. Duty periods of PGY1 residents must not exceed 16 hours in duration.
b. Duty periods of PGY2 residents and above may be scheduled to a
maximum of 24 hours of continuous duty in the hospital. Programs must
encourage residents to use alertness management strategies in the
context of patient care responsibilities. Strategic napping, especially after
16 hours of continuous duty and between the hours of 10:00 pm and 8:00
am, is strongly suggested.
i. It is essential for patient safety and resident education that
effective transitions in care occur. Residents may be allowed to
remain on-site in order to accomplish these tasks; however, this
period of time must be no longer than an additional four hours.
ii. Residents must not be assigned additional clinical responsibilities
15
after 24 hours of continuous in-house duty.
iii. In unusual circumstances, residents, on their own initiative, may
remain beyond their scheduled period of duty to continue to
provide care to a single patient. Justifications for such extensions
of duty are limited to reasons of required continuity for a severely
ill or unstable patient, academic importance of the events
transpiring, or humanistic attention to the needs of a patient or
family.
iv. Under those circumstances, the resident must: appropriately hand
over the care of all other patients to the team responsible for their
continuing care; document the reasons for remaining to care for
the patient in question and submit that documentation in every
circumstance to the program director. The program director must
review each submission of additional service, and track both
individual resident and program-wide episodes of additional duty.
4. Minimum Time Off between Scheduled Duty Periods [Ref: VI.G.5.]
a. PGY-1 residents should have 10 hours, and must have eight hours, free
of duty between scheduled duty periods.
b. Intermediate-level residents [as defined by the Review Committee] should
have 10 hours free of duty, and must have eight hours between
scheduled duty periods. They must have at least 14 hours free of duty
after 24 hours of in-house duty.
c. Residents in the final years of education [as defined by the Review
Committee] must be prepared to enter the unsupervised practice of
medicine and care for patients over irregular or extended periods.
5. Maximum Frequency of In-House Night Float [Ref: VI.G.6.]
a. Residents must not be scheduled for more than six consecutive nights of
night float. [The maximum number of consecutive weeks of night float,
and maximum number of months of night float per year may be further
specified by the Review Committee.]
6. Maximum In-House On-Call Frequency [Ref: VI.G.7.]
a. PGY-2 residents and above must be scheduled for in-house call no more
frequently than every-third-night (when averaged over a four-week
period).
F. Evaluation
1. Monthly Rotation Evaluations
Residents are evaluated in many ways and usually are most familiar with the verbal
feedback and electronic evaluations submitted by attending physicians through New
Innovations at the end of a rotation. This year marks the transition to the ACGME Next
Accreditation System which transitions to a milestone based evaluation of competency.
In support of this change, our evaluation system will be evolving to incorporate
milestones specific for each rotation and each level of training requiring changes to the
traditional New Innovations format. As this system is implemented nationwide, the
evaluation system may require modification. At the time of publication of this residency
manual, the evaluations have not been finalized, but will continue to reflect the six
ACGME core competencies further broken into sub-competencies which are evaluated
16
by achievement of milestones. At the conclusion of milestone evaluation in New
Innovations, a section will remain for comments which are encouraged and welcomed.
These evaluations are based on individual faculty’s personal and professional
experience in academic medicine. Monthly evaluations should be discussed promptly,
and the resident should seek out this meeting with the attending to ensure it occurs.
Satisfactory performance or “pass” is required in each of these areas. Failure is not the
only cause for concern in evaluations; a low satisfactory or “marginal pass” is also
alarming and will result in resident counseling and close monitoring by the Program
Director, Associate Program Director, and Internal Medicine Education Committee
(IMEC). The resident will be subject to probationary status if there is a documented
unsatisfactory or “failure,” particularly if evaluations have consistently reflected marginal
pass or pass; this is decided by the IMEC and recommended to the Program Director
(see Deficiency and Remediation section).
2. ABIM Mini-CEX
Residents will also be evaluated using the Mini-Clinical Evaluation Exercise (Mini-CEX).
Taken directly from the ABIM website
(ref: http://www.abim.org/program-directors-administrators/assessment-tools/minicex.aspx)
“The ABIM Mini-Clinical Evaluation Exercise (Mini-CEX) is intended to facilitate formative
assessment of core clinical skills. It can be used by faculty as a routine, seamless
evaluation of trainees in any setting. The Mini-CEX is a 10-20 minute direct observation
assessment or “snapshot” of a trainee-patient interaction. Faculty are encouraged to
perform at least one per clinical rotation. To be most useful, faculty should provide timely
and specific feedback to the trainee after each assessment of a trainee-patient
encounter.” There are twelve required each academic year, six focusing on an aspect of
history gathering, or patient counseling, and six focusing on an aspect of the physical
exam. Completion of the twelve Mini-CEX each post-graduate year by a faculty member
is required for promotion to the next level of residency training. Please refer to the
dffm54 or the ABIM website for a PDF of the Mini-CEX.
3. Academic Presentations (Grand Rounds, Resident Lecture, Journal
Club)
Residents will receive faculty evaluations from their presentations during Grand Rounds,
Resident Lectures, Journal Club, and Clinical Pathology Conference. The evaluation
forms are available on-line and in the appendices of this manual.
4. Program Director Meetings
Semi-annually, second and third year residents meet individually with the Program
Director (first year residents meet with the Intern Advisor). These meetings are designed
not only to review residents’ training files (progression toward promotion to the next level
of training and graduation), but also to provide general feedback, counseling, and
assistance. Residents who have shown cause for concern (i.e. marginal passes or
failures on evaluations) can expect to discuss these items and plans toward
improvement.
17
In general, all residents have complete access to the contents of their training file, which
is kept in the Program Administrator’s spaces. Evaluations should be specific and focus
on constructive feedback in specific areas for improvement. If residents do not agree
with the contents of an evaluation, then they always have a right to refute the legitimacy
of an evaluation through a written response, which becomes a permanent part of a
training record. The Program Director reviews these responses and takes action as
necessary for clarification of any differences in opinion.
5. Internal Medicine Education Committee (IMEC)
The Internal Medicine Education Committee (IMEC) regularly meets to review residents’
performance and progression through training and expectations for promotion or
graduation, and if not, appropriate remediation is implemented (see section on
Deficiency and Remediation).
The IMEC annually reviews each resident’s personal file of rotation evaluations, ITE
scores, required procedure completion progress, and other performance documentation
for the year. A composite evaluation is developed and transferred onto the required
forms for the American Board of Internal Medicine.
G. Conferences/Curriculum
1. Noon Report
Noon Report (NR) is Monday through Thursday at noon in the Internal Medicine
Conference Room, Building 2, 2nd floor. NR is facilitated by the Chief of Residents (COR)
with strong faculty involvement. The format is typically case presentations from inpatient
ward teams, the Cardiology service, or outpatient clinics. The presentations begin with a
brief case description, but the emphasis is on clinical reasoning and decision-making:
developing a problem list and differential diagnosis followed by appropriate tests and
studies, concluding with management and a brief overview of the disorder. The goal is to
emphasize evidence-based learning around interesting case presentations, while
covering the material that will be presented and tested on the ABIM examination.
Thursday NR is reserved for board review in the Internal Medicine conference room, with
occasional dedicated Intern Noon Report held separately. Friday mornings deviate from
the typical NR with two Fridays of the block led by the Night Medicine Team with
overnight clinical questions and case discussions from the week (held in the Internal
Medicine Conference Room), and the remainder of the mornings will consist of required
Resident Lectures, Grand Rounds (Grand Rounds will be held in the main auditorium in
Building 3, 2nd floor), and chart review from the inpatient services. The Friday morning
schedule will be determined by the COR and the Program Director. Friday mornings
start at 0730.
Noon Report (NR) is perhaps the most important teaching activity and attendance is
mandatory. Due to the importance of attendance, repeated failure to be present may
result in a letter in the resident’s training file/warning status at the discretion of the
program director. Faculty members are well-represented and invaluable to the NR
educational atmosphere. The environment is educational and non-confrontational. This
is the resident’s opportunity to showcase clinical reasoning and decision-making openly
as well as a chance for the faculty to challenge the resident in these areas and analyze
18
abilities to synthesize clinical data appropriately.
2. Core Curriculum Conference
Core Curriculum Conference is held from 1245 - 1330 on Monday, Tuesday, and
Wednesday in the Internal Medicine Conference Room, Building 2, 2nd floor. Each
Internal Medicine division will present essential topics developed by the Curriculum
Committee encompassing all required subject matter areas for an accredited internal
medicine residency program. Ideally, presenters will present at the resident level and
facilitate active discussion by providing interactive, cutting edge lectures.
3. Grand Rounds
Grand Rounds is held twice a month on Wednesday or Friday mornings at 0730 in the
Main Auditorium at Naval Medical Center Portsmouth, Building 3, 2nd floor. Grand
Rounds is an important presentation for third year residents preparing to graduate, and
the schedule is determined in July by the COR. Grand Rounds will be a command-wide
event and cases must be chosen and prepared far in advance and developed with staff
input. Required uniform for Grand Rounds is Summer Whites or Service Dress Blues.
The content of Grand Rounds should answer a focused clinical question using pertinent
current literature. For additional details and a complete description of specific
requirements for Grand Rounds, please refer to dffm54.
Attendance by Internal Medicine residents in all levels of training is mandatory to Grand
Rounds. Evaluations are completed by the faculty in attendance. A copy of this
evaluation is included in the appendices of this manual.
4. Resident Lectures
Resident Lectures are held once a month on a Friday morning at 0730 in the Internal
Medicine Conference Room, Building 2, 2nd floor. Resident Lectures are an important
presentation for second year residents preparing for promotion, and the schedule is
determined in July by the COR. The required uniform for Resident Lectures is khakis or
the Navy Working Uniform. Residents are expected to choose a case well in advance
and be prepared to meet with the COR and the supervising staff 4-6 weeks prior to the
presentation date to review presentation content. For additional details and a complete
description of specific requirements for Grand Rounds, please refer to dffm54.
Attendance by Internal Medicine residents in all levels of training is mandatory to
Resident Lectures. Evaluations are completed by the faculty in attendance. A copy of
this evaluation is included in the appendices of this manual.
5. Resident Peer Review Conference
In accordance with hospital and ACGME regulations, monthly Resident Peer Review
Conferences (RPRC) will be held. The schedule will be determined by the COR in July.
Each resident is required to present at least one RPRC in either the second or third year
of training. Some will be called upon to present more than once. RPRC cases are
selected by the COR. For additional details and a complete description of specific
requirements for RPRC, please refer to dffm54.
19
Attendance by Internal Medicine residents in all levels of training is mandatory to
Resident Lectures. The presenting resident is required to complete a summary of the
RPRC he/she investigated. This summary is routed to the Executive Committee of
Medical Staff (ECoMS) for review and may even lead to hospital-wide policy change. A
copy is also kept in the resident’s training file to document completion.
6. Clinical Pathology/Autopsy Conference
In accordance with RRC and ACGME requirements, one CPC is required during PGY2
or PGY3 year. This is an important exercise in order to review the gross pathology or
histology of patients who were given a specific tissue diagnosis or who died while on
service. For additional details and a complete description of specific requirements for
CPC, please refer to dffm54.
7. House Staff Meetings
The COR and Program Director will arrange a House Staff meeting once a month. The
schedule will be determined by the COR in July. The COR will prepare the agenda and
the Program Director will be present to discuss items or answer questions. This is an
open forum in which residents can express any concerns they have about the residency
environment and suggest ways to improve it.
8. Journal Club
Journal Club is held once a month at the Squad level (please see appendices for
information regarding Squad organization). The journal article is selected at least two
weeks in advance by the resident presenter, and the Squad Mentor (faculty member)
and Squad Leader (R3) must approve it. The resident presenter will then utilize a
method of critical appraisal in order to analyze the article and concisely present the
material. The squad mentor will provide formal evaluation of the residents’ critical
analysis of the literature.
9. Division Conferences
Resident attendance is expected at division conferences while rotating on a particular
subspecialty with priority given to Noon Report, Core Curriculum Conferences and other
previously scheduled conferences.
10. Joint Conferences
On occasion, the Internal Medicine Department will conduct a joint conference with
another department, traditionally this has been with Emergency Medicine, but other
departments should not be excluded. These conferences are usually scheduled one
month in advance and when an interesting case or educational patient outcome arises.
Residents will be asked to volunteer to participate as presenters in these conferences.
11. Attendance
Attendance to the above mentioned academic and departmental endeavors is
mandatory. ACGME requires residents have an average attendance of >60%. The
20
professional expectation is that residents will willingly take part in these educational
opportunities. Attendance is taken in the form of a sign-in sheet at every conference to
ensure that minimum attendance requirements are met. Attendance percentages will be
reported to residents to allow time for improvement prior to initiating corrective
measures.
12. Johns Hopkins Modules
Academic year 2012-2013 marked the introduction of the Johns Hopkins Medicine
Internet Learning Center Ambulatory Care Curriculum, to be further referred to as the
Johns Hopkins Modules. These modules are designed to supplement the Core
Curriculum Conferences and be completed independently by residents. There are
currently 48 modules available, one of which will be assigned for each academic block.
Additionally a preoperative evaluation module must be completed during the consult
block. Residents are by no means limited to one module per block and are encouraged
to complete them at their own pace. The Johns Hopkins Modules may be accessed at
http://www.hopkinsilc.org/main.php
13. Directed Reading
Academic year 2012-2013 also debuted the directed reading program. The purpose of
this program is to facilitate further preparation for the ABIM boards based on the results
of the annual In-service Training Exam (ITE). After receiving the results of the ITE,
missed objectives will be loaded into directed reading program thus providing a
customized program for each resident. Each resident is paired with a staff mentor to
whom the resident will submit a brief explanation of the training objective. The mentor
will reply further clarifying the objective or giving an example. This is meant to be a
collaborative and interactive method of learning. It is mandatory for those ranking below
the 50th percentile for their year group, and is highly encouraged for all others. It may be
accessed at http://nmc.directedreading.org/login.
H. Scholarly Activity
Two scholarly activities must be conducted during residency and more are strongly
encouraged. Traditionally, residents complete this ACGME requirement [ref: IV.B.2] by
submitting a case or research for poster or oral presentation to the annual American
College of Physicians (ACP) Navy Chapter meeting usually held in the fall of each year
in San Diego, Bethesda/Washington, D.C., or Portsmouth. Due to current increased
requirements and scrutiny on travel and conference attendance, this year’s ACP will
likely be a collaborative teleconference, however plans are being finalized to include the
academic research competition. Other highly encouraged and acceptable scholarly
activities include peer-reviewed publications, poster presentations, or other similar
activity approved by a Program Director. Routinely required resident presentations and
conferences (e.g., lectures, journal club, and end-of-rotation presentation) do not qualify
as one of the two needed scholarly activities. Participation in scholarly activity during
internship remains highly encouraged, however work completed during internship will not
count towards satisfying the requirement for residency.
I.
Electives
Most residents choose Internal Medicine subspecialties as the bulk of their electives;
21
however, the Internal Medicine Program supports and encourages residents to engage
in research projects during their training or explore electives outside of the traditional
residency program.
1. Research
Residents may use elective months during their training to conduct research, provided
the following criteria are met: 1.) deemed in good standing by the Program Director 2.)
identifies a research mentor who will work closely with the resident and Program Director
3.) submits a formal research plan for approval by a Program Director at least three
months prior to the resident’s scheduled research month. Again, all efforts will be made
to accommodate the resident’s request to incorporate research into his/her training
program. Please see Major Jessie Glasser, the research coordinator for the Program, for
more information.
2. Outside Internal Medicine Electives
Elective rotation time is built into residents’ schedules. This program has not traditionally
had residents rotate in electives outside the Internal Medicine Department, but this
opportunity will be made available if the interested resident submits a plan for approval
several months in advance. There are requirements that must be met in order to start or
continue the elective; failure to meet the requirements will result in rotation
reassignment. These requirements are in development this year, so please discuss with
the PD, APD and COR if you are interested in pursuing an elective outside Internal
Medicine. The purpose of an elective rotation is to give residents time in an area of
interest to meet individual goals. Clearly outlined goals must be met at the completion of
the rotation.
Another possibility within the residency program is for residents to take electives outside
of NMCP in the operational community. The program will support and provide
information regarding these opportunities as they arise. Residents choosing to
participate in these unique missions are asked to share their experiences with their
peers upon their return in the form of a modified core curriculum presentation.
J. Procedures
Taken directly from the ABIM Policies & Procedures for Certification
“Safety is the highest priority when performing any procedure on a patient. ABIM
recognizes that there is variability in the types and numbers of procedures performed by
internists in practice. Internists who perform any procedure must obtain the appropriate
training to safely and competently perform that procedure. It is also expected that the
internist be thoroughly evaluated and credentialed as competent in performing a
procedure before he or she can perform it unsupervised. For certification in internal
medicine, ABIM has identified a limited set of procedures in which it expects all
candidates to be competent with regard to their knowledge and understanding. This
includes: (1) demonstration of competence in medical knowledge relevant to procedures
through their ability to explain indications, contraindications, patient preparation
methods, sterile techniques, pain management, proper techniques for handling
specimens and fluids obtained, and test results; (2) ability to recognize and manage
complications; and (3) ability to clearly explain to a patient all facets of the procedure
22
necessary to obtain informed consent.
For a subset of procedures, ABIM requires all candidates to demonstrate competence
and safe performance by means of evaluations performed during residency training.”
Specific requirements are listed on pages 8 & 9 of this manual. This year there will be a
simulation portion of the curriculum designed to augment the bedside teaching of
procedures currently relied upon for the majority of teaching.
K. Grievance Procedure
Matters that are interpreted as not in compliance with the policies and procedures of the
Resident Agreement are considered grievances.
Documentation of the matter is dependent on the primary grievance. Grievances
regarding evaluations should be noted in the comments box in the New Innovations
online evaluation. These comments will be linked to the evaluation and reviewed when
the evaluation is reviewed. The aggrieved should report matters relating to other aspects
of the Program as a memorandum to the Head, Internal Medicine Education Committee
(IMEC) and briefly describe the grievance (evaluation or other). This memorandum will
be discussed at the next IMEC meeting. In general, it is encouraged that the resident
discusses the matter first with the attending or the Chief of Residents, or, if this is not
deemed appropriate by the resident or the issue is not adequately resolved, then discuss
with the Associate Program Director or Program Director. A mutually agreeable solution
is usually reached at this point.
If the resident is not satisfied with the result after Program Director level discussion, then
a written grievance may be submitted to the Office of Graduate Medical Education
[https://intranet.mar.med.navy.mil/GME/traineesspeak.asp] per NAVMEDCEN 5420.2F
(found on the intranet). This is also the instruction to reference for the procedure if
appealing failed rotation, probation, or other disciplinary action. These are often
reviewed at the Graduate Medical Education Committee meeting that occurs monthly.
Three-Year Overview Curriculum
Internal Medicine Residency Program
Naval Medical Center Portsmouth
Adapted from the ABIM Developmental Milestones
Post Graduate Years 1-3
PGY1 – standard text
PGY2 – standard and italicized text
PGY3 – standard, italicized and bold italicized text
Patient Care
1. History and Data Gathering
a. Acquire accurate and relevant history from the patient in an efficiently customized, prioritized,
and hypothesis driven fashion
23
b. Seek and obtain appropriate, verified, and prioritized data from secondary sources (e.g. family,
records, pharmacy)
c. Obtain relevant historical subtleties that inform and prioritize both differential diagnoses and
diagnostic plans, including sensitive, complicated, and detailed information that may not often be
volunteered by the patient
d. Role model gathering subtle and reliable information from the patient for junior
members of the healthcare team
2. Performing a Physical Examination
a. Perform an accurate physical examination that is appropriately targeted to the patient's
complaints and medical conditions. Identify pertinent abnormalities using common maneuvers
b. Accurately track important changes in the physical examination over time in the outpatient and
inpatient settings
c. Demonstrate and teach how to elicit important physical findings for junior members of the
healthcare team
d. Routinely identify subtle or unusual physical findings that may influence clinical
decision-making, using advanced maneuvers where applicable
3. Clinical Reasoning
a. Synthesize all available data, including interview, physical examination, and preliminary
laboratory data, to define each patient’s central clinical problem
b. Develop prioritized differential diagnoses, evidence-based diagnostic and therapeutic plan for
common inpatient and ambulatory conditions
c. Modify differential diagnosis and care plan based upon clinical course and data as appropriate
d. Recognize disease presentations that deviate from common patterns and that require
complex decision-making
4. Invasive Procedures
a. Appropriately perform invasive procedures and provide post-procedure management for
common procedures
5. Diagnostic Tests
a. Make appropriate clinical decisions based upon the results of common diagnostic testing,
including but not limited to routine blood chemistries, hematologic studies, coagulation tests,
arterial blood gases, ECG, chest radiographs, pulmonary function tests, urinalysis and other body
fluids
b. Make appropriate clinical decision based upon the results of more advanced diagnostic tests
6. Patient Management
a. Recognize situations with a need for urgent or emergent medical care including life threatening
conditions
b. Recognize when to seek additional guidance
c. Provide appropriate preventive care and teach patient regarding self-care
d. With supervision, manage patients with common clinical disorders seen in the practice of
inpatient and ambulatory general internal medicine
e. With minimal supervision, manage patients with common and complex clinical disorders seen
in the practice of inpatient and ambulatory general internal medicine
f. Initiate management and stabilize patients with emergent medical conditions
g. Manage patients with conditions that require intensive care
h. Independently manage patients with a broad spectrum of clinical disorders seen in the
practice of general internal medicine
i. Manage complex or rare medical conditions
j. Customize care in the context of the patient’s preferences and overall health
7. Consultative Care
a. Provide specific, responsive consultation to other services
24
b. Provide internal medicine consultation for patients with more complex clinical problems
requiring detailed risk assessment
Medical Knowledge
1. Core Content Knowledge
a. Understand the relevant pathophysiology and basic science for common medical conditions
b. Demonstrate sufficient knowledge to diagnose and treat common conditions that require
hospitalization
c. Demonstrate sufficient knowledge to evaluate common ambulatory conditions
d. Demonstrate sufficient knowledge to diagnose and treat undifferentiated and emergent
conditions
e. Demonstrate sufficient knowledge to provide preventive care
f. Demonstrate sufficient knowledge to identify and treat medical conditions that require intensive
care
g. Demonstrate sufficient knowledge to evaluate complex or rare medical conditions and
multiple coexistent conditions
h. Understand the relevant pathophysiology and basic science for uncommon or complex
medical conditions
i. Demonstrate sufficient knowledge of socio-behavioral sciences including but not limited
to health care economics, medical ethics, and medical education
2. Diagnostic Tests
a. Understand indications for and basic interpretation of common diagnostic testing, including but
not limited to routine blood chemistries, hematologic studies, coagulation tests, arterial blood
gases, ECG, chest radiographs, pulmonary function tests, urinalysis and other body fluids
b. Understand indications for and has basic skills in interpreting more advanced diagnostic tests
c. Understand prior probability and test performance characteristics
Practice Based Learning and Improvement
1. Improve the Quality of Care for a Panel of Patients
a. Appreciate the responsibility to assess and improve care collectively for a panel of patients
b. Perform or review audit of a panel of patients using standardized, disease specific, and
evidence-based criteria
c. Reflect on audit compared with local or national benchmarks and explore possible explanations
for deficiencies, including doctor-related, system-related, and patient related factors
d. Identify areas in resident’s own practice and local system that can be changed to improve
e. Engage in quality improvement intervention
2. Ask Answerable Questions for Emerging Information Needs
a. Identify learning needs (clinical questions) as they emerge in patient care activities
b. Classify and precisely articulate clinical questions
c. Develop a system to track, pursue, and reflect on clinical questions
3. Acquires the Best Advice
a. Access medical information resources to answer clinical questions and library resources to
support decision-making
b. Effectively and efficiently search NLM database for original clinical research articles
c. Effectively and efficiently search evidence-based summary medical information resources
d. Appraise the quality of medical information resources and select among them based on
the characteristics of the clinical question
4. Appraises the Evidence for Validity and Usefulness
a. With assistance, appraise study design, conduct and statistical analysis in clinical research
25
papers
b. With assistance, appraise clinical guideline recommendations for bias
c. With assistance, appraise study design, conduct, and statistical analysis in clinical
research papers
d. Independently, appraise clinical guideline recommendations for bias and cost-benefit
considerations
5. Applies the evidence to decision-making for individual patients
a. Determine if clinical evidence can be generalized to an individual patient
b. Customize clinical evidence for an individual patient
c. Communicate risks and benefits of alternatives to patients
d. Integrate clinical evidence, clinical context, and patient preferences into decisionmaking
6. Improves Via Feedback
a. Respond welcomingly and productively to feedback from all members of the health care team
including faculty, peer residents, students, nurses, allied health workers, patients and their
advocates
b. Actively seek feedback from all members of the health care team
c. Calibrate self-assessment with feedback and other external data
d. Reflect on feedback in developing plans for improvement
7. Improves via self-assessment
a. Maintain awareness of the situation in the moment and respond to meet situational needs
b. Reflect (in action) when surprised, applies new insights to future clinical scenarios, and
reflects (on action) back on the process
8. Participate in education of all members of the health care team
a. Actively participate in teaching conferences
b. Integrate teaching, feedback, and evaluation with supervision of interns’ and students’ patient
care
c. Take a leadership role in the education of all members of the health care team.
Interpersonal and Communication Skills
1. Communicate effectively
a. Provide timely and comprehensive verbal and written communication to patients/advocates
b. Effectively use verbal and non-verbal skills to create rapport with patients/families
c. Use communication skills to build a therapeutic relationship
d. Engage patients/advocates in shared decision-making for uncomplicated diagnostic and
therapeutic scenarios
e. Utilize patient-centered education strategies
f. Engage patients/advocates in shared decision-making for difficult, ambiguous or
controversial scenarios
g. Appropriately counsel patients about the risks and benefits of tests and procedures
highlighting cost awareness and resource allocation
h. Role model effective communication skills in challenging situations
2. Intercultural sensitivity
a. Effectively use an interpreter to engage patients in the clinical setting including patient
education
b. Demonstrate sensitivity to differences in patients including but not limited to race, culture,
gender, sexual orientation, socioeconomic status, literacy, and religious beliefs
26
c. Actively seek to understand patient differences and views and reflects this in respectful
communication and shared decision-making with the patient and the healthcare team
3. Transitions of Care
a. Effectively communicate with other caregivers in order to maintain appropriate continuity during
transitions of care
b. Role model and teach effective communication with next caregivers during transitions of care
4. Interprofessional team
a. Deliver appropriate, succinct, hypothesis-driven oral presentations
b. Effectively communicate plan of care to all members of the health care team
c. Engage in collaborative communication with all members of the health care team
5. Consultation
a. Request consultative services in an effective manner
b. Clearly communicate the role of consultant to the patient, in support of the primary care
relationship
c. Communicate consultative recommendations to the referring team in an effective
manner
6. Health Records
a. Provide legible, accurate, complete, and timely written communication that is congruent with
medical standards
b. Ensure succinct, relevant, and patient-specific written communication
Professionalism
1. Adhere to basic ethical principles
a. Document and report clinical information truthfully
b. Follow formal policies
c. Accept personal errors and honestly acknowledge them
d. Uphold ethical expectations of research and scholarly activity
2. Demonstrate compassion and respect to patients
a. Demonstrate empathy and compassion to all patients
b. Demonstrate a commitment to relieve pain and suffering
c. Provide support (physical, psychological, social and spiritual) for dying patients and their
families
d. Provide leadership for a team that respects patient dignity and autonomy
3. Provide timely, constructive feedback to colleagues
a. Communicate constructive feedback to other members of the health care team
b. Recognize, respond to and report impairment in colleagues or substandard care via peer
review process
4. Maintain Accessibility
a. Responsibilities including but not limited to calls and pages
b. Carry out timely interactions with colleagues, patients and their designated caregivers
5. Recognize conflicts of interest
a. Recognize and manage obvious conflicts of interest, such as caring for family members and
professional associates as patients
b. Maintain ethical relationships with industry
c. Recognize and manage subtler conflicts of interest
27
6. Demonstrate personal accountability
a. Dress and behave appropriately
b. Maintain appropriate professional relationships with patients, families and staff
c. Ensure prompt completion of clinical, administrative, and curricular tasks
d. Recognize and address personal, psychological, and physical limitations that may affect
professional performance
e. Recognize the scope of his/her abilities and ask for supervision and assistance appropriately
f. Serve as a professional role model for more junior colleagues (e.g., medical students,
interns)
g. Recognize the need to assist colleagues in the provision of duties
7. Practice individual patient advocacy
a. Recognize when it is necessary to advocate for individual patient needs
b. Effectively advocate for individual patient needs
8. Comply with public health policies
a. Recognize and take responsibility for situations where public health supersedes individual
health (e.g. reportable infectious diseases)
9. Respect the dignity, culture, beliefs, values and opinions or the patient
a. Treat patients with dignity, civility and respect, regardless of race, culture, gender, ethnicity,
age or socioeconomic status
b. Recognize and manage conflict when patient values differ from their own
10. Confidentiality
a. Maintain patient confidentiality
b. Educate and hold others accountable for patient confidentiality
11. Recognize and address disparities in health care
a. Recognize that disparities exist in health care among populations and that they
may impact care of the patient
b. Embrace physicians’ role in assisting the public and policy makers in understanding
and addressing causes of disparity in disease and suffering
c. Advocates for appropriate allocation of limited health care resources.
Systems-Based Practice
1. Works effectively within multiple health delivery systems
a. Understand unique roles and services provided by local health care delivery systems
b. Manage and coordinate care and care transitions across multiple delivery systems, including
ambulatory, subacute, acute, rehabilitation, and skilled nursing.
c. Negotiate patient-centered care among multiple care providers.
2. Works effectively within an interprofessional team
a. Appreciate roles of a variety of health care providers, including, but not limited to, consultants,
therapists, nurses, home care workers, pharmacists, and social workers.
b. Work effectively as a member within the interprofessional team to ensure safe patient care.
c. Consider alternative solutions provided by other teammates
d. Demonstrate how to manage the team by utilizing the skills and coordinating the
activities of interprofessional team members.
3. Recognizes system error and advocates for system improvement
a. Recognize health system forces that increase the risk for error including barriers to optimal
28
patient care
b. Identify, reflect upon, and learn from critical incidents such as near misses and preventable
medical errors
c. Dialogue with care team members to identify risk for and prevention of medical error
d. Understand mechanisms for analysis and correction of systems errors
e. Demonstrate ability to understand and engage in a system level quality improvement
intervention.
f. Partner with other healthcare professionals to identify, propose improvement
opportunities within the system.
4. Identify forces that impact the cost of health care and advocates for cost-effective care
a. Reflect awareness of common socio-economic barriers that impact patient care.
b. Understand how cost-benefit analysis is applied to patient care (i.e. via principles of screening
tests and the development of clinical guidelines)
c. Identify the role of various health care stakeholders including providers, suppliers, financiers,
purchasers and consumers and their varied impact on the cost of and access to health care.
d. Understand coding and reimbursement principles
5. Practices cost-effective care
a. Identify costs for common diagnostic or therapeutic tests
b. Minimize unnecessary care including tests, procedures, therapies and ambulatory
or hospital encounters
c. Demonstrate the incorporation of cost-awareness principles into standard clinical judgments
and decision-making
d. Demonstrate the incorporation of cost-awareness principles into complex clinical
scenarios
29
ACADEMIC & PROFESSIONAL REQUIREMENTS FOR PROMOTION AND
GRADUATION FOR RESIDENTS IN FINAL YEARS OF TRAINING (R2-R3)
Responsibility
Scholarly Activity1
Resident Lecture
Grand Rounds
Journal Club
End of Life Reflective
Exercise2
Medical Error Reflective
Exercise3
RPRC
Mini-CEXs
Rotation Evaluations
Annual Program Evaluations
Procedures4
C1 Status5
Rotation Goals & Objectives
Signed (NI)
Attendance at Daily
Conferences6
Clinical Pathology/Autopsy
Conference
Johns Hopkins Modules
Requirement
2 (per R2 & R3)
1 (R2)
1 (R3)
1 (per R2 & R3)
1 (R2)
1 (R3)
1 (R2 or R3)
12 (per R2 & R3)
Monthly (R2 & R3)
Each Year (R2 &
R3)
See pages 8 & 9
Each Year (R2 &
R3)
For each block (per
R2 & R3)
Required both R2 &
R3
1 (R2 or R3)
27 (1 per rotation +
consults)
1
Scholarly Activity: [ACGME Requirement Ref: IV.B.2.] Clinical vignette or
Original Research.
2
End of Life Reflective Exercise: Please reference website or talk to COR or PD
for guidance.
3
Medical Error Reflective Exercise: Please reference website or talk to COR or
PD for guidance.
4
Procedures: Covered in detail in next section.
5
C1 Status: Professional requirement as a United States Naval Officer.
6
Attendance at Daily Conferences: Attendance is maintained on a sign-in sheet
at this time.
30
Squads
1. What are Squads?
The concept is simple. The residency is divided into 4 squads: Squad
One, Squad Two, Squad Three, and Squad Four. Each resident is
assigned to a squad with which they will remain during their tenure at
NMCP (with occasional exceptions due to the variable nature of GME2+
selection process and changes in continuity clinic requirements).
2. Why Squads?
Many academic hospitals have similar concepts calling them “firms” or
“services.” We’re in the military. It’s part of our unique identity and we
embrace it. Squad connotes the esprit de corps of cohesive military units
throughout our shared Naval and Marine Corps heritage and the capacity
of diverse groups of people to pull together persistently and consistently
under great duress in pursuit of a common purpose.
3. How does it work?
First year residents are assigned to a squad on arrival (with guidance from
the PD to try and make the squads balanced in aptitude). Ideally, they
remain in that squad until graduation, but re-alignment may be required
from year to year as circumstances dictate, especially as enter PGY2 year
to balance the squads. Each squad is responsible for manning a ward
team. Responsibility for other inpatient services (CCU, NFT) for the year
will be divided evenly among the squads. All word will be passed from the
COR to senior resident leadership and disseminated accordingly.
Resident leadership will be available for peer counseling and mentorship
and responsible for first-line remediation of struggling members. Squad
members will assume responsibility for various tasks within the squad to
be determined later such as monitoring of work hours, medical
documentation, training/career development, and scheduling, etc.
Ultimately, this should help prepare residents for staff-level responsibilities
and help to develop their leadership skills. The Squad concept is designed
to provide a netcentric infrastructure for further innovation and
development over time. The hope and expectation is that the roles of the
squads will expand within all aspects of the curriculum and enhance the
overall training experience.
4. Value Added:
a. Organization
Smaller functional units allow greater flexibility that can be utilized in all
phases of residency training. From applications in the patient-centered
medical home to small group learning sessions during academic day,
the organizational infrastructure offered by established squads is very
powerful.
b. Leadership
Upper level residents are accountable to those they lead. This fosters
greater personal responsibility and prepares them better for the roles
they will assume following graduation.
31
c. Ownership
All residents are stakeholders in the program. Their squad gives them
a tangible connection to the program. Shared experiences and friendly
squad competition will help foster a sense of identity.
d. Development/Retention
Residents have a more vested interest in developing members of their
squad and kindling their interest in Internal Medicine. Bigger squads
mean more flexibility with scheduling and less work for everyone.
Similarly, more capable squads mean less work and better patient
care. First years will also form more organic mentoring relationships
earlier in the year and feel a stronger connection to the IM department.
e. Peer Learning
Squads will have 4-5 residents who will share inpatient responsibilities
and discuss the service regularly with each other. This will foster a
collegial environment for peer learning and open communication
among the housestaff.
f. Continuity
The squad will provide an element of familiarity and comfort amid fast
paced schedules and long hours. It will provide continuity for the
residents, but also for the patients. Communication will be more open
and fluid in close-knit teams and this will improve patient care.
Resident afternoon block clinic will be scheduled on the same
afternoon as their interns, with a small set of preceptors dedicated to
that squad, minimizing the number of different providers each of their
empanelled patients and providing continuity of supervision and
feedback for interns and residents.
32
INTERNAL MEDICINE CLINIC
This is the opportunity to care for YOUR own patients and develop the other side
of an internist: outpatient care. Our colleagues, through the results of many
graduating resident surveys nationwide, suggest that training programs effect
great skills in inpatient/ hospitalist care but dismally prepare residents for the bulk
of their future practice in the office/ clinic arena. Thus, your training ground of
clinic participation and involvement, providing medical care to active duty and
retired sailors and their dependents, is essential to a successful career while in
the Navy and afterwards. As such, high priority is placed on professionalism in
scheduling, attendance, and follow-through via telephone consults. We hope that
this will be a challenging and rewarding experience for you.
CLINIC TEAMS: Patient Center Medical Home Port Teams
1. Each of the two teams will consist of 2-3 attendings, 5 PGY-1 residents
and 4-5 PGY-2 and PGY-3 residents.
2. The attendings of your team will be your point of contact when you have
questions regarding a patient outside of your normal clinic time and for all
telephone contacts.
3. The assigned clinic preceptor should be the person you first contact for
questions regarding management of patients seen at scheduled clinic
time.
OUR PATIENTS
Tricare Prime
Tricare Prime is the Navy’s “Managed Care” Program. Dependents of active
duty do not pay an enrollment fee, but retirees and their dependents (under the
age of 65) pay an annual enrollment fee ($460 for a family, $230 for an
individual). When individuals/families sign up for Tricare Prime, they are
assigned to a clinic and a primary care manager within that clinic. We are a
TRICARE Prime clinic site. Individuals/Families who are enrolled receive the
highest priority for appts. second only to active duty service members. If a
TRICARE Prime enrollee cannot be seen at NMCP, they are scheduled to see a
civilian physician for a minimal fee ($12). Beneficiaries over the age of 65 are
not eligible to sign up for TRICARE Prime. However, once they have completed
paperwork for both Medicare parts A and B, they are eligible for TRICARE FOR
LIFE, which supplements Medicare so that nearly all out-of-pocket costs are paid
when these patients see a civilian physician. We also receive consults from
other TRICARE Prime Clinic sites to see a patient. These patients should be
seen and once the initial question(s) addressed, referred back to their referring
TRICARE Prime Physician/Primary Care Manager.
33
TRICARE Service Center
This is also a contract service, but separate from TRICARE Prime. Most
appointments and consults to other departments are scheduled by this
scheduling service, regardless of whether the patient is active duty, TRICARE
prime or retiree over age 65. Our established patients make followup appts at
the front desk or the waiting room phone prior to leaving clinic. If appointments
are not yet available then the patient is instructed to call the service center at a
future date.
HOURS OF OPERATION
1. Monday – Friday 0800-1630: Corps staff and secretarial staff available to
service phone calls and appts.
2. Resident Clinic Basics
a. The clinic schedule is on the dffm54 server in the “Internal Medicine
Clinic” folder.
b. 0830-1200 and 1330-1630 are the scheduled hours of resident
clinics. Resident clinics will be structured in preset time intervals
from 0830-1130 and 1330-1600.
c. Should a physician require assistance beyond this time, there will
be a staff attending, RN, and corpsman available.
d. Clinic schedules and patient appointments are made 30-45 days (46 weeks) in advance. Any changes in your rotation schedule will
affect your clinic schedule; you MUST notify the clinic manager
as soon as possible of any and all changes. Leave and TAD
requests need to be routed through the Division Head (Dr. Hicks)
as soon as possible so that we can block or cancel your clinic as
necessary. Requests to cancel or reschedule clinics need to be
approved by the chief of residents and the clinic manager
e. There may be one "hold slot" at the end of the clinic. If you do not
use this spot for one of your patients, it may open up on the day of
your clinic and may be filled by the attending or at the discretion of
the RNs. This gives you some flexibility when trying to arrange
needed and prompt follow-up for unstable patients. Any of the
paraprofessional staff can help you book this hold slot.
3. Block Clinic: Clinics will be set in blocks of 2 weeks for the PGY2s and
PGY3s. PGY1 residents will still have clinic one afternoon a week.
During the 2 week block, residents will have 6 clinic sessions. Each year
there are 5 clinic blocks. If no clinic sessions are missed, each upper level
resident would see 120 clinics. During the PGY1 year most residents will
have at least 30 sessions. The RRC requires 130 sessions during
residency.
34
4. During the 4 sessions free of direct patient care, the resident will be
responsible for:
a. Personal and squad Quality and Process improvement projects
b. Chart audit or peer review
c. Administrative clinical tasks such as reviewing labs or Tcons
35
TELEPHONE CONSULTS
1. Your patients will call the clinic (953-2277) for medication refills and with
questions.
2. The support staff will take a message and place a phone consult to you in
AHLTA. Staff have been instructed not to give out physicians' pager
numbers or offer to page doctors for patients. If they feel a patient's
message is important they will check with the staff attending before paging
the doctor.
3. These telephone consults must be answered within 48 hours and should
be addressed by the next business day. If there is an emergency, the staff
will refer the patient to the emergency room or have the attending of the
day take the call.
4. All Telephone Consults must be designated for cosignature by your team
attending (see the team list on the first page). The attending physician is
responsible for every patient interaction, including those by telephone. It
is also an easy way to get some feedback on documentation, advice on
management and for the clinic.
5. If your patient is calling in for a medication renewal, the staff will give you
the drug, dose, and pharmacy where the patient wishes to pick up the
medicine. There is no need to call the patient back for medication
renewals unless the staff places such a instruction on the telephone
consult; simply fill the medicine to the appropriate pharmacy within onetwo days.
6. You must list a diagnosis for each telephone consult.
7. If you call a patient, generate a telephone consult yourself so that you get
credit for a visit as well as have documentation of the conversation.
Again, make sure that you designate these for cosignature by your
attending. The staff should not be asked to return phone calls.
8. Remember to designate a surrogate for telephone consults and lab results
when you are on leave or TAD.
9. There is no means within AHLTA for you to designate someone else as
your telephone consult surrogate. Instead it is the surrogate’s
responsibility to set their AHLTA Telephone Consults screen to display
pending consults for themselves and for the person for whom they are
covering.
1. On the Telephone Consults screen click “change selections” button,
then, under “providers” click on “selected providers” and choose the
resident who’s consults you’ll be checking. Until you change this
back, AHLTA will display this persons telephone consults each time
you log in.
10. Adequate documentation is essential with telephone consults! The
telephone consult is a medicolegal document and is considered part of the
medical record. Thus, informal or vague language describing the
information passed to patients is discouraged. Be sure to document the
following:
36
1. Appropriate background of the question or clinical complaint
2. Documentation of problem list (see below) or important underlying
medical problems
3. Adequate “screening” (example, for patient with dysuria, noting if
there is any back pain, fevers, rigors)
4. Appropriate management plan, including follow-up (i.e. follow up in
2 weeks at regularly scheduled appointment) and contingency (i.e.
if pain continues greater than 5 days to call the clinic again).
5. Please add the procedure code for telephone consult to each
telephone consult
37
Grand Rounds Assessment
Resident Name ________________________
Date _________________
Topic ________________________________
Approved by _________ PD _________COR
Instructions: Residents should provide a copy of this evaluation form to the
PD, COR, and selected faculty, such as a specialist in the area of the topic
covered (at least 2 of the 3 listed). Evaluators should check the boxes for tasks
completed or skills demonstrated in the left column AND for the level of
overall skill attained for each item in the right column. Specific comments
can be made in Elements and Skill Level boxes, as appropriate.
Elements
Skill level attained
Content of lecture:
□ appropriate focus on a
reasonable # of teaching points
□ depth of pathophysiology
appropriate to clinical
application, or is an important
review
Expertise
Proficiency
Competence
Advanced
Beginner
Novice
Delivery:
□ good eye contact
□ clarity, enunciation, volume
□ rate of speech appropriate for
volume of information
□ um’s, body language, etc.
Expertise
Proficiency
Competence
Advanced
Beginner
Novice
Effective use of audiovisual
aids:
□ slides in bullet format, vice
sentence/paragraph
□ appropriate # words on slides
□ tables and graphics
appropriate font size
□ slides used to augment
presentation, vice reading off
slides
□ slides used to emphasize
important points
□ uses references
appropriately—i.e. footnotes on
slides vice a reference slide
Expertise
Proficiency
Competence
Advanced
Beginner
Novice
Effective use of handout:
□ format focused on the teaching
points
□ not just a copy of slides
□ includes reference
Expertise
Proficiency
Competence
Advanced
Beginner
Novice
□ use of literature—i.e. original
literature, review articles,
use of text or UpToDate only
when appropriate
□ presentation reflects
understanding of the material
38
Resident Lecture Assessment
Resident Name _________________________________________ Date _________________
Topic ___________________________________________ Approved by _________ PD _________COR
Instructions: Residents should provide a copy of this evaluation form to the
PD, COR, and selected faculty, such as a specialist in the area of the topic
covered (at least 2 of the 3 listed). Evaluators should check the boxes for tasks
completed or skills demonstrated in the left column AND for the level of
overall skill attained for each item in the right column. Specific comments
can be made in Elements and Skill Level boxes, as appropriate.
Elements
Skill level attained
Content of lecture:
□ appropriate focus on a
reasonable # of teaching points
□ depth of pathophysiology
appropriate to clinical
application, or is an important
review
Expertise
Proficiency
Competence
Advanced
Beginner
Novice
Delivery:
□ good eye contact
□ clarity, enunciation, volume
□ rate of speech appropriate for
volume of information
□ um’s, body language, etc.
Expertise
Proficiency
Competence
Advanced
Beginner
Novice
Effective use of audiovisual
aids:
□ slides in bullet format, vice
sentence/paragraph
□ appropriate # words on slides
□ tables and graphics
appropriate font size
□ slides used to augment
presentation, vice reading off
slides
□ slides used to emphasize
important points
□ uses references
appropriately—i.e. footnotes on
slides vice a reference slide
Expertise
Proficiency
Competence
Advanced
Beginner
Novice
Effective use of handout:
□ format focused on the teaching
points
□ not just a copy of slides
□ includes reference
Expertise
Proficiency
Competence
Advanced
Beginner
Novice
□ use of literature—i.e. original
literature, review articles,
use
of text or UpToDate only when
appropriate
□ presentation reflects
understanding of the material
39
Resident Journal Club Evaluation
Resident Name ______________________________
Date_______________________
Topic_______________________________________________________________________
Approved by __________PD __________COR__________Squad Mentor
1) Did the resident meet with staff to review article and presentation prior to
scheduled journal club? YES NO
2) Did they use one of the accepted methods to review the article in a
systematic manner (Landry, Sackett, etc.)? YES NO
Comments:
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________
3) Was the methods section adequately evaluated?
Expertise Proficiency Competence Advanced Beginner Novice
Comments:
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________
4) Were the statistics adequately evaluated and explained?
Expertise Proficiency Competence Advanced Beginner Novice
Comments:
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________
5) Was a good argument made for or against the validity of the study?
Expertise Proficiency Competence Advanced Beginner Novice
Comments:
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________
6) Did the resident discuss whether the study would change their clinical
practice?
Expertise Proficiency Competence Advanced Beginner Novice
Comments:
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________
7) Final Grade:
PASS
FAIL
Comments:
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________
40
Rolling Admissions or “The Drip”
1. Quarterback (QB) responds to all consults and distributes them
sequentially to W1-3
2. Rotation is determined by consult received, not by admission,
meaning that discharges “count” for your team, and the next consult
will be given to the subsequent team. The caveat to this is that
each consult must be staffed with a full note written by the resident
regardless of disposition. This includes recommendations for
evaluation by another medicine service such as CCU or ICU.
The only exception is transfers that are deferred. In this instance,
the ward resident should inform the QB that the transfer was
deferred, and they will be returned to the queue.
3. The rotation continues at night and during the weekend with each
consult assigned to the appropriate team and discharges staffed
with that team’s attending.
41
THE WATCH (aka “Call”, for civilians)
In an attempt to give “standard of care” attention to each patient, meet the RRC
work-hour guidelines, and set an environment for maximal resident learning, the
inpatient medical service has undergone many watch schedule changes.
The COR will outline the current Watch Bill, aka Call Schedule and guidelines
and provide a copy on the DFFM54 drive. Any changes will be reviewed with all
residents and updated on the drive.
Setting the Watch
HOURS
MON-THU 1700-0600
FRI 1500-0600
SAT 0600-0600
SUN 0600-1700
SIGN-OUTS
1. Sign out will occur at the following times:
a. Weekday sign-out will occur at 1700 when the day inpatient
teams and IM consult service will sign out to the NFT and in the
morning at 0600 when the NFT will sign out to the day teams.
b. Weekend sign-out will occur at 0800 when the day inpatient
teams and IM consult service will sign out to the call team.
Pager turn-over will occur at 0600.
SHOW UP ON TIME !
2. Location: All weekday sign-outs will take place in the GME Conference
Room, and all weekend sign-outs will occur in the 4H Ward Room,
outside the entrance to ward 4H.
3. The entire NFT and all residents that are on IM wards, Oncology Ward,
CCU, consults are responsible for taking part in sign-out.
4. Residents are to sign out in the following order*:
AM
PM
0600
CCU
1700
IM Consults
0610
W1
1705
CCU
0615
W2
1710
W1
0620
W3
1715
W2
0625
IM Consults
1720
W3
* If an attending is covering sign-outs, he/she goes first.
42
Sign-Out (Standardized Form)
1. Be on time. You will go after all other teams if you are late.
2. Prior to sign out of patients, 3 sign-out sheets printed: 2 for interns and
one for SROC. You will not sign-out and will move to the end if you do not
have these.
3. Your junior/senior resident MUST be present to supervise. You will not
sign-out and will move to the end if they are not present (unless it is their
day off).
4. TEAM ___, STAFF ___, # IN SDU ____, ANY DNR/DNI ___
Patient sign-out TEMPLATE:
Patient ___ is a ___ year old male/female on __ (ward) __ w/ PMHx significant for
__ (only pertinent issues that led/contributed to current admission and significant comorbidities) __ who
presented on __ (date) __ for __ (admitting diagnosis/symptoms that led to admission or seeking
medical care) __.
Working diagnosis(es) is/(are) ____ and the current treatment plan is ______.
Hospital course is unremarkable/remarkable for __ (key events, sig labs, studies,
procedures, consults) __.
Pending labs/consults/studies for follow-up overnight include _____.
Further specific instructions for overnight issues include __ (pain, insomnia, n/v, fever,
BP, AMS, etc.) __.
Code status is FULL/DNR/DNI.
Questions?
Please use this template for consistency and standardization. Thank you.
43
Past COR Messages
June 2012
The excitement of the new academic year is upon us! We have had growth and development in many aspects of the
program over the last two years, and now is the time to solidify the recent changes by operationalizing them. As we move
forward, smart adjustments will be made to improve the process, but the basic “powerful changes” that were made will be
the foundation for things to come. This manual has been rewritten to set the tone for clear expectations on policies and
procedures of the program. Great things are on our horizon, and we will all work together toward a successful and
rewarding year!
Kristina Kratovil, Chief of Residents 2012-2013
June 2011
The new year again brings a myriad of challenges and opportunities for growth in our residency program. We will continue
to develop our Night Float system and implement the newest RRC guidelines for resident work hours. The most significant
projects for this year will be the new ambulatory curriculum and block clinic schedule, the continued evolution of a rolling
admissions cycle (“the drip”), and reorganization into resident-led squads. Hopefully, these basic but powerful changes
will provide a structure for further innovation and well-rounded training for the residents both this year and beyond. I know
that your enthusiasm, curiosity, and compassion will push us all to do great things this year.
Daniel Bowers, Chief of Residents 2011-2012
Program Director Introduction
Usually there is no PD Intro, but as this is my last year as PD, I am taking the liberty. I wish I could write something
incredibly wise and eloquent based on my long experience. But, instead what I will say is READ THIS MANUAL. It will
help ground your expectations of your training, and your understanding of the program’s expectations for your training. If
you see something inconsistent with what you were told or that you don’t understand, ASK. Help make the document
something that will work for you to make your residency training the most fulfilling experience of your career.
Lisa Inouye, MD MPH, FACP; CAPT MC, Program Director 1999-2011.
June 2010
If you read the comments of my predecessors below, you’ll note the recurring theme of change; this program has, and will
continue to evolve each year it exists. This year we’re hoping for both significant system and cultural changes in the
program- neither of which will be a small task, but both of which I think we can accomplish by working together as a
TEAM. We will (re)institute a Nightfloat system, (re)expand to a 4-GIM-team system, and our R3s will become permanent
rotators in the SNG ICU. This will bring with it a new format to morning report, and a blurring of the previously welldemarcated, physical and professional lines between “intern” and “resident”. We will emphasize strict adherence to our
ideals of professionalism and patient care as general internists, and we’ll try to have some fun while doing it!
Justin Lafreniere, Chief of Residents 2010-2011
June 2009
The Naval Medical Center Portsmouth (NMCP) resident manual outlining responsibilities, goals, objectives has been the
foundation of this program for the last 15 years. The updates made in the 09-10 manual reflect new challenges and new
goals our program is aiming to achieve to help to build on our residency program. My goal is to build on a program by
strengthening our core competencies. This years program is highlighted by resident as teacher program, ambulatory clinic
rotation lecture, and increase emphasis of critical appraisal of primary literature.
I am looking forward to working with you to accomplish these goals, and have a successful year.
Eric Yeung, Chief of Residents 2009-2010
June 2008
With the dawning of a new academic year comes new responsibilities, goals, and objectives. This manual is a resource
that has been produced and amended time and again to help you succeed in each of your academic, military, and clinical
endeavors. Looking through these pages, you will notice some substantial changes in the way we function as a team.
Together, we enter this new era of change, highlighted by the recent reduction to a three ward team system, a revamped
call schedule, new RRC guidelines and regulations, and increasing degrees of documentation in electronic medical
records – all in a time of strict work hour regulations and decreased staff and resident manning. Do not be discouraged
by these challenges – use them to build strength in character. Together we can succeed.
Tod Morris, Chief of Residents 2008-2009
June 2007
In our ongoing attempt to adapt the residency to the strains of work-hour restrictions and staff deployments, as well as our
continued ambitions to improve the clinical and academic experience of the house staff, many aspects of the the
residency, and in turn, the resident manual, have undergone revision. These include the change to a two-resident call
system and elimination of the night float, the addition of a dedicated oncology ward team, the movement of all staff
lectures to Thursday afternoons for a dedicated ½ day of academics and the addition of a 3rd year ICU rotation. Please
use this manual as a roadmap to help navigate these changes and as a starting point for refining the program even
further.
David Furman, Chief of Residents 2007-2008
June 2006
44
This year signals new changes in the curriculum which hold great promise for even better training. There is a
restructuring of Geriatrics and Ambulatory Medicine. Perhaps the most exciting is the creation of a standing HematologyOncology Ward Team. In the past this manual has helped to provide guidance during the ever-changing circumstances of
residency. My goal was to make clear the expectations for the residents in regard to individual rotation goals as well as
the overall goals of the program. My hope is that you will find this manual informative and user-friendly while at the same
time using it to maximize your experience as a resident.
James Fletcher, Chief of Residents 2006-2007
June 2005
As you can see, this manual has had many contributors and even more changes through the years. My hope was to make
this patchwork quilt user-friendly for you, both concise and organized, while updating nearly every section. Make sure you
review the presentation expectations, watch responsibilities (again!), admissions, dictation access, and board procedure
sections, which have had greater upheaval.
Karen Bullock, Chief of Residents 2005-2006
June 2004
Several additions and clarifications have been included in this year’s manual. Clarification of the expectations for morning
report, changes to the on-call responsibilities due to the use of the float system, required patient safety information, RRC
requirements, policy for leave, due process, and the impaired resident have been included. You will find that the residency
is always changing. I have tried to answer questions here instead of dictate policy. I hope this will assist you during this
year.
Anthony Nations, Chief of Residents 2004-2005
June 2003
The call system is still in flux as we attempt to find the system which works best for us and complies with the new RRC
regulations. I have left some of the details of the system out, as it is still subject to change, but the basic roles of the
various on-call designations are described. Other changes in the manual include some modifications of the morning
report format, the addition of senior board review and intern morning report, changes in the Journal Club format, and
some notes on professionalism.
Ben Fischer, Chief of Residents 2003-2004
June 2002
This year includes the new “away” rotations offered at DePaul Hospital as well as the Washington Hospital Center. There
are also some changes in the requirements for Grand Rounds, as well as some clarification of paperwork responsibilities.
I hope that this year’s edition clears up some confusion and will answer more “nuts and bolts” questions.
Dan Rakowski, Chief of Residents 2002-2003
June 2001
In this year’s manual we included the program requirements for graduation (#’s of procedures, etc), a summary of
ancillary clinics the internal medicine clinic offers, as well as subtle changes in the morning report and journal club
formats. I hope this serves as a useful resource even as the NMCP continues to evolve.
Daniel Seidensticker, Chief of Residents 2001-2002
June 2000
Since moving into Charette, the normal routine of patient care has changed in many ways. I have updated the manual
based on observations over the past year. Parts have been rearranged and, at times, rewritten for better flow. New items
include the Observation Unit and closed ICU. I hope this manual continues to be a valuable resource.
Art Pemberton, Chief of Residents 2000-2001
June 1999
Now that we have moved into the Charette Medical Center, I have made the appropriate changes in the resident manual.
This manual served as wonderful resource for me during my residency, and I hope it serves in the same capacity for you.
Meg Perusse Oberman, Chief of Residents 1999-2000
June 1997
Enclosed you will find a revised resident manual. Hopefully this will assist you with your transition to PGY-2 and 3
residents. Notable changes are increases in the NAR hours, morning report, intern night float and resident academic
responsibilities.
Richard Scranton, Chief of Residents 1997-1998
May 1996
This manual is intended to cover the theory as well as the “nuts and bolts” of our residency program. I hope that it will
serve as a valuable resource for you this upcoming year. This update will cover some of the changes necessitated by the
NAR, etc. As above, any suggestions for improving this manual for future years are appreciated.
Kevin Sumption, Chief of Residents 1996-1997
May 1995
45
This resident’s manual was developed by Lisa Inouye, Chief Resident 1993-1994. It has served as an incredible resource
for many of us throughout the year. With Lisa’s permission, I have updated a few items and added some others.
Hopefully, we have covered the major resident responsibilities and guidelines for clinics/lectures/call etc. Any suggestions
you have for future years’ manual, just let me know.
Margaret MacKrell Gaglione, Chief of Residents 1995-1996
June 1994
The Naval Hospital has had an intern orientation (lasting for 2 weeks before actually starting internship) for years. To my
knowledge, however, the Internal Medicine department has not had a formal RESIDENT orientation for the “new” junior
and senior residents. This would imply that it is not a big deal to progress from the intern level to junior resident, or from
junior to senior resident. Although it may not involve as much anxiety as going from 4th year medical student to
“physician”, there are still many new responsibilities and expectations, which can generate anxiety initially, and
consternation later when told that you’re not living up to standards which weren’t clear to you. While by no means allinclusive, this manual will hopefully be a resource for you as you enter the next level of training in Internal Medicine. The
orientation will cover much of what is written, but I recommend perusing each page at least once. I’ve included as much
as I can remember about each subject in terms of “most commonly asked questions/points of confusion”, and much of the
material is included because you asked for it on the survey distributed earlier this year.
Lisa Inouye, Chief Resident 1993-1994
46