Clinical Curriculum - Billings Clinic Internal Medicine Residency

Our program trains residents to:

  • Develop an academically rigorous understanding of internal medicine with the goal of becoming confident generalist practitioners upon graduation. Residents will also be well prepared to apply this knowledge to future subspecialty careers if desired.
  • Think critically by applying evidence-based medicine in an individualized manner to provide patient-centered care
  • Communicate effectively to build therapeutic relationships with patients and partner with interdisciplinary team members
  • Understand how to effectively practice medicine in resource-limited areas to provide high quality care equitably across all communities
  • Care for their patients, the health system and local community by investigating issues related to quality improvement, patient safety and health equity

In addition, our program ensures that all residents meet ACGME competencies and are well-positioned to successfully obtain ABIM board certification.

Yearly Schedule

PGY1 Year

  • Ambulatory Medicine: 12 weeks (4 rotations)
  • Inpatient Medicine/Night Float/MedConsult: 24-27 weeks (8-9 rotations)
  • MICU: 3 weeks (1 rotation)
  • Subspecialty Rotation: 9-12 weeks (3-4 rotations)
  • Vacation: 3 weeks

PGY2 Year

  • Ambulatory Medicine: 12 weeks (4 rotations)
  • Inpatient Medicine: 15 weeks (6 rotations)
  • MICU: 6 weeks (2 rotations)
  • Subspecialty Rotation: 9-12 weeks (3-4 rotations)
  • Emergency Medicine: 3 weeks (1 rotation)
  • SameDay Care: 1 week
  • Perioperative: 1 week
  • Elective: 3 weeks (1 rotation)
  • Cultural Awareness Week: 1 week
  • Vacation: 3 weeks

PGY3 Year

  • Ambulatory Medicine: 12 weeks (4 rotations)
  • Inpatient Medicine/Night Float/MedConsult: 15 weeks (6 rotations)
  • MICU: 6 weeks (2 rotations)
  • Subspecialty Rotation: 12 weeks (4 rotations)
  • Rural Rotation: 6 weeks (2 rotations)
  • Vacation: 3 weeks

Clinical Curriculum for Categorical Residents

Our residency utilizes a 3-week rotation schedule along with a longitudinal Continuity Clinic component which runs throughout the year to allow categorical residents to immerse themselves in specific areas of training while maintaining patient continuity in the outpatient setting. A “Jeopardy” system is in place to provide back-up coverage for residents with emergent or unexpected absences. Residents will gain experience in the following areas:

(click a specialty to advance to that section)

Ambulatory Clinic

The ambulatory experience has been designed to provide robust, longitudinal training allowing residents to practice with a high degree of autonomy. Residents establish their own patient panel and learn to collaboratively care for patients within the residency medical home when the patient’s primary care physician is unavailable. Given the breadth of knowledge and skills required to succeed in Primary Care, the ambulatory rotation has embedded Special Patient Activity (SPA) clinics which exposes residents to select outpatient subspecialties. These clinics are intermittent half days spent in Wound Care, Spine, Podiatry, Radiology Procedures, among others, which add to our understanding of how to provide comprehensive primary care.

Structure

  • Ambulatory Rotation component: this is a 3-week block designed to provide an immersive experience. Residents are embedded in the clinic for the entirety of each Ambulatory Rotation and will not have inpatient responsibilities during this time.
  • Continuity Clinic:
    • One half day per rotation during Inpatient Medicine, Night Float and MICU rotations
    • Two half days of clinic per week during all other rotations
  • Ambulatory Clinic team: generally consists of four to eight residents of varying levels (PGY1 through PGY3) supervised by one to two Internal Medicine faculty attendings. We maintain resident to faculty ratios of 3:1 to 4:1.
  • The Ambulatory Clinic is supported by a robust staff inclusive of PharmDs, RNs, CNAs and care managers. Resident providers have access to the clinic’s Integrated Behavioral Health team to aid in co-management of primary care psychiatric patients.

Inpatient Medicine

Inpatient Medicine rotations are spent on general internal medicine wards, allowing residents to evaluate a wide variety of pathologies under the guidance of academic faculty attendings. An emphasis is placed on resident autonomy and senior residents gain extensive experience in leading and educating ward teams.

Structure

  • Three week block
  • There are 3 wards teams: IMR 1, 2, and 3.
    • IMR 1 and 2 consist of one senior resident + two interns and generally have one medical student.
    • IMR 3 consist of one senior + one intern and a fourth-year medical student sub-intern or psychiatry intern.
  • The designated Day Teams accept admissions from 6 AM to 5 PM with the long call senior resident triaging patients 5 PM to 6 PM.
  • The designated Post-call Team accepts patients who were admitted after midnight.
  • There is a separate Night Float team (see below) who takes hand-off at 6 PM and accepts admissions until 6 AM when they give handoff to the Day Team.
  • Team census varies but is typically between 10-14 daily.
  • Three days off during each three week rotation.

Night Float

Night Float rotations are spent on general internal medicine wards.

Structure

  • Two senior residents split the three week rotation and when off they serve as our first call jeopardy resident.
  • There is one intern who does two blocks of 6 nights in a row, for a total of 12 nights during the rotation.
  • A hospitalist attending is on site and precepts all admission 6 pm to midnight. After midnight the attending is available via phone call if needed, otherwise the team staffs those patients with the post call attending at 7 am.
  • Teams average 4 to 6 admissions overnight in addition to providing cross coverage for the IMR teams.

MICU

Residents are essential providers at the Billings Clinic MICU and manage critically ill patients while performing a variety of bedside procedures including intubation, thoracenteses and central line placements. Faculty attendings are present 24 hours a day to provide guidance when needed.

Structure

  • Generally, two senior residents and one PGY1 are on MICU at any given time.
  • Interns will work 6 out of 7 days (7 AM to 5 PM) with no night shifts.
  • Senior residents work 6 out of 7 days (7 AM to 5 PM alternating with 7 AM to 9 PM every third day) for two weeks with a third week working nights. The third week of nights is covered by the ICU staff.

Subspecialty Rotations

Residents will rotate through all major subspecialties (see list below) working directly with experts in both inpatient and outpatient practice.

(List of subspecialties with hyperlink to their subspecialty pages)

Structure

  • One resident on any given subspecialty service at a time
  • Schedules vary by subspecialty, although most clinical obligations run 7 AM to 5 PM on weekdays with weekend responsibilities on a very limited number of services

Emergency Medicine

Residents will rotate in the Emergency Department which serves a critical role in Billings Clinic’s function as a Level 1 Trauma Center.

Rural Medicine

Each of our senior residents experiences the ‘real world’ of the General Internist in a rural community through our Rural Rotation Program. Residents spend two rotations at Central Montana Medical Center (Lewistown, MT), a 25-bed Critical Access Hospital. Through these rural rotations residents gain insight into the exciting possibilities and practical problems of health care delivery in a remote, rural setting.

Same-Day Clinic

This is a 1-week rotation in which residents will evaluate and manage acute ambulatory patients at the Billings Clinic’s Same Day Clinic.

Cultural Awareness Week

This is a 1-week rotation designed in conjunction with Billings Clinic’s Office of Diversity, Equity and Inclusion. More information on this rotation can be found here.

Clinical Curriculum for Preliminary Residents

Our program prides itself on providing preliminary residents with thoughtful training designed to provide a solid foundation for their future practice. Preliminary residents follow the PGY1 Yearly Schedule noted above, except preliminary residents do not have Continuity Clinic responsibilities.