Curriculum

1st House Staff Class 1925

Inpatient Rotations

The Department of Medicine operates on the thesis that the best patient care is rendered when major responsibility rests with the intern and assistant resident under the purview of the chief resident, all having ready access to attending faculty and consultants.

PGY1 (Internship)

PGY-1 residents, otherwise known as interns, have the following major responsibilities:

1. Initial evaluation of all patients, including assimilation of old records and outside information.
2. Developing a plan for each patient to present to the resident.
3. Communicating with the patient and family about treatment plans, consultations, risks and benefits of procedures and medications, and other aspects of care.
4. Getting write-ups on the chart no later than 8:00 a.m. following a call day.
5. Discussion of "Do-Not-Resuscitate (DNR)" orders and other end-of-life issues when appropriate.
6. Asking surviving family members for permission to perform an autopsy.
7. Working on discharge planning from day one.
8. Writing daily progress notes.
9. Interns are expected to attend all daily attending rounds (except when off duty), morning report, Grand Rounds, and all other teaching conferences.
10. Interns work closely with medical students and assist with their education.

The PGY1 year is organized to ensure a comprehensive clinical experience in a variety of settings. The intern "learns by doing" and must be kept at the forefront of patient evaluation and therapeutic decision making if he or she is to develop the confidence and proficiency upon which sound clinical judgment is based. The teams provide the intern with individualized supervision and the resident with time for study, case management, and teaching. A typical internship year is as follows:

PGY2, PGY3 (Assistant Residency)
The approximate design of the junior and senior assistant residency years is outlined below:

The primary roles of the PGY-2 and 3 residents are supervision and education. This includes:

1. Seeing every patient on the day of admission and writing a note
2. Review and approve diagnostic and treatment plans with the interns
3. Review patients' progress daily, giving feedback to the intern on progress notes, order writing, and discharge planning
4. Organizing and planning attending rounds, meetings with consultants, and other teaching opportunities
5. Setting time aside for teaching medical students, including reviewing write-ups and giving timely feedback
6. Creating an atmosphere such that the intern is encouraged to ask for help when appropriate
7. Supervising procedures
8. Dictating discharge summaries
9. Interacting with nurses and other personnel in a way that respects all members of the healthcare team and encourages their input
10. Being certain all members of the team are familiar with the current literature regarding their patients
11. Attending teaching conferences including Grand Rounds, Morning Report, Noon Conference and Journal Club

Note: The upper-level resident is responsible for all aspects of the patients' care. As such, this resident is ultimately responsible for requesting consultations and interacting with them, for keeping the attending fully informed of changes in status, and for overall supervision of the intern(s) and student(s).

Admissions and Night Call

Admissions to all general medicine services are taken on a long call/short call schedule with short call restricted to two patients per intern. Long-call/night-call is every 4th day on the Vanderbilt Hospital inpatient services, every 6th day at the VA, and every 3rd day on the MICU rotations. The number of new admissions assigned to an intern on long call is limited to five in a 24-hour period. Team admissions average 40-45 per month (20 in the MICU). While on inpatient service rotations each intern and resident is given one day off per week, when averaged over a four-week period.

Emergency Medicine Training

All interns are assigned a rotation in the Emergency Department under the supervision of full-time academic faculty in emergency medicine. This is a well-organized rotation with excellent teaching; on this rotation interns attend a morning didactic series that addresses topics in emergency medicine and ambulatory care. A second designated emergency medicine rotation is assigned during the PGY3 year.

Rounds and Conferences

Attending Rounds : Bedside teaching rounds are conducted on the inpatient clinical services seven days per week. The emphasis is on developing fundamental clinical skills, diagnostic reasoning, pathophysiology, and professionalism. Our department has a written policy that teaching rounds are to be conducted "at the bedside". Emphasis is on evidence-based medicine and on creating an environment that optimizes learning and patient care.

Resident Morning Report : Morning report is held at both hospitals 3 days per week. All interns and students on the appropriate rotations are expected to attend unless off duty.  Morning report is led by the chief resident with the chairman, program director, and/or chief of service in attendance. Selected cases are presented and emphasis is given to clinical reasoning, pathophysiology, cost-effective use of diagnostic tests and selective review of the relevant literature. A separate ambulatory morning report is held four days per week for residents doing ambulatory block rotation.

Intern Report : Once weekly the interns rotating at VUH meet with the vice-chairman and chief resident to discuss practical aspects of patient management and to troubleshoot any problems arising in the day-to-day flow of ward work.

Chairman's Rounds : Once weekly the department chairman conducts a teaching conference on the VUH medicine service addressing the evaluation and management of electrolyte, acid-base, and other metabolic disorders.

Grand Rounds : The single department wide weekly academic activity, attended by virtually all of our housestaff and faculty. This is a topic-based, state-of-the-art discussion wedding basic science with clinical medicine.

Fox and Hedgehog Conference : Weekly conference lead by the chief residents where four cases seen at Vanderbilt and its affiliated teaching sites are presented as unknowns with brief discussion and key teaching points by designated faculty. This conference is popular and well-attended by faculty and residents.

Mortality Conference : A mortality conference is conducted on a regular basis at both hospitals, led by senior faculty members in medicine and pathology. In addition, there is a quarterly department-wide M and M Conference that focuses on quality improvement.  At any given time, there will be several teams of residents working on quality improvement projects generated by these M and M Conferences.  The purpose is to demonstrate the diagnostic value of careful pathologic investigation, to enhance our understanding of the natural history of disease, and to discuss medical errors.

Noon Lecture Series : A twice-weekly combined VA/VU noon lecture series, designed to cover all the major clinical topics in internal medicine, runs the entire academic year. Senior residents present scholarly reviews of clinical topics in the last five months of the academic year.

Ethics/Professionalism Series : A monthly noon conference focused on communication skills, clinical ethics, and other aspects of professionalism.

Journal Club : a weekly conference for all PGY-2 and PGY-3 residents in which a member of the housestaff, after working closely with a faculty mentor, leads an in-depth analysis of a paper from the current literature. Residents are taught not only to appreciate the literature, but also to interpret it critically. For journal club housestaff are assigned to one of two groups along with a faculty member in order to create a small group environment that facilitates good discussion. Interns are assigned to a journal club in April of each year.

Intern Orientation in the Simulation Lab

Ambulatory Medicine and Primary Care Training

Training in ambulatory medicine and primary care is incorporated into all three years of the residency program, under the purview of the Division of General Internal Medicine. The division consists of 90 full-time faculty, including 73 clinical faculty and 2 primary care chief residents. Resources for primary care training include Vanderbilt and VA clinics and faculty practices. A core training experience is provided to all housestaff during the first two years, utilizing one and two-month block rotations, ambulatory morning report, didactic lectures, and assignments to acute general medicine and subspecialty outpatient clinics. A brief description of the block rotations, teaching conferences, and continuity of care clinic is given below.

PGY1 - Primary care/geriatric rotation - four weeks: (a) ambulatory morning report, didactic lecture series, faculty geriatric practice one half day per week; (b) a four-week ambulatory block with assignment to selected clinics including acute general medicine, endocrinology, geriatrics and rheumatology.

PGY2 - All PGY2 residents are given a two-month ambulatory care elective that combines additional general medicine experience with outpatient training in selected subspecialty clinics. In addition to one day in the Vanderbilt General Medicine (walk-in) Clinic each resident selects two-week block rotations from a menu of subspecialty clinics including allergy, dermatology, diabetes, endocrinology, hematology, hypertension, rheumatology, geriatrics, infectious diseases and others. All residents attend ambulatory morning report and a weekly didactic lecture series on topics in general medicine/ambulatory care.

PGY3 - Residents intending to enter general internal medicine practice are assigned a two-month primary care block rotation in the senior residency year. Rotations include geriatrics, medical subspecialty clinics, and a variety of individualized training experiences such as office gynecology, otolaryngology, orthopedics, private practice preceptorship, etc. In addition, senior residents on this track may add an additional office-based continuity clinic in geriatrics or general medicine.

The ambulatory curriculum also includes a selection of office-based subspecialty block rotations in psychiatry/neurology, rheumatology, endocrinology, clinical pharmacology/hypertension, and oncology.

Didactic lectures, conferences, and ambulatory morning report are used to address a wide range of clinical issues, including clinical epidemiology, decision analysis, critical review of the literature, preventive medicine, and managed care.

Continuity Care Clinic

Each resident is assigned a half-day per week continuity care clinic early in the PGY1 year. The continuity clinic may be taken at either Vanderbilt or the VA Hospital as each conducts a busy outpatient general medicine clinic with full-time faculty available for consultation and teaching. In the Vanderbilt program resident continuity clinic enjoys a high priority and a high level of satisfaction among our residents. It functions essentially as a group practice with modules of three or four residents and a faculty preceptor. Designated administrative and secretarial support and our universal pager system allow the resident physician to be informed promptly whenever his/her patient calls no matter where the resident is rotating in the system. In addition, our electronic medical record system at both hospitals allow residents to interact with their patients and their records from remote sites.

Quality Improvement Activities

Internal Medicine residents have the unique opportunity not only to measure the care they  provide, but also to develop and test interventions designed to improve patient care.  These opportunities occur at multiple points throughout residency.    

Ambulatory Block Experience:
The most intense curriculum on quality improvement occurs during the second year of residency.  Residents work with Dr. Waldon Garriss and chief residents during their 8 week ambulatory block to understand the key principles of quality improvement as well as to learn basic tools of quality improvement.  Residents meet for 2 hours every Thursday to learn about and apply these tools to actual patient care situations.  Residents analyze their own patient care data specifically pertaining to diabetes care (e.g. glycemic control, blood pressure control, smoking cessation, etc.).  Additionally, residents work together to identify patient safety problems and then apply the principles and tools of quality improvement to collect data and test interventions to improve the safety issues identified.  This educational experience culminates in a presentation to key leaders at the end of the rotation with the goal of enacting changes in the system.  Many of these resident-generated QI projects have been implemented with hospital-wide impact.  A recent resident QI project from this experience was presented at the Fall 2008 national meeting of the Institute for Healthcare Improvement.  

Quality Improvement in the Continuity Clinic Setting:
Residents and interns in each of our continuity clinics work together to improve both the preventive care and chronic illness care they provide to their clinic patients.  A seminar series disseminated throughout the year helps direct residents to helpful resources with the goal of impacting resident-selected quality improvement targets.  All members of the house staff review and analyze pertinent patient data related to the quality improvement efforts.  Residents have the opportunity to measure their performance compared with their peers and also to measure the effect of proposed quality improvement interventions using Plan-Do-Study-Act cycles.   Resident teams receive guidance and feedback throughout the year on their proposed clinic projects from mentors in quality improvement, many of whom completed a VA Quality Scholars fellowship at Vanderbilt University. 

Morbidity, Mortality and Improvement Conference (MM&I):
This conference is designed for residents to identify and discuss system-based problems.  At the end of each of four yearly MM&I conferences, residents can volunteer to participate in a task force to develop, test, and implement interventions designed to improve the system problems identified in the M,M&I cases.  These multi-disciplinary conferences provide residents with the opportunity to work with hospital patient safety officers throughout this process.