Internal Medicine / Neurology Guidelines
The American Board of Internal Medicine and the American Board of Psychiatry and Neurology have agreed to offer dual certification for candidates who have completed five years of combined accredited training in internal medicine and neurology suitable to both Boards.
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The objective of combined residency training in internal medicine and neurology includes the preparation of internists and neurologists for careers in clinical practice or on academic faculties as specialists in the broad spectrum of adult illness shared by internal medicine and neurology. These include, but are not limited to:
- geriatric neurology
- congenital and hereditary diseases of the nervous system
- myasthenia gravis
- seizure disorders
- mental retardation
Graduates of combined training may be expected to be involved with clinical practice, teaching, research or administration in internal medicine and neurology.
The strengths of the residencies in internal medicine and neurology should complement each other to provide an optimal educational experience to trainees.
Combined training includes the components of independent internal medicine and neurology residencies which are accredited respectively by the Residency Review Committee for Internal Medicine and by the Residency Review Committee for Neurology, both of which function under the auspices of the Accreditation Council for Graduate Medical Education. While combined programs will not be independently accredited, the accreditation status of the parent internal medicine and neurology programs shall influence a combined program resident's admission to the certifying examinations of each Board. Residents for combined training must not be recruited if either program has probationary or provisional status. Proposals for combined residencies must be submitted to and approved by the ABIM and ABPN before a candidate can be accepted into joint training.
Combined training in internal medicine and neurology must include at least five years of coherent training integral to residencies in the two disciplines which meet the program requirements for accreditation by the RRC-IM and the RRC-Neurology, respectively.
It is strongly recommended that combined training be in the same institution. Documentation of hospital and faculty commitment to and institutional goals of the combined training must be available in signed agreements. Affiliated institutions must be located close enough to facilitate cohesion among the house staff, attendance at weekly continuity clinics and integrated conferences, and faculty exchanges of curriculum, evaluation, administration and related matters.
Ideally, at least 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.
At the conclusion of 60 months of training in internal medicine and neurology, the residents should have had experience and instruction in the prevention, detection and treatment of acute and chronic illness, in the rehabilitation of patients, as well as in the socioeconomics of illness, the ethical care of patients and in the team approach to the provision of medical care.
The training of residents while on internal medicine rotations is the responsibility of the internal medicine faculty and while on neurology rotations, the responsibility of the neurology faculty. Vacations, leave and meeting time will be shared equally by both disciplines. Absences from training (vacation, leave) exceeding five months of the 60 months should be made up.
Except for the following provisions, combined residencies must conform to the program requirements for accreditation of residencies in internal medicine and neurology.
Residents should enter combined training at the R-1 level, but may enter as late as the beginning of the R-2 level only if the R-1 year was served in a categorical (or preliminary) residency in internal medicine in the same academic health center. Under unusual circumstances and with the permission of both Boards, the Boards will consider accepting individuals who have trained in other accredited programs. Residents may not enter combined training beyond the R-2 level. Transfer between combined programs must have prospective approval of both Boards, and is allowed only once during the five-year training period. In a transfer between combined programs, residents must be offered and complete a fully integrated curriculum. A resident transferring from combined training to a straight internal medicine or neurology program should have prospective approval of the receiving Board.
Transitional year training shall receive no credit toward the requirements of either Board unless eight months or more have been completed under the direction of a program director of an ACGME-accredited sponsoring residency in internal medicine.
Training in each discipline must incorporate graded responsibility throughout the training period, and supervisory responsibility must be provided to the resident for at least six months during each discipline's 30 months of training.
The Training Director(s)
The combined residency must be coordinated by a designated full-time director or co-directors who can devote substantial time and effort to the educational program. An overall training director must be appointed from either specialty, or co-directors from both specialties. If a single training director is appointed, an associate director from the other specialty must be named to insure both integration of the training and supervision in the discipline. The training director(s) should be certified by the ABIM or ABPN. An exception to the above requirement would be a single director who is certified and/or residency trained in both specialties and has an academic appointment in each department. The two directors must embrace similar values and goals for their training. The supervising directors from both specialties must document meetings with one another at least quarterly to monitor the progress of each resident and the overall success of the training.
Length of Training
Training requirements for credentialing for the certifying examination of each Board will be fulfilled by 60 months of training in an approved combined program. A total credit of 12 months over that required for two separate residencies is possible due to overlap of curriculum and training requirements. The requirement of 36 months internal medicine training is met by 30 months of internal medicine training with six months' credit for training appropriate to internal medicine obtained during the 30 months of neurology training. Likewise, the 36 months of neurology training requirement is met by 30 months of neurology training with six months' credit for training appropriate to neurology obtained during the 30 months of internal medicine training.
Core Curriculum Requirements
A clearly described written curriculum must be available for residents, faculty and both Residency Review Committees. The curriculum must assure a cohesive, planned educational experience and not simply comprise a series of rotations between the two specialties. Duplication of clinical experiences between the two specialties should be avoided and periodic review of the program curriculum must be performed. This review must include the training directors from both departments, with consultation with faculty and residents from both departments.
The 12 months of training in the R-1 year must be spent in the internal medicine residency. During the final 48 months, continuous assignments to one specialty or the other should be not less than three or more than six months in duration.
Joint educational conferences involving residents from internal medicine and neurology are desirable and should specifically include the participation of all residents in combined training.
Internal Medicine Requirements
During the 30 months of internal medicine training, each resident must obtain 20 months of experience with direct responsibility for patients with illnesses in the domain of internal medicine, including geriatric medicine.
Each resident shall have a one-month experience during years one or two in the emergency room with first-contact responsibility for the diagnosis and management of adults.
Each resident will be assigned to the care of patients in a medical intensive care unit for three to four weeks in years one or two and again during years two, three, four or five during the 30 months of internal medicine training.
At least 33 percent of the 30 months of internal medicine experience must involve non-hospitalized patients. This must include a continuity experience for each resident in a half-day per week continuity-care clinic during the 30 months of internal medicine training, and block experience in ambulatory medicine for at least two months. These experiences 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.
Subspecialty experience must be provided to every resident for at least four months. Some of this must include experience as a consultant. Significant exposure to inpatient cardiology exclusive of coronary care unit assignments is necessary. Subspecialty experience may be inpatient, outpatient or a combination thereof.
Residents must regularly attend morning report, medical grand rounds, work rounds, and mortality and morbidity conferences when on internal medicine rotations.
Among the 30 months of neurology, each resident must obtain 18 months (full-time equivalent) of clinical adult neurology with primary responsibility in patient care. This must include at least six months (full-time equivalent) of outpatient experience in clinical adult neurology. The outpatient experience also must include a resident longitudinal continuity clinic with attendance by each resident one-half day weekly throughout the 30 months of training. In addition, each resident must obtain experiences with neurological disorders in children under the supervision of a child neurologist with ABPN certification or suitable equivalent qualifications. This must consist of three months (full-time equivalent) in clinical child neurology with management responsibility in patient care.
The training must include the indications for and limitations of clinical neurodiagnostic tests and their interpretation. The resident must learn to correlate the information derived from these neurodiagnostic studies with the clinical history and examination in formulating a differential diagnosis and management plan.
Residents must participate in the evaluation of and decision-making for patients with disorders of the nervous system requiring surgical management. They also must participate in the management of patients with psychiatric disorders, and must learn about the psychological aspects of the patient-physician relationship and the importance of personal, social and cultural factors in disease processes and their clinical expression. Residents must learn the principles of psychopathology, psychiatric diagnosis and therapy, and the indications for and complications of drugs used in psychiatry. Residents also must learn the basic principles of rehabilitation for neurological disorders, and must participate in the management of patients with acute neurological disorders in an intensive care unit and an emergency department. The resident must receive instruction in the principles of bioethics and in the provision of appropriate and cost-effective evaluation and treatment for patients with neurologic disorders. Residents must receive instruction in appropriate and compassionate methods of end-of-life palliative care, including adequate pain relief, psychosocial support and counseling for patients and family members about these issues.
In addition to the patient care activities, residents must learn the basic science on which clinical neurology is founded, including:
- neural development
- molecular biology
Concentrated training in one or more of these areas, accomplished with a full-time equivalent experience of at least two months total, is required for each resident. Elective time should be a minimum of three months.
Residents must regularly attend seminars and conferences in the following disciplines:
- neuromuscular disease
- cerebrovascular disease
- movement disorders
- critical care
- clinical neurophysiology
- behavioral neurology
- infectious disease
- pain management
- child neurology
- the neurology of aging and general neurology
There must be gross and microscopic pathology conferences and clinical pathological conferences. Residents must learn about major developments in both the basic and clinical sciences relating to neurology and must attend periodic seminars, journal clubs, lectures in basic science, didactic courses and meetings of local and national neurological societies.
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, ABIM and site visitor, 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 visitor. Written evaluation of each resident's knowledge, skills, professional growth and performance, using appropriate criteria and procedures, must be accomplished at least semiannually and must be 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 have it accessible to the resident and other authorized personnel. The training director and faculty are responsible for 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. 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 60 months of combined training and this must be verified by the directors of both training programs. The written certifying examinations may not be taken until all required years of training in both specialties are satisfactorily completed. 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.