CURRICULUM PREAMBLE
In an attempt to better prepare our internal medicine trainees to become comprehensive general internists, a large proportion of their training has been shifted to the outpatient setting. To deliver effective primary care medicine, general internists must be competent in the evaluation of undifferentiated medical problems, the management of acute and chronic medical illnesses, identification and management of psychosocial problems associated with illness, and comprehensive preventive services which include disease prevention, early detection and health promotion. Clinical training therefore must incorporate a wide range of knowledge and skills that are increasingly only encountered in the ambulatory setting. Ambulatory training is not only aimed at increasing the residents’ clinical experiences in longitudinal care of continuity patients, but it also moves the residents to where the majority of the patient encounters are occurring in subspecialty medicine, i.e., where most of the diagnostic and therapeutic interventions are taking place. While this shift to a more outpatient-based training experience has been essential, it has also posed new challenges for our training program.
One of the most significant challenges we’ve encountered involves standardizing the educational experience. Graduate medical education, in general, is relatively uncontrolled as it is based on actual clinical encounters which can really only be proscribed in the most general of ways. While this has always been the case, the shift from inpatient-based learning to outpatient-based learning has resulted in a structural change that has made it even more difficult for preceptors and trainees to insure that a given body of knowledge and skills has been learned in a given area of medicine. Certainly there is much to be gained from the broad clinical exposures our houseofficers are now receiving (in terms of both clinical variety as well as working with different attendings with differing practice styles and teaching skills.) However, the absence of clear, cogent, and accessible training guidelines has resulted in uneven and disparate training amongst our housestaff. In developing a comprehensive curriculum, we hope to create a structural tool to enhance our effectiveness as educators and our trainees’ effectiveness as students of internal medicine. The intention of this document is to provide a "well-thumbed" guide that will allow faculty and residents to better structure the teaching/learning experience. Of course, the predominant substrate for learning in any clinical encounter will be driven by the clinical encounter itself; however, we hope the curriculum will serve as a guide to fill in "gaps" in clinical exposure as well as to direct teaching (and learning) around clinical conditions.
To create a curriculum for our trainees and ourselves, our first task is to clarify and articulate the goals of our training program. To this end, the Curriculum Committee has worked in small groups of subspecialists and general internists to develop a comprehensive three year internal medicine curriculum. Although the curriculum is still incomplete (as it does not yet include a number of non-internal medicine specialties such as neurology, orthopedics, etc.), it does encompass all of the medical subspecialties plus some of the allied medical specialties such as dermatology and gynecology. Of note, a separate curriculum already exists for geriatrics, though this may be integrated into this document with the next edition. While we have worked to keep a consistent format throughout each of the sections of the curriculum, there is still a reasonable amount of variation in the level of detail between sections. This document is not intended to be an all-inclusive catalogue of medical condition; rather, it is intended to be a guide that outlines the essentials (the minimum requirements) of what a trainee should learn during his/her internal medicine residency.
As physicians, we are more than practitioners of the medical arts. Training in basic science is the foundation upon which clinical medical education rests. However, at a time when physicians are being asked to assume more clinical responsibilities, the potential to lose sight of the scientific underpinnings of our clinical activities emerges. The importance of science to clinical practice is profound, and without a proper understanding of the scientific principles guiding clinical medicine, our abilities to practice sound and effective internal medicine is stunted. Therefore, the Curriculum Committee believes that within every discipline of medicine, training must include attention to the scientific knowledge and investigation which bears on the fundamental mechanisms of disease and therapy. These are not spelled out separately in the following pages, though it is expected that key scientific points (from basic science research to outcomes data) be included in the learning process wherever applicable.
The following curriculum represents the first efforts of the Curriculum Committee. We fully expect (and want) people to take exception to it, identifying errors of omission, inclusion, structure and categorization. This document is meant to be useable and most importantly, used. We welcome input from houseofficers and faculty. Through this working document, we hope to clarify for teacher and student alike the goals and expectations of our Internal Medicine Residency Training Program.
Definitions:
I. Common Clinical Presentations - Extensive understanding of the full differential and knowledge and ability to carry out a prioritized cost effective work-up. [Some overlap between subspecialty curricula occurs.]
II. Physical Diagnosis - Specific physical findings related to various subspecialties are listed and should be in the knowledge base of all houseofficers graduating from the program.
III. Procedure Skills - These are procedures that all housestaff are expected to be able to perform independently at completion of the program.
IV. Primary Interpretation of Tests - These are tests that should not require additional consultation to assess and interpret. If a subcategory is listed beneath a test, then it is that specific part of the test that we expect the program graduate to be able to independently order, assess and interpret the results. If no subcategory is listed, then it is all aspects of the test that should be understood.
V. Ordering and Understanding Tests - These are tests for which the indications and the basic understanding of the information derived should be known by program graduates; however, specific test interpretation by subspecialists or experts in the test area would be expected.
VI. Clinical Conditions - These are diagnosis and findings which are the core conditions of each subspecialty. They are subcategorized to two additional levels.
Those listed as A are conditions that the program graduate should be expected to manage without consultation. Obviously, some changes in the character of the condition might require additional consultation, but in general these conditions would be the responsibility of the primary physician.
B means cases that would typically be co-managed with subspecialty consultants. This may mean that a full diagnostic work-up would often be completed by the subspecialist and then the PCP would be expected to provide most of the care, or perhaps that the subspecialist would need to play an integral part in the ongoing management of the patient. The acuity of the condition might result in shifting back and forth between the two responsibilities as patient care dictates.
C are those areas that should be recognized and diagnosed by the primary physician but managed in general by the subspecialist. Again, in certain chronic states of these various conditions, the primary physician may have a greater or lesser role.
In general, the housestaff would be expected to have primary management experience with most of the A conditions, a large number of the B conditions, but probably only a few of the C conditions. The housestaff should be exposed to the B conditions at least by some direct contact, either through exposure on the inpatient service or in subspecialty clinics but might not have the opportunity for continuity/co-management of the conditions listed as B status. C conditions might also be seen as direct contact during the training program, but at minimum should be presented as case-based presentations or conference discussions.
Program graduates should be able to recognize and establish a diagnosis and the initial acute work-up for all of the clinical conditions listed.