Internal Medicine Residency

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, particularly those seeking a subspecialty fellowship, as well as abundant opportunities for residents interested in primary care and hospitalist 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 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 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.

Balance of Rotations and Curriculum

During the three year program, residents spend one-third or more of their time in ambulatory rotations, including a weekly continuity medical clinic, four Ambulatory Block Rotations, the Faculty Practice Offices, the emergency room, walk-in clinics and subspecialty clinics during consultation rotations. The timing of their clinic days is balanced with their inpatient responsibilities so that residents can focus their attention on each area.

Residents spend approximately half their time on inpatient rotations, including general medicine units, subspecialty services (e.g., cardiology, infectious diseases, 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, all the 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 two electives in the intern year. A summary of the clinical rotations by year of training can be found in Curriculum in Internal Medicine. The entirety of our written curriculum, which details the competency based objectives for every required and elective rotation, can be accessed at Core Written Curriculum.

A Comprehensive mentoring program is an important component of our residency. We ensure that residents are paired with faculty with similar interests who guide residents as they develop and solidify their career goals. 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, or a primary care or hospitalist position.

Residents adjust their curricula based on their career goals. Residents planning a subspecialty career are strongly encouraged to engage in either clinical or basic science research activities. 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 supports 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, approximately 30 residents present their research or clinical vignettes.

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. Residents 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. They are also encouraged to spend a month at one of our AHECs where they learn the unique practice of rural medicine. Regardless of career choice, our residents are encouraged to seek a broad curriculum in ambulatory medicine from the many choices available.

An increasing number of residents are entering careers in hospitalist medicine. Some residents will be hospitalists as a life-long career, while others are hospitalists for a few years as they transition to a private practice or subspecialty fellowship. Residents interested in hospitalist medicine are encouraged to take electives that emphasize inpatient medicine, such as general medical consultation, cardiology, infectious diseases, GI and pulmonary medicine, as well as rotations in anesthesiology. We also offer an Elective in Hospitalist Medicine that gives residents exposure to medical consultation, quality assurance, utilization management, hospital administration and finance, and delivery of evidence based care in the inpatient setting. Residents may also choose our Procedure and Critical Care Consultation Elective. Here, residents consult on services throughout the institution becoming proficient in key internal medicine procedures. We are implementing an exciting new curriculum in Patient Safety and Quality Improvement (PSQI). Under the guidance of our academic hospitalists and PSQI chief resident, elements of this curriculum are incorporated into a variety of conferences and the 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.

Residency Reform

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, ensuring that all residents work <80 hours/week on average, have 8-10 hours off between duty shifts, are on duty <16 hours for interns and <28 hours for upper level residents, and have 4 full days off each month. With implementation of the July 2011 ACGME Duty Hour Requirements, we have undergone a 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.

At The University of Maryland Medical Center, we have 4 fully staffed general medicine teams in a team call structure. A Day Float position at University and the VA help the teams complete their work in a timely fashion.
We have a Team Call System for the general medicine and Med-ID teams at University and the general medicine teams at the VA with the Night Team arriving at 9 PM, and the long call team taking their last admission at 6 PM. There is Night Team coverage 7 nights/week with Night Team members working no more than 5 nights in a row. Hence, no interns or residents on any of the general medicine teams or on Med-ID stay overnight.
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 works with the senior resident and night intern in admitting and cross-covering patients. A similar structure exists in the CCU, where the senior resident, night intern and nocturnist admit and cross cover the patients at night. In both units, the interns take call every 4th to 6th nights until 9 PM and also do a "6 night run" of 16-hour night shifts during the month. This schedule allows interns to be involved in acute admissions and cross cover issues at night while maintaining a continuity in caring for a panel of patients. This structure provides a robust educational experience. Upper level residents do a variety of shifts -- some only until 9 PM and others that are 28-hour overnight shifts. At the VA, the MICU and CCU services are covered at night by the ICU resident doing a 28-hour 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, meet patient safety standards, and comply with all ACGME Duty Hour Requirements.
Rotations that have overnight call are structured so that the upper level resident leaves within 28 hours after arrival the previous day when rotating in the Cancer Center and in the ICU's. Thus, residents stay under the 24+4 hour cap for duty shifts.
Call on all services - including floor teams and ICU's at all sites - is every fourth night. The only exception is the MICU at UMMC where interns are on-call every 6th night.
Interns are strictly capped at 5 admissions per night and 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 systems 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."
We track resident duty hours on a regular basis through a self-reporting method to ensure compliance with all RRC Duty Hour Requirements. Data are shared at our Postgraduate Education Committee and with all residents.
It is important to mention our non-teaching services in conjunction with residency reform. Over the past 10 years, we have seen an explosion of non-teaching services. This is a direct result of our determined stance to ensure the we meet all ACGME rules while providing our residents with the best possible clinical training. Our ever-increasing patient volumes at UMMC have been easily absorbed by these non-teaching services. Currently, we have non-teaching services for general medicine, a step-down intermediate care unit (IMC), oncology, and the bone marrow transplant services.

All these components ensure that the service needs of the hospital do not diminish our primary mission - the education of our medical residents.

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 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.

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 of resident competence provides continuous feedback for residents, attendings and the program director. Residents are evaluated every month by the attending and receive an immediate email that they have an evaluation ready for viewing. Similarly, residents evaluate their attendings' teaching abilities and the educational value of the rotations every month, providing real-time feedback to Dr. Wolfsthal and the attending. A highly successful Peer Evaluation System allows residents to evaluate their interns and for interns to evaluate their supervising residents. Nurses in the clinics and various inpatient units also assess residents' skills. Students evaluate residents on their clinical, teaching and leadership skills, and the residents also evaluate 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.

Conference Series

A wide variety of conferences are held throughout the week -- each with a different format and purpose -- and provide residents with diverse learning environments. A highlight of each day is Morning Report, which also includes the Ambulatory Core Curriculum and Senior Resident Conferences. We are in the process of revamping our entire Core Conference Curriculum in all venues to ensure residents have a comprehensive exposure to the entirety of internal medicine and the skills necessary for their success. Our monthly 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. Morbidity and Mortality 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 Blackboard. You are welcome to view our Acute Medicine Lecture Series, Ambulatory Care Seminars, CATS from Journal Club and our Senior Resident Conferences on our Blackboard site. Enter the username and password imres to access the conferences. It is a marvelous compendium for our residents and provides a valuable educational resource throughout the year.

This page was last updated on: August 1, 2012.