Internal Medicine Residency Curriculum

Over this 4-week rotation, you’ll join a team and gain experience practicing inpatient internal medicine. Each team is staffed by 1 attending physician. Services average a census of 12–16 patients. Each week of internal medicine service consists of 6 days of short call, with admissions ending at 4 pm weekdays and 1 pm weekend days. There also is 1 day of long call ending at 7 pm. A night team (2 residents and 1 hospitalist) cover the nights. A team can expect 2-3 admissions on a typical day. Each service team is composed of a second or third-year resident, 3 first-year Internal Medicine, Transitional or Family Medicine residents and 1-2 medical students. Two of the 3 interns on each General Medicine teaching team do a brief night medicine stint during the rotation. This consists of 5 nights in a row (Sunday through Thursday, 10 pm to 7 am) during which they are responsible for up to 3-4 new admissions. All patients are turned over in the morning to the day-time General Medicine teams. Consultations are obtained, as needed, with other specialties. When a patient is admitted, the team has full decision-making capabilities.

At Gundersen, a tertiary care center, you’ll gain experience under the supervision of board-certified cardiologists, including state-of-the-art diagnostics, an active open-heart surgery program and aggressive interventional cardiology. Cardiology averages 8-10 patients, including many with acute myocardial infarction and its complications. Teams consist of 3 residents and a medical student. All 3 residents on this rotation complete 6 nights of night coverage during which they care for patients on the service, plus admit new patients. Night coverage takes place Sunday through Thursday and Saturday nights within the same week.

You'll gain experience in intubation, ventilator management, central line and arterial line placement and interpretation of pulmonary function tests. The ICU averages 8-10 patients per day. Pulmonary teaching conferences are held each weekday. Teams consist of 3 residents and a medical student. All 3 residents on this rotation complete 6 nights of night coverage during which they care for ICU patients on the service, plus admit new patients. Night coverage for the ICU is Sunday through Thursday and Saturday nights within the same week.

During this rotation, senior residents have an opportunity to work outside the traditional teaching service model alongside practicing hospitalists. You'll spend time on an independent daytime admitting service, managing their own census of patients under the supervision of hospitalist staff. In addition, you’ll work with utilization review and billing to enhance understanding of the economic side of medicine. You’ll also have responsibilities for Emergency Room/Hospital triage and didactic sessions on quality improvement and medical information technology. The Hospitalist team is issued an iPad mini and Butterfly IQ ultrasound probe to augment evaluation and care of patients and residents’ learning.

This rotation focuses on treating acute medical issues that arise in the hospital. You'll cover the hospitalized patients of the General Medicine teams, under the supervision of the in-house hospitalist. In addition, the senior resident responds to medical emergencies with the medical response team. They also supervise the night medicine intern and admit patients.

This rotation consists of a combination of simulation and hands-on point-of-care ultrasound, as well as didactics. You'll be issued a SonoSim simulation probe and work through simulated ultrasound and a case list. Additionally, ultrasound is learned on patient models and hospitalized patients with unique pathology. You’ll also use a high-fidelity ultrasound training simulator to allow real-time ultrasound of disease in a simulated environment to augment learning of pathology. 

After completing the rotation, you'll be proficient in limited echo, lung/pleura, vascular, soft tissue and abdominal ultrasound (including the eFAST, BLUE and RUSH protocols). All resident inpatient teams in general medicine, cardiology, ICU and hospitalist, are issued a Butterfly ultrasound probe and iPad Mini. This way, you’ll have easy and immediate access to ultrasound on inpatient rotations. This also allows for continued training beyond the rotation.

Our simulation course is an integrated experience in our simulation center which involves interdisciplinary training with pharmacy residents, family medicine residents, nurses and PA students. The purpose of these simulations is to prepare our residents to lead medical emergency teams. During the intern year, you’ll navigate simulation sessions which are structured to focus on team-based treatment of high stakes, high risk encounters in medical settings encompassing ambulatory, acute care and emergency services. Training activities are launched with a workshop that focuses on the use of team-based strategies and interventions, based on the TeamSTEPPS curriculum developed by the Agency for Healthcare Research and Quality (AHRQ). 

During simulation sessions, training will involve responding as an interdisciplinary team to simulated medical emergencies (e.g., acute dyspnea, chest pain, shock, etc.). The team will incorporate point of care ultrasound, Epic as the electronic health record (EHR) and utilization of a high-fidelity mannequin to enhance the overall fidelity of the medical simulation. 

“Jeopardy Rotation” 

This rotation is 2 weeks during PGY-2 and PGY-3 to cover another resident’s absence during inpatient rotations. The jeopardy rotation is paired with another elective with choices of research, ultrasound or procedures while being available for unexpected resident absences. These absences occur infrequently. 

You’ll begin to build your own patient panel as a first-year resident. In addition to Resident Clinic, during the second or third year, you'll see patients at Gundersen Urgent Care. Residents planning careers in ambulatory medicine require 1 less inpatient General Medicine service in each of their PG2 and PG3 years; they may substitute more ambulatory rotations or increase Continuity Clinic experience. 

Resident Clinic occurs, on average, once every 3 blocks for about 2 weeks with both morning and afternoon sessions. Friday afternoons are available as administrative time to complete patient follow-up and EHR in-basket management. 

This clinic occurs, on average, once every 3 blocks for about 2 weeks, with both morning and afternoon sessions. Friday afternoons are available as administrative time to complete patient follow-up and EHR in-basket management. Clinic does not occur on inpatient rotations including general medicine, nights, ICU or Cardiology. 

While priority is given to autonomy, you’ll have the opportunity to learn clinical medicine from our experienced faculty. During your 3-year experience, you’ll also learn clinic operation, including billing, insurance and appropriate patient referral. Special emphasis is placed on evidence-based clinical medicine. 

Your clinic consists of patients you cared for in the hospital in General Medicine and subspecialty rotations who then become your primary patients, as well as patients referred from Emergency Services and Urgent Care. You’ll obtain a mix of common and rare medical problems from with patients of varying ages and socioeconomic statuses. 

To enhance and enrich your experience, we have assembled a top-notch team of support staff, registered nurses, medical assistants and patient liaisons. They are ready and willing to help with procedures, fielding calls from your patients, handling prescription refills and addressing patient scheduling. 

A typical first-year resident sees 4 patients in the morning and 3patients in an afternoon. As your training progresses, your volume may increase. You can schedule patients outside of your scheduled clinic, if needed. You do not have clinic during your month of Night Float or on inpatient rotations. 

Our academic focus is one of the things that attracts residents to our program. We strongly emphasize evidence-based and cost-effective medicine, basing our patient care decisions on a critical review of literature. We do not make care decisions based on maintaining a status quo, and there is always proof behind our clinical choices. This approach permeates all our conferences, staff teaching sessions, "curbside consults" and bedside teaching. 

During the Research/Quality Improvement Rotation in PGY-1, there is an evidence-based medicine section that teaches basic concepts as they relate to research and patient care. These principles quickly become incorporated into your medical decision-making process. We have 1-2 formal teaching conferences each day, and every staff member in the hospital is involved in medical education at some level. 

We have long-standing board-review curricula that helps us achieve board exam excellence. Our current 15-year ABIM certifying exam pass rate is more than 95%. 

We have a weekly board review class for all our residents. We use both MKSAP and MedStudy curricula and emphasize in detail the key points each resident needs to know to achieve board exam excellence. Test taking strategy is also reviewed in detail. 

All residents have a paid subscription to NEJM Knowledge+, an online comprehensive adaptive learning question bank for additional board preparation. 

The Internal Medicine In-Training Examination is administered to Internal Medicine residents at each PGY level. The results of this examination are used as a baseline to judge residents' progress in residency training, as well as to fine-tune their knowledge in preparation for the American Board of Internal Medicine Certifying Exam. The results from this test are also used as an indicator for teaching staff in a continuing effort to modify our curricula, which ultimately enhances teaching. 

Autonomy and supervision are 2 important aspects of a residency program. At Gundersen, staff provide an excellent blend of both. Autonomy is given in a graded fashion according to each resident's ability. Staff do not micromanage and are always eager and willing to hear your impression and patient care plan. 

By PGY-2, most residents have significant autonomy. The attending physician is always available, in person or by phone, if you have any questions. Thus, residents have appropriate responsibility and autonomy but always with the best supervision.

Close bedside supervision by staff working one-on-one with residents and a range of elective rotations enable mastery of many procedures. For example, a resident may choose to take Office Gynecology to learn endometrial biopsy technique and cervical polyp removal, or they may take Office Orthopedics to learn to perform arthrocentesis and joint injections. There also is an elective procedure rotation available if a resident desires a large volume of a variety of procedures. With the development of our Point-of-Care Ultrasound curriculum over the past couple of years, we anticipate a significant increase in the volume of bedside procedures available to our Internal Medicine residents. 

Residents have opportunity to master or gain significant experience with the following procedures: 

• Central venous line placement 
• Arterial line insertion 
• Endotracheal intubation 
• Mechanical ventilator management 
• Thoracentesis 
• Paracentesis 
• Lumbar puncture 
• Skin biopsy 
• Joint aspiration and injection

Gundersen is a Level II Trauma Center. Our ICU functions as a closed unit, giving residents on their ICU rotation valuable experience in caring for a wide range of critically ill patients with myriad problems. We have an ICU rotation every year dedicated to intensive care medicine. As a result of the excellent training in critical care, previous residents have gone on to do a fellowship in pulmonary critical care.

Residents work closely with medical students in many inpatient and some outpatient rotations. Gundersen is the western academic campus of the University of Wisconsin School of Medicine and Public Health. Visiting medical students are also welcome. For more information, please visit the GHS Medical Student page. 

If you are a medical student interested in rotating through Gundersen, please email the Medical Student Program coordinator at medstudentprgm@gundersenhealth.org.