The Internal Medicine Residency Program at Beth Israel Deaconess Medical Center has a long history of being a leader and innovator in medical education. Below are just a few examples of novel programs we have created to help our residents excel and achieve their career goals.
Education Innovations Project (EIP)
BIDMC's unique program in medical resident training - featuring an integrated, intensive focus on patient safety and health care quality - merited its selection as one of an initial group of 17 internal medicine residency programs nationwide to be enrolled in the Education Innovations Project, sponsored by the ACGME/Residency Review Committee in Internal Medicine. In addition to our mission of graduating residents to be outstanding clinicians, exemplary educators, and premier researchers, we have created an innovative educational infrastructure to ensure that our residents attain the requisite knowledge, skills, attitudes, and hands-on experience to serve as expert health system leaders wherever their future practice may take them. The program features:
- A principal rotation (mentored by dedicated Patient Safety Core Faculty) in which residents learn the fundamental concepts of health care quality and patient safety, participate in peer review of adverse events, and take leadership in the design and implementation of performance improvement initiatives
- A medical service divided into clinical microsystems of geographically-based multidisciplinary teams, for which local process and outcome data provide feedback for ongoing improvement
- An overall institutional commitment to the highest levels of quality, safety, and transparency through universal participation of all staff (including residents) in continuous performance improvement
Training in patient safety and quality will be absolutely essential to any future career as a leader in medicine. We offer simply the best training in these areas that is available in the United States.
Alternating Call and Elective Scheduling (ACES)
Most programs require residents to attend ambulatory continuity clinics while on inpatient rotations such as the medical wards. Unfortunately, by requiring residents to attend to inpatient responsibilities while simultaneously caring for ambulatory continuity patients, a stressful learning environment develops that can potentially compromise learning and patient care in both the inpatient and outpatient settings.
As a founding program in EIP, we were allowed to create a novel model of Alternating Call and Elective Scheduling (ACES) that separates resident inpatient clinical responsibilities from outpatient continuity care. Our goals with this unique model were to enhance the learning environment and reduce stress amongst residents in both the inpatient and outpatient settings, while maintaining or increasing patient safety and the number of continuity clinic sessions for each resident. As a result of this novel redesign, the residents felt the new structure significantly minimized conflict between inpatient and outpatient experience, promoted enhanced inpatient and outpatient safety, and promoted a continuous healing relationship with continuity patients
Look for more about our ACES educational innovation in a soon to be published manuscript in a major medical education journal.
Resident-as-Teacher and Clinician Educator Track
While all of our residents participate in our resident-as-teacher programs and are offered extensive opportunities to develop and fine-tune their teaching and leadership skills, we have designed a novel Clinician Educator Track to help those who envision a career in medical education the opportunity to fully develop the knowledge and skills needed to succeed in a future clinician educator.
This novel Clinician Educator Track not only provides you the opportunity to develop your teaching and education skills now, but also helps you to rapidly advance your career goals as a clinician educator. For more details about this novel track, see the June, 2014 issue of Academic Medicine.
In addition to the Clinician Educator Track, all of our residents receive extensive opportunities to learn about medical education and to develop their teaching skills. This year we have developed a novel week-long course on medical education for residents who want even more opportunities to become an exceptional medical educator. The Foundations of Medical Education Course will utilize a "flipped classroom" model to stimulate group discussions and learning on common topics such as adult learning theory, cognitive learning theory, feedback, small group teaching, bedside teaching, and ambulatory teaching. In addition, during the course residents will have ample opportunity to practice these skills and receive feedback from educational leaders.
Over 25 years ago Beth Israel Deaconess Medical Center created a novel teaching, learning and patient care environment in the form of our medical firm system. At the time, BIDMC was one of the first institutions in the country to create and utilize such a firm structure. Each house officer is assigned to a firm for the duration of their training. The Firm is led by a Firm Chief, Associate Firm Chief, and Chief Medical Resident; this group organizes teaching on the Firm, social events, and provides mentorship and feedback. The Firms each have geographical homes on the wards. When on a general medicine ward rotation, a house officer will always go to the same floor—work with the same nurses, case managers, and staff—under the direction of the Firm leadership. They will work with other residents and interns on the same Firm, and each week they will go to Firm Conference, led by the Firm Chief and Associate Firm Chief. In this way, a smaller group of residents and housestaff get to know each other very well. On all other rotations (ambulatory, ICU, cardiology, oncology, electives, etc.), residents work with any other resident from the entire residency—you get to know everyone in the program. Throughout the year, Firm leadership is available to serve as mentors and advisors, and also arrange formal, individual meetings several times a year.
Transitions in Care
The discharge process from the hospital is an important care transition for patients. At teaching hospitals, residents are primarily responsible for coordinating the discharge process for patients. Most learn about transitional care through an apprenticeship model of working directly with patients and through supervising peers and attending physicians. Although practical experience is beneficial, a lack of standardization can lead to variable degrees of learning amongst the residents. Therefore, we developed a novel curriculum for residents that would provide exposure to post-acute care settings, methods to improve the transfer of critical information between sites of care, skills in writing discharge summaries, and an understanding of reasons for readmission and techniques to prevent them.
Our Transitions in Care Curriculum begins intern year with sessions on how to write good discharge summaries and a review of the key components of an effective transition. In the spring, interns review profiles of the patients they’ve cared for in the hospital all year and perform a root-cause analyses of their readmitted patients. The curriculum continues junior year with case-based discussions on key topics in Transitions and resident participation in the ECHO-Care Transitions (ECHO-CT) clinic, a novel program at BIDMC that uses on-line video technology to educate practicing clinicians, medical residents, and students on key issues in transitions for recently discharged patients. Principles of Transitions in Care are re-emphasized during the senior year through a variety of practical experiences including home visits of high-risk patients, sessions at post-acute care sites and our Post-Discharge clinic, time with local VNAs, and continued participation in the ECHO-CT clinic.
Intern Orientation Program
Our novel Intern Orientation Program (IOP) was created to help interns to adjust to structure and systems of their new role, especially in their ambulatory clinics. This orientation is designed to help interns, who often having variable experience in primary care during medical school, rapidly acclimate to the outpatient setting. At the beginning of the first year, all interns begin with two weeks of either ambulatory rotation or inpatient wards, and then switch places after two weeks. During their time in the ambulatory IOP, interns are oriented to their specific clinic site and have half-day patient care sessions 3-4 times per week. They are also provided with didactic lectures on common outpatient clinical and systems topics. The IOP experience has been highly reviewed by both our interns and faculty.
Traditional internal medicine residency training consists primarily of inpatient rotations with continuity clinic sessions of variable frequency. This fragmentation makes it challenging for residents to gain comfort and skill in the ambulatory setting and does not accurately represent the practice of primary care. Our newly structured Primary Care Track is designed to increase continuous time spent in the ambulatory setting and teach residents about innovations in primary care. Our program allows residents to spend 6 consecutive months in the outpatient setting during their junior and senior years. In addition, residents participate in unique projects focused on practice redesign and quality improvement, and receive leadership training focused on the primary care experience. Our program was recently selected as a finalist in the Harvard Center for Primary Care’s Primary Care Challenge, a competition to identify innovative approaches aimed at improving primary care.
In traditional residency education most learners participate in a uniform program dictated by their residency. Such a uniform program can provide a core educational curriculum, but does not provide residents an opportunity to identify and participate in advanced educational and career development that can help residents accelerate their career trajectory along one of many diversifying career paths of internal medicine.
Thus, we have created a series of learner-centered tracks, pathways and supplemental educational experiences that complement our core educational curriculum, allowing learners to identify and participate in advanced educational and career development programs.
We offer interns the opportunity to apply to one of four formal tracks: 1) HIV Primary Care, 2) Global Health, 3) Primary Care, and 4) Clinician Educator Track. In addition, comprehensive supplemental pathways in Research and Quality Improvement exist for all residents.
BIDMC, which has a stated institutional commitment to leadership in healthcare quality and safety, offers advanced QI training for all our IM residents. Every resident participates in a QI rotation, led by one of eight funded Patient Safety Core Faculty; these specially trained faculty mentor three rotating residents each month. These residents participate in ongoing safety and quality activities at the institutional and departmental levels, perform root cause analyses, and participate in hands on project work. The faculty member mentors the project and imparts the basic concepts of QI through small group seminars.
For residents who want further QI training, we offer a one-week intensive “QI Retreat.” A dozen residents each year participate in this intensive, multidisciplinary course that teaches advanced QI skills through analysis, design, and improvement of a multidisciplinary project. The curriculum includes teaching sessions with national thought leaders in systems re-engineering and the patient perspective. Activities included a “waste walk,” analysis of the current state, and design of an ideal state.
Many residents do additional scholarly QI work through our comprehensive research pathway and opportunities as described elsewhere.