The training program's emphasis on the continuum of care from the inpatient to the post-acute, to the home care setting begins during the PGY-1 year of training. Interns spend nine months divided among the general medical wards, the coronary and medical intensive care units, cardiac progressive care (i.e. “step down” unit), night float rotations, and 2-6 weeks of elective time. There are two ambulatory-based rotations (Foundations of Clinical Excellence and evidenced-based medicine and practice), described in more detail below, that are wonderful opportunities for interns to learn the psychosocial aspects of medicine; to become effective and compassionate communicators; to learn and refine physical diagnosis skills in small group sessions with faculty; to develop the skills necessary to critically appraise the medical literature, and to learn and analyze the evidence for and against specific treatments or therapies. While on the general medicine wards, interns evaluate up to five new patients on long-call and two new patients on a short-call (every fourth night). Intensive care services average two to four admissions per call day. Interns are supervised by junior or senior residents and full-time attending teaching physicians. House staff are the primary physicians, and interns write all orders using a state-of-the-art computerized provider order entry system. Ancillary staff draw blood, start IVs, perform EKGs, obtain blood cultures and perform arterial blood gas sampling 24 hours a day. Laboratory data, microbiology, EKGs and imaging results, as well as discharge summaries, are available on-line. Computer terminals with access to medical literature and the Internet are available on all inpatient units as well as in the Harrison Medical Library. The Medicine Education Center is our brand new major teaching conference room, located on the 1st floor of the acute care building, houses a state-of-the-art multi-headed microscope, video projectors, camera suitable for creating publication-quality material, and computer terminals with immediate Internet access.
In the first half of the year, each intern spends one month on the Foundations of Clinical Excellence rotation, learning to organize ambulatory patients visits, important interviewing skills, and proficiency in the psychosocial aspects of medical practice. During the month, interns participate in one-on-one intensive learning sessions with faculty from the GIM division, using role play and simulated patients and video reviews of ambulatory patient visits. Interns also learn and refine their physical examination skills in small group sessions with leading faculty members in the Department of Medicine. For example, the cardiovascular physical examination is taught by cardiology faculty who demonstrate how to assess jugular venous pressure and appreciate heart sounds and murmurs on patients in the clinic or hospital. Auscultation skills are demonstrated using an electronic teaching stethoscope that allows up to five interns to simultaneously listen to a patient along with the cardiologist. Interns are also taught the basic skills necessary to perform and interpret cardiac ultrasound (i.e. echocardiography) using a portable hand-held ultrasound device, benefiting from one-on-one training by a dedicated echo technician.
In the second half of the year, each intern spends one month learning the fundamentals of evidence-based medicine and practice: clinical decision-making, critical appraisal of the literature and clinical epidemiology. Medical informatics offers residents the opportunity to learn or improve their literature-searching techniques and to become familiar with software that supports patient care activities, including creating patient databases. Under the guidance of a GIM divisional faculty member, each intern chooses a clinical question or practice, investigates the quality of evidence supporting that practice and presents findings at a seminar at the end of the month. Half-day workshops offer residents time to explore ambulatory-medicine topics in depth. Some of the topics covered are: HIV care, the use of advance directives, women's health, personal chart auditing, prevention and screening, and clinical skills in the managed care setting, each taught by leading faculty in a small group setting. The goal is to encourage skepticism of practices for which support and evidence are lacking and to help search for and choose practices based on sound evidence. Interns are also taught the fundamentals of quality improvement (QI) initiatives in the healthcare setting. Some interns choose to focus on, and later present, a QI project addressing a topic of specific interest to them. In the evidence-based medicine and practice rotation, interns learn about the health care system from more senior house officers and faculty who helped develop these curricula in systems based practice and the principles of quality improvement.
PGY-2 residents spend four months on the inpatient service on the general medical wards and the coronary and medical intensive care units, and a month of outpatient and consultative neurology and/or emergency medicine. The remainder of the year is spent on elective or in selected ambulatory block rotation. (Block rotations in ambulatory medical subspecialties are taken in the PGY-2 and PGY-3 years. This experience is known as the Bayview Ambulatory Subspecialty Interdisciplinary Curriculum [BASIC]).
PGY-3 residents spend three months on the inpatient service and one month as the physician-in-charge of the MHSP. One goal of the MHSP month is to hone skills in evaluating acute outpatient medical problems, ambulatory cross coverage, and telephone medicine. Another is to develop teaching skills by supervising two to three PGY-1 interns one-half day per week in their new patient evaluations. The remainder of the PGY-3 year is elective or selected ambulatory block rotations. (Block rotations in ambulatory medical subspecialties are taken in the PGY-2 and PGY-3 years in BASIC.)
A total of 2 months in the PGY-2 and PGY-3 years is spent focused on hematology and oncology, working with ambulatory patients in the Johns Hopkins Hematology and Oncology clinics on both campuses and on the Acute Leukemia Service at Johns Hopkins Hospital.