Curriculum

The Department of Medicine operates under the premise that the best patient care is rendered when major responsibility rests with the intern and resident with ready access to attending faculty and consultants. Interns "learn by doing" and are kept at the forefront of patient evaluation and therapeutic decision making so that they develop sound clinical judgment. Residents are ultimately responsible for all aspects of patient care, including requesting consultations, keeping the attending fully informed of changes in patient health status, and managing interns and students.

PGY-1 (Internship)

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

-Initial evaluation of all patients, including assimilation of old records and outside information.
-Developing a plan for each patient to present to the resident.
-Communicating with the patient and family about treatment plans, consultations, risks and benefits of procedures and initiation of medications, and other aspects of care.
-Discussion of "do-not-resuscitate (DNR)" orders and other end-of-life issues when appropriate.
-Working on discharge planning.
-Writing daily progress notes.
-Attending all teaching conferences including Medicine Grand Rounds, Morning Report, Professor Rounds, and noon conferences.
-Working closely with medical students and assisting with their education.

 

PGY-2 and -3 (Assistant Residency)

PGY-2 and -3 residents, otherwise known as upper-level residents, have the following major responsibilities:

-Seeing every patient on the day of admission and writing resident admission notes when appropriate.
-Reviewing and approving diagnostic and treatment plans with the interns.
-Reviewing patients' progress daily.
-Giving feedback to the intern on progress notes, order entry, and discharge planning.
-Organizing and planning attending rounds, meetings with consultants, and other activities relevant to patient care.
-Setting time aside for teaching medical students, including reviewing write-ups and giving timely feedback.
-Supervising procedures.
-Writing discharge summaries.
-Familiarizing all members of the team with the current literature behind the care being rendered.
-Attending all teaching conferences including Medicine Grand Rounds, Morning Report, Professor Rounds, and noon conferences.
-Creating a professional atmosphere such that the intern is encouraged to ask for help when appropriate and such that team members interact with allied health staff in a respectful manner.

STRUCTURE OF ROTATIONS

All residents are now on a “4+2” block schedule with two-week ambulatory rotations separated by four-week inpatient or elective rotations.. They rotate through a variety of inpatient services including general medicine, the medical intensive care unit, cardiology, hematology, oncology, and other inpatient specialty services. Interns typically have four weeks of night float. They also have two weeks of emergency medicine and two weeks of neurology. Upper-level residents typically have three weeks of night float each year. PGY-3 residents also have two weeks of emergency medicine.

ATTENDING ROUNDS

Bedside teaching rounds are conducted on all inpatient clinical services seven days per week in order to optimize learning and patient care. The emphasis of attending rounds is on developing fundamental clinical skills, diagnostic reasoning, and professionalism as well as on the bedside review of the pathophysiology of disease. Special emphasis is given to evidence-based medicine.

AMBULATORY MEDICINE

Training in ambulatory medicine and primary care is incorporated into all three years of the residency program. Primary care settings include internal medicine clinics in Medical Center East, the One Hundred Oaks ambulatory center, and the primary care clinic at the Nashville VA Medical Center. Specialty settings include the Vanderbilt Clinic, the Nashville VA Medical Center, and a variety of Vanderbilt-affiliated ambulatory centers.

Interns have twelve weeks of ambulatory medicine and complete four weeks in geriatrics, two in endocrinology, and two in rheumatology. Four ambulatory weeks are reserved for research and continuity clinic.

Upper level residents complete 16 weeks of ambulatory medicine per year including two weeks in the Vanderbilt Acute Medical Practice (walk-in) clinic and two weeks reserved for research and continuity clinic. The remaining weeks are spent rotating through a variety of outpatient rotations in order to increase familiarity with and exposure to the medical specialties, including allergy and immunology, cardiology, endocrinology, gastroenterology, hematology, hepatology, hypertension, infectious diseases, nephrology, oncology, pulmonology, rheumatology, women’s health. Residents may also complete ambulatory blocks with Vanderbilt Student Health, in local community health centers, and in dermatology, among other settings.

CONTINUITY CLINIC

Each intern is assigned a continuity clinic for which they provide longitudinal care to a panel of patients over their two to three years of residency. Residents are assigned a full-time faculty member as preceptor who provides both oversight and teaching.

Under our 4+2 block schedule, all residents have three half days of continuity clinic per week during their two-week ambulatory blocks.

Nurses and support staff at Vanderbilt University Medical Center and the Nashville VA Medical Center, along with robust informatics, allow residents to keep up with their responsibilities to their panel of continuity clinic patients while rotating through various services.

Shannon_Skinner-chief-ed-r.jpg

Shannon Skinner, M.D.
Vanderbilt University School of Medicine
Ambulatory Chief Resident,
VU Medical Center

The primary care clinic experience is integral to the internal medicine residency program.  As interns, Vanderbilt residents assume care of a panel of patients for whom they act as the primary care physician for all three years of residency.  Throughout these years with the same patient panel, residents manage chronic diseases while also working up patients' new issues and practicing preventative medicine.  The aspect of longitudinal care is often missed in the inpatient setting, but the regular use of continuity clinics provides a more comprehensive sense of patient care in a time frame measured in years rather than days. 

Vanderbilt has fully converted to block scheduling on a “4+2” system, in which residents have 4 weeks of inpatient time followed by 2 weeks of dedicated clinic time.  This allows for regularly scheduled clinic visits and development of a true sense of ownership for patients. Also, each clinic in the residency program is organized into a team of attendings with several residents and multiple medical staff including nurses. Over the course of three years, direct and consistent teaching from a dedicated group of attendings as well as the same staff and patient panels allows for continuity of learning for the resident as well as continuity of care for the patient, no matter if the resident is on an inpatient or outpatient block. 

 Access to the larger medical system, including diverse diagnostic and treatment modalities and specialty referrals, at Vanderbilt Medical Center and/or the Nashville VA, allows for primary care to be delivered at a high level as a resident. The continuous link between attendings, residents, medical staff, and patients over years creates a different experience from the fast paced and often episodic inpatient world. An educational experience that helps prepare residents to become fully functioning physicians in their eventual practice. 

 

QUALITY IMPROVEMENT ACTIVITIES

Employing principles and tools of quality improvement, residents are responsible for developing and testing interventions designed to improve patient care. These opportunities occur at multiple points throughout residency.  

Morbidity, Mortality, and Improvement (MM&I) Conferences

A quarterly MM&I conference—led by Dr. Yakes, one of our associate program directors—helps residents identify and propose solutions to system-based problems. Each one of these conferences generates a resident-run quality improvement project that is subsequently addressed in dedicated quality improvement didactic sessions. Many of these projects have resulted in changes with hospital-wide impact.

Quality Improvement in the Continuity Clinic Setting

Residents measure the care they provide to their continuity clinic patients along various preventative and chronic disease management metrics using tools acquired during quality improvement didactics. Mentors in quality improvement, many of whom have completed the VA Quality Scholars Fellowship, subsequently assist residents in developing improvement targets and using Plan-Do-Study-Act cycles to achieve their targets.

SIMULATED PATIENT EXPERIENCES:

Residents use Vanderbilt's state-of-the-art patient simulation center called CELA (the Center for Experiential Learning and Assessment) to supplement their education. Residents practice critical care procedures, such as intraosseous or central venous catheter insertion, and participate in mock codes before they become code team leaders in their PGY-2 year. Additionally, CELA experiences are used to evaluate residents in the core competencies using standardized patients. These individualized sessions allow residents to receive one-on-one feedback from clinical faculty.