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IM Residents Performing a Thoracentesis Procedure

Curriculum Table of Contents


Overview

The OHSU Internal Medicine curriculum provides training leading to qualification for entry to the certifying exam of the American Board of Internal Medicine (ABIM). Graduates of our programs have achieved a 90 percent first attempt pass rate over the last three years. See the ABIM site for data on the board pass rates for all internal medicine programs.

The major focus of our residency program is train future physicians to be outstanding clinicians, responsible learners and mindful practitioners in a rigorous training environment that supports outstanding scholarship in teaching and research. As the only University-based training program in the state of Oregon, we have a broad mission in serving the public interest. This mission ranges from training the finest practitioners in primary care to preparing residents for entry into hospital medicine, subspecialty and investigative careers.

Our residents divide their time among general medicine and subspecialty wards, intensive care units, ambulatory care, consultation services; and emergency room and long-term care settings. Those residents planning careers in primary care spend additional time in ambulatory care, focusing on behavioral medicine and experiences in related areas such as gynecology, dermatology and medical orthopedics. In the PGY-2 year, Primary Care residents complete a community-based preceptorship, usually in a rural area of Oregon.

Our PGY-1 residents spend their entire year at OHSU Hospital and the adjacent VAMC, which are connected by a sky-bridge. We believe that limiting the first year rotations to the "Hill" fosters strong collegial relationships among the housestaff and between the housestaff and faculty, building a strong esprit de corps. In addition to acquiring experience in general inpatient and subspecialty medicine, interns rotate through ambulatory care and emergency room services, intensive care units, geriatrics, neurology and subspecialty consultation services.

The second and third years of the programs include general and subspecialty ward services and intensive care units, where residents supervise a team of interns and students, subspecialty consultation services ("selectives"), electives and ambulatory blocks. Residents also rotate for two months in both their PGY 2 and PGY 3 years at Kaiser Permanente in Portland and may also rotate for one month at another local hospital (Providence Portland). These community-based facilities provide exposure to a broad-based and diverse practice environment.

Finally, as part of our new scheduling system, all residents spend one week in clinic each month (3+1; see our FAQ).  This innovative approach to ambulatory medicine allows residents more consistent exposure in ambulatory medicine with a wide variety of exposures to not only the primary continuity clinic but various other clinics including dermatology, musculoskeletal clinic, gynecology etc.  Our curriculum in this +1 week has also been restructured to provide a cohesive set of learning objectives each month. 

Inpatient Services: OHSU and Portland VAMC

OHSU

At the OHSU Hospital, five general medicine ward teams accept and admit patients in a drip model, allowing more consistent care of patients over time (please see schedule FAQ).  Ward teams are composed of an intern, a resident, 2 medical students, a physician assistant student and an attending physician. There is a night float resident and intern on duty 6 nights a week. The attending physicians for the general medicine teams are full time faculty of the Department of Medicine, the majority of whom are full time hospitalists in the Division of Hospital Medicine and the Division of General Internal Medicine and Geriatrics whose primary goal is to teach and encourage your growth as a clinician.

At OHSU Hospital, there are two critical care teams: a MICU service and a CCU-Cardiology team. The MICU team has four interns and four residents. Each of the 4 resident-intern teams takes a week serving as the night team. The CCU-Cardiology team has 4 residents. Each member of the CCU team takes one week of night coverage with supervision from the Cardiology fellow.

Faculty from the Divisions of Cardiology and Pulmonary-Critical Care, respectively, serve as the attendings for these teams. Critical care and Cardiology fellows are present in the hospital 24/7 and provide assistance to the on-call teams and coverage of overflow patients.

Portland VA Medical Center

At the Portland VA Medical Center, five general medicine teams admit and accept patients in a drip model system similar to the University setting.  A night float team is available 6 nights of the week with the remaining night covered by a resident from the overnight team.  Attendings are full time faculty and include a mixture of hospitalist, general internal medicine and subspecialty faculty. We limit (cap) these teams to 16 patients. There is a combined team of 4 residents and 4 interns responsible for the combined MICU/CCU service.  Each team takes turns serving as the night team with day call staggered in a drip model. Faculty from both the Division of Cardiology and Pulmonary-Critical Care attend on those patients and fellows are present all day and immediately available at night.

Patient and Program Diversity

Our residents have many opportunities to be exposed to a diversity of patients and healthcare delivery.  Because OHSU is Oregon's only tertiary/quaternary academic medical center, we see a wide variety of both common and complex clinical scenarios.   Additionally, we care for patients from many sociocultural and socioeconomic backgrounds thus facilitating our education and awareness of different cultures and health beliefs.  Given the number of diverse patients, we have a comprehensive interpreter services providing language services for Bosnian/Serbo-Croatian, Chinese, Vietnamese, Russian, Spanish, and other languages including sign language.  The Department of Medicine also has a number of researchers and clinicians who are interested in understanding the multiple ways that racial, ethic and socioeconomic diversity affect health.

Specific to our residency program, OHSU residents rotate through Central City Concern’s Old Town Clinic (OTC), a non-profit agency serving individuals and families affected by homelessness, poverty and addiction.  We have a unique collaboration with OTC where our residents gain an understanding of the effects of patients’ education levels, unemployment, poverty, housing, addiction, and lack of primary care on their health and well being by working with Internal Medicine faculty who supervise the clinic.  Our residents further their understanding of healthcare issues experienced by homeless youth by participating in Outside In, a facility whose mission it is to help homeless youth and other marginalized individuals move towards improved health and self-sufficiency.  Residents also have the opportunity to participate in a second clinic in multiple diverse locations including the Multnomah County Clinic and Portland State University Student Clinic.  Finally, our residents have used their elective to broaden their horizon as a physician by participating in healthcare programs in a number of countries from Ecuador to China.


Conferences and Rounds

Each ward and ICU team makes daily work rounds. Our faculty conducts attending rounds seven days per week. Residents on inpatient services are expected to attend the following teaching conferences:

  • Noon Report (formerly morning report) in their respective hospital (OHSU or VAMC) 
  • Tuesday morning Medical Grand Rounds (OHSU)
  • Friday noon Clinical Case Conference (OHSU)
  • Noon conferences (VAMC). 

At OHSU, ward teams review daily radiographic studies with faculty from the Department of Radiology in a teaching conference Monday through Friday.

Noon Report

Noon Report is held Monday and Wednesday at both OHSU and the VAMC and lasts 45 minutes. The discussions are directed by the program director at the OHSU and the Medical Chief Residents at the VAMC. Residents, fellows and faculty participate in the discussion of a single patient chosen and presented by a designated resident. The discussions focus on the diagnostic and management issues, with an emphasis on clinical reasoning, problem solving, and formulation of clinical questions to be answered from the literature.

On Thursday, there is a separate resident report. At OHSU, residents from both the OHSU and VAMC general medicine teams meet with the Department Chair, Dr. Lynn Loriaux, as well as the division chiefs from Cardiology, Pulmonology, Nephrology, and Infectious Disease to review selected patients, focusing on challenging diagnostic or management issues.

On Friday, there is a separate intern noon report where interns meet with the Chief Residents and Dr. Andrea Cedfeldt (Associate Program Director) to present a case, with a specific focus on diagnostic reasoning.

Noon Conferences

Noon conferences are the forum for our core internal medicine curriculum that is presented over approximately 18 months and thus presented twice during the usual residents' tenure in the program. Noon conferences are presented on Tuesday, Thursday and Friday. During the initial 2 months of each academic year, the noon conference is devoted to a review of medical urgencies and emergencies that new interns and residents often confront in the ER, ICU and on the wards.

In addition to the core curriculum, the noon conference series includes additional content such as a monthly interactive EKG conference, clinical problem solving challenges, Fireside chats with the Program Director, fellowship advice and much more. Finally, as part of their scholarly requirements for residency, senior residents (PGY-3) prepare and present topics of their choice during the academic year.

The Clinical Case Conference is held Fridays at noon. During this conference both chief residents and Department of Medicine Faculty lead a clinicopathologic case discussion or a monthly morbidity and mortality conference.  

Subspecialty Selectives and Electives

The OHSU and VAMC offer subspecialty consultation rotations (“selectives”) in Cardiology, Endocrinology, Gastroenterology, Hematology/Oncology, Infectious Diseases, Nephrology, Pulmonary, and Rheumatology. Over the course of 3 years, residents will rotate on almost all of these “selectives”, with assignments based on resident preferences. When on subspecialty consultation services, residents participate in the clinics, conferences, consulting rounds and diagnostic laboratories of those subspecialties, working closely with the faculty and fellows. The residents play a central role in the consultation component of those disciplines, but also have opportunities to develop related procedural skills. Senior medical students on subspecialty electives often work with the consulting residents.

In addition, rotations in Neurology and Geriatrics are provided in the intern year. The neurology rotation is available at OHSU Hospital and is usually done in the PGY-1 year. Interns on this service work alongside the Neurology housestaff and are supervised by Neurology faculty. The Geriatrics services are based at the VAMC and its associated extended care programs in Vancouver, Washington, just across the Columbia River.  This service focuses on ambulatory and long-term-care and includes a nursing home care unit with a rehabilitation emphasis, a home care program, as well as the Geriatric assessment clinic. Interns and resident work directly with the Geriatric and Rehabilitation Medicine faculty on this service.

We also assign two elective blocks to every PGY2 and PGY3 during their training (3-4 weeks of elective time per upper level training year).  Residents may choose to fill this time with local, national, or international experiences.   

Ambulatory Training

Our residency program prides itself on a dedication to outpatient training.  This served as one of a number of important reasons we redesigned our program into the "3+1" schedule. Every month, residents have one full week focused on primary care. Each "+1 week" includes 3-5 primary continuity clinics, 1 secondary continuity clinic (for R2s and R3s- in the clinic of their choice), two Ambulatory seminar half-days, and 2-4 half-days in a wide variety of outpatient clinics  (including Women's Health, Med-Psych, Dermatology, Sports Medicine/Orthopedics, ENT/Allergy, our unique Chronic Illness Management clinic, and Social Medicine/Urban Primary Care).

While rotating in the Chronic Illness Management Clinic, residents will work on quality improvement projects and work in a team-based model for patients with diabetes mellitus. The seminar half-days are focused around a particular topic in primary care internal medicine and include case-based lectures, team-based activities, EBM reviews, a "Practice Management/Medical Home Skills" series, and Ambulatory report.  As part of our innovative Practice Management/Medical Home skills curriculum, residents receive clinic data about their panel of patients and work on team-based projects in population management.

In addition to the wide number of offerings during the +1 week, residents also rotate through an Ambulatory block and two 2-month long blocks at Kaiser Permanente. These blocks are carefully arranged to provide residents with exposure to a variety of primary care topics and venues including a unique social medicine curriculum through our affiliation with Central City Concern and a wonderful Health Systems curriculum at Kaiser.   

Primary Care Track

The Department of Medicine at OHSU is committed to practice and training in primary care internal medicine. Newly matched interns are invited to complete a career planning survey before arriving for internship. Information from this survey determines which residents are given a primary care track schedule. In the spring of each academic year, all residents complete this same survey, indicating their evolving career plans. Thus, residents may "track" in or out of the primary care track, creating an opportunity to better tailor rotations and experiences to meet their future goals and plans.

View more about the Primary Care Track


Mentorship/Advising

Our program offers both formal and informal mentorship and career counseling opportunities for resident trainees.  The formal mentorship structure consists of twice yearly meetings with the resident’s linked program director.  At the beginning of internship each resident is linked to one of the five associate residency program directors.  The Associate Program Director not only reviews the resident's rotation and self evaluations, but also offers guidance to enhance their continuing development and career planning.  The Associate Program Director helps to connect residents with subspecialty research and/or career mentors who work collaboratively to create a good balance between becoming an expert clinician and leading a healthy, fulfilling life outside of residency. 

With respect to informal mentorship, we have found that the faculty at OHSU to be warm and invested in our residents.  They are receptive to residents who approach them seeking  guidance and collaboration.  Many have chosen to spend their careers here because of their deep interest in students and residents.  Residents often develop professional and personal friendships with faculty members with whom they have served rotations or done research that focus on the resident's growth and happiness.  Most residents have several advisors and mentors.

Research

Residents have an opportunity to participate in research activities during their elective rotations and at other times during their training.  Residents may choose to work with faculty at OHSU or the Portland VA Medical Center or go off-campus (local and abroad).

Over the years, residents have completed projects that led to abstract presentations at national society meetings and subsequent publications. In the past several years, residents have presented papers at the AFCR, the International AIDS meeting, the American Gastroenterology Association, American Society of Microbiology (ICCAC) and the American College of Physicians national meetings and have won national abstract competitions sponsored by the American College of Physicians.

Fellowships

The OHSU Internal Medicine Residency Program's performance in the Fellowship Match has been excellent, with residents routinely matching in the most competitive subspecialty fellowship programs, including cardiology, gastroenterology, and hematology-oncology. While similar to other academic institutions in that many of our residents choose to remain at OHSU for their fellowship training, we strongly encourage residents to pursue specialty training at other institutions to broaden their training experience.  We believe every resident desiring a competitive fellowship will be able to obtain one and achieve their long term professional goals. We have willing and capable subspecialty and generalist mentors available to assist residents navigate that path and many OHSU faculty members welcome residents who are interested in doing research during their residency.

ABIM Research Pathway

The Department of Medicine supports the research pathway of the American Board of Internal Medicine. This pathway permits a resident to satisfy training requirements for certification in Internal Medicine with two years of clinical training and two years of research training. An applicant interested in this pathway applies for the internal medicine residency program through ERAS and if accepted then applies for the research pathway during their intern year.

Program Development

The Department of Medicine has a residency advisory committee that meets monthly throughout the year to examine and evaluate the residency program. The committee is organized into two subcommittees that have responsibilities for specific portions of the residency curriculum: inpatient and subspecialty medicine and ambulatory medicine. In addition to faculty members, the chief residents and residents from each training level serve as voting members.  These subcommittees advise the Department of Medicine on the structure of schedules, night call, and the organization of educational and patient care activities for the various housestaff rotations. They review all components of the curriculum in a structured manner on a scheduled basis. In addition, the Department periodically assembles Task Groups for specific projects.

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