Internal Medicine Curriculum

The Virginia Mason internal medicine residency curriculum consists of core inpatient rotations, ambulatory experiences including full day continuity clinic and ambulatory blocks, customizable electives, and high-yield conferences. The program has excellent adherence to ACGME duty hour limits, maximizing clinical time and supporting our mission to train excellent physicians, fulfilled individuals and innovative leaders.


Rotation Summary

Wards

R1

Categorical: 20 weeks

Primary Care: 16 weeks

Prelim: 20 weeks

R2

8-12 weeks

R3

8-12 weeks


ICU

R1

8 weeks

R2

4-8 weeks

R3

4-8 weeks


Night Float

R1

4 weeks

R2

4-8 weeks

R3

4-8 weeks


Outpatient General Internal Medicine

R1

Categorical: 4 weeks

Primary Care: 8 weeks

Prelim: As Elective

R2

0-4 weeks
(4 for Primary Care track)

R3

0-4 weeks
(4 for Primary Care track)


Emergency Medicine

R1

4 weeks

R2

0-4 weeks

R3

0-4 weeks


Elective

R1

12 weeks

R2

20-24 weeks

R3

20-24 weeks


Continuity Clinic

R1

Categorical and Primary Care:
Full day per week on electives;
Full day every other week on wards, none on nights or ICU

R2

Same as R1

R3

Same as R1


* There are 13 four-week blocks in the academic year.

   [Back to Top

Inpatient Rotations

Wards
Wards provide the backbone of our inpatient clinical education, and allow for the development of diagnostic and patient care skills. While on wards, residents are immersed in the culture of continual improvement that defines Virginia Mason as an institution.

  • Our innovative “one-piece flow” rounding system increases efficiency and patient safety, and exemplifies the Lean principles and practice for which Virginia Mason is nationally recognized.
  • Each inpatient team is composed of one senior resident (R2 or R3), two interns, and a third or fourth year medical student, with a full time teaching hospitalist attending.
  • Four ward teams share admitting with the hospitalist service during the day. Night float team provides cross-cover and admits for the resident teams overnight. All residents have one day off per week while on wards.
  • Teaching occurs at the bedside as our faculty employ an interactive teaching style which encourages residents to answer their own clinical questions using electronic resources in real-time while caring for patients.
  • Wards teams attend a didactic session and case report Monday through Thursday, as well as Grand Rounds on Friday. In addition, once per month the senior resident leads a teaching didactic on a core inpatient medicine diagnosis to improve knowledge and teaching skills. Refer to Formal Inpatient Curriculum below.

Formal Inpatient Curriculum
The Inpatient Curriculum is a resident-driven educational experience which allows senior residents to hone their teaching skills during their wards months. It was created to allow the senior resident opportunities for teaching, while also setting them up for success on inpatient months and the internal medicine board examination at the completion of residency. The curriculum entails premade modules and internal medicine board review style questions which highlight crucial hospital medicine topics, making for focused teaching and participation.

Medical Intensive Care Unit (MICU)
In addition to teaching the skills necessary for the care of the complex, critically ill patient, our MICU rotation emphasizes leadership, interdisciplinary collaboration and end-of-life care. Our award winning ICU is staffed by board-certified subspecialists who are passionate about resident education.

  • The critical care team consists of two senior residents, four interns, a daytime intensivist, and a MICU night hospitalist. The four interns are split between the day and night shifts, and they switch halfway through the rotation. 
  • Interns work approximately 11 night shifts and 11 day shifts, with six days off over the rotation. Senior residents do not work any night shifts and have five days off over the rotation.
  • Rounds are attended by a multidisciplinary team that includes not only the residents and attending, but also nurses, pharmacists, respiratory therapists, and patients with their families.

Night Float
Our night float rotation emphasizes the development of autonomous decision making, efficiency and communication. It is instrumental in training interns to admit patients in an organized, comprehensive and efficient manner, while balancing the demands of cross-cover.

  • The night float team consists of two interns, one senior resident and a nocturnist attending.
  • The night float shift is from 7 p.m. - 7:30 a.m.
  • Interns have two days per week off, and senior residents have two to three days off per week.

Swing Rotation
The swing rotation focuses on admitting new patients to the hospital and is done by second year residents as an opportunity to build clinical acumen and independence. The resident admits patients independently and then staffs with an attending. While there is always an attending in-house to offer support, residents enjoy the autonomy that this rotation offers.

  • The swing shift is from 3 p.m. to midnight with the last admission starting no later than 10 p.m. If the resident is in clinic the following day, they must leave by 10 p.m.
  • A resident admits up to four patients per shift and then hands them off to resident or hospitalist teams.
  • Primary care residents have a full day of continuity clinic once a week, while categorical residents have a full day of continuity clinic every other week.
  • The swing rotation is optional for primary care and required for categorical residents.

Elective Hospitalist Float Rotation
The resident on the hospitalist elective works one-on-one with a Virginia Mason hospitalist faculty to care for six to eight patients without a larger intern team. The resident rounds independently, checking in with the attending throughout the day. This rotation emphasizes autonomy and advanced clinical decision making skills, and is a good option for those interested in a hospitalist career.

  • Chosen as an elective by second or third year residents.
  • The shift is from 7 a.m. to 7 p.m., or 9 a.m. to 9 p.m., Monday through Sunday, every other week.
  • In the off weeks, the resident has about two days of continuity clinic and is otherwise free.
  • Residents continue to attend conferences and didactic sessions when they are in the hospital.

Emergency Medicine
Our emergency medicine rotation allows residents to hone their skills in the initial workup and management of patients with a wide range of diseases. Like all departments at Virginia Mason, our Emergency Department (ED) is designed to maximize patient safety and quality care, while minimizing cost and unnecessary testing.  

  • Residents work one-on-one with board-certified emergency medicine physicians.
  • During the block, interns work 15 shifts, consisting of day, evening and night shifts.
     

   [Back to Top]

Ambulatory Education

Continuity Clinic
Virginia Mason has a long tradition of excellence in ambulatory internal medicine. Residents from Virginia Mason consistently score in the top 10th percentile in general internal medicine on national exams and frequently go on to enjoy careers in outpatient primary care. All categorical and primary care track residents have a single continuity clinic for their three years of training.

Residents establish a panel of patients and have initial and primary responsibility for evaluation, decision-making, care planning, record keeping, follow-up and ongoing management for all their continuity clinic patients. Attendings supervise residents with increasing autonomy as they demonstrate abilities to provide excellent patient care. Residents are part of a team of care providers in the ambulatory setting, including attending physicians, nurses and medical assistants.

The clinic experience consists of a full day each week on electives and every other week on wards. Residents do not have inpatient or elective duties on their clinic days. There is no clinic on night float and ICU rotations.

Residents join one of three clinic experiences:

Eastgate Public Health Clinic

  • Eastgate is the largest of three King County public health clinics. Started in 2008, this public-private partnership has been very successful in its goals of educating residents and providing increased health care access in King County. Residents manage a diverse population of underserved, largely non-English speaking patients under the supervision of Public Health (mornings) and Virginia Mason educators (afternoons). Residents see a stunning diversity of illness presentations and learn to manage them in a resource-limited setting with the assistance of administrative and clinical staff. Ancillary services at Eastgate are excellent — with on-site Spanish interpreters as well as nurses and medical assistants dedicated to the Virginia Mason program. By expanding the capacity of the public health clinic, residents play valuable roles in providing care to patients who might otherwise go without adequate health care.
     
  • Eastgate Public Health is located in Bellevue, a 15-20 minute drive from the Hospital and Seattle Medical Center

The Pike Market Medical Clinic

  • Serving predominately an indigent, often homeless population, this clinic has served as a site for continuity practice for Virginia Mason residents for more than 20 years. Residents build their own patient panel and have considerable autonomy at this site.
     
  • Located in Pike Place Market on the waterfront in Seattle

Collaborative Practice (Virginia Mason General Internal Medicine Clinic)

  • Designed in direct response to resident feedback, this unique continuity clinic model pairs each resident with a single Virginia Mason general internal medicine attending for all three years of residency. Residents manage their panel of patients while being integrated into the larger clinic, allowing them a hands-on experience in a cutting edge, high-functioning primary care clinic.
     
  • Working with the same preceptor throughout the residency allows for more personalized resident education, creates a strong, personal relationship with an experienced clinician, and offers insight into the long-term benefits of a continuity practice.

  • Residents choose between GIM clinics in Seattle, Bellevue, Federal Way, Bainbridge Island, Issaquah, Kirkland and Lynnwood.
     

Formal Ambulatory Curriculum
Every week, all categorical residents engage in an interactive, small-group discussion on key topics in primary care. Handouts and current readings are distributed weekly and stored for future reference.

General Internal Medicine Block
This rotation provides additional ambulatory training for residents. It takes place in the General Internal Medicine (GIM) clinic, which is at the forefront of innovation in low cost, efficiently-delivered, patient-centered primary care. Residents get education in both clinical management of outpatient problems and in the systems-based improvements, which make our GIM clinics unique. Residents work one-on-one with a one or two attendings for the month. GIM clinics are located at the downtown Hospital, and medical centers in Bellevue, Federal Way, Bainbridge Island, Issaquah, Kirkland and Lynnwood. Primary care residents have an additional General Internal Medicine block in their first year (total of 2), as well as Advanced General Internal Medicine blocks in each year their second and third years. See Primary Care Track for more information.

HIV Clinic
In addition to their general medicine continuity clinic, senior residents have the opportunity to participate in our HIV continuity clinic one half-day per week for two years. Residents participate in ongoing evaluation and management of HIV-infected patients in the ambulatory and inpatient settings. Regional and national experts in HIV infection supervise the residents in this setting. This is a unique opportunity for HIV care in a continuity setting and one of only a few residencies in the country that offers this option. There is an additional didactic schedule for this continuity clinic that allows residents to be well versed in providing comprehensive care for the HIV patient.


   [Back to Top]
 

Electives

Electives are primarily outpatient based, and residents work one-on-one with specialty attendings. Rotations are taken in two- or four-week blocks and residents work Monday through Friday without weekends or call.

Electives can be customized to meet the educational goals of individual residents — to focus on inpatient or outpatient medicine, particular disease states or subspecialties, or patient populations of interest.

Residents complete all MKSAP questions during their specialty electives and review topics missed on the In-Training Exam with faculty preceptors.

All residents participate in the Systems-Based Improvement elective during their R2 or R3 year, allowing them the unparalleled opportunity to learn about the internationally renowned Virginia Mason Production System.  

Elective Options

Electives in bold are required for completion of Categorical and Primary Care Programs. 

  • Allergy and Immunology
  • Anesthesiology (Moderate sedation certification, optional)
  • Away rotation (another institution, rural, or international — R2&R3 only)
  • Cardiology
  • Dermatology — Required for Primary Care
  • Emergency Medicine at Harborview (R3 option)
  • Endocrinology
  • ENT — Recommended for Primary Care
  • Gastroenterology
  • General Internal Medicine I
  • General Internal Medicine II – Required for R1 Primary Care
  • General Internal Medicine – Advanced – Required for Primary Care, R2 and R3
  • Geriatrics — Required as R2
  • Gynecology — Required for Primary Care
  • Hematology/Oncology
  • Hyperbaric Medicine — Recommended for Primary Care
  • Infectious Diseases
  • Nephrology
  • Neurology
  • General Surgery — Recommended for Primary Care
  • Urology — Required for Primary Care
  • Ophthalmology — Recommended for Primary Care
  • Orthopedics/Sports Medicine/PMR/Podiatry (Musculoskeletal) — Required for Primary Care
  • Palliative Care
  • Pathology
  • Physical Medicine and Rehabilitation — Recommended for Primary Care
  • Primary Care Innovations - Primary Care only
  • Procedures (R2 and R3 only)
  • Pulmonary
  • Radiology (R3 option, upon approval by department)
  • Rheumatology
  • Scholarly
  • Systems-Based Practice R2 or R3

   [Back to Top]
 

Conferences

Example Conference Schedule
Click on image to enlarge.

Afternoon Report
Monday through Thursday, noon-12:30 p.m.

Afternoon report is an interactive conference focused on clinical diagnosis skills and the development of evidence-based medical practices. Residents present challenging or interesting cases, and the group discusses the differential diagnoses and appropriate work-ups.

Noon Conference
Monday through Thursday, 12:30-1 p.m.

Medicine noon conference occurs daily throughout the year and is didactic in nature. Sessions are taught by medicine subspecialists and general internal medicine faculty.

Clinic Didactic
Monday through Friday, 1-1:30 p.m.

Each resident attends once per week

Clinic didactic is an interactive, small-group discussion on key topics in primary care and lead by core primary care faculty. Cases and readings are distributed weekly and stored for future reference.

Morbidity and Mortality Conference
Monthly

A monthly presentation led by senior residents in conjunction with attending faculty. This conference focuses on improving patient care, with a particular emphasis on systems-based prevention of medical errors.  

Grand Rounds
Friday, 7:30-8:30 a.m.

Grand Rounds are multidisciplinary, weekly presentations aimed at providing timely updates in research, diagnosis and treatment. Topics vary widely across a full array of medical specialties, with presenters from both Virginia Mason and other nationally recognized medical intuitions.

Journal Club
Twice Monthly

A twice-monthly reading seminar for all medicine residents led by a senior resident in conjunction with our faculty expert in evidence-based medicine. The core reading material for this conference is JAMA's User's Guide to the Medical Literature. Senior residents present cases with associated journal articles. As a group, we then apply rigorous analytic techniques to the literature, with an emphasis on the interpretation of medical statistics. 

Morning Skills Workshop
Twice a week the chief medical residents lead focused workshops on common topics including EKG interpretation, EBM statistics, radiographic reading, procedures and board review. Additionally, procedural skills such as knee injections, thoracentesis, skin biopsy and laceration repair are practiced. These sessions are highly interactive and are designed to allow residents the chance to work on practical skills in a supportive environment.

Continuing Medical Education
Virginia Mason has a fully accredited Continuing Medical Education (CME) program, sponsoring outstanding continuing medical education opportunities at the Hospital and Seattle Medical Center. These course offerings are open to our residents free of charge. Examples include courses in primary care, cardiology, evidence-based medicine, diabetes management and reduction of health care costs.

   [Back to Top]