Internal Medicine – Curriculum

Resident Rotations

There are 13 four-week long rotations each year. R1s start one week before seniors, so there is always continuity of patient care on the services.

Days off are always on weekends, even for interns.

R1 Rotations

How many? Name of Rotation # of Days/Wk
4 General House staff 6 days/wk
1 In-pt Cardiology 5 days/wk
1 Medical ICU 6 day/wk
1 Night Float-Medical ICU 5 nights/wk
1 Sub-Specialty Elective 5 days/wk
1 Emergency Medicine
20 shifts/rotation
1 Night Float 5 nights/wk
1 Ambulatory (continuity clinic) 5 days/wk
½ – 1 Out-pt Dermatology 5 days/wk
1 – 1 ½ Electives
(examples: out-pt neuro, ENT, Ophtho, GYN, Radiology, PM&R)
5 days/wk
On-going Continuity Clinic ½ day/week

R2 Rotations

How many? Name of Rotation # of Days/Wk
1 ½ General House staff 6 days/wk
1 Hospitalist Consult Service 5 days/wk
1 Medical ICU 6 day/wk
1 Out-pt Cardiology 5 days/wk
1 In-pt Neurology 5 days/wk
½ In-pt Psychiatry Consult Service 5 days/wk
1 Night Float 5 nights/wk
1 Ambulatory (continuity clinic) 5 days/wk
½ Out-pt clinic with community internist 5 days/wk
1 Endocrinology 5 days/wk
1 Infectious Disease 5 days/wk
1 Geriatrics 5 days/wk
½ Systems of Medicine 5 days/wk
1 ½ Electives
(examples: out-pt neuro, ENT, Ophtho, GYN, Radiology, PM&R, Palliative Care)
5 days/wk
On-going Continuity Clinic 1 day/wk

R3 Rotations

How many? Name of Rotation # of Days/Wk
2 General House staff 6 days/wk
1 DMC in-pt Pulm 6 days/wk
1 Medical ICU 6 day/wk
1 In-pt Cardiology 5 days/wk
1 Hospitalist Service
Shifts modeling hospitalist schedule
1 Night Float 5 nights/wk
1 Ambulatory (continuity clinic) 5 days/wk
1 Nephrology Consult 5 days/wk
1 Hematology/Oncology 5 days/wk
1 Out-pt Pulmonology 5 days/wk
1 Out-pt Rheumatology 5 days/wk
1 Electives
(examples: out-pt neuro, ENT, Ophtho, GYN, Radiology, PM&R, Palliative Care)
5 days/wk
On going Continuity Clinic 1 day/wk

Resident Call

We utilize four-week block rotations of Night Float. Residents assigned to this rotation work Sunday through Thursday 1730 to 0700. One senior and two interns provide continuity coverage for housestaff patients as well as admit new patients.

Friday and Saturday nights are covered by residents on rotations such as electives or ambulatory. Interns generally have 4 weekends of call scattered throughout the year, R2s generally have 3 weekends, and R3s have 2 weekends.

There are significant advantages to the Night Float system:

  • The resident concentrates 20 nights of call (in many programs these are scattered throughout an academic year) into a single block without having daytime responsibilities
  • Continuity of patient care improves by having the night float team familiar with housestaff patients for the month and participating in twice daily transitions of care sign-out.
R1 R2 R3
Night float 4 weeks 4 weeks 1-2 weeks
ICU night float
4 weeks n/a n/a

M & M

Reviewing case management for both outpatient and inpatient care provides an important learning opportunity for all physicians. Residents and faculty present a case, then assist in dissection of decisions made. This opportunity for reflection establishes a life-long skill that all physicians need to continually critique patient care.

ITE question review

Senior residents choose questions from a bank of frequently missed In-Training exam questions. They model how to read and analyze a test questions and provide background information needed to dissect that test question and lead “the team” to the correct answer.

Journal Club (monthly)

Under the guidance of a faculty member, residents will perform and present critical appraisal of a journal article. Journal club has 2 objectives: First, to stay current with the latest evidence-based clinical information relevant to general internal medicine. Second, learn the basics of biostatistics, understand the methodology of clinical trials and accurately interpret applicability of research to your practice.

Noon Conferences

Our noon conference teaching is based on a 3-year rolling curriculum that covers a broad range of internal medicine topics. Typically these lectures are given by invited guest speakers, residents, attendings and subspecialists within the medical community. Lectures are broadcast to other clinical sites.

Acute Care Conference Series

Lectures take place during the first 3 months of the academic year. These case-based lectures are designed to help interns recognize/manage common emergent situations in internal medicine.

EXAMPLES:

  • Calls in the middle of the night Part 1 of 3 (pain, fever, confusion)
  • Informed consent/decisional making capacity/POLST
  • Recognition and management of arrhythmias
Diabetes Workshop at Noon Conference

Physical Exam conference (monthly)

We are dedicated to promoting a culture of bedside medicine. Similar to the Stanford 25 curriculum, the residents and medical students present/demonstrate common physical exam maneuvers and discuss its significance in disease process. Examples:

  • Gait abnormalities
  • Pulsus Paradoxus
  • Pleural effusion

Case Presentations (twice/week)

Case presentations are case-based discussions led by attending physicians and senior residents with a focus on clinical reasoning, generating differential diagnoses and evidence-based-management. A 15-minute ”clinical pearl” is usually presented prior to each case presentation.

Medicine Grand Rounds/Osler Rounds (monthly)

Senior residents, as part of scholarly activity, are required to present an in-depth discussion on clinical manifestation, diagnostics and therapeutic management of a disease process in internal medicine.

Other lecture series include Humanities and High Value Care.

Ultrasound

Ultrasound workshop/Longitudinal Bedside Point-of-care Ultrasound curriculum: The introductory workshop takes place in the R1 year. In addition to the bedside POCUS curriculum, senior residents have opportunities to attend conferences and preset at regional/national POCUS workshops with faculty mentorship from our POCUS director, Dr. Kang Zhang.

Procedures

IMRS residents perform many procedures, usually with ultrasound guidance. Residents do not compete with fellows for the experience.

Residents generally obtain at least 20 central lines (although several residents have numbers in the hundreds). Other common procedures include arterial lines, paracentesis, thoracentesis and dialysis catheter placement.

    LV Function Assessment

    “In my first year, I had over 90 procedures including central lines, arterial lines, chest tubes, paracenteses, thoracenteses and lumbar puctures.”

    Vanessa Hoytfox

    Class of 2022

    HIV Clinic

    Spokane Internal Medicine Residency prepares residents for future practice in managing HIV and related diseases by having residents participate in a developed, integrated HIV curriculum where people living with HIV are followed by residents as their primary care provider in the resident continuity clinic.  During each ambulatory block, residents will get 1:1 teaching with faculty who are HIV specialists on how to manage HIV patients in the outpatient setting while seeing patients in our HIV walk-in clinic.  Residents will have access to the UW National HIV Curriculum and the opportunity to discuss cases with UW HIV ECHO one afternoon per week.  No matter the setting of their future practice, we train graduating residents to provide high-quality medical care to persons currently living with HIV.

     

    Hepatitis C Clinic

    The Hepatitis C clinic is a collaborative opportunity for both Internal Medicine and Family Medicine residents. Residents learn to evaluate referred patients with chronic Hepatitis C and to prepare them for treatment with new direct acting antiviral medications. The clinic works closely with pharmacy residents and faculty in the outpatient pharmacy clinic at Providence Sacred Heart Medical Center, enabling a maximum amount of learning with a minimum of paperwork as residents follow patients throughout the treatment process.

    Scholarly Activity

    Scholarly activity is obtained in a variety of ways – from a QI Matrix to original research and everything in between. Residents are encouraged to submit their work for publication and/or presentation at local, regional and national meetings.

    Collaborative QI

    Residents from FMRS, IMRS, TY and Psychiatry are divided into inter-residency groups. They identify a patient safety issue from any patient care setting and perform a root cause analysis which they then present to the hospital’s QI leadership.  Senior residents continue in these groups to complete a PDSA cycle the following year.

    Additional Scholarship is showcased in local, regional and national events.

    Local

    Northwest Medical Research Symposium

    This Symposium highlights the work of all of the Spokane residents. Abstracts are submitted and 9-12 selected for oral presentation. Posters are also prepared for this meeting. Both the oral and poster winners in this judged competition are awarded cash prizes.

    SCMS

    The Spokane County Medical Society hosts an annual CME event where at least one IMRS resident presents an abstract.

    SSIM

    The Spokane Society of Internal Medicine (SSIM) partners with Washington ACP to host a local poster competition for IM residents.  

     

    REGIONAL

    ACP

    The Washington chapter of ACP (American College of Physicians) sponsors a competition for residents of the four Internal Medicine training programs in the state. Each IMRS senior resident prepares an abstract about an interesting case or a research project. The abstracts are judged and several are chosen for oral presentation at the Regional ACP meeting. The presentation winner gets an all-expense paid trip trip to National ACP for presentation. Spokane was the winner of the 2020 competition! In addition, residents can submit posters of their work.

    The state chapter also hosts a Spring Scientific meeting for presentation of QI/research/works-in-progress.

    SGIM

    Society of General Internal Medicine has both a regional and national meeting for residents where oral and poster presentations are given. Generally, Spokane has several residents who participate.

    NATIONAL

    Each year our residents present abstracts at national meetings.

    RESEARCH

    Residents at all levels have the opportunity to collaborate with faculty on projects. Several projects are completely clinical – examples include revision of DKA protocols in the ICU, Sepsis project utilizing ProCalcitonin and Hypothermia research. Other projects proceed along a more traditional research pathway.

    Advocacy

    Residents are encouraged to advocate politically for their profession and for their patients. A resident is a member of the Spokane County Medical Society board and opportunities exist for board participation in the Washington State Medical Association. In addition, IMRS residents annually participate in the ACP Leadership Day in Washington, D.C.

      Certifying Board Examination

      Our three year average board exam pass rate is 93%, which is higher than the national average. A few of the methods we use to help residents prepare include:

      • Special mentorship opportunities are available to assist residents in board preparation
      • ITE (in-training exam) Noon conferences dissect the most frequently missed questions on the annual practice board exam.
      • Residents often choose to host board review sessions in the evenings with food and beverages provided by the program

      Your residency starts here. What are you waiting for?