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Primary Care Track

OVERVIEW

The mission of the Primary Care Track (PCT) of the Dartmouth Internal Medicine Residency Program is to train outstanding general internists with a balanced expertise in the management of complicated inpatient and outpatient medical patients. The PCT provides outstanding and unique opportunities for residents to develop general internal medicine expertise at a tertiary care academic medical center, complemented by training in rural and medically underserved primary care teaching practices.

The Primary Care Track offers four PGY-1 positions each year under a unique match number.

OBJECTIVES

The specific objectives of the Primary Care Track are to:

• Balance and integrate outpatient and inpatient training (including full intensive care unit experiences).
• Focus on skills and resources needed to efficiently and effectively use medical evidence in clinical problem solving.
• Emphasize longitudinal and community-based ambulatory care learning with special opportunities in underserved settings throughout the region.
• Increase ambulatory elective experiences in traditional medical specialties.
• Expand electives in critical non-medical specialties (e.g. Orthopedics, ENT, Ophthalmology, Women's Health, Occupational Medicine).

Residents in the Primary Care Track are closely integrated with the Categorical Track and share many of the same educational objectives and opportunities. PCT residents participate in the overall Residency's comprehensive curriculum including all conferences and retreats, and work alongside categorical residents in all their inpatient rotations.

PROGRAM STRUCTURE

PCT Curriculum: The residency program employs a competency-based curriculum for all rotations. In areas that overlap with the categorical program, the two tracks share common curricula.
The highlights of the PCT curriculum are to develop knowledge and skills in:

• general ambulatory and inpatient internal medicine
• appropriate subspecialty competencies (e.g. dermatology, orthopedics, women's health, geriatrics)
• evidence-based medical decision making
• communication skills
• practice management (clinical and business)
• information management
• population approach to health care
• quality improvement in healthcare (including working in teams)
• assessing and meeting community health needs
• lifelong learning

Ambulatory Electives: Ambulatory Subspecialty Electives and subspecialty clinics are a valuable setting in which to learn skills necessary to be a practicing general internist. Five Ambulatory Elective rotations per year (four in PGY 1) provide intensive training in managing the complexities of outpatient clinical problems and medical practice. Each one-month rotation confines intensive subspecialty ambulatory clinical elective experiences with an expanded resident continuity clinic. The subspecialty electives can be scheduled in flexible and creative ways based on the needs of the resident.

Longitudinal Clinical Experiences: PCT residents see their own patients in continuity clinic one to two half days per week throughout their three-year residency. This intensive longitudinal involvement provides a true "continuity" clinic experience. Residents may conduct their continuity clinics either at DHMC or at an experienced community-based practice.

Two additional longitudinal clinical experiences are available for PCT residents. During PGY 2 & 3 years, residents have the option to participate in specialty longitudinal clinics. In addition, all residents participate in a clinical experience at the Good Neighbor Clinic, a local "free clinic" for medically underserved patients that is staffed by DHMC faculty.

Community Based Block Rotations: In each of the three years, PCT residents practice for two months in community based practices in rural or urban sites, under the supervision of experienced community based internal medicine faculty. These rotations provide outstanding clinical as well as medical practice organization experience. Opportunities to travel outside the region or participate in international health care during a community based rotation are available.

During these rotations, residents participate in all aspects of medical practice including experiences in outpatient, inpatient, emergency room, extended care facilities, and other health care settings. An extensive computer network connects regional practices enhancing learning on community rotations. During these rotations, residents usually continue their longitudinal clinic one half day per week.

Inpatient Experience: PCT residents spend 5-6 months each year on inpatient rotations (7 during PGY 1). These rotations include general medicine ward, intensive care unit, inpatient cardiology, and hematology-oncology ward rotations. Because intensive care training is often critical for rural practice, Primary Care residents spend a total of 2 months training in ICU rotations and 2 months in CCU rotations over the three year training period. PCT residents gain additional inpatient experience through inpatient activity during community based rotations. One Inpatient general medicine consultation rotation is scheduled during the senior year.

Emergency Department: PCT residents develop competence in the emergency room setting during block rotations at DHMC, Inpatient rotations at the VA, and during their community health rotations.

Research Electives: As in the Categorical Track, PCT residents are encouraged to utilize one or more elective months to accomplish their required research project. Residents have easy access to faculty willing to engage in planning and implementing projects or in incorporating residents in their own research. Planning for the research projects is coordinated by the Department of Medicine Resident research coordinator.

TEACHING SITES AND FACULTY

The main venues for teaching in the PCT are:

1. The Section of General Internal Medicine at DHMC provides the faculty and the clinical setting for  some continuity clinics, the ambulatory didactic curriculum, and resident mentoring. The section is comprised of over 20 general internists practicing at two sites:  the main DHMC campus, and a community-based site about 20 minutes north of the campus in Lyme, NH. Faculty at both sites have a strong commitment to supervising, teaching, and mentoring Primary Care and Categorical Track residents.
2. Specialty clinics provide the clinical setting for ambulatory electives. Most of these clinics are located at DHMC; a few are community-based practices. All are staffed by Dartmouth faculty. Each specialty practice has a designated administrative educational coordinator and faculty member responsible for the resident's educational experience. The Program Director is in regular contact with each site based on the feedback received from residents regarding strengths and needs of the rotation.
3. A nearby community-based internal medicine practice in Windsor, Vermont hosts PCT longitudinal clinics and community block rotations. The faculty in this private, non-university based practice has been teaching residents and students for over 20 years. They provide outstanding supervision, training and clinical exposure.  Several recent PCT resident graduates have joined this practice.
4. Other regional community-based practices host community based block rotation residents. All of these teaching practices in New Hampshire, Vermont and Maine are hospital based, small to medium sized practices and many are Rural Health Clinics located in federally-designated underserved areas. Most sites are within 2 hours of DHMC and housing is provided for non-commutable sites. These practices and faculty have received extremely positive evaluations by residents. 

EVALUATION AND FEEDBACK

An effective evaluation and feedback system is critical to the success of the PCT, and serves to help residents, faculty and the Program Director recognize strengths and improve weaknesses. The PCT and Categorical Track have identical approaches to evaluation and feedback. Both utilize a Web-based electronic evaluation system, direct meetings with supervising faculty, biannual meetings with the program director, inservice written exams (to assess preparedness for Internal Medicine Boards), and informal mentoring and feedback sessions with faculty.

LEARNING ENVIRONMENT

Dartmouth offers a positive and supportive learning environment for trainees with a career interest in General Internal Medicine.  The faculty are enthusiastic teachers and the Section of General Medicine is highly regarded among their colleagues, thus creating a respectful environment that is conducive to professional growth.

The Program Director actively solicits and responds to feedback from the residents regarding the program's educational activities including meetings with program leadership approximately twice a year.  Resident feedback is an essential component of quality improvement and curriculum development.