Core PGY4

Specialty Training in Internal Medicine requires four years of approved residency training which includes three foundational years and one year of “advanced internal medicine training”1. This Core Internal Medicine (CIM) PGY-4 year has Royal College mandatory rotations as outlined below. Moreover, the U of A CIM has created a set rotation default curriculum we encourage all CIM PGY-4 trainees to adhere to. If there are specific goals or rotations a trainee would like, outside of the set rotations, these may be considered in discussion with the Associate Program Director responsible for this year, and/or the CIM Program Director.

The approval by the RCPSC of General Internal Medicine (GIM) as a subspecialty of internal medicine, allows residents the option of remaining in the Core Internal Medicine program for their PGY4 year. Simultaneously, the GIM Fellowship Residency Training program provides a two year curriculum to all residents who match to the 2 year GIM program in the Medicine Subspecialty Match. At the University of Alberta, these changes were implemented over the 2013/14 Academic year. For those seeking to pursue a career in General Internal Medicine, the GIM Fellowship program is preferentially recommended to permit additional development of niche skills, and to maximize recruitment potential (e.g. Academic or urban centre GIM).

The Core IM program at the University of Alberta fully adheres to the General Standards of Accreditation2. The following points will describe the goals, objectives, structure, organization, resources and curriculum of our PGY4 advanced Internal Medicine Training.

Administrative Structure

1. The Associate Program Director – IM R4 is fully responsible for the training of the PGY4 residents who remain in the Internal Medicine training program.
2. The Internal Medicine residency program committee (RPC) continues to support the PGY4 residents, and includes a PGY-4 resident representative seat on the committee. The subcommittees (Academic program subcommittee, Assessment subcommittee, Resident Research Subcommittee, and Resident Development Subcommittee) also ensures that their scope and planning includes the PGY4 residents. In CBD, the Competence Committee reviews and advises the Program Director and RPC on promotion and completion of training.
3. A Medical Education Program Assistant (MEP-A) has the responsibility to support PGY4 residents in the Internal Medicine Program.
4. The Associate Program Director will also function as an Academic Advisor to guide the PGY4 resident. Meetings should occur quarterly, at which time, all assessment information will be reviewed in anticipation of clinical practice.

Goals & Objectives

1. The overall goals of the internal medicine program are inclusive of the PGY4 year. As of 2017, the primary focus of these goals is the completion of entrustable professional activities (EPAs) in all four stages. The primary focus of the PGY4 year is the transition to practice stage. Completion of CIM EPA's including "Transition to Practice" is mandatory for progressing as expected required to graduate from the Internal Medicine Residency Program.
2. Specific educational objectives are developed for all rotations provided in the PGY4 year. These are included in the biannual mini-program review of the RPC.

Structure & Organization of the Program/Longitudinal Clinic

Minimum 20 half-day clinics over 12 months. To develop the skills required to confidently practice ambulatory medicine, the Royal College requires that a longitudinal clinic be undertaken. Clinic may be GIM or any other subspecialty of Medicine. The PGY4 resident will be asked to identify, contact and confirm a preceptor for their longitudinal 3 months prior to the start of their PGY-4 year, at the latest. If a preceptor is not found by the trainee prior to this deadline, then a clinic/preceptor will be chosen and provided to the trainee.

CIM PGY-4 Rotation List (not in sequential order)

Jr Attendinga 1 of 2 (one of UAH, RAH, GNH) (Mandatory, Royal College Requirement)
Jr Attendinga 2 of 2 (one of UAH, RAH, GNH) (Mandatory, Royal College Requirement)
ICUb (suggest MCH or GNH – more procedures, more medicine ICU, fewer/no competing trainees for procedures) (Mandatory, Royal College Requirement)
Community medicine: SCH, MCH, Red Deer (Mandatory)
Rural Medicinec – Grand Prairie, Yellowknife, (BC possibly if interest) (Mandatory, Royal College Requirement)
GIM consult service at RAH including Pre-op Clinic (Mandatory)
ECG Rotation RAH (includes CCU call) (Mandatory)
Neurology at GNH – mix of acute/subactue stroke, general neurology, inpatient plus outpatient clinics (including stroke, headache clinic, general neuro clinic), in a preceptorship model. No overnight call required. (Mandatory)
Obstetrical medicine (Mandatory)
Ambulatory blockd (Mandatory, Royal College Requirement)
POCUS block (Recommended)
Elective
Vacation (4 weeks total, may be taken in increments of 1, 2, 3, or 4 weeks)

a. Junior Attending Inpatient Rotation (2 blocks). This is organized in collaboration with the General Internal Medicine program, and can be undertaken at either an academic or community teaching hospital, depending on the resident’s goals, preferences, and site availability. The resident functions under the supervision of the attending physician in a clinical teaching unit or preceptor-based teaching unit, assuming their primary duties. They are given as much independence as permitted by ability, licensure restrictions and hospital policy, in preparation for transition to independent practice.

b. Critical Care (1 block). Having completed only two blocks of Critical Care training in the PGY1-3 years, the PGY4 resident should complete one additional block of critical care training, with graduated responsibility, as appropriate to the intended practice setting in internal medicine.

c. Community Internal Medicine (1 block). The PGY4 resident participates in a general practice in internal medicine in a community outside of Edmonton and may include Grande Prairie, Yellowknife, potentially BC interior/north/island if able to secure rotation electively through UBC. The program will also be flexible in approving other settings that may be of interest to the residents.

d. Ambulatory Clinics (1 block). The PGY4 resident should participate in one month of ambulatory clinics in internal medicine. The goal is approximately 28 half-day clinics in a rotation block in a community-based setting (ie. 7 half-day clinics per week)

Resources

1. As with other residents in the core program, the teaching staff for PGY4 residents will be derived from the Department of Medicine as a whole rather than unduly expecting any single division such as General Internal Medicine to shoulder this responsibility.
2. The PGY4 resident will have access to the same computers and facilities for information management, on-line references and computer searches as the other residents in the program. This includes the resident lounge and locker space.
3. The program will provide funding for a NEJM Knowledge Plus subscription.

Academic Program

1. Internal Medicine Academic Half Day. The PGY4 resident has the option of attending the CIM academic half day on Thursdays. If not the academic half day, then usual clincal service per the rotation is required
2. Quality Improvement. EPA TP8 "Identifying/Analyzing system-level safety" - PGY-4 Residents will have the following options for completion of this EPA:

i. Prepare and present a QA (Quality Assurance) rounds (one hour talk) at one of the hospital sites or at the CIM Academic Half day, with a Attending supervisor overseeing your presentation.

ii. Complete the IHI (Institute for Healthcare Improvement) Patient Safety or QI online modules outlined at this link: https://www.ihi.org/education/ihi-open-school/Pages/Curriculum.aspx

iii. Complete a Quality Improvement project (the program will help you find a supervisor for the project)

Assessment of Resident Performance

1. Rotation ITERs
2. EPA Observations – continuation from PGY1-3. CBME was implemented at the U of A CIM program in July 2017. CBME became mandatory for CIM PGY-4 in Juy 2022 with a requirement to complete EPAs for the Transition to Practice (TP) stage. A minimum of 3 EPA attempts per week are required (except while on vacation) in order to remain on pace. The CIM Competence Committee will review EPA progress and may recommend minor or major learning plans for failure to complete or maintain pace.
3. Personal Learning Plan. Residents should complete one narrative reflection after each rotation and formal assessment encounter, and continue with case-based reflections as per FD7. These can be completed in Assess.Med and reviewed in Portfolio.Med (Transition to Practice, under TP7 Narrative Form). The narrative reflection can be about a challenging diagnostic dilemma, challenging interaction with a patient/patient family or other health care team member, a reflection on the rotation and what skills have been gained and how they be incorporated into your future practice or a reflection on any challenges this rotation has highlighted in terms of practicing independently.
4. Multi-source Feedback. Residents should receive multi-source feedback during at least one of the two Junior attending rotations, using the same mechanism that was used in the PGY3 year.

References

Specialty Training Requirements in Internal Medicine, Royal College of Physicians and Surgeons of Canada, 2011 Version 1.0.
General Standards of Accreditation, Royal College of Physicians and Surgeons of Canada, January 2011.

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