The internal medicine residency at Lahey Hospital & Medical Center is designed to give a high level of expertise and advanced training to tomorrow’s outstanding clinicians in internal medicine. We have 12 categorical residents per year, and six preliminary interns who are part of the Tufts Neurology program.
Time is spent in the following areas:
- Cardiology and cardiology critical care
- General medicine service
- Hematology (will be phased out in favor of a consult service)
- Medical ICU
Outpatient: all subspecialties of medicine, geriatrics, neurology. General Medicine resident clinic (“4+1” system).
Residents also spend time on night float for both the wards and critical unit. They perform general medicine consultations.
The Mondays of the general medicine weeks are dedicated as “What I Need” days (WIN days), where categorical residents can use the available time as they need for their professional development. This can include research, scholarship, QI projects, or self-care. Neurology prelim interns will have these days on their elective weeks.
We follow a 4+1 schedule in which residents are divided into five “firms” and spend every fifth week in resident continuity clinic. We have themed educational weeks in which morning reports, midday didactic conferences and board review are all centered around one specialty to help reinforce learning.
We seek regular input from residents through focus groups, elective class representative and monthly business meetings.
Our Quality Improvement curriculum is centered in the general medicine weeks. One of the associate program directors run didactics and mentors residents on a required small group QI project.
There is a protected academic day during the General Medicine continuity clinic week that includes general medicine topics, QI, Health Informatics, and simulation (scenarios and procedures).
We offer quarterly connect and reflect sessions for each PGY class with younger medicine faculty who helps facilitate discussion with the goal of easing burnout and improving resilience.
Resident ombudsmen are available to residents. Several attendings from different specialties have made themselves available for times when guidance is needed from another person outside the internal medicine residency program.
Our mentor program matches interested residents with an attending who can help them navigate the aspects of training, including personal challenges, professional goals, research interests and fellowship applications.
PGY1 residents spend time at premier public health hospital the Lemuel Shattuck Hospital in Boston. This provides exposure to underserved populations including prisoners, with a variety of disease pathology including HIV/AIDS.
Early in the second year, residents spend two to four weeks caring for patients on their own with a supervising attending. This provides an opportunity to consolidate 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.
Senior residents are encouraged to take charge of their team, directing attending rounds, proposing care plans and teaching and supervising interns. The attending is always available for direct supervision and guidance, so residents learn these skills in a safe environment that promotes quality patient care and education.
Senior residents develop consultant skills working directly with the general medicine consult hospitalist evaluating surgical and neurological patients who require internal medicine care.
Details of our program’s weekend scheduling include:
- All residents get at least one day off in seven
- Interns get approximately 16 full weekends free
- Preliminary interns get approximately eight full weekends free during electives
- PGY2 get approximately 19 full weekends free
- PGY3 get approximately 21 full weekends free
Our ward attendings are a select group from either Hospital Medicine or General Internal Medicine. This person is the attending of record for all of the patients on a service.
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—making sure 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, which eliminates overnight call for the most part. Residents requested some overnight call, which is done on the night float resident’s day off in the critical care unit. This provides the residents with an experience that they may see during fellowship. This happens about two times when on a critical care rotation for the month. There are also two nocturnal medicine attendings and an intensivist every overnight to provide supervision.
Because we and our families can get sick, we have found it important to have a mechanism for residents to take time off when needed. Our sick call system is assigned to everyone, so residents equally shoulder the task of covering for colleagues.
If there is an extended absence like maternity leave, clinical time may need to be made up during training or by extending training to make certain a resident does not lose their eligibility for American Board of Internal Medicine (ABIM) certification.
Prolonged absences may also require pay back into the sick call pool to ensure fairness.
Electives, Research and Scholarship Time
Elective, research and scholarship time is included throughout the course of the program. There is time built into the general medicine clinic weeks. Residents can tailor this time to their interests and educational needs.
Elective options include:
- Transfusion medicine
- Palliative care
A resident’s mentor can foster introductions to various attendings in a field of interest and help navigate the numerous options for research and scholarship at Lahey. Residents also forge such relationships naturally during inpatient or ambulatory rotations in fields of interest. There is funding to support resident travel should resident efforts lead to a presentation at a national meeting.
Elective time can also be used for away electives for seniors, and for research time if there is a specific project plan in place for the week.
Attending rounds for inpatient ward teams and the critical care units take place every morning. There is an emphasis on bedside rounds and integrating didactics with clinical skills.
Senior ward residents are expected to round with their interns prior to attending rounds to provide supervision and education to the interns and nurture clinical leadership. The clinical plan can be initiated when appropriate and presented at attending rounds.
Sign-out happens in the residency room for ward teams, with interns and residents signing out to their respective night float residents. This ensures that any potentially active patients overnight will be known to both the intern and resident night float.
Conferences are often grouped into a themed week chosen from the recommended American College of Physicians curriculum. All morning reports, noon conferences and high-value teaching sessions build on this theme.
Morning reports occur Tuesdays and Thursdays. These are case presentations often presented by a resident with a discussion led by the chief resident. Journal Club is also held during this time, which centers on an evidenced-based discussion lead by a senior resident. Our evidence-based medicine curriculum is bolstered by our Chair of Medicine, Sheri Keitz, MD, a nationally recognized expert in teaching EBM.
Noon conferences are held Tuesday, Wednesday and Thursdays. These are didactic lectures by subspecialty attendings or general internists. They focus on the latest guidelines, evidence-based medicine and board preparation.
Radiology conference is held every Monday. They review common and interesting findings on imaging studies from patients on the ward’s teams.
Electrocardiogram (ECG) conference is hosted once a month by our staff electrophysiology attendings with an emphasis on reading and identifying key ECG findings.
The week ends with a dedicated board review session.
Intern report takes place on Fridays starting in January (after some sessions in the summer). Senior residents will cover the interns’ pagers during this time, and the chief residents or a program director leads the session. Emphasis is on fundamental clinical skill development and core medical knowledge. Later in the year, there are sessions on clinical teaching.
Grand rounds for internal medicine are scheduled from 7:30 to 8:30 a.m. each Friday.
Visiting professorships occur at least once per year. A nationally recognized physician is invited and presents at grand rounds as well as smaller sessions specifically for the house staff. A dinner and luncheon also occur, allowing residents a less formal opportunity to talk with the physician.
Medical Jeopardy is held monthly. We also send four residents annually to participate in the ACP Medical Jeopardy Contest.
Simulation sessions occur weekly during continuity clinic. Emphasis is on procedural skills in a simulated environment.
The education includes:
- Faculty didactics
- Hands-on practice
- Online didactics
Other sessions include patient scenarios to share clinical, leadership and communication skills.
The Simulation Center at Lahey Hospital & Medical Center has several mannequins, including a heart/lung model, to enhance the experience.
The residents informally socialize outside of work. This is a result of the great camaraderie of our house staff. Formal events include a welcome cookout for incoming interns and a graduation celebration for all house staff and faculty in the spring.
Intensive Care and Coronary Care Units
The Intensive Care Unit (ICU) team includes:
- Pulmonary-critical care fellow
- Two interns
- Two senior residents
House staff 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 except once a week. Overnight coverage is provided by an intern and senior resident for both ICU and Coronary Care Unit (CCU) patients. There is a critical care attending in-house overnight who is available for admissions and other issues.
The CCU team has the same house staff 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.
Ambulatory and Other Experiences
At least one-third of the residency experience is designed to occur in ambulatory settings.
The categorical resident continuity clinic experience in our general internal medicine practice on the Burlington campus provides the foundation for this training. Residents work closely with a designated group of attendings every five weeks when this group of residents, labeled Firms A-E, rotate throughout the three years.
To enhance continuity, residents are encouraged to assume primary responsibility for patients who do not already have primary care physicians. 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.
Residents rotate through required subspecialty ambulatory experiences. They spend two weeks at a time concentrating on the various internal medicine subspecialties.
Intensive educational programs have been developed for each rotation to ensure robust learning. These rotations also provide residents the chance to experience the subspecialties as they examine career choices. The residents can also rotate through outpatient surgical subspecialties to enhance their skills as internists.
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.
General Medicine Wards
- Teams consist of two interns, one resident, one attending (hospitalist or internist)
- At the start of the year, each intern is paired with one resident for their first rotation
- No overnight call, night float rotation present
- Census up to eight patients
Lemuel Shattuck Hospital
- Four-week rotation
- Team of four interns from different hospitals, one Tufts PGY-3 resident, one attending
- Provide care to inmates and underserved populations of the city
- Combined resident subspecialty services
- Liver team consists of one liver intern, one GI fellow, liver attending
- Oncology/hematology team consists of one intern, one senior resident and oncology/hematology attendings
Junior Hospitalist-Early in PGY2 Year
- PGY-2 resident working one-to-one with hospitalist or GIM attending
- Allows resident to consolidate clinical knowledge and managerial skills
- Team consists of two interns, two residents, one cardiology fellow, one cardiology attending
- CCU unit plus general cardiology floor
- No overnight call, night float resident present
- Team consists of two to three interns, two residents, one PCCM fellow, one PCCM attending
- Closed ICU unit
- No overnight call, night float rotation present
- Categorical residents rotate through all required over the course of 3 years
- Prelims can rotate as an elective
- Outpatient rotations in medical subspecialties, including cardiology, pulmonary, endocrinology, gastroenterology, etc.
- Many electives available, to be chosen by discussion with chief residents
- Away electives can be arranged, including international electives with a recognized organization that does overseas work. Past residents have traveled to locations such as Jordan and Bolivia.
- Elective rotation that is also designated as sick call
- One day off a week
Continuity Clinic in a 4+1 Schedule
- Categorical residents only
- Residents work with a designated group of preceptors in General Internal Medicine clinic every fifth week
- One session is in a subspecialty clinic of choice for PGY2 residents to allow for career exploration
- Experiences related to general medicine and quality improvement
- Half day per week that can be used for research, scholarship, quality improvement and a simulation half day
- Four weeks for prelim interns
- Two weeks for categorical (PGY2/PGY3) residents
- 6 p.m. to 6 a.m. shift
- Two intern night floats cross covers day teams’ inpatients
- One resident night float admits overnight to housestaff teams
- Separate CCU/ICU night float to cover units
- Bedford VA Hospital
- Outpatient neurogeriatrics
- Inpatient and outpatient consult service
- Providing care in perioperative medicine
- Co-manage patients with surgical subspecialty services
- Outpatient neurology
- Work directly with various attendings who specialize in different fields like movement disorder, epilepsy and stroke