Internal Medicine / Nuclear Medicine Guidelines
The American Board of Internal Medicine and Nuclear Medicine have agreed to offer dual certification for candidates who have completed four years of combined accredited training in internal medicine and nuclear medicine.
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The objective of combined residency training in internal medicine and nuclear medicine is to produce physicians with broad-based training in internal medicine and nuclear medicine for careers in clinical practice, teaching, research or administration in internal medicine and nuclear medicine.
The strengths of the residencies in internal medicine and nuclear medicine should complement each other to provide an optimal educational experience for residents.
Proposals for combined training must be approved by ABIM and ABNM before a candidate can be accepted for training. Combined training incorporates components of internal medicine and nuclear medicine residencies, which are independently accredited by the Accreditation Council for Graduate Medical Education (ACGME). Combined training will not be separately accredited and residents for combined training must not be recruited if either program has probationary or provisional accreditation status.
Combined training in internal medicine and nuclear medicine must include at least four years of training that meet the program requirements for accreditation by the Residency Review Committee for Internal Medicine (RRC-IM) and the Residency Review Committee for Nuclear Medicine (RRC-NM), respectively.
It is strongly recommended that combined training be in the same institution. Signed agreements must document institutional and faculty commitment to the goals of the combined training. Affiliated institutions must be geographically close enough to permit a cohesive program during the last 24 months of training. Ideally, at least one resident should be enrolled in combined training. If no trainees are enrolled for a period of three years, the training will not be listed in the AMA's Graduate Medical Education Directory. ABIM and ABNM will consider prospective proposals on behalf of individual candidates whose training follows these guidelines.
At the conclusion of 48 months of training in internal medicine and nuclear medicine, the residents should have had experience and instruction in the prevention, detection and treatment of acute and chronic illness; in the rehabilitation of patients; in the socioeconomics of illness; in the ethical care of patients; and in the team approach to medical care.
The training of residents while on internal medicine rotations is the responsibility of the internal medicine faculty and while on nuclear medicine rotations, the responsibility of the nuclear medicine faculty. Absences from training for vacation or leave exceeding four months during the 48 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 nuclear medicine.
The first two years of the combined residency is identical to the training for categorical internal medicine. Both Boards must be notified of the resident's entry into combined training by the end of the R-2 year. A resident transferring from combined training to a straight internal medicine or nuclear medicine program should have prospective approval of the receiving Board.
Training must incorporate graded responsibility from one year to the next, and supervisory responsibility for more junior residents must be provided to the resident for at least six months during the R-3 year.
The Training Director(s)
A full-time director from either specialty or co-directors from both specialties must be designated to oversee the training. If a single training director is appointed, an associate director from the other specialty must be named. The training director, associate director or co-directors should be certified by ABIM or ABNM according to their specialty. A single director may be appointed if certified by both Boards and appointed to each academic department. Directors or co-directors must embrace similar values and goals for training and must document at least quarterly meetings with each other to monitor the progress of residents and the overall success of the training.
Length of Training
Training requirements for admission to the certifying examination of each Board will be fulfilled by 48 months of combined training rather than 72 months of sequential training. A categorical or preliminary R-1 year in internal medicine meets 12 months of training requirement for both Boards. The R-2 training year in categorical internal medicine fulfills 12 months of senior internal medicine training. The R-4 year fulfills 12 months of training requirement in nuclear medicine.
A reduction of an additional 12 months of training occurs during the R-3 year by providing one-year credit for both internal medicine and nuclear medicine requirements:
- Twelve months of nuclear medicine credit is granted for the following: (a) three months of nuclear medicine under the direction of the nuclear medicine residency program, (b) six months of combined nuclear medicine and internal medicine subspecialty rotations under the direction of both residency programs, and (c) three months of nuclear medicine credit for internal medicine rotations directed by the internal medicine residency program.
- Twelve months of internal medicine training is achieved by the following: (a) three months of categorical R-3 rotations in internal medicine, (b) six months of combined nuclear medicine-internal medicine subspecialty rotations (e.g., endocrinology, oncology, pulmonary medicine, non-invasive cardiology, etc.) under the direction of both residency programs, and (c) a three-month elective in nuclear medicine directed by the nuclear medicine residency program.
Core Curricular Requirements
A clearly described written curriculum must be available to residents, faculty and both Residency Review Committees. Joint educational conferences involving residents from internal medicine and nuclear medicine are desirable and should specifically include the participation of all residents in combined training.
Internal Medicine Requirements
During the 33 months of internal medicine training, each resident must have 20 months of clinical rotations with direct responsibility for patients with illnesses in the domain of internal medicine, including geriatric medicine. Each resident shall have:
- One month of experience during R-1 in emergency medicine with first-contact responsibility for the diagnosis and management of adult patients.
- Four weeks' experience during R-1 and again in R-2 or R-3 with the care of patients in a medical intensive care unit.
- At least one-third of the 33 months of internal medicine experience learning the care of non-hospitalized patients. This must include a half-day per week continuity clinic for 36 of the 48 months.
- At least two months of ambulatory medicine block experience, which may include work in subspecialty clinics and walk-in clinics, and brief rotations for appropriate interdisciplinary experience in areas such as dermatology, office gynecology and orthopedics. Health maintenance, prevention and rehabilitation should be emphasized.
- Residents should work in the clinics with other professionals such as psychiatrists, social workers, nurse practitioners, physician assistants, behavioral scientists and dietitians.
- Residents will be encouraged to follow their clinic patients during the course of the patients' hospitalizations.
- Three months of elective in nuclear medicine during the R-3 year.
- Significant exposure to inpatient cardiology exclusive of coronary care unit assignments.
- Combined nuclear medicine-internal medicine subspecialty experience, which may be inpatient, outpatient or a combination, and some rotations must include experience as a consultant.
- An opportunity to regularly attend morning report, medical grand rounds, work rounds, and mortality and morbidity conferences when on internal medicine rotations.
Nuclear Medicine Requirements
Residents will be required to take the following nuclear medicine training during the R-3 and R-4 years of combined training:
- R-3: Six months of nuclear medicine relevant to internal medicine subspecialties training. Three of the following subspecialties must be included: endocrinology, hematology-oncology, cardiovascular disease, nephrology and gastroenterology, and a three-month nuclear medicine elective. This combined subspecialty experience may be inpatient, outpatient or a combination, and will include an opportunity to attend medical Grand Rounds and other conferences relevant to the nuclear medicine training experience.
- R-4: Twelve months of nuclear medicine training.
There must be adequate, ongoing evaluation of the knowledge, skills and performance of the residents. Entry evaluation assessment, interim testing and periodic reassessment, as well as other modalities for evaluation, should be utilized. There must be a method of documenting the procedures that are performed by the residents. Such documentation must be maintained by the program, be available for review by the internal medicine RRC and ABIM site visitors, and be used to provide documentation for future hospital privileges.
The faculty must provide a written evaluation of each resident after each rotation, and these must be available for review by the resident and site visitors. Written evaluation of each resident's knowledge, skills, professional growth and performance, using appropriate criteria and procedures, must be accomplished at least semiannually 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 must maintain a permanent record of evaluation for each resident and make it available 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 verify that the resident has demonstrated sufficient professional ability to practice competently and independently. This final evaluation should be part of the resident's permanent record maintained by the institution.
To meet eligibility for dual certification, the resident must satisfactorily complete 48 months of combined training, which must be verified by the directors of both training programs. Residents will be eligible for admission to the written certifying examination in internal medicine after successfully completing the R-3 year of training and for the nuclear medicine examination after the R-4 year. Lacking verification of acceptable clinical competence and performance in both specialties in combined training, the resident must satisfactorily complete the training requirements as required by each specialty.