Internal Medicine / Dermatology Policies Guidelines

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Guidelines for Combined Training in Internal Medicine and Dermatology

Combined residency training in internal medicine and dermatology is designed to permit the acquisition of knowledge and experience across both disciplines that will aid in the care of patients with complex medical and dermatologic illnesses. This includes, but is not limited to, the management of autoimmune and blistering disorders, cutaneous vasculidities, lymphomas, other unusual cutaneous tumors, severe dermatoses requiring toxic immuno-modulatory therapies and pernicious leg ulcers, as well as the recognition of the dermatologic manifestations and implications of systemic diseases. This combined training will prepare internists and dermatologists for careers in clinical practice or on academic faculties as specialists in the broad spectrum of adult illness shared by internal medicine and dermatology.

Combined training includes the components of independent internal medicine and dermatology residency programs accredited respectively by the Residency Review Committee for Internal Medicine and the Residency Review Committee for Dermatology, both of which function under the auspices of the Accreditation Council for Graduate Medical Education (ACGME). While combined training will not be independently accredited by the RRCs and the ACGME, the continued approved accreditation status of the parent internal medicine and dermatology programs is essential for the stability and continued approval of the combined training program in internal medicine and dermatology. Thus, residents for combined training must not be recruited if the accreditation status of either program is probationary or provisional. Proposals for combined residency training programs must be submitted to and approved by the American Board of Internal Medicine (ABIM) and the American Board of Dermatology (ABD) before a candidate can be accepted into this joint training.

General Requirements

Combined training in dermatology and internal medicine must include at least five years of coherent training integral to residencies in the two disciplines that meets the program requirements for accreditation by the Residency Review Committee for Internal Medicine and the Residency Review Committee for Dermatology.

Combined training must be conducted under the auspices of the Committee on Graduate Medical Education within a single institution and its affiliated hospitals. Documentation of the unqualified commitment of the hospitals and faculty to the institutional goals for the combined training must be available in signed agreements. Affiliated institutions must be located close enough to facilitate cohesion among the house staff, attendance of trainees at weekly continuity clinics and integrated conferences, and faculty exchanges relating to the curriculum, evaluation of trainees, administration of the program and related matters.

Ideally, one resident should be enrolled in combined training each year. A combined training program with no trainees for a period of five years cannot continue to be approved. ABD and ABIM will only approve a combined training program intended to be offered to residents annually and not a training track for a single resident.

At the conclusion of 60 months of training in internal medicine and dermatology, the resident should have had experience and instruction in:

• the prevention, detection and treatment of acute and chronic illness
• the ethical care of patients
• the team approach to medical care
• the effects of illnesses on the socioeconomic status of patients

While residents are on internal medicine rotations, their training is the responsibility of internal medicine faculty, and while they are on dermatology rotations, it is the responsibility of the dermatology faculty. Vacations, leave and meeting time will be taken from the training time in each discipline, on an equal basis. Absences from training (vacation, leave) exceeding five months of the 60 months must be made up.

Except for the following provisions, combined residencies must conform to the program requirements for accreditation of residencies in internal medicine and dermatology.

The Resident

Residents should enter combined training at the PGY-1 level, but may enter as late as the beginning of the PGY-2 level if the PGY-1 year was served in a categorical or preliminary residency in internal medicine in the same institution. Under unusual circumstances and with prior approval of both Boards, individuals who have trained in other accredited programs may be accepted. Residents may not enter combined training beyond the PGY-2 level. Transfer between combined programs must have the prospective approval of both Boards, and is allowed only once during the five-year training period. In a transfer between combined training programs, residents must be offered and must complete a fully integrated curriculum. A resident transferring from combined training to a straight internal medicine or dermatology program should have the prospective approval of the receiving Board.

Credit for transitional year training toward the eligibility requirements for certification by either the American Board of Internal Medicine or the American Board of Dermatology shall not be recognized unless 10 months or more of this year have been completed under the direction of a program director of an ACGME-accredited residency in internal medicine.

Training in each discipline must incorporate graded responsibilities throughout the training period and each resident must assume supervisory responsibilities for at least six months during the 30 months of training in each discipline.

The Training Director(s)

The combined residency must be coordinated by a designated full-time director, from either specialty or co-directors from both specialties, who can devote substantial time and effort to the educational program. If a single training director is appointed, an associate director from the other specialty must be named to ensure both integration of the training and supervision in each discipline. The respective training director(s) should be certified by ABIM or ABD. The supervising directors from both specialties must embrace similar values and goals for the training, and must document meetings with one another held at least quarterly to monitor the progress of each resident and the overall success of the training.

Length of Training

Training requirements for eligibility for the certification process of each Board will be satisfied by 60 months of approved combined training. A reduction of 12 months over that required for two separate residencies is possible due to the overlap of curriculum and experience inherent in the training in each discipline.

• The requirement of 36 months of internal medicine training is met by 30 months of training in the internal medicine component of the combined residency, and six months of credit granted for training appropriate to internal medicine obtained during the 30 months of dermatology residency.
• The requirement of 48 months of training in dermatology is met by the 12 months of a first-year residency in internal medicine, 30 months of training in the dermatology component of the combined residency and six months of credit for training appropriate to dermatology obtained during the remaining 18 months of residency in internal medicine.

Core Curriculum Requirements

A clearly described written curriculum must be available to the residents, faculty and the Residency Review Committees of both internal medicine and dermatology. The curriculum must assure a cohesive, systematic and progressive educational experience, not simply comprise a series of rotations between the two specialties. Duplication of clinical experiences between the two specialties should be avoided, and periodic reviews of the program curriculum must be performed. These reviews must include the training directors from both departments in consultation with faculty and residents. Combined training must not interfere with or compromise the training of the general residents in either field.

During the first year, the resident must have at least 10 months of training in internal medicine. During the second year, the resident must have at least 10 months of training in dermatology. In each of the remaining three years, the resident shall have six months of training in internal medicine and six months of training in dermatology. Rotations of shorter duration, but not less than three months, are also acceptable. During these last three years, it is important that program directors make certain that in the PGY-3, -4, and B5 years, each resident will have 18 months of training in each specialty.

Requirements for Internal Medicine

During the 30 months of training in internal medicine, each resident must have 20 months of direct responsibility for patients with illnesses in the domain of internal medicine.

Each resident must have a one-month experience during the first or second year in emergency medicine, having first-contact responsibility for the diagnosis and management of adults.

Each resident must be assigned to the care of patients in a medical intensive care unit for 3-4 weeks in the first year and again, at least on one four-week rotation, during the months of internal medicine training in years PGY-3, PGY-4 or PGY-5.

At least 20 percent of the 30 months of internal medicine experience must involve non-hospitalized patients (six months of dermatology is credited for 13 percent of the ambulatory requirement). This must include a continuity experience for each resident in a half-day per week continuity-care clinic for 36 consecutive months and block experience in ambulatory medicine for at least two months. Ambulatory experience may include work in subspecialty clinics and walk-in clinics, and brief rotations for appropriate interdisciplinary experience in areas such as office gynecology and ENT. Residents will be encouraged to follow their continuity-care clinic patients during the course of the patients' hospitalization. During the internal medicine phase of training, subspecialty experience must be provided to every resident for at least four months. Some of this experience must include a role as a consultant. Subspecialty experience may be in settings that include inpatient, outpatient or a combination thereof. Significant exposure to geriatrics, infectious disease, and outpatient rheumatology and endocrinology is necessary.

When on internal medicine rotations, residents must regularly attend morning report, medical grand rounds, work rounds, and mortality and morbidity conferences.

Requirements for Dermatology

During the 30 months of dermatology training, 28 months (full-time equivalent) must be spent in clinical dermatology with the primary responsibility in patient care. This must include at least 25 months (full-time equivalent) of experience in clinical dermatology, which must be primarily in the care of outpatients but also include consultations and appropriate inpatient rotations. In addition, each resident must obtain three months of experience in dermatologic surgery under the supervision of a dermatologic surgeon or board certified dermatologist with surgical experience, and two months of dermatopathology under the supervision of a dermatopathologist who is board certified in this subspecialty. Indeed, continuity of training in dermatopathology should be sustained throughout the dermatology residency, in lectures, conferences and as residents follow their patients in clinics and in the hospital.

Residents must learn the basic sciences on which clinical dermatology is founded, including cutaneous pharmacology, molecular biology, genetics, immunology, epidemiology and statistics. Elective time in one of these areas is encouraged and should be for a minimum of two months, which may be substituted for time in the 25-month segment of clinical dermatology.

Residents must regularly attend seminars and conferences in general dermatology. There must be clinical pathological conferences. Residents must learn about major developments in both the basic and clinical sciences relating to dermatology and must attend seminars, journal clubs, lectures in basic sciences, didactic courses and meetings of local and national dermatologic societies.

Evaluation

There must be adequate, ongoing evaluation of the knowledge, skills and performance of residents. Entry evaluation assessment, interim testing and periodic reassessment utilizing appropriate evaluation modalities, including in-training examinations, should be employed. There must be a method of documenting the procedures that are performed by the residents. Such documentation must be maintained by the program director, be available for review by the Residency Review Committees in internal medicine and dermatology, the American Board of Internal Medicine, the American Board of Dermatology and site visitors, and may be used to provide documentation for application for hospital privileges by graduates of these training programs.

The faculty must provide a written evaluation of each resident after each rotation and these must be available for review by the site visitors of Residency Review Committees. Written evaluation of each resident's knowledge, skills, professional growth and performance, using appropriate criteria and procedures, must be accomplished at least semi-annually and communicated to and discussed with the resident in a timely manner.

Residents should be advanced to positions of higher responsibility only on the basis of evidence of their satisfactory progressive scholarship and professional growth.

The program director is responsible for the maintenance of a permanent record of each resident and its availability to the resident and other authorized personnel. The training director and faculty are responsible for the provision of a written final evaluation for each resident who completes the program. This evaluation must include a review of the resident's performance during the final period of training and should verify that the resident has demonstrated sufficient professional ability to practice competently and independently, and is prepared to apply for the certification processes of both internal medicine and dermatology. This final evaluation should be part of the resident's permanent record and maintained by the institution.

The program director should anticipate periodic reviews of the combined training programs by site visitors from the ACGME, who will be reviewing the primary internal medicine or dermatology residency program at the institution where the combined training program is conducted. Such reviews will ordinarily include interviews with the combined training resident(s).

Sixth Year

Both Boards encourage residents to extend their training for an additional sixth year in investigative, administrative or academic pursuits in order to prepare graduates of combined training in dermatology and internal medicine programs for careers in research, teaching or departmental administration.

Certification

To meet the eligibility requirements for the certification processes in internal medicine and dermatology, the resident must satisfactorily complete 60 months of combined training as verified by the director and associate director or the co-directors of these combined training programs.

ABIM Board approval 12/3/00
ABDerm Board approval 1/11/01