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MEDICAL RESIDENCY - 2007 Curriculum

Designed around the six general competencies (medical knowledge, patient care, interpersonal skills and communication, system based practice, practice based learning and professionalism), our curriculum accentuates feedback and evaluation that are crucial to any learning environment. Teaching attendings, ambulatory preceptors and supervising residents provide periodic feedback sessions to facilitate individualized learning and ongoing evaluation. Histories and physical examinations are observed and periodically videotaped for peer review. All interns take part in two Observed Structural Clinical Exercises (OSCE) of basic skills, and are observed conducting four history and physical examinations. Each house officer is paired with a faculty advisor who plays an advocacy role and assists with curricular goals as well as career planning.

Sample Rotation Schedule

Inpatient Rotations

Outpatient Experiences

Seminars and Didactics

Medicine and Population Health

Sample Rotation Schedule

The following chart indicates the sample distribution of time devoted to the various clinical experiences during the three training years. Each year is divided into 12 blocks, each approximately one month in length.

The schedule of inpatient coverage is organized to minimize stress by reducing the weekly work hours and consecutive daily hours and by limiting the number of admissions. Ancillary services are readily accessible on a 24-hour basis.
Accommodations are made for coverage during illness and for parental leave. The inventive Intern Support Group is praised yearly by interns as an invaluable source of peer help throughout the year.

Clinical Experiences Number Rotations/Year

Clinical Rotations

Cambridge Health Alliance training programs provide an excellent foundation for those pursuing academic and/or community-based primary care or internal medicine subspecialties. This training experience gives residents direct patient responsibility in both hospital and ambulatory care settings, enhancing their knowledge of medicine and patient care. Faculty foster a spirit of inquiry and learning and develop close collegial relationships with the house staff. Two PGY4 Chief Residents and medical students in a variety of capacities in the inpatient and outpatient environment further enhance the spirit of teaching and learning.

Inpatient Rotations

The medical units provide a rigorous experience caring for patients with a broad assortment of acute and complex problems. House officers and attending staff share responsibility for all patients; only house staff write orders.
The Cambridge Hospital Wards: Medical teams consist of a resident and two interns. Interns take overnight call only once in 14 days. A night intern, supported by night residents, is an integrated member of the team in a system that promotes continuity of care overnight and models effective collaboration among providers. A unique combination of primary care providers and hospitalists contribute to the academic rigor of the inpatient experience and facilitate resident understanding of the continuum of medical care.

The Somerville Hospital Wards: Two interns work under direct supervision of the hospitalist attending physician. There is no overnight call. At Somerville, interns carry a load of four patients each. The reduced patient load makes possible such curricular innovation as patient home visits and hospital quality improvement projects.

Intensive Care at The Cambridge Hospital Campus: The intensive care unit provides sophisticated, intensive monitoring and treatment for critically ill patients. The ICU team, consisting of one resident and three interns, is supervised by a dedicated pulmonary-critical care specialist who serves as the attending of record on all ICU patients. This intensivist leads daily multidisciplinary work rounds and delivers a didactic ICU curriculum on core critical care topics. Residents gain substantial experience performing complex procedures. Interns take call twice a week and go home after rounds the following day.

Step Down unit at Massachusetts General Hospital: Second year residents rotate through this tertiary care step down unit to further hone their skills in management of acutely ill cardiac care patients.

Liaison Psychiatry: Two staff psychiatrists, a psychiatric nurse, a PGY3 psychiatry Resident, Harvard medical students and a PGY1 medical Resident comprise the liaison psychiatry service. House officers learn to evaluate and treat many of the behavioral, cognitive and forensic problems common to hospitalized patients.

Elective Rotations: Residents avail themselves of a myriad of opportunities at Cambridge Health Alliance, in the Greater Boston area, and in international settings during their elective time. Residents may rotate to the tertiary care Harvard hospitals for inpatient subspecialty consultation experiences. Residents also use elective time to work on their scholarly projects.

Outpatient Experiences

Structured block rotations provide additional experiences in ambulatory medicine and the associated medical and non-medical specialties. Interns participate in one continuity clinic per week. At the start of the PGY2, they add a second continuity clinic, typically at the same site. Special programs are also available in health promotion and disease prevention, occupational and environmental health, women's health, and public health-including AIDS/HIV care and tuberculosis.

Continuity Clinics: Residents build a panel of patients in their continuity clinics. At all clinical sites, the Resident becomes a member of a caregiving team consisting of a staff physician, psychiatrist, nurse practitioner and a social worker. Sites include:

The Primary Care Center (PCC) - based at the new state-of-the-art Ambulatory Care Center at The Cambridge Hospital. The PCC facility serves our multicultural patient populations who make over 20,000 visits per year.

Neighborhood Health Centers (NHC) - Residency training is offered at several of the NHC's that are located in our richly diverse neighborhoods. They are clinically and administratively integrated with the hospital and offer excellent training sites particularly for those interested in cross-cultural medicine or community outreach.

Somerville Primary Care (SPC) - Clinic serves the Somerville community with cultural sensitivity and attention to academic rigor applied to primary care.

Harvard Vanguard Medical Associates (HVMA) - HVMA is a pre-paid closed panel HMO. The HVMA internists are members of the medical staff at Cambridge Health Alliance.

Cambridge Family Health - This group practice includes graduates of this training program and provides comprehensive child and adult care one block from the hospital.

Ambulatory Block Rotations: Residents gain intensive exposure to a variety of specialties relevant to outpatient practice, including rheumatology, orthopedics, office gynecology, ENT, dermatology, neurology, oncology, endocrinology, occupational and environmental health, ophthalmology, pulmonary medicine and gastroenterology. During the ambulatory block rotations, residents also participate in a number of well supervised multidisciplinary care programs including HIV care and tuberculosis clinic.

Cambridge Occupational and Environmental Health Program (OEHP) - Basic principles of recognizing and preventing occupational health diseases are integrated into primary care training through a lecture series and clinical experiences. Residents may participate in work site evaluations and projects in this elective.

Public Health - The Department of Medicine is involved in public health education about the spread of HIV-related illness, of tuberculosis and other communicable diseases. Other public health projects include immigrant health, diabetes, health concerns of men of color, CHF and pediatric asthma. Residents have the opportunity to see patients along with public health specialists and to devise educational interventions working in concert with many community programs such as the Institute for Community Health and the AIDS Task Force.

Addictions Medicine - PGY1 Residents consult on patients in withdrawal, many of whom have polydrug abuse as well as significant additional medical problems. Interns participate in individual and group counseling and family meetings, learn about community substance abuse prevention and treatment resources. Interns also gain exposure to methadone maintenance programs.

Women's Health Elective - PGY2 or PGY3 Residents may devote one elective block to a concentrated exposure to women's health. A multi-disciplinary faculty emphasizes the holistic care of women, and the principles of an integrated community-based approach to women's health.

Geriatrics - The geriatrics rotation in the PGY2 year emphasizes community-based care and both outpatient and inpatient consultation. The faculty emphasize interdisciplinary evaluation of the common problems of the frail elderly, neuropsychiatric assessment and rehabilitation.

Emergency Department at The Cambridge Hospital Campus - The state-of-the-art emergency department at The Cambridge Hospital is staffed 24 hours a day by attending physicians who supervise medical residents and interns. Residents manage acute medical and surgical problems in this busy emergency room (averaging over 70 visits/day). The full-time Medical Director and Educational Director provide an ongoing program of peer review and didactic conferences.

Seminars and didactics

In addition to weekly grand rounds there are a variety of didactic conferences which include: morbidity and mortality conference; journal club; psychiatry liaison rounds; and a variety of subspecialty conferences. A unique weekly Intern Report delivers a curriculum to meet Interns' needs.

Further education is provided through case reviews and peer reviews. Residents in outpatient settings participate in an hour-long, multidisciplinary case review conference at the conclusion of each ambulatory care session. Both psychiatric and medical preceptors participate. Peer review of charts or videotaped interviews are conducted weekly. On the inpatient service, teaching rounds and 1:1 precepting augment the daily morning report.

Inpatient Service

(1:1 Teaching with the Ward Visit approximately once/ week)

Ambulatory Services

Thursday Morning Ambulatory Conferences

Nurturing Residents' Areas of Special Interest in
Medicine and Population Health

We believe that fostering the growth of the resident involves not only supporting their progress in the core internal medicine competencies, but also nurturing their interests in special areas of medicine and population health. In parallel to the core medical program, we identify with the residents their special emphasis areas (SEA), and then create individualized educational plans that facilitate experiences, rotations, projects and mentoring, both within and outside Cambridge Health Alliance, that nurture their individual interests. Some of the topic areas for these special emphasis areas include (but are not limited to): women's health, health care policy and advocacy; occupational & environmental medicine; international health; cultural competency; geriatric medicine; preventive cardiology; medical education; patient education; pulmonary medicine; and humanities in medicine.

Examples of SEA programs include:

1) Several residents expressed strong interests in health care advocacy. One of the residents, along with a faculty advisor, organized and implemented a one month elective rotation (5 residents participated in the elective) in which they learned and expanded advocacy skills (writing, speaking, resources, being interviewed by media, etc) and started an advocacy project. The elective also included attending the American Public Health Association meetings in Washington, DC and lobbying congress about health care issues.

2) Several residents over the years have expressed interest in Occupational and Environmental Medicine, and have attended Occupational & Environmental Medicine clinic (some as a longitudinal experience), and completed OEM-related projects.

3) One resident had multiple related interests in pain management, geriatrics, and end-of-life care. She was connected with a psychiatrist who runs a palliative care fellowship at another Harvard teaching hospital, and plans to set up a rotation at this outside hospital in palliative care, and explore it as a future career option.

4) Residents interested in women's health have been given opportunities for experiences and mentorship at Cambridge Health Alliance, but also at programs/clinics at Massachusetts General Hospital and Boston University Medical Center.