Curriculum
Overview
The Internal Medicine residency program at UTHSCSA is fully accredited by the Accreditation Council on Graduate Medical Education (ACGME). The program offers approximately 26 categorical (three year) and ten preliminary (one year) positions annually.Internship The curriculum provides a diverse experience for interns. The rotations consist of bone marrow transplant or night float, general medicine wards, cardiology, critical care, ambulatory care, oncology, emergency medicine, and one elective. Each intern is assigned a resident mentor to help with the initial transition into residency training.
Residency At the completion of their intern year, our residents attend a highly successful leadership retreat to prepare them for their new role as an upper level resident. At this level of training the resident assumes team leadership and teaching responsibilities for both students and interns. Required inpatient rotations during the second year include general medicine wards, cardiology, critical care, and HIV services. Other required rotations include general hematology, neurology and outpatient geriatrics. In addition to the required curriculum, the second year resident has three months of electives and can choose from a broad range of clinical disciplines (see below). Third year residents required rotations include medicine consultation, night float, critical care, cardiology and 2 general medicine wards. Senior housestaff have five months of electives to choose from.
PRELIMINARY INTERNSHIPS
Preliminary interns rotate through general medicine wards (six months), Cardiology, MICU, Emergency Medicine. Preliminary Interns will also rotate through the Bone Marrow Transplant Service and have two elective months, which may be used to rotate in areas of their chosen specialty (such as neurology, radiology, anesthesia or ophthalmology). A brief description of each service with regards to organization, work and time demands, training goals, etc. will serve to illustrate the training program in the Department of Medicine.
GENERAL MEDICINE WARDS
Two interns and one resident (usually with 2 third year medical students, a fourth year medical student "extern," frequently a pharmacy and physician’s assistant student), supervised by an attending physician, comprise one team serving the general medicine patients at one of the two inpatient training facilities (University Hospital or the Audie L. Murphy VA hospital). At UH, there are five such teams rotating "long call" on an every fifth day basis with a hospitalist attending. At the VA there are five such teams rotating "long call" on an every fifth day basis with a combination of traditional faculty attendings and hospitalists. All teams not on "long call" are on "short call." Long call ends at 8PM (7PM at the VA) when night float assumes responsibility. Admissions are capped at the ACGME limits for both call teams and night float. The training goals for interns on the general ward services include: developing a cost- and time-efficient approach to the diagnosis and management of common medical disorders, becoming proficient at common procedures, and maintaining and refining caring, humanistic patient relationships. Finally, interns make the transition from student to teacher in their interactions with the medical students under their supervision.
CARDIOLOGY / CCU
Two or three interns and two fellow residents (often with a fourth year "extern") comprise the cardiology team. The residents have long call every fourth night (alternating with the two residents on the medical critical care team). This rotation also applies to the interns (call nights divided evenly between the medical and cardiology critical care teams). During in-house call the resident and intern accept all new cardiology and critical care patient admissions for a 24 hour period (7 AM to 7 AM). They also provide care for all other unit patients once those team members have left for the day. Short call occurs from 7 AM until 5 PM for a specified cardiology resident and intern.. The cardiology experience involves caring for all cardiology admissions to both telemetry and cardiology ICU beds. Supervision and teaching is provided in daily rounds with the cardiology staff attendings and fellows. Training goals for the cardiology service include: managing patients with myocardial infarction and its complications, treatment of unstable coronary syndromes, diagnosis of complex rhythm disturbances, advanced electrocardiographic interpretation, etc.
CRITICAL CARE
Two interns and two residents (often with a fourth year "extern") comprise the critical care team. As mentioned above, housestaff take long call every fourth night. During in-house call the resident and intern accept all new cardiology and critical care patient admissions for a 24 hour period (7 AM to 7 AM). They also provide care for all other unit patients once those team members have left for the day. Short call occurs from 7 AM until 5 PM. The critical care experience involves covering all MICU admissions. Supervision and teaching is provided in daily rounds with the critical care staff attendings and fellows. Training goals for the critical care service include: management of complicated patients requiring interventions such as mechanical ventilation and vasoactive medications, in addition to procedures such as endotracheal intubation and central venous catheter placement. Common disease processes encountered include: the adult respiratory distress syndrome, sepsis, gastrointestinal hemorrhage, pancreatitis, severe community-acquired pneumonia, and others. The ethical issues commonly arising during ICU care (e.g. end-of-life care) are an integral part of the resident's training.
EMERGENCY MEDICINE
Interns rotate through the Emergency Room at University Hospital. The UH ER evaluates approximately 2500 patients each month, so that trainees encounter a tremendous variety of diseases. During the ER month the intern works approximately 19 twelve-hour work shifts with at least one full day off per week for all house officers. In the ER setting, the PGY-I resident generally has the first chance to evaluate patients and the majority of semi-stable ambulance arrivals (CODE I and II patients). After the intern's initial evaluation he/she presents the case to the ER attending, including his/her assessment and management plan. The attending will review the data and amend the plan as they see fit, providing valuable instruction and feedback to the intern. The intern will follow that patient throughout their ER course until patient dismissal or admission to the hospital. During that time the intern will write all initial orders, progress notes, admission orders, and call consultants where appropriate. Training goals of the ER service include: managing a broad range of medical urgencies/emergencies, developing an understanding of criteria for admission versus outpatient management of non-emergent medical conditions, learning the judicious use of laboratory and radiologic studies in the initial assessment of patients, and the application of principles of advanced cardiac life support (ACLS).
GERIATRICS
This experience occurs at the VA Hospital's Extended Care and Therapy Center (ECTC) during the PGY-2 year, and is coordinated by the director of that service. This 90 bed facility serves as a "step-down" alternate to a nursing home placement for elderly patients with chronic health problems, who have had frequent or prolonged hospitalizations and are not yet functional enough to return home but who, with intensive therapy, are expected to recover to a degree sufficient to ultimately return home. The duties of housestaff rotating through this service include performing the initial screening evaluations of patients referred to the center, providing a report on those patients at a biweekly committee meeting to determine eligibility for acceptance, and writing an assessment and medical orders of all new patients upon transfer. In addition to these inpatient responsibilities, there is a bi-weekly geriatrics clinic, a musculoskeletal medicine curriculum, and sessions on physical therapy and rehabilitation medicine. There is no call on this service and no weekend responsibilities. Training goals for the geriatric service includes developing an appreciation for the management of many chronic and debilitating illnesses common and/or unique to the geriatric patient, learning how treating the elderly (an ever-growing segment of the population) differs from usual adult internal medicine, and inculcating a sensitivity to the wants, needs, fears and expectations that this cohort has of its health care providers.
PRIMARY CARE BLOCK ROTATION
Usually 2-4 interns per month rotate through this service, which occurs exclusively in the outpatient setting, both at the University Health Center-Downtown and the VA hospital clinic. Principally patients are seen in the acute care clinic with a medical problem requiring a focused history and physical examination. The housestaff also participate in weekly women’s health and musculoskeletal clinics. The interns on this rotation will be supervised by general internists with special interest in teaching primary care and preventive medicine. Due to the much more frequent follow-up opportunities, the intern gets a better feel for how a complicated medicine patient can be managed with frequent interim clinic visits. Most of these patients will become the established continuity patients for the intern who evaluated them. There is a bi-weekly journal club and conference on primary care topics. There is no call or overnight duty during this month.
ONCOLOGY
The oncology service is a consult and outpatient rotation with 2 interns, medical students, an oncology fellow and a staff physician. Each intern will only have 2 overnight calls at the VA hospital during this month to provide the night float team a night off. Training goals for the oncology service include: learning the staging techniques and treatment options for common malignancies, mastering the fundamentals of chemotherapy administration (including the prevention and/or management of common side effects), treatment of neutropenic fever, and management of other oncologic emergencies such as spinal cord compression.
HEMATOLOGY CONSULTS
Two junior residents per month are assigned to the hematology consult service. Non- leukemic patients with hematology problems such as multiple myeloma, sickle cell disease, thrombocytopenia, and severe anemias are managed on the general medicine ward teams, with the assistance and input of the hematology consultation team. There is no call or overnight duty during this month, except for two nights a month providing a day off to one of the members of the night service. Training goals for the heme service include learning staging techniques (including bone marrow biopsy), evaluation of peripheral blood smears, diagnosis and treatment options for the most common hematologic disorders.
BONE MARROW TRANSPLANT
One or two preliminary interns are supervised by a hematology fellow and staff physician on the BMT service. The BMT inpatient service largely deals with the bone marrow transplant recipients with a variety of disorders including neutropenic fever, graft versus host disease, veno-occlusive disease, aplastic anemia and acute leukemia. There is no call or overnight duty during this month. Admissions evaluated by the night team are distributed to the appropriate team in the morning. Training goals for the BMT service include an exposure to the promise and pitfalls of BMT, transfusion medicine, the care of profoundly immunosuppressed patients, the use of recombinant growth factors, and the role of other sophisticated diagnostic modalities useful in the evaluation of hematologic malignancies.
HIV SERVICE
Two junior residents per month and an infectious disease fellow are supervised by an infectious disease attending on this inpatient service, which specializes in the care of patients with acquired immunodeficiency syndrome and its complications. The residents evaluate admissions to this service from the emergency room or outpatient HIV clinic and accept patients transferred from general medicine services. The residents also attend a bi-weekly clinic to become better familiar with the preventive/ambulatory management of AIDS patients, i.e., PCP prophylaxis, anti-retroviral therapy, reducing HIV transmission risk, and treatment of opportunistic infection. There is no call or overnight duty during this month.
NEUROLOGY CONSULTS
Two second year residents per month rotate on the neurology consult service. Duties include providing consultation of patients with neurologic diseases in a variety of settings such as the emergency room, medicine and surgical wards, and outpatient clinics. Call occurs 4 times per month (2 overnight shifts and 2 short call shifts). The neurology rotation includes several half-day neurology clinics with exposure to common neurology conditions such as seizure, migraine, peripheral neuropathies, spinal cord lesions, and chronic diseases such as multiple sclerosis. Residents also attend a clinic specializing in the treatment of muscular diseases such as muscular dystrophy and amyotrophic lateral sclerosis. The interns will also attend weekly Neurology grand rounds and other didactic teaching sessions given by the Department of Neurology. Training goals for the neurology service include: perfecting the neurologic physical examination, reviewing neuroanatomy and the localization of neurologic lesions based on physical exam findings, appropriate use of neuroradiology imaging modalities, prevention and management of acute stroke, managing neurologic urgencies/emergencies such as complicated seizure disorders, and appropriate referral stategies for patients with neurologic diseases.
NIGHT FLOAT
The night service is a team composed of one senior resident and one categorical intern for each hospital. Each housestaff with rotate at each hospital for 2 weeks. The senior residents admit new patients and provide urgent medical consultations (to other services such as surgery or obstetrics) during the night. The intern is responsible for cross coverage of the established inpatients on the HIV, hematology/oncology, and general medicine services. The senior residents supervise and provide back-up to the interns as they manage acute medical problems on these services. A faculty attending physician provides supervision and teaching on this service each night at both hospitals. He or she is available to supervise procedures and code resuscitations, as well as provide immediate feedback and guidance on the new admissions. The night service has formal teaching rounds every morning to review the cases admitted and discuss principles of cross cover management. The float admissions are then distributed as "short call" patients to the general medical or subspecialty teams.
MEDICINE CONSULTATION
Two to three senior residents and an attending physician staff the medicine consult service each month. This team generally sees consultations between the hours of 7 AM and 8 PM daily, at which time the night service takes over such duties (see above). They provide consultation and assist non-medicine services (surgical subspecialties, obstetrics, psychiatry, etc) in the management of concomitant medical disorders. They also perform both inpatient and outpatient pre- and peri-operative evaluations. They also make decisions about appropriate transfers to medicine services from non-medicine services. The lessons learned in this month are very valuable to the future internist, as they provide a background for assisting non-internists with their management of common medical problems.
ELECTIVES
Elective months provide the opportunity to individualize the training experience. They can be used to enhance primary care training, to concentrate on medical subspecialties, or to do research. We offer rotations in all medicine subspecialties. The resident sees consultations and participates in outpatient clinics, conferences, and procedures. Primary care outpatient electives include women's health, HIV management, adolescent medicine, as well as office dermatology, otolaryngology, ophthalmology, musculoskeletal medicine, nephrology, rheumatology and hepatology. Research electives are conducted with the guidance of a faculty advisor in the field of interest, and culminate in a presentation at the annual South Texas American College of Physicians Associates Program held in San Antonio each Spring. At the Spring 2007 meeting, over 50 presentations of research and clinical vignettes were given by internal medicine residents from six participating South Texas teaching programs. Residents also present at our local Department of Medicine Research Day and may present at regional and national specialty conferences as well.