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Categorical Program

The categorical residency training program at DHMC provides residents with a comprehensive and thorough education in internal medicine. The goal of the program is threefold:

• to train internists to care for the sickest, most complex patients across a wide spectrum of disease;
• to provide the best training possible in general internal medicine, which is the foundation upon which all subspecialties are built;
• to train internists to be life long learners who are able to expand their range of competencies as the face of medicine changes.

The categorical program offers 15 PGY-1 positions each year. Because of its relatively modest size, the program affords residents an opportunity to get to know one another very well over the three years of training. Equally important is the opportunity residents have to develop relationships with faculty within the Department of Medicine and throughout the Dartmouth-Hitchcock Medical Center. Categorical residents develop confidence with inpatient care during the residency. At the same time, they build a strong framework for outpatient medicine. These themes - a collegial learning environment and comprehensive training - are intricately woven into the curriculum, the evaluation process and the support systems that are the foundation of the training program.

CURRICULUM

DHMC's web based curriculum follows an adaptation of the FCIM Curriculum, a compilation of core competencies prepared by the Federated Council for Internal Medicine and published by the American College of Physicians in 2002.  The curriculum we follow is written in the language of the Six Core Competencies. The curriculum identifies graduated competencies as well as therapeutic skills, procedures, and tests which the resident must master in each rotation. The Internal Medicine training program also utilizes an ambulatory curriculum, which includes outpatient and ambulatory topics. Teaching skills, End of life care, and other "non-medical" curricular issues are addressed through pre-clinic ambulatory conferences, interdisciplinary noon conferences, and resident retreats.

The rotational experiences of the residents provide the clinical learning opportunities that allow residents to acquire the competencies described in the written curriculum. Residents divide their time between inpatient and outpatient care and the latter accounts for approximately one-third of a resident's experience. The housestaff assume progressively greater responsibility for the primary decisions of patient care over the three years of training. During the PGY-1, interns are immersed in inpatient and outpatient care; during the PGY-2, juniors become experts at inpatient management; and during the PGY-3, seniors become adept at outpatient and consultative medicine.

Inpatient Services

Cardiology: There are two inpatient cardiology rotations, both of which take place at DHMC. Interns rotate through the Intermediate Cardiac Care Unit (ICCU) and assume primary responsibility for patients with cardiac problems, which range from unstable angina to valvular dysfunction to acute arrhythmias. Junior and seniors spend one month each year caring for critically ill patients in the Coronary Care Unit (CCU), a state-of-the-art intensive care facility for patients with acute MI, post-infarction complications, severe pulmonary edema, and life-threatening rhythm disorders. In both the ICCU and the CCU, a team of three houseofficers works closely with a cardiology attending and fellow. The team also attends a series of teaching conferences devoted to cardiology topics.

Consult Service: This senior resident rotation offered at DHMC provides an opportunity to work one-on-one with a skilled general medical consultant. Assessment of medical issues in adult patients throughout the hospital forms the core of the experience, which also includes significant exposure to preoperative medical evaluation.

Inpatient Internal Medicine: These rotations, at DHMC and the VA, form the core experience for learning how to recognize and care for truly sick, complex internal medicine patients. At DHMC, each team consists of one intern and one resident working directly with a hospitalist. The team admits a steady number of patients every day, with no overnight call. At the VA, one intern and one resident are paired with a designated teaching attending, utilizing a standard every 4th night call system for admissions.  Dartmouth medical students and sub-interns round out the teams at both locations.

Hematology/Oncology: As the regional, federally-designated comprehensive cancer center, DHMC maintains a busy inpatient hematology/oncology service. Houseofficers gain experience with every stage of cancer treatment, including initiating chemotherapy, using new transplant protocols, and end-of-life and palliative care.

Intensive Care Unit: Staffed by a multidisciplinary team of medicine, surgery and anesthesia housestaff and attendings, the ICU offers medicine residents the opportunity to act as consultants and primary care givers for medical and surgical patients. Didactic conferences focus on the learning needs of residents.

Night Float: At DHMC, a night float team consisting of an intern paired with a senior resident manages acute overnight care for the general medicine service. This team evaluates and admits new patients to the hospital and provides cross-coverage for other medicine patients.

Outpatient Experiences

Ambulatory Block Rotations: Medicine housestaff have two ambulatory block rotations per year. These rotations may take place at the VA and at DHMC. Residents work in acute care clinics and longitudinal clinic and gain experience in otolaryngology, opthalmology, dermatology, geriatrics, and HIV. Pre-clinic conferences and reading time complement the patient care experience.

Community Practice Selective: A required elective, the Community Practice (CP) month is taken during the junior or senior year. The CP affords residents the opportunity to experience the practice of medicine in a non-academic, non-teaching hospital setting. The rotation may be used to try out a practice that the resident later joins, to learn the needs of referring physicians, or to decide on a future career path. Residents may choose from a number of local or regional practices that have hosted many residents over the years, or they may choose a practice beyond the northeast or international settings.

Continuity Clinics: Medicine housestaff begin their continuity clinics no later than August of the PGY-1 year. Residents have clinics at DHMC or at the VA. Clinics are held one half day per week at one site or another, except when the resident is on ambulatory rotations when the number increases to two half days per week. Interns inherit a panel of patients from an outgoing resident and then add to it while they are on rotations such as the emergency department, ambulatory block rotations, and the inpatient services. Housestaff are assigned new patients throughout training.

Electives: Interns, juniors and seniors have two, three and four elective rotations respectively.  They may choose electives from each medicine subspecialty and from offerings of other departments. Residents may also select electives at other institutions if DHMC and the VA do not offer the experiences they want.

Emergency Room: As the first health professionals to evaluate all patients in DHMC's medical-surgical ED, medicine housestaff quickly gain competence in assessing patients with the full spectrum of presenting complaints. DHMC's ED is a Level I trauma center and supports a helicopter urgent transport program. Since there is no ED residency at DHMC, medical, surgical, anesthesia, and OB/Gyn housestaff are supported at all times by certified Emergency Medicine attendings and they work side by side to provide emergency care.

Research:  All residents in the categorical program are required to complete an academic research project during their three years of training.  This project can consist of original benchtop laboratory research, involvement in clinical trials, critical review of a medical topic, outcomes-based research, involvement in a Quality Improvement project for the medical center or a residency program, or any other academically-based project.  There is a designated Research Director who organizes and mentors residents through the process, a self directed two week research training block in the PGY-1 year, as well as a weekly journal club to teach critical appraisal of the literature.  Many resident research projects are presented at peer-reviewed regional and national conferences.