Internal Medicine Residency

General Internal Medicine staff photo 

Introduction

Lahey Hospital & Medical Center is a 325 bed, tertiary care medical center located in Burlington, MA. Our patients come from communities north and west of Boston, Lowell, Nashua and southern New Hampshire. Patients are transferred to the inpatient and intensive care services from community hospitals in Massachusetts and New Hampshire. Because of the large catchment area, our patients reflect the socioeconomic diversity of our region.

Internal Medicine residency training in a tertiary care medical center with a large transfer population means a lot of interesting patients! In addition to common internal medicine diagnoses like heart failure, pneumonia and acute MI, we also care for patients with advanced liver disease (we have one of the busiest liver transplant centers in the area), and oncology patients receiving chemotherapy, including as part of research protocols and autologous stem cell transplants. Our cardiac catheterization and electrophysiologic labs are very active. Patients are also transferred here with acute rheumatologic, infectious disease and endocrine disorders requiring specialized inpatient or intensive care.

Our outpatient population is equally interesting. The General Internal Medicine practice has approximately 120,000 visits each year. We service a large geographical area so the general medicine practice where residents have their continuity clinic offers a large amount of chronic disease management, eg diabetes mellitus, hypertension and asthma. Residents also have the opportunity to see patients with urgent medical problems, for pre-operative evaluations, and general preventive medicine. The practice is transforming into a medical home, and we anticipate the residents will be an integral part of these changes. This will be an opportunity to practice teamwork skills, and to thoroughly understand the many guidelines and recommendations available to help optimize health.

Lahey Clinic prides itself on its integrated group practice model. Residents work closely with all the subspecialty physicians, and rotate through each subspecialty on an ambulatory basis.

Lahey Clinic also values the sense of collegiality and teamwork that is palpable throughout the institution. This means that our residents work in a place where their input, energy and effort are recognized and appreciated. It also means that communication with attendings and other colleagues is sincere, respectful and productive.

Training residents in the 21st century

Healthcare is rapidly changing, and internists care for patients in a variety of settings, with a wide-range of medical conditions and preventive medicine needs. Our training program’s mission is to provide our residents with the skills necessary to thrive in our changing medical environment.

Because of the acuity and breadth of patients at Lahey – from intensive care to general internal medicine – our residents care for patients across a wide spectrum of disease in an efficient system supplemented by active faculty members and a supportive institution.

Our residents also have a chance to participate in other aspects of hospital and ambulatory clinic activities, including serving on committees and participating in quality improvement projects.

Lahey Clinic also offers a variety of continuing medical education programs across New England, and welcome resident participation and attendance. 

Lahey Hospital & Medical Center Internal Medicine Residency Mission Statement and Goals   

Mission  

  • To educate our residents in providing unsurpassed patient care as tomorrow’s health care leaders.
  • To support the professional development, personal growth and specific goals of residents and medical students.
  • To educate our residents in becoming a well rounded physicians, with strong understanding of the fundamentals of Internal Medicine, evidence based practice, and the refined  art of physical diagnosis. 

Goals 

The Internal Medicine Residency will: 

  • Support trainees as they learn how to deliver the highest quality and safest patient care using evidence-based medicine, quality improvement , patient safety goals, and team work. 
  • Outline and implement specific learning objectives of an educational curriculum that ensures the broad knowledge and clinical skills required of qualified physicians to provide excellent patient care, and to advance medicine through research and education.
  • Promote a culture of mutual learning, respect, and education, acknowledging diverse views that foster healthy discussions among residents, clinicians, colleagues, patients and families.
  • Utilize transparent systems for timely, meaningful and constructive resident evaluation and feedback in professionalism, patient care, medical knowledge, practice based learning, communication and systems based practice that are aligned with the Lahey Clinic’s mission statement of providing superior health care to our patients.
  • Support, guide and educate residents to provide ethical and patient-centered care and fulfill professional obligations.
  • Nurture residents to become lifelong learners.
  • Recruit and retain exemplary residents, medical students, and faculty.
  • Maintain a balance of education, service and research, while adhering to Lahey Clinic’s internal GME committee guidelines and maintaining GME accreditation.
  • Promote scholarly activities and opportunities for research projects while providing mentoring and supervision by faculty.  

Inpatient Ward Medicine

In addition, early in the second year, residents spend 4 weeks caring for patients on their own with a supervising attending. This provides them an opportunity to consolidate their clinical skills and medical knowledge, prior to assuming responsibility as team leader/manager. To transition into this role, PGY2 residents typically first work with just one intern, before leading two interns.

All senior residents are encouraged to take charge of their team, directing attending walk rounds, proposing care plans and teaching and supervising the interns. The attending is always available for direct supervision and guidance so the residents learn these skills in a safe environment that promotes quality patient care and education.

Our ward attendings are a select group from either Hospital Medicine or General Internal Medicine. Occasional subspecialty attendings also spend time as general ward attending, including our chair of internal medicine. This person is the attending of record for most or all of the patients on a service. This means attending rounds and ongoing care is efficient. Ward attendings generally have no other obligations, facilitating the direct observation of and feedback to residents as they provide patient care. These physicians also champion learning on the rotation – insuring that education supplements patient care at the bedside, through presentations and the dissemination of relevant literature. Attendings are encouraged to attend morning report as well.

There is a night float system for both interns and residents, eliminating overnight call. There are also 2 nocturnal medicine attendings and an intensivist every overnight to provide supervision.

PGY1 categorical residents spend time at the Lemuel Shattuck Hospital in Boston, a premier public health hospital in Massachusetts. This provides exposure to underserved populations, including prisoners, with a variety of disease pathology, including HIV/AIDS.

Senior residents develop consultant skills working directly with the General Medicine Consult hospitalist evaluating surgical and neurological patients who require internal medicine care.

Intensive Care and Coronary Care Units (ICU and CCU)

The ICU team includes 2 senior residents, 2 interns, a pulmonary-critical care fellow and an intensivist. Housestaff develop the clinical skills required in the care of critically ill patients. Simulation training provides the foundation for procedural skills used frequently in the ICU. There is no overnight call. The residents rotate through a night medicine shift over the course of the 4 week block, which still allows the residents direct contact with the fellows and critical care attendings. There is a critical care attending in-house overnight, available for admissions and other issues.

The CCU team has the same housestaff staffing, and includes a cardiology fellow and cardiology attending. The call schedule is the same as for the ICU. The cardiology fellow assists with all admissions. The CCU team also cares for cardiology patients on a general ward. This provides continuity for patients transferred out of the CCU, and also augments exposure to less critically ill cardiac patients.

The ICU and CCU night residents work as a team, with an intern from one service and a resident from the other service. The units are physically connected, making intern supervision straightforward. This, along with the fellow and attending presence, means that the residents provide care in a supervised and well-staffed environment.

Ambulatory Experiences

At least one third of the residency experience is designed to occur in ambulatory settings.

The foundation of this is the categorical resident continuity clinic experience in our general internal medicine (GIM) practice on the Burlington campus. The residents work closely with a designated attending on a specified afternoon throughout the 3 years. The residents spend additional sessions in GIM during various ambulatory experiences. This allows them to work with a variety of the attendings, enhancing the clinical education. There are also required GIM blocks in each academic year, providing a concentrated experience in general medicine and related areas such as pre-operative medicine and dermatology. To enhance continuity, residents are encouraged to assume primary responsibility for patients they care for on the inpatient service who do not have primary care physicians already. In addition, residents have the opportunity to care for a subset of their continuity preceptor’s panel of patients. This provides the chance to care for patients with chronic illness over time.

The residents rotate through required subspecialty ambulatory experiences. This is a chance to spend 2 weeks concentrating in the various internal medicine subspecialties. Intensive educational programs are being developed for each rotation to insure robust learning. These rotations also provide residents the chance to experience up close the sub-specialties as they ponder career choices. The residents will also rotate through outpatient surgical sub-specialties to enhance their skills as internists.

The categorical residents spend time in neurology and the emergency department. They also spend time learning various aspects of geriatric medicine. This experience includes time at a local VA, in palliative care, and with neurology faculty learning about cognitive disorders and other issues that preferentially affect elderly patients.

There is also elective and research/scholarship time over the course of the training program. Residents can tailor this time to their interests and educational needs. Elective options include radiology, psychiatry, transfusion medicine, and anesthesia. There is a faculty research champion to help facilitate scholarship. The resident’s mentor can foster introductions to various attendings in a field of interest, and help the resident navigate the numerous options for research and scholarship at Lahey Hospital & Medical Center. There is funding to support resident travel should resident efforts lead to a presentation at a national meeting.

Elective time can also be used to travel abroad as part of the Global Outreach Program in which various Lahey faculty members participate. Typically each year, 2 or 3 residents join the electrophysiology cardiology team for an annual visit to Bolivia for Project Pacer. This group, for more than 25 years, has been providing specialized cardiac care to patients in Bolivia, where Chagas disease is endemic.