Our Curriculum

The Internal Medicine Residency Program at CHA is committed to excellence in outpatient training. In our “2+4” program structure, residents spend two weeks immersed in ambulatory rotations, alternating with four weeks of other training experiences (inpatient wards, ICU, elective, etc.) throughout the 36 months of training. This structure allows residents to be engaged in outpatient medicine without the distraction of concurrent inpatient ward responsibilities and allows our residents to truly function as primary care providers at the ambulatory practices where they see patients.

The distribution of blocks over the entire 36-month curriculum is below. Ambulatory Medicine immersions include 4 continuity clinic sessions each week, longitudinal block experiences in medical subspecialties and Ambulatory Teaching Resident, longitudinal experiences in geriatrics, mental health, addictions medicine, quality improvement and research-based health advocacy. Night rotations are split equally between inpatient medicine and critical care medicine.

Ambulatory/Inpatient Rotations	Number of weeks per year
	PGY1	PGY2	PGY3
Ambulatory	16	16	16
Inpatient Medicine	10	12	6
Critical Care Medicine	8	4	2
BIDMC Cardiology Service	4	-	-
Emergency Medicine	2	2	2
Night Rotations	6	6	6
Senior Block*	-	-	4
Electives	2	8	12
Vacation	4	4	4
Total weeks	52	52	52

*PGY3 rotation consisting of 1 week of nights, 2 weeks of inpatient/critical care/emergency medicine, and 1 week of independent reading.

Continuity Clinics

Each trainee is assigned to one of our three continuity clinic training sites where they will develop an outpatient practice during the three years of training: CHA Primary Care, Cambridge Hospital, CHA Broadway Care Center, or CHA Windsor Street Care Center. We are delighted that each of the ambulatory training sites for our Internal Medicine Residency Program achieved Level 3 PCMH recognition from the National Committee for Quality Assurance (NCQA). Each clinic has a unique patient population and group of preceptors to provide supervision, but they are all similar in their robust team-based approach to care, with integrated social work, nutrition, pharmacotherapy, mental health care teams, and robust administrative support staff. Residents receive information about each site after matching and can express a preference for their continuity site. 

At all continuity sites, resident physicians act as the primary care physician for their patient panel, with close preceptor supervision tailored to individual learning needs. Residents gain comprehensive experience in chronic disease management, acute care office visits, and screening and prevention across the full spectrum of adult age groups. A dedicated panel management curriculum and training in a team-based approach to population health are provided throughout the year. 

Ambulatory Block Rotations

Interns and residents have 4 continuity clinic sessions (1/2 day each) per week during ambulatory rotations, as well as one half day per week reserved for administrative responsibilities. The remainder of the time on ambulatory rotations for interns is spent in longitudinal ambulatory rotations in Geriatrics, Mental Health, and Addictions Medicine. Second- and third-year residents spend the remainder of their time on ambulatory rotations rotating through medicine subspecialty clinics.

Longitudinal Experiences for Interns:

On ambulatory rotations, interns spend a half-day per week at Addictions Medicine, a half-day per week seeing patients with members of their clinic’s integrated mental health care team, and one half-day on Geriatrics. These experiences occur during the entirety of the internship year and provide important foundations for a comprehensive education in ambulatory medicine.

Ambulatory Sub-specialties:

In addition to their continuity clinic sessions, second- and third-year residents on ambulatory rotations have dedicated time to learn in the subspecialties of Internal Medicine. Each resident will rotate through Cardiology, Endocrinology, Gastroenterology, Hematology-Oncology, Infectious Diseases, Neurology, Pulmonology and Rheumatology during their training. Residents are assigned to 4 subspecialties during each of the PGY2 and PGY3 years, and they see patients alongside attending faculty longitudinally, with one ½ day of each subspecialty clinic during each ambulatory block.

Ambulatory Didactics

Ambulatory Morning Report:

Every morning during the ambulatory block, all the residents will come together for a small group case-based teaching conference. Each second and third-year resident on ambulatory is assigned to be the Ambulatory Teaching Resident (ATR) once during each ambulatory block and is responsible for developing and leading the daily Ambulatory Morning Report conference. Residents choose patients they have seen in the clinic who have presented diagnostic, management, or communications challenges and present the case to the group, along with an evidence-based approach to the clinical problem. This is an opportunity for the resident to develop skills as a teacher and facilitator, with the coaching of an expert faculty mentor.

Ambulatory Academic Half Days

One half-day per week on ambulatory rotations is set aside for protected curriculum time in ambulatory medicine. These half-day seminars are led by our expert teaching faculty and comprise a comprehensive ambulatory curriculum that spans the 36 months of residency training. In these small group learning sessions, residents learn in-depth topics in primary care, including core concepts in screening and prevention, women’s health, management of chronic diseases and common ambulatory complaints across all organ systems.

During the ambulatory academic half-day, several seminars expose our residents to important concepts in the care of marginalized patients, social determinants of health, medical professionalism, doctor-patient communication and risk management.

Patient Care

Each medicine team has a resident, two interns and a designated hospitalist attending. Teams have access to excellent social work staff, 24-hour interpreter services, engaged consult liaison psychiatrists, comprehensive outpatient services for special populations - immigrants, the frail elderly, the homeless, the chronically mentally ill and those struggling with addictions - to make it possible to provide high-quality comprehensive care for a socially complex and diverse panel of patients. The breadth and depth of medical pathology provide a rich environment for learning. Patient care teams are geographically staffed in one ward to enable closer collaboration between nurses, doctors, and care-coordinators.

Daily Work Schedule

Interns arrive at 6:30 - 7 AM to pre-round on patients and take sign-out from the night team. From 8:30 - 10:30 AM, teams do bedside patient care work rounds with their team's hospitalist attending.

At 3 PM, the ward team meets again for afternoon rounds with the attending to review patient care plans for the current day as well as prioritize the task list for the remainder of the day. This is also an opportunity for 'bring-backs' - clinical questions that come up during routine care of patients during work rounds and are assigned to team members. Emphasis is placed on learning to manage common and 'cannot-miss' diagnosis, learning to generate clinical questions and applying available evidence to patient care decisions. Case discussions may also focus on issues related to cultural competence, ethics, and health systems.

Work Hours

We know that exhausted residents can't learn and can't take good care of others. Both teams admit every day, alternating between short-call and long-call days. On short-call days, the team takes morning signout and then takes new admissions and transfers until 2 PM. At 6 PM, they sign out to the night team. Having shorter days and longer days makes it possible to balance hard work with life outside the hospital.

We share the work of caring for hospitalized patients with a third inpatient clinical team staffed by a Hospitalist and a resident. 

Learning Conferences

This program runs regular teaching conferences on Tuesdays and Fridays, with lunch provided by the training program.

On Tuesdays, residents sign-out their clinical work to the team’s attending in the afternoon and gather in a conference room for our Tuesday School Program, a four-hour block of protected time for teaching and learning the core curriculum in inpatient medicine.

 On Fridays, residents gather at lunchtime for other programs including house officer meetings with the program leadership, resident union meeting, social hour, and journal clubs in a monthly rotation. 

Feedback and Evaluation

Attendings and residents and interns meet in the beginning of the rotation to review expectations; and to set learning goals.  Feedback is given in real time when appropriate and once a week the interns and residents meet with the attending to review their progress on the previously discussed goals and expectations.  

The attending evaluates each trainee at the end of the ward rotation on ACGME milestones.

The residents evaluate the attendings they work with during the block which are completed anonymously and reviewed confidentially at the end of academic year.  The residents also evaluate every rotation and these are reviewed quarterly by the program.

Inpatient Medicine Rotations

Rotation Director: Priyank Jain

Description of rotation

Two teams, each comprising of one resident and 2-3 interns, provide care to hospitalized internal medicine patients on general medical wards. For the first 3 block of academic year, the teams have 3 interns each, for remaining 10 blocks the teams have 2 interns each. All resident care of patients is supervised by hospitalist attending physicians.

Resident service patients are primarily located on 4W per our geographic rounding policy. Residents receive a broad introduction to the evaluation and management of a wide variety of problems in general internal medicine. The patient population is diverse with approximately 50% of patients speaking primary languages other than English. In addition to the routine case mix for general internal medicine wards at a community hospital, the rotation provides a unique opportunity for residents to consider the complex relationships between health status and poverty including in-depth clinical experiences with substance abuse, co-morbid medical and psychiatric disease, geriatrics, HIV/ AIDS, homelessness, international and immigrant health.

The inpatient service functions on the premise of shared responsibility between house officers and attending staff. Interns (and acting-interns) will admit and manage patients, calling upon the resident and attending staff for guidance as needed. House officers enter all orders. The attending physicians have legal responsibility for patient care. Residents, as trainees, and attendings, as teachers, will collaborate to guarantee their patients the best medical care, the best learning experience, and the most collegial and satisfying work environment possible.

Goals and objectives
Broad goals for the inpatient rotation are listed below:

Medical knowledge:

During the inpatient rotation, interns and residents should:

• Expand understanding of the basic, clinical, and social sciences underlying the care of medical inpatients
• Build basic fund of knowledge related to clinical diagnosis and management of common and “cannot miss” diagnoses.

Patient Care: 

During the inpatient rotation, interns and residents should improve their ability to:

• Interview and examine patients
• Define and prioritize patients’ medical problems
• Generate and prioritize differential diagnoses
• Develop rational, evidence-based management strategies
• Understand the role of the hospital and the acute phase in the overall illness episode and develop effective patient care plans for post-hospital care
• Perform basic clinical procedures and interpret common radiology studies
• Manage common inpatient medical emergencies

Interpersonal skills and communication

During the inpatient rotation, interns and residents should improve their ability to:

• Communicate effectively with patients and families
• Communicate effectively with physician colleagues at all levels
• Communicate effectively with all members of the health care team
• Present patient information concisely and clearly, verbally and in writing
• Teach colleagues effectively

Professionalism

During the inpatient rotation, interns and residents should:

• Develop greater self understanding
• Practice self care
• Behave respectfully with colleagues including effective conflict resolution, reliability, honesty, punctuality
• Demonstrate a commitment to standards for lifelong excellence
• Cultivate compassionate relationships with patients and family
• Reflect on physician responsibilities to society

Practice-based learning and improvement

During the inpatient rotation, interns and residents should:

• Demonstrate curiosity
• Develop capacity to ask relevant clinical questions
• Complete a learning goals worksheet with personal learning objectives for the rotation
• Identify knowledge gaps in personal knowledge and skills in the care of hospitalized patients
• Develop and implement strategies for filling gaps in knowledge and skills

Systems-based practice

During the inpatient rotation, interns and residents should improve their ability to:

• Understand and utilize the multidisciplinary resources necessary to care optimally for hospitalized patients
• Manage transitions of care effectively
• Use evidence-based, cost-conscious strategies in the care of hospitalized patients.
• Participate in improving systems of care
• Participate in improving the inpatient ward rotation as a resident clinical learning experience

Clinical learning venue and schedule

During the rotation, residents will learn through participation in:

• Initial evaluation of new admissions, daily evaluation and management of inpatients, and multidisciplinary discharge planning; all patient care activities will take place under the supervision of an attending physician
• Procedures including abdominal paracentesis, ABG, lumbar puncture, NG tube placement, thoracentesis, central line placement, EKG analysis
• Monthly review of radiologic studies with a radiologist and daily as needed
• Formal teaching sessions including Tuesday School and Grand Rounds
• Morning and afternoon patient management rounds with the hospitalist attending physician

Daily Schedule

6 - 7:30 a.m.: Day interns arrive, get signout on old patients, pre-round on old patients, read new patient H&Ps.

7:30 - 8 a.m.: Day interns and residents get signout on new patients from day team (7:30 for short call, 7:45 for long call).

8:30 - 10:30 a.m. Morning Work Rounds

The interns and resident join attending to round on patients and finalize management plan for the day. Interns are expected to present preliminary plan for their patients in rounds, residents are expected to determine sequence of patients and identify learning opportunities, attendings are expected to support the team and resident in their learning and patient care decisions. Use of the rounding template (Appendix E) is encouraged. Efficient day begins with efficient and effective work rounds and suggestions for planning these are in Appendix F.

10:45 -11:15 a.m. Multidisciplinary Rounds
Team resident meets with allied health providers including case managers, nutritionists, physical and respiratory therapists, social workers and nurses to coordinate care and make discharge plans. MDR rounds are facilitated by case management and occur near 4W nurses station.

2 p.m. Short-call team takes its last admission

3 - 4 p.m. Afternoon Rounds
Each ward team convenes with their attending to review the patients' progress, discuss new patients. Thereafter, team members share their answers to previously identified clinical questions. This time also serves as a venue to discuss team dynamics and identify strategies for improvement.

6 p.m. Handoff to the night team

Short call team can signout to long call resident earlier than 6 p.m. if their work is done.

Caps: Team assignment of new admissions is facilitated by the triage hospitalist. Residents are responsible for understanding and ensuring compliance with policies outlined in the house officer policy manual including intern and team caps as follows:

1. .Each intern may accept a total of 5 new patients and 2 transfers in a 24 hour period; each intern may accept a total of 8 new + 2 transfer patients in a 48-hour period. When an intern “caps” before the team meets cap, the resident is responsible for doing a “res-intern” work up and note.
2. The team may accept a total of 10 new + 4 transfer patients in a 24-hour period up to a team cap of 16 patients.
3. Transfers from other services within the hospital, including the ICU will be treated as admissions in the flow of patients. Residents should work collaboratively to ensure relative balance in patient load between the two teams and between interns on each team.
4. Patients readmitted within 7 days of discharge will be readmitted to the intern who previously cared for the patients. If the patient is admitted at a time when this intern is not taking admissions, the patient will be worked up by the admitting team and then transferred to the previous intern on the following day.
5. After meeting team caps, residents will not admit additional new patients to their own team, but are available to assist in care of other patients including cross-coverage, procedures

Specific Rotations

Hospitalist Medicine

This is a 2- week rotation during the PGY2 and PGY3 year, wherein one resident is paired directly with a Hospitalist faculty member. Residents independently manage their panel of patients under the direct supervision of the teaching hospitalist.

The goals of this rotation are to 1) gain experience in independently managing patients admitted to the general medicine ward in a community hospital and 2) gain experience in providing Medicine Consultation to non-medicine services.

Critical Care Medicine

In this setting, residents develop expertise in managing sepsis, respiratory failure, toxic overdoses, doing invasive procedures, caring for families in crisis, and negotiating goals of care in ethically and medically complex situations. Since there are no critical care fellows, residents assume a significant amount of autonomy in the care of patients and work directly with the attending physician to make decisions and execute plans of care.

The day begins at 7 AM with sign-out from the night ICU team to the day ICU team. Work rounds are led by the intensivist and begin at 8:30 AM. After rounds, the tasks of patient care are undertaken by the day team, including any procedures, consults, transfers and new admissions.

The intern critical care experience is split between our two acute-care hospital campuses. At Cambridge Hospital, one resident and one intern (two interns during the first ¼ of the year) work together with critical care nurses, respiratory therapists, and a pulmonary-critical care intensivist to provide care to critically ill patients in a 6-bed ICU. At Everett Hospital, one intern works directly under the supervision of a pulmonary-critical care intensivist in a 6-bed ICU. Each afternoon, time is carved out for dedicated resident teaching, which is led by an intensivist.

BIDMC Cardiology Inpatient Service

Medicine Interns spend a month at the Beth Israel Deaconess Medical Center, one of our partner hospitals in the Harvard system. The BIDMC Zoll service is the cardiology inpatient service that provides clinical care to patients with acute coronary syndromes, decompensated heart failure, and a variety of cardiac arrhythmias. Formal teaching rounds meet daily to discuss current cases and review primary data obtained through stress, echo and catheterization. With a particular focus on interventional cardiology, the rotation provides a nice complement to community hospital training at Cambridge Health Alliance.

At BIDMC, Cambridge interns join two interns on a team with a resident, cardiac fellow and staff cardiologist. There are no overnight calls.

Night Rotations at CHA

One intern and resident work together on the wards to care for in-patients on the medicine service, while another intern and resident pair work together in the medical intensive care unit. As the administrative hustle and bustle of the day quiet down, residents focus on managing emergent medical problems and admitting new patients. An overnight hospitalist is always available in the hospital for consultation on patient care.

Despite the expenditure of vast resources, the US healthcare system faces numerous public health challenges and a failure to provide quality healthcare for everyone in our society. Our system continues to result in inequalities in access to care for vulnerable populations including the uninsured, racial and ethnic minorities, LGBTQ+ persons, immigrants, prisoners, people with chronic mental illness, and homeless persons. Too often, health policies and medical decision-making are guided by corporate and pharmaceutical interests – rather than sound medical and ethical principles.

Physicians have a unique vantage point to identify the social, political, and economic forces that adversely affect the care of patients. We are also highly effective advocates in shaping health policy and in making social change. CHA has a rich tradition of advocacy for the poor and disenfranchised. Faculty, staff and trainees have co-founded Physicians for Human Rights, coordinated earthquake relief efforts in Haiti, and produced research that has been leveraged on the floor of the US Senate.

In 2012, the CHA Internal Medicine Residency Program transformed a popular elective into a required social medicine and research-based health advocacy course. We have described this course in paper published in Academic Medicine and a news article in Boston Globe Media’s STAT News. Our residency program believes that to meaningfully address health inequities and threats to health and human rights, medical education should play an important role in training future clinicians in the role of health advocate and social change agent.

The social medicine and research-based health advocacy curriculum are designed to provide medical residents with knowledge of key health policy issues, social determinants of health, human rights, global poverty and disease, and theoretical foundations of physician advocacy. It also provides training to develop skills to conduct health services research and successfully engage in advocacy on behalf of patients and populations. In our course, residents are exposed to successful and inspiring physician advocates to encourage careers that incorporate advocacy. Each year residents meet with media professionals at either NPR/WBUR or the Boston Globe.

Course Goals

1.  Clarify and develop values that brought residents to train in a residency program committed to the care of underserved populations

2.  Explore the role physicians play in addressing systemic health equity

3.  Improve knowledge of topics in health equity, social determinants of health and health policy

4.  Develop skills in research methodology, leadership and health advocacy

5.  Provide mentorship and role modeling to support career development that may incorporate health advocacy

Course Format

Each year one of the ambulatory cohorts participates in this curriculum, such that every resident will participate during one of their three years of training. Residents participating in the curriculum will meet throughout the year with experts in health policy, research methodology and advocacy in sessions comprised of lectures, skill-building workshops, discussion and case studies. Sessions occur both on campus at CHA and around Cambridge and Boston. The course is delivered during two 2-week immersion blocks in the fall and spring and through various morning didactic sessions throughout the year.  

Although many forms of advocacy exist, emphasis is placed on research-based advocacy – the collection and presentation of data in an understandable form to policymakers, government regulators, the media, and the general public to influence health policy. A highlight of the course is experiential learning through a research-based health advocacy project. The project gives residents a real-world experience of serving in the role of a health advocate. The projects have produced significant scholarships, including publications and presentations at Regional and National Society of Internal Medicine conferences. A recent project on the impact of the Affordable Care Act on individuals with chronic disease was published in the academic journal Annals of Internal Medicine, with an accompanying op-ed in NPR/WBUR’s Commonhealth Blog. Residents identify stakeholders in the community and develop an advocacy plan on how to use their research findings to make change.

Academic Conferences

• Ambulatory Morning Report
• Cardiology Case Conference
• Tuesday School Program
• Resident as Teacher Conference
• Ambulatory Didactics

Weekly Noon Conferences

There is different conference every week of the month:

• House Officers Meeting
• Resident Social Hour
• CIR Meetings
• Journal Club
• Department of Medicine Morbidity and Mortality Conference
• Social Medicine Rounds

Residents have 23-weeks of elective time during the 3-years of residency. Residents avail themselves of a myriad of opportunities at CHA, in the Greater Boston area and international settings during their elective time.

Specially designed elective experiences within CHA

Medical Subspecialty Consultation Elective: Residents may opt for 2 to 4-week immersion experiences in several medical specialties, Laboratory Medicine and Radiology.

Health Care for the Homeless Elective: A popular elective amongst our residents wherein trainees work with a multidisciplinary team providing care in area homeless shelters and practice street-based care to patients.

Occupational and Environmental Health Elective: Basic principles of recognizing and preventing occupational health diseases are integrated into a series of didactics and clinical experiences. Residents participate in worksite evaluations and projects in this elective. 

Nutrition Elective: Residents learn about nutrition assessment and risk; the indications, prescribing guidelines, and monitoring guidelines for parenteral and enteral nutrition; and nutrition education and counseling skills.

Resident-Designed Electives: Residents may select a faculty mentor and participate in the design of an elective to meet their educational/research needs. Recent examples include medical education, behavioral medicine, systems improvement, acupuncture, healthy systems, and anti-racism in medicine. Residents may also use elective time to work on their scholarly projects. Domestic away electives at Indian Health Service sites, Beth Israel Deaconess Medical Center, or other sites arranged by the resident are also encouraged.

Other Harvard Experiences

Residents regularly rotate to the tertiary care Harvard hospitals for in-patient or out-patient subspecialty consultation, elective experiences in areas such as infectious diseases, endocrinology, hematology-oncology, nephrology, cardiology, gastroenterology and pulmonary medicine.

International Electives

Many CHA residents participate in international health experiences before residency training. Our residency program strongly encourages these activities, during training and more than half of our residents work and study abroad during PGY2 and PGY3 electives. 

Residents in good academic standing may use up to 4-weeks of elective time during their PGY2 and PGY3 years away from the Boston area. Residents must submit a written proposal for the elective to the Program Director, describing the desired program of study, the planned supervision, and the expectation of how this experience would contribute uniquely to the resident’s personal educational goals.

CHA is a remarkably rich community of clinicians with interests and expertise in international health. These individuals are available to our residents for advising and mentoring.