Curriculum & Rotation Descriptions

The curriculum provides comprehensive training in outpatient and inpatient internal medicine, medical and non-medical subspecialties, emergency medicine, critical care medicine, community-based experiences and elective rotations. Residents may also design curricular experiences which meet their individual goals for training.

Because so much of the practice of primary care medicine occurs in the outpatient setting, a comprehensive experience in ambulatory medicine is the main objective of the program. In the first year, residents begin to build a panel of patients to follow during the three years of their residency. This three-year continuity experience is based in the Medical Primary Care Unit (MPCU) at Rhode Island Hospital serving an ethnically, racially and socioeconomically diverse patient population. Residents choose to maintain continuity of care when their patients are admitted to the hospital by either taking care of the patient directly or by consulting with other house staff.

Ambulatory Block

At the core of the program is the Ambulatory Block which is scheduled as three months in each of the first two years and two months in the third year. This time, devoted solely to teaching and experiences in outpatient medicine, exposes residents to all aspects of ambulatory internal medicine and its interface with other medical and non-medical subspecialties. Approximately one third of the time in block is devoted exclusively to the practice of outpatient internal medicine, a third to subspecialty ambulatory rotations and the remaining 30-40% to a structured curriculum of topics in ambulatory medicine, weekly ambulatory morning report, behavioral sciences, medical ethics, health promotion, clinical teaching seminars, and professional development, as well as weekly journal club and special primary care seminars and events.

Block allows residents to work closely with program faculty and to participate in innovative curricular developments. One such example is the curriculum in medical ethics, which is presented during block in the first two years of the program. This curriculum is taught by a general internist/ethicist. Topics include informed consent, do-not-resuscitate orders, advanced directives, confidentiality and medical decision-making. Specific case scenarios are presented and discussed with a view towards practical application and sensitive communication around these topics.

The women's health curriculum is a more recent addition and is presented in ambulatory block seminars. Residents also work closely with the women's health faculty in both the inpatient and outpatient settings. MPCU (Medical Primary Care Unit - see below) case conferences complete this component of the overall curriculum. Two recent additions include (1) Primary Care Orthopedics Lecture Series and (2) Evidence Based Screening Guidelines Seminars.

Ambulatory Morning Report was added in 2003. It has been a wonderful addition to the ambulatory curriculum. Residents choose a case from their outpatient experiences to present in a morning report style format. It is a unique conference in that the residents are in smaller, more intimate groups, learning from and teaching one another about important ambulatory topics.

A significant portion of block is devoted to the resident's longitudinal care of her or his own patient panel, with additional time in the walk-in facility of Bristol Medical Practice, a practice that includes 4 of our graduates. This helps first-year residents to develop skills in urgent care. Subspecialty ambulatory rotations during block include geriatrics, office gynecology, allergy, ophthalmology, ENT, rheumatology, orthopedics, dermatology, endocrine and others. As illustrated in the sample week of ambulatory block, the subspecialty rotations are often scheduled together based on similar themes, such as musculoskeletal specialties. These experiences broaden the resident's knowledge of ambulatory medicine and help to establish the skills related to the treatment and referral of specific problems in the practice of outpatient general internal medicine.

At the conclusion of each block, residents meet with the program director and program coordinator and staff to share evaluation and feedback. This discussion often becomes the basis for ambulatory block curricular change and innovation.

Community-Based Experiences

In the second and third years of the program, residents expand their outpatient training by choosing a community-based site in which to practice. This component broadens the scope of practice and adds an important dimension to the ambulatory experience. Because several types of practices are available, residents choose sites based on their interest and career goals. Examples include: Providence Ambulatory Health Services (community health center), Brown University Student Health Services, Women's Health Associates (a faculty-based practice offering comprehensive coordinated care to women) and private internists' offices.

An innovative, new community-based experience is beginning this year for our interns. During the 3 months of block in internship, our interns will be paired one-half day per week with our most esteemed generalist faculty at 3 faculty-based practices. The aim of this experience is to enable a physician-in-training to learn ambulatory medicine from a more seasoned primary care provider in practice. We feel this experience will enhance and complement the ambulatory experience of the MPCU.

Medical Primary Care Unit

The Medical Primary Care Unit (MPCU) is located in the Ambulatory Patient Center of Rhode Island Hospital. The patient population is diverse and includes a broad socioeconomic, ethnic and diagnostic mix. Patients make more than 20,000 visits each year to the MPCU. The unit is divided into individual primary care teams, each comprised of a nurse, a nurse practitioner, a faculty internist, medical residents, and medical students, nurses and medical assistants round out the teams. Teams meet during the same session each week. Pharmacists and social workers provide additional support services to each team.

Residents treat their patients with personalized, continuous care. If a patient cannot be seen by her or his resident, another resident or nurse practitioner who is in close communication with the primary provider sees the patient. Residents maintain an on-call telephone system for MPCU patients, with a faculty member readily available for consultation. A computerized appointment system simplifies patient scheduling.

Each patient care session is precepted by faculty general internists whose sole responsibility during the session is to provide teaching and supervision. Faculty preceptors also present the MPCU curriculum, consisting of a two-year cycle of topics. Each weekly unit includes a case with questions as well as a current article from the medical literature. These materials are compiled into a syllabus for each resident. HIV clinic meets bi-monthly in the MPCU and serves as a point of entry into, and a consultative resource for, the medical clinic system. Residents participate in HIV clinic during ambulatory block. Cases are presented to a team of multidisciplinary experts in HIV illness and management plans are established. Residents may also refer their own HIV-positive patients to the HIV clinic for consultation.

Primary Care Journal Club

Primary Care Journal Club (PCJC) is scheduled weekly. It is one of the longest running academic journal clubs in the country. A resident and faculty member work together to choose and develop a topic based on a recent article from the medical literature. Topics cover the full spectrum of medical care problems and issues that confront physicians today. Group discussions provide a forum for debating primary care topics. The PCJC gives the resident an opportunity to learn the skills of critical appraisal of the literature and presentation, working closely with a faculty member. This conference is highly regarded throughout the institution.

Ambulatory Medicine Seminars

In the ambulatory medicine seminars, a faculty member presents a topic in which he or she has expertise. Topics include hypertension, diabetes, substance abuse, women's health, clinical epidemiology/biostatistics, adolescent medicine, geriatrics/hospice and HIV management. Seminar topics are chosen based on their importance to outpatient practice. The teaching format varies depending on the topic and may include role-play, case discussion, videotape reviews or site visits.

Two additional specific seminar series are presented during ambulatory block. A course in critical appraisal of the medical literature allows residents to formally learn skills important to the practice of evidence-based medicine. Clinical teaching skills are taught in a seminar series, which focuses on the theory and practice of effective clinical teaching. The Seminar is run by one of our revered faculty members who has attended the Stanford Faculty Development Course for Clinical Teaching.

Behavioral Sciences Curriculum

One major emphasis of the program is in the psychiatric and psychosocial aspects of medicine. In the course of the three-year curriculum, residents learn to work effectively with patients whose psychiatric and/or psychosocial problems constitute a major aspect of their illness. The behavioral sciences faculty is multidisciplinary and includes a clinical psychologist and a psychiatrist, along with several internists in general medicine and faculty members from the Brown Medical School Centers for Preventive and Behavioral Medicine.

In addition to lectures, discussions and case conferences, innovative educational experiences are offered. In the first year, residents are involved in a course on communication, covering such topics as doctor-patient communication, the role of family in primary care and cultural differences in the experience of illness. Some interviews are videotaped for feedback from the faculty. Concurrently, a general psychiatry lecture series completes the first-year curriculum. Common clinical problems are chosen for their applicability and relevance.

In the second year, residents are involved in extensive patient interviews. The group meets monthly and provides consultation for patients followed by residents and faculty in the Medical Primary Care Unit who present difficult diagnostic and/or management issues. Program residents, working with the internist and clinical psychologist, serve as consultants and develop new management strategies for the patients' primary physicians.

In the third year, residents have the opportunity to serve as instructors in the first year medical interviewing course at Brown Medical School. Advanced electives in psychosocial medicine and inpatient and consultation psychiatry are also available. Residents are involved in curriculum development in this area by serving on the behavioral sciences curriculum committee.

Third Year Block

Each resident participates in 2 months of block as a 3rd year. Traditionally, the months have been chosen by the resident and the curriculum is designed by the resident. Residents have often chosen to complete their scholarly project or chosen additional ambulatory experiences.

This year, we created a more formal 3rd year block month, while still allowing for substantial flexibility. Residents stayed in their "Block Group" that they were with during 1st and 2nd year. Approximately one-quarter of the month, we conduct seminars/didactics aimed at further enhancing ambulatory knowledge and the professional development of our more experienced residents, including advanced critical appraisal skills, nutrition counseling, incorporating PFT's and Holter monitors into outpatient practice in addition to other seminars. The other ¾ of the month remain flexible allowing residents to do scholarly work and/or additional ambulatory experiences.

In addition to enhancing their ambulatory knowledge, this formal 3rd year block allows GIM residents to maintain the camaraderie and faculty interactions fostered throughout the 1st two years of residency.

Inpatient Setting

Rhode Island Hospital combines the energy of a busy metropolitan hospital with the sophisticated technology of a major trauma and referral center. The hospital is a founding partner of Lifespan, a comprehensive health system providing accessible, high value health services to the people of Rhode Island and southern New England.

General internal medicine residents provide inpatient care during all three years of the program. Inpatient patient care teams consist of interns and residents from both three-year internal medicine residencies and our 4-year Med-Peds Program, as well as preliminary medicine, ob-gyn, psychiatry emergency medicine interns. Both Rhode Island Hospital and The Miriam Hospital provide extensive night float systems so that teams do not stay overnight on call (home by 10:00PM). Residents work one month in the first year and one month in the third year at the Providence Veterans Administration Medical Center. Interns go home at 10:00PM on call nights and residents leave the post-call day by 1:00PM. Additionally, at Rhode Island Hospital, residents learn to diagnose and manage critically ill patients in the emergency department, medical intensive care unit and coronary care unit rotations.

During the first year, residents are responsible for direct patient management under the guidance of senior house officers and attending physicians. During the second and third years, the residents' inpatient responsibilities shift to supervising and teaching first-year residents and medical students. Although still intimately involved in patient care, senior residents are able to pursue other academic interests. Formal teaching sessions include daily morning report, attending rounds four times a week, daily housestaff conferences, weekly intern conference, weekly medical grand rounds and weekly residents' journal club or medical mortality conference. Various visiting professor programs are conducted throughout the year.

Night Float

Like most other training programs today, interns, junior and senior resident physicians have night float rotations - to ensure that interns and residents receive adequate rest. We have created a night float curriculum, which is case-based and is delivered by the 3rd year night float to the intern night floats.

Day Float

Supervision by a resident is provided for ward interns at Rhode Island Hospital in the absence of their resident who is attending clinic and his/her second ambulatory site. This coverage is provided by the Day Float, a system developed over a decade ago.

Critical Care (CCU/ICU)

General Internal Medicine residents will spend up to five months over the course of their three years learning how to diagnose and manage problems in critically ill patients. Residents and Interns work together in teams on call every third night. State-of-the-art technology, superb Critical Care faculty and fellows, and a diverse mix of patients for whom the residents are directly responsible are the key factors, which make this aspect of training so successful here at Brown.

Emergency Medicine

Residents will be the first contact physicians for adults with undifferentiated illnesses in the Emergency Room. Residents will spend one or two months in the ER during 2nd and 3rd year. Residents will be supervised around the clock by Board certified Emergency Room faculty. For residents who spend one month in the ER, the second month will be spent in the 3rd year as the Medical Admitting resident, serving as the admitting liaison between the medicine services and the ER.

Neurology

Interns will spend one month on the Neurology service learning the approach to patients with neurologic disease, perfecting their physical examination skills, and broadening their knowledge base in this important area of internal medicine.

Medical Consult

In the third year of residency, residents experience from two inpatient consultation rotations. The obstetrical medicine and gynecological consultation service is based at Women and Infants Hospital (located adjacent to Rhode Island Hospital) which is one of the country's busiest ob-gyn hospitals. Residents work with faculty who are nationally recognized for their expertise in medical complications of pregnancy to provide medical consultation for obstetrical and gynecological patients in both the inpatient and outpatient settings. At Rhode Island Hospital, residents serve as medical consultants to non-medical specialties and medical subspecialties. Working with a faculty preceptor, residents learn preoperative assessment and perioperative management of non-medical patients.

Electives