Overview

The Emory University Internal Medicine Residency Program strives to train highly competent internists and leaders in medicine, regardless of ultimate career pathways. Internal Medicine encompasses the study and practice of health promotion, disease prevention, diagnosis, care, and treatment of men and women from adolescence to old age, during health and all stages of illness. Intrinsic to the discipline are scientific knowledge, the scientific method of problem solving, evidence-based decision making, a commitment to lifelong learning, and an attitude of caring derived from humanistic and professional values.

Residents are trained through direct patient care activities, both inpatient and outpatient, balanced with didactic instruction and education. The curriculum is structured such that a minimum of one-third of the training time is spent in ambulatory sites and a minimum of one-third of the time in inpatient sites.

Over the 36 months of training, each resident spends at least 1/2 day each week is spent in a continuity clinic managing a panel of general internal medicine patients under the direct supervision of Internal Medicine faculty.

A major strength of the Emory program is the diversity of clinical exposure. During their three years of training, residents will rotate through four affiliated hospitals and have the opportunity to rotate through the Wesley Woods Geriatric Center.

 

Emory University Hospital

Emory Hospital is a 587-bed facility that provides primary through quaternary care for adult patients. It is a site where residents are exposed to state of the art facilities, cutting edge technology, and translational medicine. Emory Hospital includes a nine-bed, NIH-funded General Clinical Research Center staffed by Emory School of Medicine faculty. Emory Hospital was named in 10 of 16 specialties ranked by the U.S. News & World Report publication Best Hospitals in America. Members of the Atlanta community have repeatedly named Emory University Hospital the Consumer's Choice Award winner. In October 2002, a Hospitalist service was created to provide 24-hour inpatient coverage and assist with resident supervision and admissions.

Grady Memorial Hospital

Grady Hospital first opened in 1892 for the purpose of providing medical care to the medically underserved residents of this community. It is now an 810-bed facility with over 30,000 admissions per year. The Grady Emergency Care Center offers the only Level One trauma care in the region. In 1988 Grady underwent a $400 million renovation and expansion project, which created state-of-the-art facilities. State Officials selected Grady Hospital as the site of major investment in a new Center of Excellence in Cancer Treatment and Prevention that opened in January 2003. This initiative is under the leadership of Dr. Otis Brawley, Professor of Medicine in the Department of Hematology and Oncology. In July 2002, Grady Memorial Hospital opened an NIH-funded General Clinical Research Center (G-CRC), making Grady Hospital one of the few public hospitals in the nation with a G-CRC on site. The Residency Program administrative staff is located on the Grady Campus.

Atlanta VA Medical Center

The VA Hospital is a 171-bed facility staffed entirely by Emory physicians. It is one of the top 10 VA medical centers in the nation for research funding. In October 2002, a new service staffed by hospitalists and physicians was added to the VA inpatient service. Patients admitted to the new service (called the “Fifth Team”) include those awaiting nursing home placement, those admitted for social reasons, and patients admitted electively (e.g., cardiac catheterization, chemotherapy).

Crawford W. Long Hospital of Emory University

Crawford Hospital is a 583-bed, community-based, tertiary care center in Atlanta's midtown and is staffed by both Emory University School of Medicine Faculty and community physicians. Medical services include four 12-bed acute intensive care units and a two-chamber hyperbaric oxygen unit. Crawford Long Hospital has just completed a $270 million development project, the largest hospital construction in Georgia.

Wesley Woods Geriatric Center

Wesley Woods is a 100-bed center of excellence in geriatric and rehabilitative medicine. It is a leading center for excellence in clinical care and research.

Conferences and Seminars

In addition to morning report and rounds, the Emory program provides core conferences for a minimum of 150 hours per year of conference-based educational experience. We expect each resident to attend at least 60% of these conferences.

The core conference series covers the major topics in general internal medicine, including issues arising in ambulatory and extended care settings and the internal medicine subspecialties. The conference series is described briefly below and in more detail in the subsequent curriculum sections:

1. Core lectures (Tues am 7:00-8:30 am): July-September
   (Tues am 7:00-7:30 am): September-July
2. Medical Grand Rounds (Tues 7:30-8:30 am): September - July
3. Pre-clinic Conference (30 minutes prior to clinic each week)
4. Journal Club (12:00-1:00 pm) conference once monthly
   evening conference once monthly
5. M & M/CPC (12:00-1:00 pm) conference once monthly
6. Subspecialty Review (12:00-1:00 pm) conference once monthly
7. Ambulatory Medicine lecture and workshop series, including evidence-based medicine and procedure workshops

The core conference series is a 2-year rotating curriculum and is available for review on tape, electronically, and via handout to afford each resident an opportunity to attend or review most of the core conference topics. The curriculum includes the interdisciplinary topics such as adolescent medicine, clinical ethics, medical genetics, quality assessment, quality improvement, risk management, preventive medicine, medical informatics and decision- making skills, law and public policy, pain management, end-of-life care, domestic violence, physician impairment, and substance-use disorders. The conferences include information from the basic medical sciences, with emphasis on the pathophysiology of disease and reviews of recent advances in clinical medicine and biomedical research.

Faculty members are directly involved with the core conferences including journal club sessions emphasizing critical appraisal of the medical literature and evidence based medicine; clinical pathologic conferences correlating current pathological material, (including material from autopsies, surgical specimens, and other pathology material), with the clinical course and management of patients; and clinical quality improvement (morbidity and mortality) conferences focusing on adverse clinical events on the teaching services. At Morbidity and Mortality conferences, faculty and residents jointly analyze the causes and consequences of each event, and propose actions to avoid recurrence of similar events.

Library and Literature Appraisal Skills:

To facilitate patient care and resident education, residents have ready access to an on-site library, a computerized literature search system, and electronic medical database at each site, at all times. PGY-1 residents receive an in-depth orientation on the use of library services by trained librarians, followed by close contact with librarians throughout the 3 years of training. A Medical Librarian is present at resident report sessions and assists residents with literature searches related to the case discussions.

Ambulatory Medicine

Approximately one-third of the residency training occurs in the ambulatory care setting. This includes time in the general medicine continuity clinics, subspecialty clinics, ambulatory block rotations, emergency medicine, walk-in clinics, neighborhood health clinics, and home-care visits.

In the ambulatory setting, the faculty’s primary responsibilities are to supervise and teach the residents. In the outpatient clinics, residents are also able to obtain appropriate and timely consultation from other specialties for their ambulatory patients, and there are services available from other health-care professionals such as nurses, social workers, language interpreters, and dietitians.

Residents may be excused from attending their continuity clinic when they are assigned to the intensive care unit, to emergency medicine, to an away-elective, or to night float. Residents must attend a minimum of 108 weekly continuity clinic sessions during the 36 months of training. The continuing patient-care experience should not be interrupted by more than 1 month, excluding a resident's vacation.

The number of patients seen by a first-year resident, when averaged over the year will range from 3 to 5 per scheduled 1/2-day session. The number of patients seen by a second-year resident, when averaged over the year, will range from 4 to 6 per scheduled 1/2-day session. The number of patients seen by a third-year resident, when averaged over the year, must be at least 4 per scheduled 1/2-day session. Each resident must follow patients with chronic diseases on a long-term basis.

Every effort will be made to inform residents of the status of their continuity patients when they are hospitalized so the resident can make appropriate arrangements to maintain continuity of care.

Geriatrics

Residents receive formal didactic instruction in geriatric medicine by ABMS-certified geriatricians as part of the core curriculum and have clinical experience in geriatric medicine. These experiences can occur at one or more specifically designated geriatric inpatient units, geriatric consultation services, long-term care facilities, geriatric ambulatory clinics, and/or home-care settings. Some residents will be assigned to a month-long block of time at the Wesley Woods Geriatric Hospital, while others rotate through the outpatient geriatric clinics during the ambulatory block months.

Emergency Medicine

Internal medicine residents assigned to emergency medicine will have first-contact responsibility for a sufficient number of unselected patients to meet the educational needs of the residents. Triage by other physicians prior to this contact will not occur. Internal medicine residents are assigned to emergency medicine for a total of 4 to 6 weeks of direct experience in blocks of 2 weeks. During emergency medicine assignments, continuous duty will not exceed 12 hours. Residents have direct patient responsibility, including participation in diagnosis, management, and admission decisions across the broad spectrum of medical, surgical, and psychiatric illnesses, such that the residents learn how to determine which patients require hospitalization. Internal medicine residents assigned to emergency medicine rotations are supervised on site by qualified faculty members, and timely, on-site consultations from other specialties are available.

Consultative experience

Residents have a structured clinical experience to act, under supervision, as consultants to physicians in other specialties. The consultative experience occurs in both the inpatient and outpatient rotations. During inpatient general medicine months, residents have the opportunity to serve as general medical consultants to the non-medicine specialties, and are directly supervised by the medical attending. While on the subspecialty rotations, residents serve as subspecialty consultants to medicine and non-medicine specialties and are directly supervised by the subspecialty attending. Residents receive formal training on how to serve in the consultative role as part of the core curriculum and during each of the general medicine and consult months.

During the ambulatory block months, residents are assigned to the pre-operative clinics where they provide medicine consultation to the surgical services and receive formal training on pre-operative medicine.

Inpatient Medicine/Subspecialty Experience

Residents spend a minimum of 12 months on inpatient rotations. There are 9 to 10 months of inpatient internal medicine teaching service assignments in the first year, 5 to 6 months of inpatient internal medicine teaching service assignments during the second year, and 7 to 8 during the third year of training.

The typical resident has 9 to 10 months of inpatient general internal medicine teaching service assignments over the 3 years of training (4-5 months occur in the first year).

On these rotations, the resident writes all orders for patients under the team’s care, with appropriate supervision by the attending physician. In those unusual circumstances when an attending physician or subspecialty resident writes an order on a resident's patient, the attending or subspecialty resident must communicate his or her action to the resident in a timely manner. There is a resident on-call schedule and detailed check-out and check-in procedures, so residents learn to work in teams and effectively transmit necessary clinical information to ensure safe and proper care of patients. The on-call system includes a plan for backup to ensure that patient care is not compromised during or following assigned periods of duty.

Clinical experience in each of the subspecialties of internal medicine occurs in both the inpatient and ambulatory settings. Residents can be assigned to a dedicated rotation in the specialties and the curriculum must be designed to ensure that each resident has sufficient clinical exposure to the diagnostic and therapeutic methods of each of the recognized internal medicine subspecialties.

Critical Care

Residents are assigned to critical care rotations for approximately 4 months during their training. The total required critical care experience will not exceed 6 months in 3 years of training. However, when elective experience occurs in the critical care unit, it cannot result in more than a total of 8 months of critical care in 3 years of training for any resident.

All critical care training occurs in critical care units that are directed by ABMS certified critical care specialists, and all coronary intensive care unit training occurs in critical care units that are directed by ABIM-certified cardiologists.

Timely and appropriate consultations are available from other internal medicine subspecialists and specialists from other disciplines.

Procedures

All residents are instructed in the indications, contraindications, complications, limitations, and interpretations of findings, and develop technical proficiency in performing the following procedures: advanced cardiac-life support (American Heart Association documentation of successful training within the teaching institution), abdominal paracentesis, arterial puncture, arthrocentesis, central venous line placement, lumbar puncture, nasogastric intubation, pap smear and endocervical culture, and thoracentesis.

Residents have the opportunity to achieve competence in additional procedures that may be required in their future practice settings, including arterial line placement, cryosurgical removal of skin lesions, elective cardioversion, flexible sigmoidoscopy, endotracheal intubation, skin biopsies, soft tissue and joint injections, temporary pacemaker placement, and treadmill exercise testing.

Interpretative skills

All residents develop competency in interpretation of electrocardiograms and should develop competency in interpretation of chest roentgenograms, peripheral blood smears, Gram stains of sputum, microscopic examinations of urine, spirometry, and KOH and wet prep examinations of vaginal discharge.

Residents have the opportunity to achieve competence in additional common interpretive skills required in the residents’ expected practice settings. These include but are not limited to ambulatory electrocardiography, ambulatory blood pressure monitoring, and spirometry.

Scholarly Activities

The Emory University School of Medicine fosters a spirit of inquiry and scholarship on a day-to-day basis. The Emory faculty are active participants in medical research, and the Emory University School of Medicine is the fastest growing school of medicine in the area of NIH research dollars. Both faculty and residents participate actively in scholarly activity, including the scholarship of discovery, as evidenced by peer-reviewed funding or publication of original research in peer-reviewed journals; the scholarship of dissemination, as evidenced by review articles or chapters in textbooks; and the scholarship of application, as evidenced by the publication or presentation at local, regional, or national professional and scientific society meetings (for example, case reports or clinical series). Faculty mentors offer guidance and technical support (e.g., research design, statistical analysis) for residents involved in research and provide support for resident participation, as appropriate in, scholarly activities.

Residents and faculty actively participate in clinical discussions, rounds, journal club, and research conferences in a manner that promotes a spirit of inquiry and scholarship.

ACGME Competencies

The Emory Internal Medicine Residency Program requires residents to obtain competencies in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. The program leadership strives to provide educational experiences to ensure residents develop these competencies to the level expected of a new practitioner. We are continually working to develop accurate ways of measuring these competencies. The systems that are currently in place to assess the six competencies are outlined below:

1. Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

   Educational curriculum: Throughout residency training, faculty serve as role models for providing compassionate and effective patient care. The program directors, chairman, senior professors, and chief medical residents reinforce how to provide excellence in patient care. In order to ensure that residents learn to provide excellent patient care the following skills are evaluated:

   • Caring and respectful behaviors
   • Patient interviewing skills
   • Physical examination skills
   • Performance of routine medical procedures
   • Ability to develop and carry out management plans
   • Informed decision-making
   • Ability to work within a team.

   Evaluation: The evaluation of patient care is conducted through the following instruments:

   • Clinical Evaluation Exercise (CEX) performed during the first year of training
   • Mini-Clinical Evaluation Exercise (mini-CEX) performed during the resident rotation in the Urgent Care Center at Grady Memorial Hospital
   • Procedure logs
   • Monthly rotation evaluation completed by the resident’s supervising attending, residents, and medical students
   • Auscultation skills using a heart sound simulator, “Harvey”
   • Continuity clinic evaluations
   • 360° evaluations of the resident by nurses and the case manager assigned to the resident’s inpatient medical team

2. Medical knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiologic and social-behavioral) sciences and the application of this knowledge to patient care.

   Educational curriculum: The residency core curriculum and additional conferences such as daily noon conference, morning report, and the workshop series throughout the ambulatory months provide residents with the most current medical information available, as well as appropriate references. Workshops include sessions on epidemiology and sociocultural medicine.

   Evaluation: The evaluation of medical knowledge is conducted through the following instruments:

   • Standardized In-Training Examination (PGY-2 level)
   • Monthly rotation evaluation completed by the resident’s supervising attending, residents, and medical students
   • Senior Resident Grand Rounds evaluation

3. Practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.

   Educational curriculum: Throughout residency training, residents are expected to provide a scientific and well referenced basis for their medical decisions. At Grady Memorial Hospital, a medical librarian attends resident report sessions and works closely with the presenting residents to assist with literature search and information retrieval skills. The resident and medical librarian develop an approach to developing and answering a clinical question that is relevant to the patient at hand and both the clinical question and reference that best addresses the question are posted on the morning report website. After the case presentation and discussion, the resident presents a short summary of the relevant literature and its applicability to the patient at hand. This allows the resident to learn how to use information technology, how to search for and use evidence obtained from scientific studies and how to facilitate the learning of others. In addition, as a performance improvement project, the residents receive periodic feedback on their management of their patients with diabetes. These specific and targeted feedback sessions have allowed the residents to improve their practice management of diabetes in the outpatient setting and obtain better results with their patients.

   Evaluation: The evaluation of practice-based learning is conducted through the following instruments:

   • Resident case presentations during report must include a review of relevant current literature
   • Continuity care performance feedback sessions on outpatient diabetes care as part of a disease management program
   • Monthly rotation evaluation completed by the resident’s supervising attending, residents, and medical students

4. Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and other health professionals.

   Educational curriculum: Throughout residency training, residents are expected to learn how to communicate effectively with their patients, their families and other members of the healthcare team. In addition, residents are encouraged to create a therapeutic relationship with their patients and earn the necessary listening skills that will allow them to develop into better doctors.

   Evaluation: The evaluation of interpersonal and communication skills is conducted through the following instruments:

   • 360° evaluation completed by the nurse case manager and social worker assigned to the inpatient General Medicine team
   • 360° evaluation competed by the staff (nurses, clerks, clinic assistants) in the resident continuity clinic
   • Monthly rotation evaluation completed by the resident’s supervising attending, residents, and medical students
   • Continuity clinic evaluations

5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

   Educational curriculum: The ambulatory block rotation curriculum includes sessions on professionalism, sociocultural medicine and medical ethics. In addition, all rising PGY1 and PGY2 residents are required to attend a half-day workshop in the spring entitled “How To Be A Better Resident” that covers a variety of topics including issues of professionalism, in particular, how to be sensitive to culture, age, gender and disability issues as they become team leaders.

   Evaluation: The evaluation of professionalism is conducted through the following instruments:

   • Monthly rotation evaluation completed by the resident’s supervising attending, residents, and medical students
   • 360° evaluation completed by the nurse case manager and social worker assigned to the inpatient General Medicine team
   • Completion of a professionalism checklist each year at the time of one of the semi-annual evaluations with the Program Director (see addendum)
   • Continuity clinic evaluations

6. Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the availability to effectively call on system resources to provide care that is of optimal value.

   Educational curriculum: On the inpatient and outpatient rotations and in their continuity clinics, in addition to their interactions with the nursing staff, residents work closely with social workers, clinical pharmacists, nutritionists, health educators, physical and occupational therapists, and chaplain services depending on the needs of the patient. On the Grady General Medicine inpatient rotation, each team of residents is assigned a nurse case manager and social worker with whom they work closely throughout the month. This close collaboration with the case manager and social worker allows the resident to understand the interaction of their practice with the larger system, encourages the resident to be an advocate for patients within the healthcare system, and instructs them on the knowledge and use of the various healthcare delivery systems available.

   Evaluation: The evaluation of systems-based practice is conducted through the following instruments:

   • 360° evaluation completed by the nurse case manager and social worker assigned to the inpatient General Medicine team
   • 360° evaluation competed by the clinic staff, including nurses, health educators, pharmacists, social workers, and nutritionists in the resident continuity clinic
   • Monthly rotation evaluation completed by the resident’s supervising attending, residents, and medical students

   Primary Care Track The PGY1 Cardiology rotation at Emory Hospital (H-2) required of categorical residents is not required of Primary Care Track residents. One of the 2 electives in the PGY2 Categorical Track residents’ curriculum and the PGY-3 elective rotation in the Categorical Track curriculum are also not part of the Primary Care Track curriculum.

   The Primary Care Track residents spend a minimum of 45% of their training in the outpatient setting. The Primary Care Track residents have 1 additional ambulatory block month in the PGY1 year, 1 additional ambulatory block month in the PGY2 year, and 2 additional ambulatory block months in the PGY3 year. Every PGY2 Primary Care resident also joins the Society of General Internal Medicine and attends the national meeting in the spring of their PGY2 year.

   The Primary Care Track and Categorical Track residents have access to the same faculty and/or facilities for medical experiences.

   The Department of Medicine established the Internal Medicine-Primary Care (PC) Track in 1996. The goal of this track is to recruit and train physicians who are planning a career in general internal medicine. More specifically, the major goals are to:

   1. Train the future leaders in general internal medicine
   2. Equip graduates with the knowledge, skills, and attitudes to become successful general internists and primary care physicians through:
      1. increased time in the ambulatory setting
      2. intensive training in inpatient general medicine, critical care, and medical subspecialties
      3. extensive exposure to the surgical subspecialties and other non-internal medicine specialties required for our graduates to be complete general internists
      4. a comprehensive, coordinated didactic curriculum complementing the clinical experiences and,
   3. Exposure of our trainees to the broad scope of general medicine including clinical practice, education, research, community service, health care policy, and administration.

   Since its inception, over 80% of the graduates have remained in general internal medicine, both at the academic and community-based practice levels. Several residents have pursued further training through Master’s of Science in Clinical Research, Master’s of Public Health, and other general internal medicine fellowship opportunities.

   The PC track currently recruits for 8 positions per year. The residents in this track have 3 ambulatory block months each year, on which they rotate together during their PGY-1 & PGY-2 years, and one month of their PGY-3 year. This affords them the opportunity to receive a uniform curriculum in ambulatory medicine, to build camaraderie within the group, and to have a home base in the division of general internal medicine. The planned curriculum of workshops and conferences emphasizing experiential (“hands-on”) learning addresses the skills, knowledge, and attitudes related to outpatient medicine. The conferences cover preventive medicine, episodic illnesses, management of chronic diseases, critical appraisal of the literature (e.g., diagnostic studies and outcomes research), medical psychiatry, health policy and public health, managed care, and the business of medicine. The topics of sociology, anthropology, and medical ethics are folded into an extensive psychosocial curriculum designed to foster better doctor-patient relationships. Conferences take place every morning and noontime; a 4-hour block is set aside on Thursday mornings for evidence-based medicine and psychosocial training (including cross-cultural medicine). Discussion groups, journal clubs, and social events occur each ambulatory block month in various faculty homes to bring together the PC track residents and the general medicine faculty for learning, mentoring, and socializing. On their non-ambulatory block months, the primary care residents are seamlessly integrated into the structure of the overall medicine training program, rotating with all the other medicine residents on ward services, critical medicine, subspecialty rotations, emergency medicine, and other core rotations through the coordinated efforts of the Program Director, Co-Directors, and Chief Residents.
   
   Each PC resident has a mentor within the General Medicine Division who he or she jointly chooses with Dr. Brady. Dr. Brady, as Head of the PC Track since 1999, meets with each resident individually at the start of their training and at least semi-annually throughout the years and meets with each cohort weekly during their ambulatory block months. Dr. Brady works closely with Dr. Doyle to ensure that the goals, plans, and curriculum of the PC Track meet the standards of the overall training program and meld seamlessly with the plans for the residency program. Dr. William T. Branch, Chief of the Division of General Medicine, former head of the PC Track, and author of the widely used textbook, Office Practice of Medicine(3rd ed), also meets individually with each primary care resident yearly to discuss learning goals and to provide career mentoring. Dr. Terry Jacobson, a former Primary Care resident at New York University, a former Robert Wood Johnson Clinical Scholar at the University of Pennsylvania and an Emory faculty member since 1993, serves as Associate Director of the PC Track and coordinates the research activities of the primary care residents. Dr. Stacy Higgins, a graduate of Cornell Medical School and a former resident and chief resident at Columbia University, serves as the assistant director of the track, mentors the PGY-3 PC residents for their resident grand round presentations, and is active as a faculty mentor to the minority housetaff association.

   Finally, each PC track resident becomes a member of the Society of General Internal Medicine (SGIM) during his or her PGY-2 year and attends the national SGIM meeting. Over 70% of the residents in the track have presented research abstracts, clinical vignettes, or workshops at the national meeting. Residents within the track also initiated, with Dr. Brady’s guidance, the Resident and Student Interest Group with SGIM to examine trainee-centered issues related to careers in general internal medicine.