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Curriculum & Schedule

Rotations

There are 13 four-week rotations per year as outlined below. Rotation descriptions and electives are listed below as well. There are no rotations that require being on call overnight. Most shifts for all rotations are 12 hours or less in length for all PG years.

First Year

Rotation Duration Overnight Shifts
General Medicine Inpatient 5 rotations 6, per rotation
Cardiology 1 rotation 6, per rotation
Pulmonary-ICU 1 rotation 6, per rotation
Continuity Clinic 1 rotation (1/2 days) N/A
Point-of-Care Ultrasound 1 rotation (1/2 days) N/A
Research/Quality Improvement 1 rotation N/A
Subspecialties* 2-3 rotations N/A
Electives 1-2 rotations N/A
Vacation & Conference Time** 4 weeks N/A
Wellness Time 4 days N/A

The average hours per week worked (including conferences) for PGY-1's is 60-65.

Second Year

PG 2 residents have four medicine ward rotations, including General Medicine, Hospitalist and Night Float. Residents interested in a primary care career have the option of one less General Medicine or Hospitalist rotation in lieu of another Ambulatory rotation.

Rotation Duration Overnight Shifts
General Medicine Inpatient 1-2 rotations N/A
Hospitalist Medicine 1-2 rotations N/A
Cardiology 1 rotation 6, per rotation
Pulmonary - ICU 1 rotation 6, per rotation
Night Float 1 rotation N/A
Emergency Medicine/Urgent Care 2 rotations 2-4 (EM)
Geriatrics/Palliative Care 2 weeks N/A
Continuity Clinic 1 rotation (1/2 days) N/A
Ambulatory Care 1 rotation N/A
Subspecialties* 2-3 rotations N/A
Electives/Non-Medicine Subspecialties 1-2 rotations N/A
Vacation & Conference Time ** 4 weeks N/A
Wellness Time 4 days N/A

Third Year

PG 3 residents have five medicine ward rotations, including General Medicine, Hospitalist and Night Float. Residents interested in a primary care career have the option of one less General Medicine or Hospitalist rotation in lieu of another Ambulatory rotation.

Rotation Duration Overnight Shifts
General Medicine Inpatient 1-2 rotations N/A
Hospitalist Medicine 1-2 rotations N/A
Night Float 1 rotation N/A
Cardiology 1 rotation 6, per rotation
Pulmonary-ICU 1 rotation 6, per rotation
Continuity Clinic 1 rotation (1/2 days) N/A
Subspecialties* 3-4 rotations N/A
Electives/Non-Medicine Subspecialties 3-4 rotations N/A
Vacation & Conference Time ** 4 weeks N/A
Wellness Time 4 days N/A

*Subspecialties are Endocrinology, Gastroenterology, Hematology, Oncology, Infectious Disease, Nephrology, Neurology and Rheumatology.

** Vacation and conference time may be taken during any rotation except General Medicine, Cardiology, Pulmonary-ICU and Night Float/Night Medicine. A maximum of one week of vacation or conference time per rotation is allowed. Two consecutive weeks off may be taken by using vacation the last week of one rotation and the first week of the subsequent rotation. For more information, please reference the benefits section.

All our rotations stay well within the ACGME 80-hour work week guideline. This is regularly monitored by your chief resident and program directors.

Rotation Descriptions

General Medicine Wards

This rotation consists of four weeks of practicing inpatient internal medicine. Each of the teams is staffed by one attending physician. Services average a census of 12-16 patients. Each week of internal medicine service consists of six days of short call, with admissions ending at 4 p.m. weekdays and 1 p.m. weekend days. There also is one day of long call ending at 7 p.m. A night team (two residents and a hospitalist) cover the nights. A team can expect two to three admissions on a typical day. Each service team is composed of a second or third-year resident, three first-year Internal Medicine, Transitional or Family Medicine residents and one or two medical students. Two of the three interns on each General Medicine teaching team do a brief night float stint during the rotation. This consists of six nights in a row (Sunday through Thursday, 7:30 p.m. to 7 a.m.) during which they are responsible for up to three to four 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.

Cardiology

As a tertiary care center, Gundersen has the full range of cardiology 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 a census of eight to 10 patients, including many with acute myocardial infarction and its complications. Teams consist of three residents and a medical student. All three residents on this rotation complete six to seven 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, all within the same week.  

Pulmonary/ICU

Residents gain experience in intubation, ventilator management, central line and arterial line placement and interpretation of pulmonary function tests. The ICU averages eight to 10 patients per day. Pulmonary teaching conferences are held each weekday. Teams consist of three residents and a medical student. All three residents on this rotation complete six to seven 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, all within the same week.

Hospitalist Medicine

During this rotation, senior residents have an opportunity to work outside the traditional teaching service model alongside practicing hospitalists. Residents spend time on an independent daytime admitting service, managing their own census of patients under the supervision of hospitalist staff. In addition, residents work with utilization review and billing to enhance understanding of the economic side of medicine. Residents 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.

Night Float

This rotation focuses on treating acute medical issues that arise in the Hospital. Residents 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.

Point-of-Care Ultrasound

This rotation consists of a combination of simulation and hands-on point-of-care ultrasound, as well as didactics. Residents are all 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. Gundersen is in the process of acquiring 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, residents are proficient in limited echo, lung/pleura, vascular, soft tissue, and abdominal ultrasound (including the eFAST, BLUE and RUSH protocols). Further, resident inpatient teams in General Medicine, Cardiology, ICU and Hospitalist are all issued a Butterfly ultrasound probe and iPad Mini. This allows continued training beyond the rotation.

Simulation

Our simulation course is an integrated experience in our Cleary Kumm Simulation and Training Lab, which involves interdisciplinary training with Pharmacy residents, Family Medicine residents, and physician assistant students. The purpose of these simulations is to prepare our residents to lead medical emergency teams. Sessions are structured to focus on team-based treatment of high-stake, 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 these sessions, training involves responding as an interdisciplinary team to simulated medical emergencies (e.g. acute dyspnea, chest pain, shock, etc). The team incorporates point-of-care ultrasound and Epic as the EHR and utilizes a high-fidelity mannequin to enhance the overall fidelity of the medical simulation.

Research/Evidence-Based Medicine/Quality Improvement

This rotation gives the resident a broad-based overview of the research process and provides a framework for the ACGME required research project. Each resident submits at least one paper for publication or presents one poster at a local/regional meeting prior to graduation. The rotation is set up to facilitate this goal. Residents meet with a biostatistician to review clinical epidemiological concepts, diagnostic testing and study design. This individual assists in hypothesis development, data collection methods and general analysis techniques for the resident's research project. A librarian provides didactic education and support by teaching upper-level database search techniques. The evidence-based medicine component of the rotation covers the different levels of evidence and their usefulness in making clinical decisions, how to ask appropriate questions and some of the statistical methods used to evaluate evidence in the medical literature for use at the bedside (odds ratios, positive and negative likelihood ratios, number needed to treat, etc.). The quality improvement component includes formal instruction regarding the principles, objectives and processes of quality assessment, as well as learning support systems in place to perform quality improvement work within Gundersen. Didactic and hands-on experience with research work in progress at Gundersen is an option on this rotation. Many feel that this educational experience greatly enhances Internal Medicine residents’ experiences by providing a multidisciplinary approach to problem solving.

Ambulatory

During the second or third year, residents see patients at the University of Wisconsin-La Crosse Student Health Service, Gundersen Urgent Care and Resident Continuity Clinic. Additionally, during the ambulatory blocks, residents see indigent patients at the St. Clare Health Mission two evenings a week. Residents planning careers in ambulatory medicine are required one less ward General Medicine service in each of the PG2 and PG3 years so they may substitute more ambulatory rotations or increase Continuity Clinic experience.

Emergency Medicine

The one-month rotation in Emergency Medicine allows residents to see the acute presentation of common and uncommon diseases. Residents receive plenty of hands-on experience and are afforded the opportunity to fly on our Gundersen Air helicopter on transport and rescue missions. One-on-one staff to resident teaching is the norm.

Endocrinology

This outpatient service includes evaluation and treatment of common endocrine disorders and unusual and complex endocrine problems. Endocrine grand rounds occur weekly. Residents are responsible for seeing any inpatient consultations during this rotation.

Gastroenterology

Working one-on-one with a staff gastroenterologist in the Hospital, residents are exposed to a wide variety of GI problems and observe numerous GI procedures. This is an inpatient and outpatient experience.

Hematology

Residents are exposed to a wide variety of inpatient and outpatient hematologic problems on this consultative service. Residents work one-on-one with the staff hematologist and hematology fellow. Residents become proficient in interpreting peripheral smears and bone marrow biopsies with the hematopathologist. Weekly hematology rounds occur to provide hand-off on inpatient admissions, as well as discuss challenging cases and review smears with staff and fellows.

Infectious Disease

Infectious Disease (ID) services average 12-14 hospitalized patients with 15-20 new consults a week. Outpatient infectious cases and travel medicine are also seen. There is a weekly infectious disease teaching conference. Residents have the opportunity to review clinical microbiology both in the lab and in didactic lectures. If interested, there is a quarterly ID journal club, a monthly infection control committee meeting and ID research projects. The La Crosse area offers unique opportunities to manage patients with tick-borne illnesses including Lyme disease, anaplasmosis and babesiosis.

Nephrology

This is an inpatient service that averages a census of six to eight patients with three to four consultations a day. Teaching sessions are generally held daily at the end of rounds.

Neurology

Residents gain experience in performing and understanding the neurological examination, understanding indications for diagnostic techniques and learning to use and interpret MRI, EEG, EMG and CNS-CT scans. The daily census is six to eight patients on this inpatient consultative service.

Oncology

Residents learn to stage patients and become involved in research protocols and traditional modes of treatment for common and uncommon forms of cancer. This rotation is primarily outpatient based, though some consultative inpatient experience can occur. Emotional needs of patients and families, palliative care and symptom management are emphasized. Residents are encouraged to attend weekly tumor boards.

Palliative Care

Residents work on the inpatient Palliative Care team, which averages eight to 10 patients with three to four new consults per day. Residents learn about community resources for end-of-life care, hospice enrollment and end-of-life symptom management. There are several didactic lectures covering a broad range of palliative care topics. Residents also provide care to inpatient hospice patients.

Rheumatology

This rotation emphasizes common outpatient rheumatologic conditions. Residents average two new patients daily in the Rheumatology Clinic, along with follow-up appointments and inpatient consults as requested. Objectives include mastery of the musculoskeletal exam and joint aspiration/injection techniques. The education program includes one-on-one teaching and a self-study program.

Elective Rotations

  • Allergy
  • Cardiotesting/ Treadmill Testing
  • Gynecology (office)
  • Otolaryngology
  • Pathology
  • Plastic Surgery
  • Radiation Oncology
  • Vascular Medicine
  • Anesthesia
  • CHF Clinic
  • Neurosurgery
  • Ophthalmology
  • Pacemaker Clinic
  • Pediatrics
  • Podiatry
  • Radiology
  • Sports Medicine
  • Outside Rotation
  • Behavioral Medicine
  • Dermatology
  • General Surgery
  • Occupational Health
  • Orthopedic Surgery
  • Palliative Care
  • Physical Medicine & Rehabilitation
  • Procedure Rotation
  • Urology

Conferences

Our wide variety of Internal Medicine conferences cover inpatient and outpatient medicine, including both rare and common diseases. The recently remodeled Ross Learning Center and Overholt Auditorium have a complete array of state-of-the-art multimedia tools to enhance presentation and learning.

House staff can attend all conferences unless there is a patient in need of immediate care.

Morning Report - This is a cornerstone of our resident education. It runs from 7:30 to 8 a.m. Mondays and Wednesdays. Attendance is expected for all Internal Medicine residents, other residents, students on Internal Medicine rotations and selected staff. The chief resident, a senior resident or General Medicine attending physician moderates a case in a highly interactive fashion. Cases range from quintessential internal medicine in which the fine points of management are reviewed to rarer cases in which complete differential diagnosis, test selection and treatment methods are discussed. Additionally, M&M cases are presented by staff Wednesday mornings. All teaching is accomplished with an emphasis on evidence-based and cost-effective medicine principles.

Grand Rounds - This conference is held Tuesdays from 7:30 to 8 a.m. Cases are presented by either teaching staff or residents. An in-depth discussion of disease processes or guideline updates are emphasized.

Core Conference - This conference is held every Thursday from 7:30 to 8:15 a.m. These conferences are generally based on internal medicine subspecialties with an emphasis on in-depth review of select subspecialty topics and guidelines.

Board Review Class - On Friday mornings, a small group board review class is held using MedStudy and MKSAP as a guide. The chief resident leads this class, which emphasizes the approach to difficult questions and "hot points" that will be seen on the ABIM exam.

Tuesday Noon Conference - This is a weekly conference that focuses on internal medicine topics, covering a wide range throughout the year, such as: acid/base, sepsis, EKG reading, AKI, stroke, X-ray interpretation, etc.

Noon Conference – The Gundersen Expert Lecture Series (GELS) is held each Wednesday. Various specialty topics and outside distinguished speakers comprise this most beneficial conference curriculum.

Journal Club - This is a monthly resident-led, evidenced-based review of current journal articles. Residents choose journal articles relevant to the practice of internal medicine. Emphasis is placed on a standardized method to review journal articles and determine their quality and validity. Statistics are reviewed with one of our biostatisticians to learn statistical methodology and to judge the relative strengths and weaknesses of the selected articles.

Intern Ethics Seminar - This is a monthly discussion led by Thomas Harter, Ph.D., Medical Humanities/Ethics, along with various staff. First year residents meet and discuss ethics in a case-based format. Topics are often driven by current clinical experiences to help residents handle difficult ethical issues that they will face during the remainder of their careers.

Resident Clinic

Continuity Clinic - On most rotations, our residents have Continuity Clinic a half day per week in the Resident Clinic at Gundersen in La Crosse. They also do a four-week block of afternoon half-day clinic sessions. While priority is given to autonomy, you are given the opportunity to be taught clinical medicine by experienced faculty. During your three-year experience, you 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 have 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. In this way, you obtain an excellent patient mix of common and rare medical problems, along with patients with varying ages and socioeconomic statuses.

To enhance and enrich your experience, we have assembled a top-notch team of support staff, consisting of 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 one new patient and two follow-up patients in an afternoon. As your training progresses, your volume increases. You can schedule patients outside of your scheduled clinic if needed as well. You do not have clinic during your month of Night Float.

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