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Internal Medicine Residency Curriculum

X+Y Block Schedule:

X+Y+Z is a variation on the standard X+Y schedule commonly used by many IM residency programs. In our Program, X+Y+Z represents a 2-month rotating schedule where a resident has 4 weeks of an inpatient rotation such as wards or ICU(X) then2 weeks of continuity resident clinic(Y) then 2 weeks of specialty or elective rotation(Z). This repeats every 2 months (8 weeks) throughout the year. This X+Y+Z configuration is an integral part of our well-being plan, guaranteeing that you are never far away from a two-day weekend (AKA golden weekend). You will not have continuity clinic duties on inpatient, specialty or elective rotations.

The Program makes sure all residents get the required 10 months of inpatient and 10 months of outpatient experiences within their 36-month residency. All residents will be able to spend at least 6 months over the course of their training in rotations geared towards their career goals. The intent of Shannon Internal Medicine Residency Program is to train competent, well-rounded internists that are capable of practicing full scope, evidenced based, compassionate internal medicine in rural underserved areas including West Texas on graduation.

All rotations including general ward service, ICU, specialty rotations, and electives are done at one facility, Shannon Medical Center, Shannon’s flagship hospital in downtown San Angelo. Continuity clinic is held across the street from the hospital at Shannon’s Beauregard Clinic on the basement floor. This allows for easy access to and from the clinic and hospital.

Sample Schedule:

Electives:

  • Women’s Health
  • Cardiology
  • Infectious Disease
  • Gastroenterology
  • Nephrology
  • ER
  • Hematology/Oncology
  • Pulmonary
  • Dermatology
  • Psychiatry
  • Geriatrics
  • Procedure/POCUS
  • Adolescent Medicine

We will try to honor any other requests if that service is available in the Shannon system.

Inpatient Ward Rotations:

Our curriculum follows the “learner-manager-teacher” model in that PGY1 residents are predominantly supervised by PGY3 seniors and PGY2 seniors have dedicated time one-on-one with attendings. There is no 24-hour call since night coverage is handled by a senior night float resident supervised by an attending nocturnist from the hospital’s hospitalist service. The inpatient service seeks to teach and promote team-based care with graduated levels of responsibility. Residents have daily interactions with consultants, nursing staff, case management, PT/OT, speech therapy, nutritionists, etc. All inpatient ward rotations are at Shannon Medical Center downtown. Residents will take admissions daily from the overnight nocturnist/NF team, the ER, and the resident continuity clinic.

Unique to our residency is that Shannon Medical Center has an open ICU so residents can care for patients in the ICU along with consultation with the critical care team. Residents consult directly with all specialists under the guidance of the attending so that they build confidence in developing appropriate consultative skills. Ultimately, residents are the primary physician caring for the patients on the inpatient service with attendings viewed as consultants and educators. This is to promote autonomy for the residents. There are separate ICU rotations where residents work under the supervision of intensivists in all three years of training.

Teaching rounds are conducted daily starting at 9 am and are usually concluded roughly by noon to 1 pm depending on the acuity of patients. On the AHD afternoon, this allows residents to grab lunch and arrive across the street on time to the conference area in the residency department area. This also allows for ample time for daily resident education and afternoon reports after the work of patient care is completed.

Resident Continuity Clinic Rotations:

The resident continuity clinic is on the basement floor of Shannon’s Beauregard Clinic building located across the street from Shannon Medical Center. It is across the waiting room from the Shannon IM Residency Program department area. The clinic is newly renovated and has 20 exam rooms and 2 procedure rooms. Resident teams consisting of all levels are created to promote continuity with patients. Residents are supervised by faculty attendings according to ACGME guidelines. Residents will be responsible for all patient follow-ups and concerns for the entire team while on the clinic rotation to allow for their colleagues on inpatient, specialty, and elective rotations to focus purely on those rotations. Residents do not have scheduled patients during AHD afternoon. Attendings and residents participate in daily didactic sessions at lunch focused on outpatient topics.

Didactics:

ACGME requires at least 4 hours of didactics per week, but our Program offers a variety of didactic opportunities throughout the week to support the education of our residents. Depending on the rotation, each resident has ample exposure to all inpatient and outpatient topics throughout his/her residency training. This ensures that didactics go well beyond the required ACGME expectations.

Academic Half Day (AHD)

We have a protected AHD from 1-5 pm one afternoon every week. All residents are excused from clinical duties during this protected time to attend AHD. Residents on night float or leave such as vacation are excused from AHD. Topics discussed in this group setting not only include typical internal medicine subjects but also business of medicine, ethics, safety events/M&M, interprofessional services, quality improvement, board review, coding/billing, townhalls, etc. AHD is held in the conference room in Shannon’s Beauregard Clinic in the residency department on the basement floor across the waiting room from the resident clinic area. This time is not only meant to be the most valuable didactic session but also a time for residents to engage in fellowship with their colleagues to promote resident wellness and teamwork.

Afternoon Report:

Afternoon reports are resident-led case presentations held twice weekly and attended by residents on inpatient services including wards, ICU, specialty, and elective rotations. This is the traditional “morning report” but just at the end of the day so that clinical work is not disrupted. Attendings, including specialists, participate. Presentations are based on patients cared for on wards, ICU, and specialty rotations. This report is held in the resident inpatient workroom at the hospital.

Ambulatory curriculum:

The ambulatory curriculum consists of short lectures given four times a week at lunchtime to residents who are on their continuity clinic rotations. These focus on a wide range of topics specific to outpatient internal medicine. They are typically limited to 35-50 minutes and follow an office-based curriculum model. Lectures are given by clinic attendings and residents and held in the department area in the Shannon Beauregard Clinic.

Journal Club:

Journal Club is held once monthly during AHD and is resident-led with faculty supervision. The purpose is to teach residents how to analyze a journal article then incorporate the information into their medical practice.

SIM Lab including Procedures, POCUS, and Mock Codes:

The Program has a dedicated SIM lab curriculum that ensures residents are trained in common hospitalist and outpatient procedures. During orientation, PGY1 residents have 3 days dedicated to learning procedures, point-of-care ultrasound (POCUS), and mock codes.

Typical procedures taught on ultrasound capable SIM models include arterial lines, central venous lines, paracentesis, thoracentesis, lumbar puncture, ABG, blood draws, arthrocentesis, and peripheral IV insertion. Other non-ultrasound guided procedures include skin biopsy, I&D, suturing, and PAP/pelvic exam.

An 8-hour POCUS workshop during orientation is taught by faculty well-versed in POCUS techniques along with a sonographer and structural cardiologist. Thereafter, residents hone their POCUS skills every day by having access to the Program’s Mindray TE X ultrasound machines in the hospital and clinic. The hope is that residents will carry forward what they learn to their daily care of patients in the inpatient and outpatient settings. To further reinforce and build POCUS skills, monthly sessions are held where an attending and senior resident spend dedicated time assisting other residents with hands-on scanning. This includes a presentation of an interesting case by a resident.

Residents have ACLS and ATLS training in the PGY1 orientation. Thereafter, mock code sessions will be scheduled in intervals to sharpen and maintain critical care skills. ATLS is a great way to learn chest tube placement from surgical experts.

Board Review:

Every resident is given access to MKSAP through a paid membership with ACP along with a subscription to UWorld for board preparation. In addition, PGY3 residents are given an allowance for ACP Internal Medicine Board Review Course. Questions are done with faculty present during AHD to help focus on test-taking strategies along with supplementing knowledge on pathologies not commonly encountered. This also helps residents prepare for Doctor’s Dilemma which is a friendly Jeopardy-like competition between Texas IM residency programs held during the annual Texas ACP chapter meeting.

Wellness and Annual Retreats:

A resident-led committee plans and hosts a monthly wellness activity for all residents who choose to attend. Biannual retreats are held for each class separately that involve guest lectures, time to give feedback to the Program Director, and an off-campus teambuilding activity. These are great times for residents to build relationships together and with faculty.

Career Coaching:

The Program Director meets with each resident about every 6 weeks for check-ins, feedback, and career coaching. Each resident has an additional faculty mentor. Residents are encouraged to find mentors in their career path. This typically occurs organically, but the program leadership will help make connections if needed.

Semiannual Reviews:

Each resident meets with either the Program Director or Associate Program Director twice yearly to review their Clinical Competency Committee review. The primary purpose of this review is to promote a growth mindset for each resident.

Quality Improvement and Scholarly Activities:

Each resident is required to complete at least one QI project in their three years of residency as well as two scholarly projects under the supervision of a faculty mentor. It is highly encouraged to present at a conference on the local, state or national level. Time and financial support are available. Shannon has its own robust research team resources, but through the affiliation with Texas A&M University Naresh K. Vashisht College of Medicine, residents also have access to university-based resources to help them pursue QI and scholarly projects.

Moonlighting:

Residents are encouraged and given a stipend to obtain their Texas state license after finishing PGY1 or PGY2 depending on their U.S. citizenship or VISA status. Moonlighting is approved on a case-by-case basis by the Program Director. Along with scheduled residency rotations, work duty hours cannot exceed 80 hours in a week.

Volunteerism:

Residents are required to participate in two volunteer activities per year. Residents are allowed to choose these activities and do not have to be related to the medical field. This is to promote humanism by giving back to the community that supports Shannon Internal Medicine Residency Program and their patients.