Resident Training Program
The education and clinical training of Internal Medicine residents is a central focus in the Department of Medicine. We provide comprehensive training in general internal medicine for all residents seeking career in a subspecialty fellowship, primary care and hospital medicine.
Combined training programs in Medicine-Pediatrics and Internal Medicine-Emergency Medicine (including a 6th year for EMIM-Critical Care certification) offer unique opportunities to individuals interested in dual or triple certification. Preliminary interns participate in a curriculum similar to the categorical interns and develop a solid clinical base in internal medicine before entering their specialty residency.
The broad and flexible curriculum allows residents to put together a well-rounded program suitable for their individual educational needs. Residents participate in a comprehensive core curriculum that emphasizes the breadth and depth of internal medicine and a series of electives that allow them to explore areas of clinical and research interest.
Goals of the Residency Education Program
The curriculum is based on three objectives. Residents will:
- Learn the principles and knowledge necessary for the practice of general internal medicine balanced with a comprehensive exposure to the medical subspecialties.
- Gain this clinical knowledge in diverse ambulatory and inpatient settings by caring for patients with a variety of illnesses and from many socioeconomic backgrounds.
- Receive a balanced exposure to patients with acute or life threatening illnesses and to those with chronic or subacute problems.
To meet these goals, residents gain clinical experience at three teaching hospitals and numerous ambulatory sites. Residency training is conducted at the University of Maryland Medical Center, at the modern and adjacent Veterans Affairs Medical Center, and at Mercy Medical Center -- a private community hospital within five minutes from University Center. Training in ambulatory care takes place at these sites as well as in clinics and private practices in Baltimore City and surrounding counties. Residents may also choose to do rotations at Area Health Education Centers (AHEC) in rural Western Maryland and on Maryland's Eastern Shore.
Our Career Pathways for fellowships, primary care, hospital medicine and global health provide our residents with both individual and group mentoring, workshops and seminars to help them reach their career goals.
Balance of Rotations and Curriculum
During the three year program, residents spend one-third or more of their time in ambulatory rotations, including a continuity medical clinic, Ambulatory Block Rotations, and rotations in the Faculty Practice Offices, emergency room, walk-in clinics and subspecialty clinics. Throughout their training, residents build their continuity panel and their relationships with their patients using a schedule that affords residents concentrated time to focus on their inpatient duties and dedicated time for their continuity practice.
Residents spend approximately half their time on inpatient rotations, including general medicine units, subspecialty services (e.g., cardiology, infectious diseases, and oncology), medical and cardiac intensive care units, the medical consultation service and night/day floats. The rotation schedule is carefully arranged so that each resident has exposure to general medicine, subspecialties, clinical floors and intensive care units, while not allowing any one area to dominate. The remainder of their time is spent on clinical or research electives, including 2.5 electives in the intern year. A summary of the clinical rotations by year of training can be found in Curriculum in Internal Medicine.
Mentoring and Career Pathways
A comprehensive mentoring program is an important component of our residency. Along with our FOUR CAREER PATHWAYS residents are paired with faculty with similar interests who guide residents as they develop and solidify their career goals. The Pathways provide guidelines for electives and inpatient rotations, along with a series of workshops on various topics. Workshops include how to apply for fellowships, the fellowship interview process, creating your CV, securing a primary care or hospitalist position, among others. Faculty enthusiastically welcome residents to engage in research and take an active role in ensuring residents achieve success -- whether that is securing a subspecialty fellowship, primary care job or hospitalist position.
Residents adjust their curricula based on their career goals. Residents planning a SUBSPECIALTY FELLOWSHIP are strongly encouraged to engage in either clinical or basic science research. Residents receive close mentoring by faculty who have diverse clinical and basic science interests and provide abundant opportunities for residents to do investigative work. The Department provides financial support for residents whose research is accepted for presentation at regional or national meetings. The spring meeting of the Maryland Chapter of the American College of Physicians is an annual showcase of the residents' research and clinical case reports. At each year's May meeting, over 45 residents present their research or clinical vignettes. Several workshops are held throughout the year where residents learn principles of research design, IRB submission and basic statistics, and process workshops on strategies for applying to fellowships, creating an academic CV, and having a successful fellowship interview. As a measure of their success, our residents have a high level of scholarly productivity with abstract presentations at national meetings and peer-reviewed publications.
For those planning a CAREER IN PRIMARY CARE, residents are encouraged to take rotations in geriatrics, women's health, sports medicine, neurology, endocrinology or rheumatology. To allow residents to work alongside general medicine faculty in a private practice setting, their continuity practice is at the Faculty Practice Offices. Residents also spend time in private practices in the community where they experience "real life" primary care and reach a deeper understanding of the business of medicine. Regardless of career choice, our residents are encouraged to seek a broad curriculum in ambulatory medicine from the many choices available. In addition, there are three dedicated primary conferences each week -- The Ambulatory Care Seminars, Friday's Primary Care Morning Report, and the noontime Clinic Conference based on the Yale Curriculum. These venues provide important learning opportunities in primary care.
For residents seeking a CAREER IN HOSPITAL MEDICINE, we offer an expanded curriculum in Patient Safety and Quality Improvement (PSQI), including the IHI modules (through the Institute for Healthcare Improvement), longitudinal individual and group projects, and conferences on PSQI principles. Whether residents will be hospitalists as a life-long career or only for a year or two as they transition to a private practice or subspecialty fellowship, they benefit from these offerings. They are encouraged to take electives that emphasize inpatient medicine, such as general medical consultation, cardiology, infectious diseases, GI and pulmonary medicine. We also offer an Elective in Hospitalist Medicine that exposes residents to medical consultation, quality assurance, utilization management, hospital administration and finance, and delivery of evidence based care in the inpatient setting. Our extensive curriculum in Patient Safety and Quality Improvement (PSQI) and under the guidance of our academic hospitalists and dedicated PSQI chief resident is incorporated into our Morbidity and Mortality Conference, core curriculum and ongoing clinical QI projects. Residents participate in these projects as part of their assigned rotations and practice based learning exercises, thus developing skills useful in their future clinical careers in any setting.
The 4th career pathway in INTERNATIONAL HEALTH affords residents the opportunity to attend lectures and conferences in other departments and institutes on campus, including the Institute for Human Virology and the Center for Vaccine Development. They focus their Journal Club presentations and Senior Talks on international health, choose research projects that are germane to international or global health, can participate in international rotations under the direct supervision of School of Medicine faculty. In the recent past, residents have traveled to Haiti, Geneva, Kenya, Guyana, and India among numerous others. Limited funds are available through a special endowment to support resident travel abroad.
We are deeply committed to residency reform, ensuring that residents work and learn in an environment with ample support services and with a minimum of stress. Our enormous efforts to realize these goals have resulted in a wonderful morale among our residents and an outstanding review from the RRC with a full 11-year accreditation from the RRC -- their highest level! We work diligently to be compliant with all ACGME Duty Hour Requirements. With implementation of the July 2011 ACGME Duty Hour Requirements, we underwent major restructuring of our rotations to ensure full compliance, optimal patient safety, and positive resident morale. The GME leadership at UMMC has been phenomenally supportive of our residents, including funding for additional residency positions, hospitalists, moonlighting shifts, and ancillary support. They are fully aligned with our educational mission and those of the ACGME. These changes have had a very positive for our residents and maintain our high standards for residency education.
We are part of the national iCOMPARE trial and are randomized into the intervention (or FLEX) arm of the study. For 2015-2017, the only change we made was for interns to do every 4th overnight call in the MICU and CCU at UMMC (28 hour shifts, rather than 16 hour shifts). The remainder of our curriculum schedule including night float, day float, team call and all rotations at the VA and Mercy Medical Center are unchanged. In actual fact, right now our schedule is IDENTICAL to what it was about 4 years ago before the 16-hour rule was implemented for interns. In general, residents are pleased with this schedule noting that it enhances continuity, less patient turn-over, more even work and rest schedules, and improved resident satisfaction in our UMMC ICU's during the iCOMPARE trial. We are awaiting the opinion from the ACGME as to whether this schedule will continue in July 2017.
- At the University of Maryland Medical Center and the VA, we have 4 fully staffed general medicine teams (1 senior resident + 2 interns) in a team call structure. A Day Float resident at both sites helps the teams complete their work in a timely fashion.
- We have a Team Call System for the general medicine at UMMC and the VA with the Night Team arriving at 9 PM, and the long call team taking their last admission at 6 PM. We have "drip method" where admissions are limited from 4-6 PM to ensure teams are able to finish all their work before the end of their shift. A Night Team covers 7 nights/week at both sites taking admissions and providing cross-coverage for the teaching service. Hence, no interns or residents on any of the general medicine teams or on Med-ID stay overnight.
- The team attending is the physician of record for all patients on all services. Hence, private practitioners and consultants may admit to our services, but the team attending, resident and intern assume primary responsibility for the patient.
- Patient coverage in the ICU's is done by a combination of residents, hospitalists and intensivists. At UMMC, an intensivist is present in the MICU 24/7/365. In the MICU at night, the intensivist and pulm-critical care fellow work with the senior resident and intern in admitting and cross-covering patients. In the CCU, the senior resident and intern admit and cross cover the patients at night, with a cardiology fellow available for immediate assistance if needed. As part of the iCOMPARE trial, interns and residents in both the MICU and CCU at UMMC take overnight call every 4th night for 28 hours. This schedule allows interns to be involved in acute admissions and cross cover issues at night and provides a robust educational experience. At the VA, the MICU and CCU services are covered at night by the ICU resident doing a 28-hour overnight shift and interns on a night float rotation. ICU interns do not stay overnight. The on-call grids are quite complex -- but ensure we meet all educational objectives, provide appropriate supervision and transitions of care, meet patient safety standards, and comply with all ACGME Duty Hour Requirements.
- ICU and Cancer Center rotations that have overnight call are structured so that the residents leave within 28 hours after arrival the previous day. Only a handful of interns are assigned to the Cancer Center and do not stay overnight when on-call.
- Call on all services at all sites - including floor teams and ICU's at all sites - is every fourth night.
- We track resident duty hours through a self-reporting method to ensure compliance with all RRC Duty Hour Requirements.
- Interns are strictly capped at 5 admissions per long call or night float shift. Upper level residents are capped at 10 supervisory admissions per night.
- Interdisciplinary teams and discharge planners facilitate patient care. Broad ancillary services and a comprehensive computer system help to make patient care efficient and effective. The widespread application of Wi-Fi technology has assisted residents in accessing and entering orders on their patients while "they're on the move."
- UMMC, the VA and Mercy Medical Center have full electronic medical records, with EPIC at UMMC and CPRS at the VA.
- We have numerous non-teaching services that ensure we meet all ACGME rules while providing our residents with the best possible clinical training. Our patient volumes at UMMC have been easily absorbed by these non-teaching services. Currently, we have non-teaching services for general medicine, step-down intermediate care unit (IMC), oncology, renal transplant services and bone marrow transplant unit.
All these components ensure that the service needs of the hospital do not diminish our primary mission - the education of our medical residents.
Wellness in Residency Training
We are committed to ensuring residents have a balance between their training and their personal life. We have partnered with the Center for Integrative Medicine to have a monthly series on wellness topics, such as nutrition, stress management, exercise, meditation, chair yoga and fatigue management. The visit with adorable and cuddly service dogs was the highlight of the year and a real favorite. To help residents find time for doctor's appointments, errands and other personal issues, they have four personal 1/2-days off (in addition to regularly scheduled days off and vacation time). UMMC has a special program called RISE - Resilience in Stressful Events - to help teams and individual residents cope with adverse patient events.
Our Social Committee schedules a variety of events for the residents, including baseball games (Go O's!), happy hours and recreational sports. The GME Office orchestrates events through the Housestaff Association with four big events throughout the year. The highlight of the year is the annual Valentine's Day Ball at the B&O Museum.
Leadership and Teaching Skills
The development of leadership and teaching skills is an important part of residency training. Throughout their rotations, residents develop the necessary skills to be clinical supervisors and teachers of the medical teams. By taking on progressive responsibilities, residents become comfortable dealing with a wide variety of clinical situations, including patient care, interpersonal situations and teaching. Residents attend an annual educational retreat where they improve their skills in giving feedback, teaching in small groups, specific teaching skills for medical students, managing conflict, and team building. These themes are also stressed in the outpatient setting where residents are the primary care providers for their panel of patients. We also have an educational retreat for the new interns during their orientation time, where they enhance their basic skills and explore principles of life-long learning, management daily patient care, importance of interns as student teachers, and professionalism. A second intern retreat in October helps to solidify their skills and give them an evening social event to connect with their friends and colleagues. A best resident-teacher award is given to a senior resident each year -- reaffirming the importance placed on excellence in teaching as part of each resident's core responsibilities. Our residents consistently receive the majority of the teaching awards given by the students, including AOA Honor Society and the Gold Humanism Honor Society.
Resident Evaluation and Curriculum Development
Ongoing communication between the residents and the faculty is highly valued and is considered critical to our success. We have developed a comprehensive curriculum using competency-based objectives and evaluations. Our web-based evaluation system (E*Value) provides continuous feedback for residents, attendings and the program director. Residents are evaluated every month on their milestone achievements by the attendings and receive an immediate email that they have an evaluation ready for viewing. Similarly, residents evaluate attending teaching abilities and the educational value of the rotations every month, providing real-time feedback to the education leadership. A highly successful Peer Evaluation System allows residents to evaluate their interns and for interns to evaluate their supervising residents. Nurses in the continuity clinics also assess residents' skills. Students evaluate residents on their clinical, teaching and leadership skills, and the residents provide very valuable evaluations of their third and fourth year medical students. This comprehensive multi-source feedback system ensures that residents are continually striving to improve their skills in a positive and nurturing environment. Residents meet with Dr. Wolfsthal in a formal semi-annual feedback session where we review the resident's clinical performance, career interests, and educational goals for the coming year. Through the Postgraduate Education Committee, resident representatives from each class review feedback about the program and rotations, and contribute to the educational process. An Annual Needs Assessment gives residents another way to evaluate the overall residency and its components. Residents and faculty from all the divisions actively participate in this review process to continuously improve the curriculum and meet the needs of our residents.
A wide variety of conferences is held throughout the week -- each with a different format and purpose - and provides residents with diverse learning environments. A highlight of each day is Morning Report, which also includes the Ambulatory Core Curriculum and Senior Resident Conferences. Delivered by expert faculty, our Core Conference Curriculum ensures residents have comprehensive exposure to the entirety of internal medicine. Workshops in Procedures, Ultrasound and Simulations are held through the year, providing residents a protected environment to improve their procedural and ACLS skills. Our Resident Research Forum provides a venue for residents to present their ongoing research to their peers and faculty. Medical Grand Rounds is the premier didactic conference of the week. Other conferences include the Clinicopathologic Conference (CPC), Ambulatory Care Seminars, and Board Review. Journal Club includes a comprehensive epidemiology and evidence-based medicine curriculum. Along with our Patient Safety and Quality Improvement curriculum, our Morbidity, Mortality and Improvement Conference includes a comprehensive curriculum in patient safety and quality improvement. The Acute Medicine Series is held early in the year to provide residents with a foundation for the evaluations and management of acute illnesses. The Ethics Seminars are held throughout the year. Residents are also welcome to attend any of the weekly subspecialty conferences. Please see Curriculum in Internal Medicine for more information about our conferences.
Residents have on-line access to all our major conferences through our web site - username = UMMC, password = applicant. You are welcome to view our lecture series. It is a marvelous compendium for our residents and provides a valuable educational resource throughout the year.