Educational Purpose and Goals
Physicians must demonstrate knowledge about both established and evolving biomedical, clinical, epidemiological and social-behavioral sciences.  Physicians must also be able to apply this knowledge to patient care.  Residents must develop breadth and depth of knowledge, and they must develop analytical skills to continuously refine and appropriately apply their knowledge in varied clinical settings.

Principal Teaching Methods
Supervised Direct Patient Care

At SVCMC St. Vincent's Manhattan, residents encounter diverse in-patient and out-patient populations.  When providing care to these patients under the supervision of an attending physician, residents must incorporate knowledge of both biomedical and social-behavioral sciences.  Management rounds, teaching attending rounds, and the out-patient clinic experiences all contribute to an expanding knowledge base.
Required in-patient clinical experiences include General Medical Floors, Hematology-Oncology and Bone Marrow Transplant Unit, Medical Intensive Care Unit, Coronary Care Unit, Night Float Medicine, Emergency Medicine and Medical Consultation rotations. Required out-patient clinical experiences include weekly continuity clinic and two Ambulatory Block experiences each year.

Small Group Discussions

 All residents on general medical floor rotations attend (Monday through Thursday) Morning Sign-In. Night Float residents attend Morning Sign-In to communicate directly regarding cross-coverage issues.  They then meet with the Chief Resident who will randomly choose an admitted case and go to the bedside with the residents, review findings, review written documentation and give immediate feedback.  Night float residents also have the opportunity to discuss any questions that arose during their call.  Night float interns are given a brief didactic by the Chief Resident.

In addition, PGY 2,3,4 residents attend Morning Report Monday through Thursday mornings immediately after Resident Work Rounds. Morning report includes learning exercises organized by the Chief Medical Residents. PGY 2,3 and 4 morning report includes MKSAP Board review, and formal didactic peer presentations on a patient-based topic. One day each week the Program Director of Cardiology presents an interactive EKG course, and once a week the Section Chief of Pulmonary-Critical Care Medicine reviews chest films or pulmonary function studies.  The Chairman of Medicine hears cases from residents one day a week.

Attending combined teaching/work rounds are held 6 days a week for an average total of approximately 6 hours per week.  All residents on General Medical Floor rotations meet with their assigned service attending physician with the exception of the Private teams who have Professor's Rounds for 1.5 hours three times a week.  Residents demonstrate baseline knowledge during case-based discussions, and expand their knowledge during rounds which emphasize bedside teaching and discussion of differential diagnosis, pathophysiology, data analysis, and evidence-based principles. Once each week three GMF teams meet for Didactic Rounds with all of their attending physicians to discuss an interesting case in depth.The mandatory weekly Journal Club occurs during Ambulatory Block rotations and teaches critical reading skills and evidence-based medicine with resident presentation of articles demonstrating application of EBM principles to current medical literature.

Formal Didactic Sessions  

• Core Curriculum Conference (Noon Conference)

Monday through Thursday each week all level residents gather for a didactic session.  The topics are arranged in a three year curriculum and include basic science, clinical topics relevant to general internal medicine, emergencies, subspecialty medicine, adolescent medicine, law and public policy.  Medical Jeopardy is presented once a month by the Chiefs.

• Clinical Pathological Conference

Once monthly a case is presented for discussion by the medical team, a chosen attending physician, pathology, radiology and when appropriate, surgery or other clinicians whose expertise will contribute to the discussion.
  

•  Morbidity and Mortality Conference                                                                                                        

All deaths that occur on the medical service are peer reviewed by a resident committee once a month.  Cases are identified through that review or by other means that are presented at the monthly M&M conference which focuses on practice-based learning and improvement.
   

• Grand Rounds

Traditional Grand Rounds are held weekly on Friday mornings.  

• Subspecialty Rounds

Each subspecialty conducts independent formal didactic rounds which residents must attend when they are on an elective rotation, and may attend whenever desired.
   

Primary Care Conference

A didactic presentation by a resident on a primary care or preventive medicine topic is presented weekly in the ambulatory sessions. 

Simulated Patient Care Training Sessions

Formal instruction regarding procedure indications, consent, performance technique, complications and post-procedure care are taught through formal didactic sessions integrated with small group sessions at the new Procedure and Simulation Room.

Independent Study

Independent review of MKSAP books is expected in preparation for Board Review conferences.Residents must independently complete online learning modules as part of a web-based ambulatory curriculum (Johns Hopkins.)  Modules are assigned for completion during the three year curriculum.Residents have 24-7 access to electronic medical reference materials through the SVCMC Intranet and via the internet using a barcode access to the NYMC library. Residents are assigned at least 2 weeks of research time and may request up to a total of two 4 week blocks of research elective during their three years of training.  During these blocks, residents work with a mentor to explore biomedical, clinical or cognate sciences.  Residents must present a proposal and submit a summary of their work during the elective.  All residents must prepare and submit a scholarly activity as a requirement for receiving their diploma.

Educational Content
Medical Knowledge Topics/Content: The following topics are addressed throughout didactic conferences.  Supervised patient care rotations   pertinent to each topic are noted.

• General Ambulatory Internal Medicine- included in the mandatory Ambulatory Block rotations, Continuity Clinic, Emergency Medicine as well as Primary Care Didactic series and the required web-based modular curriculum:
  • Gender specific medicine, including office   gynecology and women's medicine
  • Urgent care/emergency medicine
  • Ambulatory consultative medicine
  • Geriatrics
  • Office orthopedics and rehabilitation medicine
  • ENT office medicine
  • Dermatology
• General In-patient Internal Medicine- included in hospital medicine and night float rotations:
  •  Medical service and Private medicine floor experience.
  •  In-patient consultative service
  •  Hospitalist medicine
• Medical Subspecialties-Addressed in core didactics and the required Medical ICU, CCU, Heme-Onc and in-patient medicine rotations.  Further subspecialty training is available in elective rotations for both in-patient and ambulatory subspecialties:
  • Cardiology
  • Critical Care Medicine
  • Endocrinology
  • Gastroenterology
  • Hematology
  • Infectious Diseases
  • Nephrology
  • Oncology
  • Pulmonology
  • Rheumatology
    

Other Clinical Knowledge essential to the Practice of Internal Medicine:

• Neurology 
  • An ACGME accredited program in Neurology is offered at St. Vincent's Manhattan, and residents interact with the faculty and residents on a regular basis. An opportunity to attend Neurology Grand Rounds is available.
• Psychiatry
  o Psychosocial Medicine required in ambulatory rotation
  o General Psychiatry - elective
  o Palliative Care and Ethics
• Dermatology - both general and HIV dermatology are required in Ambulatory Medicine
• Medical Ophthalmology- elective in Ambulatory Medicine
• ENT - required in Ambulatory Medicine
•  Office Orthopedics - required in Ambulatory Medicine
• Physical Medicine and Rehabilitation- required in Ambulatory Medicine
   

Interdisciplinary Knowledge: The following topics are addressed at least once a month in the mandatory didactics:

• Adolescent Medicine
• Clinical Ethics

The following topics are addressed in the mandatory didactic sessions at least once a year:

• Medical genetics and genomics
• Quality assessment and 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
•  Substance abuse disorders
  

Knowledge Central to the performance of procedures
       Technical knowledge for performance of procedures
             Instructed during orientation (or required just prior to orientation)

•  BCLS and ACLS
• Endotracheal intubation addressed in ACLS, ICU and ventilator service rotations

             Instructed during curriculum of the Procedure and Simulator Room experience

• Arterial puncture and Arterial Line
• Central venous line
• Lumbar puncture
• Abdominal paracentesis
• Arthrocentesis of the shoulder and knee
• Thoracentesis
     

             Instructed during clinical rotations

• Abdominal paracentesis       
• Arthrocentesis
• Lumbar puncture
• Nasogastric intubation
• Thoracentesis
• Central lines
• Arterial puncture and lines
  

  Interpretation of Laboratory and other technical data: Instructed during ambulatory       orientation and in Procedure and Simulation Curriculum

• Peripheral blood smear
• Sputum gram stain
•  Microscopic urine
•  KOH prep and wet prep of vaginal discharge
•  Fecal occult blood   

             Instructed as part of mandatory conferences

• EKG
• Chest X-rays
• Spirometry                                                                                                                  Instructed in clinical rotations
• Skin biopsy
  

  Optional Procedural knowledge content available to residents during the course  of subspecialty  rotations

• Skin biopsy during dermatology and medical consultation
• Soft tissue and joint injections - ambulatory medicine, rheumatology elective

            Additional Elective content rotations

• Anesthesiology
• Medical Ethics
• Palliative Care
• Radiation Oncology
• Other resident developed electives can be proposed
  

Patient Characteristics
Medical Knowledge is acquired during supervised care of a diverse population of general medical patients, including patients with neurological presenting complaints.  Internal Medicine residents also see patients in consultation on surgical, rehabilitation, ob-gyn, psychiatry, neurology or subspecialty services.  The patient population has extensive socioeconomic diversity.

Learning Venues
All rotations are conducted at the Manhattan campus with the exception of the office orthopedics, out-patient rehabilitation medicine and office ENT.

Ancillary Educational Materials

• Medicallibrarians are available at the hospital.                                                                                   
• Full service libraries are available at St. Vincent's Manhattan and NYMC electronically.
• Residents must complete Johns Hopkins Internet Learning Center online modules for the ambulatory medicine curriculum.
• Continuity clinics and morning report conference rooms are stocked with resource texts.
• MKSAP materials are available in the Chief Residents Office.
• Power Point presentations and/or hand-outs from Noon Conferences and Grand Rounds are available in the Chief Residents office and in the library.
• Readings from primary literature are assigned by attending physicians throughout rotations.

Methods of Evaluation
Resident Performance: Faculty complete web-based electronic resident evaluation forms provided by the residency office for each rotation.  The evaluation is competency based and assesses medical knowledge.  The evaluation is shared with the resident, is available for on-line review by the resident at their convenience and is available in the residency office for internal review. Evaluations are part of the residents file and are incorporated into the semiannual performance review for directed resident feedback. Residents print a copy of their evaluations and place them in their Portfolio to be reviewed with their mentor on a quarterly basis.
        
The Clinical Competence Committee meets every 6 weeks to review specific resident performance on a rotating or prn basis, and to examine and revise standards for evaluation as necessary.  The CCC sends a letter to each individual resident reviewed with remarks. Residents are required to pass ACLS content exams on entry to the program. Annually residents must take the ACP In-Training examination.  Residents are provided their scores and made aware of content specific deficits.  Residents who perform poorly, as judged by the Program Director, may be required to participate in remediation activities.  Performance, however, does not affect promotion.
 

Program and Faculty Performance: Using the on-line evaluation system, residents complete service evaluation.  The residency office reviews evaluations and attending faculty physicians receive anonymous copies of aggregate completed evaluations.  Collective evaluations serve as tools to assess faculty development needs.
        
Residency key faculty assess instruction outcomes using results of the annual in-training exam. An annual Faculty Meeting is held in June.  A general session reviews the performance of the program during the year, and individual subspecialty sessions review the specific rotations in depth with the Program Director. ABIM Board Certification pass rates are reviewed yearly for outcomes assessment. 

Medical Knowledge Specific Competency Objectives
Residents must demonstrate knowledge about established and evolving biomedical, clinical and cognate sciences and the application of this knowledge to patient care. 

PGY 1 residents will:

• Demonstrate knowledge of common procedural indications, contraindications, equipment, specimen handling and patient after-care.
• Demonstrate knowledge of basic and clinical sciences.
• Demonstrate satisfactory knowledge of common medical conditions, sufficient to manage urgent complaints with supervision.  Residents must exhibit sufficient content knowledge of common conditions to provide care with minimal supervision by completion of PGY 1 year.
• Complete all assigned Johns Hopkins Ambulatory Curriculum modules.

 PGY 2 residents will additionally:

• Demonstrate a progression in content knowledge and analytical thinking in order to develop well-formulated differential diagnoses for multi-problem patients.
• Demonstrate understanding and responsiveness to socio-behavioral issues.
• Develop knowledge of statistical principles.  Understand and appropriately use sensitivity, specificity, predictive values, likelihood ratios, number needed to treat and odds ratio.
• Pass the USMLE Step 3 exam with documented passing grade for promotion to PGY3.
• Score a passing grade of 80% on at least 60% of Board Review final exams.
   

PGY 3 residents will:

• Demonstrate growing knowledge in the area of their chosen career path 
• Demonstrate knowledge regarding performance of procedures while minimizing patient risk and discomfort.
• Exhibit knowledge of effective teaching and evaluation methods, including RIME, one-minute preceptor and evaluation techniques.
•  Successfully meet EKG reading requirements.

Demonstrate an investigatory and analytic approach to clinical situations

PGY 1 residents will:

• Exhibit use of hospital and NYMC Medical library resources.
• Exhibit self-motivation to learn.
• Demonstrate sufficient analytical skills necessary to develop appropriate assessments and plans for common medical diagnoses and complaints.

 PGY 2 residents will:

• Independently present up-to-date scientific evidence to support hypotheses.
   

PGY 3 residents will additionally:

•  Regularly display self-initiative to stay current with new medical knowledge.
•  Regularly demonstrate knowledge of the impact of study design on validity or applicability to practice.
•  Present a formal didactic conference, demonstrating in-depth knowledge of a clinical topic of their choice.