Internal Medicine / Physical Medicine & Rehab Guidelines
The American Board of Internal Medicine (ABIM) and Physical Medicine and Rehabilitation (ABPM&R) are pleased to offer dual certification for candidates (eligible for certification by each Board) who have completed at least two and a half years of suitable accredited training in each specialty. Training must be reviewed and approved prospectively by ABIM and ABPM&R.
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The objective of combined resident training in internal medicine and physical medicine and rehabilitation includes the preparation of internists and physiatrists for careers in clinical practice or on academic faculties as specialists in the broad spectrum of adult illness shared by internal medicine and physical medicine and rehabilitation. These individuals will have special expertise in such areas as rehabilitation of geriatric and cardiac patients, chronic pain management, sports medicine and the primary care of persons with a physical disability. Graduates of combined training may be expected to be involved in clinical practice, teaching, research or administration in internal medicine and physical medicine and rehabilitation.
Combined training includes the components of independent internal medicine and physical medicine and rehabilitation residencies. The strengths of the residencies in internal medicine and physical medicine and rehabilitation should complement each other to provide an optimal educational experience to trainees.
Combined training in internal medicine and physical medicine and rehabilitation 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 Residence Review Committee for Internal Medicine (RRC-IM) and the Residence Review Committee for Physical Medicine and Rehabilitation (RRC-PM&R), respectively.
It is strongly recommended that combined training be in the same institution or academic health care system. Documentation of hospital and faculty commitment to the institutional goals of the combined training must be available in signed agreements. Affiliated programs must be located close enough to facilitate cohesion among the house staff, attendance at weekly continuity clinics when scheduled 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 physical medicine and rehabilitation, 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 and 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 physical medicine and rehabilitation rotations, the responsibility of the physical medicine and rehabilitation faculty. Vacations, leave and meeting time will be shared equally by both disciplines. Absences from training (vacation and/or 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 physical medicine and rehabilitation.
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 care system. 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, and residents must be offered and complete a fully integrated curriculum. A resident transferring from combined training to a straight internal medicine or physical medicine and rehabilitation 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 in the same academic health care system.
The Training Directors
Combined training must be coordinated by a designated full-time director or co-directors who can devote time and effort to the educational program. An overall training director may 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 ensure both integration of the training and supervision in the discipline. The training director(s) should be certified by ABIM or ABPM&R. An exception to the above requirements 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 of internal medicine training is met by 30 months of internal medicine training with six months' credit for training appropriate to internal medicine during the 30 months of physical medicine and rehabilitation training. Likewise, the 36 months of physical medicine and rehabilitation training requirement is met by 30 months of physical medicine and rehabilitation training with six months' credit for training appropriate to physical medicine and rehabilitation obtained during the 30 months' internal medicine training.
Core Curriculum Requirements
A clearly described written curriculum consisting of educational goals and objectives, teaching program and clinical rotation must be available to 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 training curriculum must be performed. This review must include the training directors from both departments in consultation with faculty and residents from both departments.
The 12 months of training in the R-1 year should be spent in internal medicine. During the final 48 months, except for one consecutive 12-month period which may be spent in physical medicine and rehabilitation, continuous assignment to one specialty or the other should not be less than three or more than six months in duration in any given year.
Joint educational conferences involving residents from internal medicine and physical medicine and rehabilitation are desirable and should specifically include the participation of all residents in the combined training program.
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.
Training must incorporate graded responsibility throughout the training period, and supervisory responsibility must be provided to the resident for at least six months during the 30 months of internal medicine training.
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. The resident's responsibility must include direct participation in reaching decisions about admissions.
Each resident will be assigned to the care of patients with various illnesses in critical care (e.g., intensive care units, cardiac care, respiratory care units) for three to four weeks during 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 in internal medicine 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 a 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 and office gynecology. Health maintenance, prevention and rehabilitation should be emphasized. Residents will be encouraged to follow their clinic patients during the course of the patients' hospitalizations.
Subspecialty experiences 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.
Physical Medicine & Rehabilitation Requirements
The non-PM&R 12-month segment of the four-year physical medicine and rehabilitation residency concerned with basic fundamental clinical skills will be credited on the basis of satisfactory completion of the regular first year of internal medicine residency. In addition, a minimum of 36 months of accredited physical medicine and rehabilitation residency is required. Up to six months of pertinent and related internal medicine rotations of one to three months will be accepted for elective credit in the 36-month physical medicine and rehabilitation segment in such areas as rheumatology, endocrinology, geriatrics, neurology, cardiovascular or pulmonary diseases.
During the 30 months in physical medicine and rehabilitation, the resident must satisfactorily complete 24 months of hospital and outpatient clinical management of patients receiving physical medicine and rehabilitation services. Physical medicine and rehabilitation training includes basic and advanced knowledge of musculoskeletal and neuromuscular anatomy and physiology as related to kinesiology, exercise and functional activities as well as to immobilization and inactivity. The application and prescription of therapeutic exercise, orthotics, prosthetics, assistive and supportive devices for ambulation and mobility are essential. The following segments of training in physical medicine and rehabilitation are also required:
- experience with inpatient or outpatient pediatric rehabilitation;
- adequate training to achieve basic qualifications in electromyography and electrodiagnosis; and
- opportunities to achieve understanding of special aspects of rehabilitation of patients in geriatric age groups.
The ABPM&R requirement for 12 months of clinical practice, fellowship, research or a combination of these activities for admissibility to Part II of its Board examination can be met by documented evidence that at least 50 percent of the time is devoted to physical medicine and rehabilitation.
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 training directors, be available for review by the RRCs, ABPM&R, ABIM and 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 directors 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 training. 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 satisfy the requirements of both Boards, the resident must satisfactorily complete 60 months of combined training, which must be verified by both training directors. A candidate may apply for the certifying examination in internal medicine in his or her fourth year of the combined residency and take the examination in the fall of their fifth year if they have successfully completed all internal medicine training requirements, except for continuity clinic, by that time. 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.
Combined training will not be independently accredited. Both the internal medicine and physical medicine and rehabilitation programs jointly offering combined training must be within the same academic health care system, and must be accredited by their respective Residency Review Committees. At the time of application for combined training, both residencies must have full accreditation status. If the residency in either discipline receives probationary accreditation after initiation of the combined training, new residents should not be appointed to combined training.
Approved April 1995
Revised June 1999
Revised March 2002