Clinical Curriculum - Billings Clinic Internal Medicine Residency

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Yearly Schedule

All rotations are 3 weeks long.

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:

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. The ambulatory rotation also has embedded Special Patient Activity (SPA) clinics which expose residents to select outpatient subspecialties. These clinics are intermittent half days spent in clinics such as Wound Care, Spine, Podiatry, Radiology Procedures, and more.

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: 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 and sub-intern.
  • IMR 3 consist of one senior + one intern and a 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 ICU attendings are present 24 hours a day to provide guidance when needed.

Structure

• 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.
• 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.

Subspecialty Rotations

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

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 rotate at Central Montana Medical Center (Lewistown, MT), and Livingston Healthcare (Livingston, MT), both 25-bed critical access hospitals. Housing is provided at no cost to residents when rotating at distant sites.

Electives

Electives are organized into Outpatient and Inpatient focused tracks, with recommended electives for each track, allowing residents to tailor their training. Elective include:

• Orthopedics
• Dermatology
• Palliative Medicine
• Ob-Gyn
• Hospitalist service
• Psychiatry
• Cardiology
• Resident as Teacher: a Medical Education elective