Curriculum

Division of General Internal Medicine and the Residency
Our Internal Medicine Resident Physicians work hand in hand with the Division of General Internal Medicine while on our four academic teams.  Our hospitalist physicians not only supervise and teach our residents, but also mentor them throughout their three years of residency training.
 

Inpatient Teams and Call
General internal medicine teams at the Hershey Medical Center are comprised of 1 senior resident and 1 intern with a team size of 10-12 patients. Teams are on call every 4th day.  Admissions are triaged-based on complexity and admitted by the teaching or hospitalist services based on patient census.  After 7 PM a night team of House Officers and Night floats take over all admission and cross cover responsibilities.

The Lebanon VA Medical Center teams consist of 1 senior paired with 1 intern, with the team size capped at 10 per team.  Teams are on call every 3rd day.  After 6:00 p.m. a night float is responsible for all admission and cross cover

PGY 1 (Categorical)
• On the inpatient service, the first year resident physician functions as the patient's primary physician.
• Interns work under the supervision of a senior resident and an attending physician on the general internal medicine, cardiology, critical care, and hematology/oncology inpatient services.
• Categorical PGY-1 residents complete an average of:
   o 12-16 weeks of inpatient general internal medicine
   o 4 weeks inpatient cardiology
   o 1 block ICU
   o 4 weeks Hematology or Oncology
   o 4 weeks of night cross-coverage
   o 12 weeks ambulatory medicine
   o 2 weeks Basic Clinical Skills Course

PGY 2/PGY 3
• The second and third year residents complete and average of:
   • 8-12 weeks per academic year as a supervisory resident inpatient general internal medicine
   • 4-8 weeks per academic year as a supervisory resident in the Medical ICU
   • 4 weeks each of Inpatient Cardiology or Oncology and Hepatology
   • 2-4 weeks per year as House Officer
   • 12-16 weeks of ambulatory medicine.
• The senior residents interested in hospitalist medicine have the opportunity to complete a 4-week rotation at Lancaster General Hospital (LGH), a large community-based hospital. The resident will function as a hospitalist for the internal medicine inpatient service with flexible roles as admitting physician, inpatient rounding and night medicine physician.
 

Electives
Electives can be selected from a wide variety of inpatient and outpatient subspecialty and general medicine rotations including: Endocrinology, Rheumatology, Sports medicine, Pulmonary medicine (including further specialization in Cystic fibrosis, Interventional Pulmonology/Bronchoscopy), Cardiology (with opportunities for further specialization for interested residents in EP, Echocardiography, Interventional Cardiology), Gastroenterology (endoscopy, inflammatory bowel disease etc. for interested residents), Hepatology, Benign and Malignant Hematology, Oncology, Infectious Disease, Allergy/Immunology, Palliative/Hospice Medicine and more.


Additional electives such as research electives and electives in faculty development, medical education, epidemiology and preventative medicine, quality improvement, or other topics can be tailored to the individual resident's interests.
 

Research Activities and Scholarly Pursuits
Our program has a rich history of scholarly pursuits, which is guided by both resident cooperation and strong faculty involvement.  Opportunities such as our Research Track allows residents interested in pursuing research as a career protected time to devote to longitudinal research projects while resources such as the Resident Research Forum allow more clinically driven residents opportunities to produce high-quality peer-reviewed projects.  The majority of our residents are completing their training with multiple achievements in the areas of research, publication, and podium/poster presentation at the regional, state, national and international level.

Resident Report
Led by the Chief residents, resident report is held on Tuesday, Wednesday, and Friday from Noon-1:00PM. This daily conference is dedicated to clinical teaching based on the most interesting cases seen at our institution in the careers of our residents.  Historical cases, fresh cases from overnight admissions whose diagnoses are not yet clear, and theoretical cases to help teach the core concepts of Internal Medicine education are used in these sessions. 

Academic Half Day
The academic half day was initially introduced in the ambulatory blocks. Due to the success we have transitioned the academic half-day into our inpatient curriculum as well. One half-day a week is reserved for lectures from various departments presenting board-relevant topics.  Our resident physicians have protected time to attend these didactic lectures.  Each month the focus of the lectures is dedicated to a specific subject of internal medicine (i.e. General Internal Medicine, Cardiology, Nephrology, etc.).  Faculty from our Division of General Internal Medicine as well as our subspecialty divisions provide board-relevant and up to date lectures to supplement the education our residents receive in clinical practice.   The outpatient curriculum academic half-day is provided for residents rotating on the ambulatory blocks.  Residents on ambulatory rotation have protected time from clinical and patient care responsibilities one half-day per week to attend small group teaching sessions. 

Journal Club
As part of our Evidence-Based Medicine (EBM) curriculum Journal Club is held once a month during the inpatient academic half day and introduces critical appraisal concepts specific for each session. Senior residents and attending physicians facilitate small group discussions, where each resident engages actively in critical study appraisal.

Grand Rounds
Tuesday mornings are reserved for Department of Medicine Grand Rounds. Here, invited guest speakers and our own experts present new research developments, updates on best clinical practice and other topics of interest from the broad realm of internal medicine.  In addition to expert panelists, residents have to opportunity to present research results or challenging case presentations during resident grand rounds.

Morbidity and Mortality (M&M) Conference
This conference is a peer-protected conference to evaluate cases with unexpected complications, medical errors or mortality. Focusing on education, system based practice and multidisciplinary quality improvement the M&M conference provides a forum for residents, faculty, nursing and administrative staff to explore the details cases with unexpected outcomes in a blame free environment. Most cases are identified by residents, presented by the chief residents and integrated directly into quality improvement projects.  This conference has proved to be a great opportunity for residents to learn and get involved in quality improvement, often with an immediate positive impact on patient care and clinical practice.

Ambulatory Training

As of July 1st, 2013 our program has successfully implemented an ambulatory block schedule to take the place of traditional weekly clinic sessions.

Our ambulatory block system enables residents to provide longitudinal patient care and limit the number of clinic sessions during busy inpatient rotations, while still meeting ACGME requirements for outpatient training.  This has significantly increased our residents' satisfaction with ambulatory training.

During any two week ambulatory block, residents provide longitudinal care for their patients in our primary care clinic but also spend time in other subspecialty clinics, which allow them to experience the full spectrum of outpatient care and prepare for a career in primary care or any other subspecialty.  Each ambulatory block has a general theme, based on the predominant area of outpatient medicine that it focuses on; for example the musculoskeletal block includes experience in sports medicine, rheumatology, podiatry and orthopedics, while our hematology-oncology block, besides rotations in our hematology and oncology clinics, it also includes an experience in clinical pathology and palliative care. Other outpatient blocks have a focus on women's health, endocrinology, gastroenterology, cardiology, geriatrics, neurology, allergy and immunology, mental health etc.  Our ambulatory curriculum also includes sessions in the procedures clinic, underserved population clinic, adolescent weight management clinic and quality care review committee.

The ambulatory block schedule incorporates protected time for self-study, quality improvement projects, as well as one half day per week which is purely dedicated to medical education (academic half day). Our academic half day features parts of our innovative curriculum in Evidence-Based Medicine (EBM modules and EBM consult) and the ACP High Value Cost Conscious curriculum. During the academic half day, residents engage in interactive, small group problem based learning and have the opportunity to assume the role of teachers for their peers.

Direct observation sessions (mini-CEX) and resident evaluations are seamlessly integrated into the residents' outpatient clinic schedule, with protected time set aside, which ensures their timely completion.

Our longitudinal care clinic is a level III patient-centered medical home and is well supported by our experienced staff. Our residents treat patients with a wide variety of disorders, ranging from routine primary care and prevention to more complex and esoteric problems.  Our residents also enjoy minimal patient no-show rate in their clinic, which allows them to quickly build and follow a patient panel.

Primary Care Track

Our primary care track enables residents with an interest in primary care to obtain more experience in the outpatient setting. In addition to their own clinic, primary care track residents spend additional time working, one to one, with an experienced primary care physician.  They also receive protected time to participate in our longitudinal outpatient quality improvement projects, as well as a two week experience as Junior Faculty. This block rotation allows our residents to work closely with the ambulatory training director, organizing educational activities such as the academic half day and improving on our outpatient curriculum. Finally, primary care track residents spend 2-4 weeks at a community based outpatient practice where they function with a high level of independence, managing common ambulatory conditions.

Evidence-Based Medicine (EBM)

Our program places a unique emphasis on the EBM training of residents. We have developed a multi-faceted curriculum, which goes beyond traditional Journal Club:

  1. EBM scripts during academic half day enable our residents to discuss important EBM concepts such as surrogate outcomes and hierarchy of evidence, without being limited to a particular research study.  EBM scripts are based on clinical scenarios and teach such concepts in an interactive and enjoyable manner.
  2. Journal Club is held once a month during our academic half day and introduces different critical appraisal concepts for each session. Senior residents and attending physicians facilitate small group discussions, where each resident actively engages in critical study appraisal. We utilize a debate format and other interactive methods to engage our residents in the process.
  3. EBM consults during academic half day, are short (10-15 min) presentations from our senior residents, each tasked with answering a clinical question. Residents practice formulating a question, searching and appraising the literature and finally discussing findings with their peers. This allows residents to become familiar with sources of original research studies but also pre-appraised information such as the PIER modules, TRIP database etc.
  4. EBM mini-CEX allows our senior residents to practice the application of EBM principles in real time, while caring for their clinic patients.

In short, EBM scripts and Journal Club provide our residents with the necessary foundations of EBM and lifelong learning behaviors, while EBM consults and EBM mini-CEX ensure that our residents practice EBM in a format easily integrated into a busy clinical practice.  

PRIMARY CARE TRACK:  Our primary care track enables residents with an interest in primary care to obtain more experience in the outpatient setting. In addition to their own clinic, primary care track residents spend additional time working one to one with experienced primary care physicians.  They also receive protected time to participate in our longitudinal outpatient quality improvement projects, as well as a two week experience as Junior Faculty. This block rotation allows our residents to work closely with the ambulatory training director, organizing educational activities such as the academic half day and improving on our outpatient curriculum. Finally, primary care track residents spend 2-4 weeks at a community based outpatient practice where they function with a high level of independence, managing common ambulatory conditions.  

Current Residents on Primary Care Track:  Jordan Balencic, PGY3; Dan Benyo, PGY2; Michael Devine, PGY3; Britt Marshall, PGY2; Laurie Shallcross, PGY3

HOSPITALIST TRACK:  Hospitalist medicine is one of the most rapidly growing and highly demanded areas of internal medicine. With a focus on the acutely ill, hospitalized patient, along with consultative medicine and perioperative management, residents on the hospitalist track will experience different care delivery, and management models. Additional rotations include Hospitalist Medicine rotations at Lancaster General Hospital, medicine consultation service, and pre-operative clinic as well as educational and elective opportunities such as quality improvement and systems based practice.

Current Residents on Hospitalist Track:  Joseph Awantang, PGY2; Stephanie Harris, PGY3; Ehsan Navabi, PGY3; Nishu Patel, PGY3; Jonathan Shallcross, PGY3

LONGITUDINAL RESEARCH TRACK:  Intended for those physicians interested in pursuing a career in basic, clinical or translational sciences, the research track offers dedicated residents protected time during their residency training to complete research with a dedicated research mentor.  There are ample opportunities for basic and clinical research through the academic resources of the medical center, Heart and Vascular and Cancer Institutes as well as the Penn State University College of Medicine. In addition to research opportunities during residency training we support the designated extended research tracks offered and supported through the ABIM

Current Residents on the Longitudinal Research Track and a brief description of their research projects:

Dr. Elizabeth Balraj: MicroRNAs and the RNA Binding Protein, TTP, in Glucocorticoid-Resistant Asthma. (Mentor: Dr. Faoud Ishmael, Division of Pulmonary, Allergy and Critical Care Medicine).

Dr. Balraj proposes to determine if TTP expression/function is different in steroid-sensitive compared to steroid-resistant asthmatics; she will also determine if microRNA expression is different in steroid-sensitive asthmatics and steroid-resistant asthmatics. The ultimate goal of the project is to use the results to design a blood test, which would identify asthmatic patients who would not benefit from steroid therapy. She will perform these studies in populations of moderate to severe persistent asthmatics, who are classified as GC-sensitive or resistant based on published criteria.

Dr. Ruchi Desai: Acute Respiratory Failure during Acute Myleoid Leukemia: Relationship with Leukocytosis and Leukemic Cell Markers. (Mentor: Dr. Andry Van de Louw, Division of Pulmonary, Allergy and Critical Care Medicine).

Dr. Desai proposes to retrospectivly characterize a cohort of newly diagnosed AML patients at HMC and relationship between leukemic cells from a quantitative and qualitative perspective. She expects that the results of the sproject will eventually lead to change in current manavgement or development of new approacthes to reduce lung injury including steroids or targeted leukemic cell anti-cytokine therapies with the goal of decreasing incidence of acute respiratory failure  and improving patient outcomes.

Dr. Maria Paula Henao: Effect of Statins on Obese Asthmatics. (Mentor: Dr. Jennifer L. Kraschnewski, Division of General Internal Medicine).

Dr. Henao will conduct a retrospective cohort study on the effects of combination asthma treatments with or without statins on asthma exacerbations and lung function in obese asthmatics. Furthermore, she will describe the phenotypes that arise when looking at the sub-population of obese asthmatics, integrating existing knowledge on the topic to provide suggestions for future research.

ABIM INTERNAL MEDICINE RESEARCH PATHWAY:  The ABIM Research Pathway is an integrated program that combines training in research with training in clinical internal medicine. This pathway is intended for physicians who intend to pursue a career in basic science or clinical research.

ABIM SUBSPECIALTY RESEARCH PATHWAY: The ABIM also offers residents a ‘Subspecialty Research Pathway' requiring 24 months of Internal Medicine and a further 12 – 24 months in sub-specialty training, after which a subspecialty or added qualification (AQ) examination may be taken in the fall of PGY-6 or 7 (dependent on specialty).

Current Resident on the ABIM Subspecialty Research Pathway:  Alaa Awad (nephrology)