Mission

To educate and develop highly skilled, compassionate physicians who will enhance patient care and contribute positively to any team, whether in health care or military operational environments.

Aims

• Train residents to be resilient, well-rounded, board-certified internal medicine providers across a diverse spectrum of clinical settings and patient populations.
• Train residents to provide high-value care that meets the unique needs of the military population, veterans, and families in a variety of clinical environments.
• Graduate residents with competency in clinical and procedural skills that can be utilized both in the hospital and battlefield settings.
• Graduate residents with the knowledge and professionalism to integrate seamlessly into the larger military health system.
• Graduate residents that are well-prepared to pursue a variety of career paths to include general internal medicine, fellowship training, and academic and military leadership roles.

Morning Report is our primary educational conference and is the cornerstone of our didactic curriculum. It takes place every weekday from 8-9 a.m. All medical students, interns, and residents not on leave, outside rotations, or non-IM rotations, attend. This interdisciplinary core conference, predicated on safe and collaborative discussion, delivers education via a wide variety of modalities. These include topical lectures led by subspecialists, case-based lectures by residents rotating on the wards with an emphasis on clinical reasoning, and unique cases seen by residents rotating at outside institutions.

In addition to these more standard morning report sessions, we vary the curriculum widely with sessions dedicated to Officer and Professional Development, “Clinical Updates” in subspecialty care conferences given by residents, joint EM/IM grand rounds, non-IM specialty conferences delivered by other programs with content relevant for an internist, ancillary staff lectures, evidence-based medicine conferences and debates, program sensing sessions, and monthly, fully anonymized M&M sessions with an emphasis on compassionate, respectful, and safe spaces for reflection and learning.

Beyond Morning Report, each cohort of residents, during their ambulatory clinic week that occurs every five weeks, attends an academic half-day session. Each session starts with peer mentorship, coaching, and check-ins on personal and program wellbeing. This is followed by lecture and discussions relating to ambulatory medicine. These include health maintenance and cancer screening, provision of high-value care, addressing and managing common outpatient complaints, and teaching on nuanced outpatient orders and medications, among other topics. Every academic half-day is followed by a longitudinal Officer and Professional Development curriculum which involves a myriad of topics to include CV workshop, officer evaluation report support form writing, and staff-led discussions regarding deployment experiences to better equip residents with knowledge of life after residency. Our academic curriculum is supplemented by Tuesday afternoon board review sessions involving a subspecialist facilitating board review questions for residents in their respective field, as well as Thursday med student lectures delivered voluntarily by motivated residents with educational topics curated for the MS-III/IV level for our rotating medical students.

1st Year	2nd Year	3rd Year
Intro to Ambulatory Medicine - 4 weeks Internal Med Clinic - 10 weeks Internal Med Wards - 20 weeks Emergency Med - 4 weeks Elective - 4 weeks ICU - 4 weeks Cardiology - 4 weeks Neurology - 2 weeks	Internal Med Clinic - 10 weeks Internal Med Wards - 14 weeks Research/Night Float - 8 weeks Cardiology - 4 weeks ICU - 4 weeks Elective - 12 weeks	Internal Med Clinic - 10 weeks Cardiology - 4 weeks Internal Med Wards - 16 weeks ICU - 4 weeks Primary Care - 4 weeks Elective - 16 weeks

Intro to Ambulatory Medicine

Each PGY-1 starts training with an “Intro to Ambulatory” medicine block. In addition to small group sessions led by the chiefs of medical residents dedicated to preparing interns for clinic, this block includes time devoted to orienting and onboarding to our neighboring VA facility, preparing interns for procedural competence in arterial and central line placement, dedicated time to learning point-of-care ultrasound with our ultrasound fellows, additional orientation to inpatient medicine at Madigan with ample time allotted for guidance and mentorship, and a half-day intended to ensuring full understanding of the block schedule and maximizing the allotted leave days available during a busy intern year.

Primary Care

Graduating residents have one, 5-week block during their third year in which they spend a week rotating through an outpatient clinic in specialty outside of IM. This includes: one week of special forces PT clinic, one week of outpatient physical medicine and rehab, one week of outpatient addiction medicine, one week in outpatient gynecology, and one week in STI/travel clinic. There is an optional second primary care elective that allows residents to choose additional subspecialty opportunities to include:

• Adolescent Clinic
• ENT Clinic
• General Surgery Clinic
• Ophthalmology
• Psychology
• Urology Clinic

Individualized Learning (Electives)

At least six months of individualized learning (Program Requirement IV.C.3.d) is provided to aid each resident in identifying self-directed learning goals, exposure to specific skill sets for potential career growth and development, and foster research and mentorship with faculty. Residents have opportunities to explore electives in:

• Allergy/Immunology
• Anesthesia
• Cardiology
• Dermatology
• Endocrinology
• Echocardiography
• Faculty Development
• Gastroenterology
• Hematology/Oncology
• Infectious Diseases
• Medical Informatics
• Nephrology
• Palliative Medicine
• Pulmonary Medicine
• Quality Improvement and Patient Safety
• Radiology
• Rheumatology
• Senior Teaching
• Sleep Medicine
• Surgery and Trauma ICU
• Ultrasound (Point-of-Care)

All rotations are organized on day/night shifts. All rotation schedules strictly adhere to ACGME clinical and educational work hour requirements. Wards teams are on call every fourth day and admit patients between 1-5:30 p.m. PT. A dedicated senior on nights takes admissions every night from 5:30 p.m. to 6:30 a.m. the following morning.

There are no 24-hour shifts in the MAMC IM program, either at Madigan or outside rotations. IM Interns perform “cross-cover” for two, one-week intervals during intern year. The shift is 4:30 p.m. to 6 a.m. and is preceded and proceeded by an entire calendar day off of work (interns starting work Friday evening do not work the day prior; interns ending work Friday morning are not expected back until Sunday morning). Inpatient rotations (Wards, ICU, CCU, senior night float) follow a six on/one off schedule.

Residents in our training program prepare to become not only outstanding general internists but equally excellent military medical officers and leaders, in a time where the latter skills will undoubtedly be required and tested in any position after training. Our graduating residents have been increasingly tasked to serve in vital military roles, ranging from battalion and flight surgeon positions to intensivists in combat support hospitals. Military unique training opportunities are provided through a variety of educational programs to provide our trainees with the medical knowledge, patient care skills, and systems-based practice understanding to be successful military medical officers.

The Officer and Professional Development Curriculum is the foundation of our military medicine instruction. This resident driven curriculum focuses on preparing MAMC graduates to practice in dynamic practice environments, including fellowship, at a MEDDAC or larger MEDCEN, serving as clinic/service/department chief, careers in academic military medicine, operational unit positions, and other positions of high impact and large sphere of influence within the military.

Examples of specific military unique curricular elements and opportunities include:

• Fundamental Critical Care Support Course
• Capstone Course which includes Transition to Practice Course
• Combat Casualty Care Course (C4)
• Military Mountain Medicine Course
• Dive Medicine Course
• Sports Medicine and physical medicine and rehabilitation clinic rotations
• Point of Care Ultrasound elective rotation starting during intern orientation, and other POCUS training throughout the didactic curriculum
• Numerous military unique curricular didactics including topics such as sports medicine, special warfare, military finance, military profiling for medical officers, medical retention standards, flight
• medicine, military utilization panel presentation, deployment readiness, leadership, garrison care.
• Simulation sessions on trauma care and battlefield procedural competency
• Military Tropical Medicine course with optional international rotational experience
• Tactical Combat Medical Care Course
• Military Humanitarian Course

All residents are required to maintain Basic Life Support and Advance Life Support certification throughout residency. These courses are readily available at Madigan Army Medical Center at no cost to the residents. All residents complete Combat Care Casualty Course (C4) training prior to graduation (unless they completed Bushmaster training in medical school). In addition, Madigan boasts a proud tradition of Capstone – a required weeklong course for graduating residents that encompasses all of the aspects of OPD and Sim training learned throughout residency in which residents are provided instruction in and participate in a field training exercise that utilizes the procedural and tactical skill learned in TCCC. In addition, residents are provided further guidance and mentorship regarding military life after residency to ensure continued success in their professional and military careers.

Madigan is a Center of Excellence for simulation-based medical education within the Department of Defense. The internal medicine simulation curriculum is conducted at both the Anderson Simulation Center at the Madigan Annex and the Just -In-Time Simulation Center within the main hospital. These training centers offer residents access to high fidelity mannequins complete with fully customizable vital signs, physical exam audible and palpable physical exam findings, and opportunity to practice code scenarios with functional defibrillators. In addition, our residents are offered tremendous opportunity for procedural practice on mannequins to include central lines (with mannequins compatible with ultrasound use mimicking real patients), arterial lines, intubations, thoracenteses, paracenteses, and more. We are fortunate to partner with the University of Washington’s highly touted simulated patient program which provides residents with state-of-the-art interpersonal and professional training in de-escalation, delivering bad news, and difficult conversations occurring in our simulation curriculum.

The program provides a robust opportunity to develop leadership skills throughout residency training. These opportunities run the gamut of leadership potential and include leading small group discussions during morning report or on an elective rotation, serving on MAMC IM committees, as well as hospital-wide committees. At MAMC we are fortunate to be the only MEDCEN with a faculty development fellowship and offer our senior resident’s opportunities to rotate through the department to bolster their skills in teaching, leadership, career advancement, and more.

Other opportunities include:

• Opportunity to lead ward or Intensive Care Unit (ICU) team on a regular basis
• Opportunity to lead residency and hospital-wide committees
• Ability to serve as a junior chief of the IM program
• Quality improvement and patient safety projects
• Scholarly projects and curating potential case reports for junior learners
• Residency and IM clinic sponsored community service projects

Our Department of Medicine Research Committee plays a pivotal role in fostering resident participation and publication of case reports and original research, as well as quality improvement and patient safety initiatives. This underscores our department's commitment to research and quality improvement initiatives.

To facilitate a commitment to lifelong learning and garner an appreciation of clinical research in the early years of training, all MAMC IM PGY-1s participate in Department of Medicine Research Day. This involves presenting a case report encountered during the intern year to an audience of physician faculty and their peers in a low stake setting. This allows interns to practice researching and preparing a case presentation and significantly contributes to our residency's unparalleled success in research. Virtually all residents have yet to present at a regional conference, with many graduates having presented (and won awards at) regional and national conferences.

We also have Assistant Program Directors for Research and Quality Improvement and Patient Safety. They maintain a database of research opportunities and work with residents and their mentors to ensure they use research time effectively and receive appropriate guidance and coaching to turn ideas into results. This research emphasis has led to many resident-directed projects and publications. Our graduates are well prepared for academic careers and competitive for fellowship selection through these research endeavors in addition to their expertise as resourceful, master clinicians.

Our program has a quality improvement and patient safety graduation requirement for all our trainees. Our program also has assistant program directors for research and QIPS who can help you in your efforts. Residents at graduation are expected to:

• Complete the online coursework necessary to earn the Institute for Healthcare Improvement’s Open School Basic Curriculum in Quality and Safety.
• At a minimum, participate actively in a quality improvement/patient safety project.

Our program provides ample funding opportunities and support for residents to perform, publish, and present research and scholarly work. Graduates of our program are highly sought after in many domains of military medicine and are incredibly competitive for fellowship applications in all subspecialties. As PGY3s, our residents also have the opportunity to attend faculty development workshops given by our local Faculty Development fellowship program, which facilitates learning, mentorship, and professional growth for our residents who benefit from their subsequent peer mentorship.

• Madigan Army Medical Center, Tacoma, Washington
• Puget Sound VA Healthcare System, Seattle, Washington
• Sacred Heart, Spokane, Washington
• Deaconess ICU, Spokane Washington
• Tacoma General, Tacoma, Washington
• Good Samaritan Hospital, Puyallup, Washington
• Providence Centralia Hospital, Centralia, Washington
• Cedar Wellness Center, Tacoma, Washington

Our program offers rotations to fourth year medical students interested in applying to internal medicine. Rotations are typically four weeks long (can be split into two-week blocks) and can be requested in a variety of clinical environments (see list below).

• Inpatient (Wards)
• Critical Care (ICU)
• Cardiology
• Endocrinology
• Rheumatology
• Pulmonary
• Nephrology
• Gastroenterology
• Infectious Disease
• Internal Medicine Clinic/Consult Clinic

If there is a rotation you would like but do not see on this list, please reach out to the email below to contact the Chiefs of Medical Residents and we will work to accommodate you!

To schedule medical student rotations or interviews, you must be a U.S. military HPSP or USU medical student. Please send an email to dha.jblm.gme-acad-o.list.internal-medicine-cmr@health.mil and include the following:

• Preferred rotation dates and rotation experience (Inpatient wards, cardiology, ICU, etc...)
• Indicate if you would like to interview with us during your rotation.

Interviews are offered from July - October 15th, annually. Interested applicants can schedule an interview virtually or in person by contacting dha.jblm.gme-acad-o.list.internal-medicine-cmr@health.mil.

Program graduates take the American Board of Internal Medicine (ABIM) Certifying Examination. This exam is offered annually in August. All Internal Medicine physicians who have met the standards for Board Certification in general internal medicine are considered Board Eligible for a period of seven years. During this period of board eligibility, the candidate may apply for the certifying examination in internal medicine. To be eligible to take this exam, graduates must complete all pre-requisites required by the American Board of Internal Medicine by August 31st.

Madigan Internal Medicine residents must leave our institution prepared to educate others. To this end, we offer many opportunities. Uniquely, we provide a dedicated "senior teaching rotation" opportunity where senior residents will either be supervising interns in their continuity clinic or they will assisting the chiefs of medical residents in delivering educational content during the morning, academic half-days, simulation and procedure training, medical student weekly lectures, or other focused educational content that they are inspired to deliver. Otherwise, trainees have opportunities to practice and hone their skills as educators from the outset of training in both formal and informal settings.

Some examples of teaching opportunities available to all trainees in our program include:

• Interns and residents teach third—and fourth-year medical students on wards, intensive care units (ICUs), and elective rotations throughout the academic year.
• Residents participate in teaching interns in both the inpatient and ambulatory settings throughout the academic year.
• Junior chief positions: Each of the four junior chief roles plays a crucial part in delivering formal and informal academics (Academic Junior Chiefs), organizing and teaching simulations (Simulation Junior Chiefs), delivering Officer and Professional Development Content (OPD Junior Chiefs) and providing mentorship, guidance, recruitment, and education to potential program matriculants (Outreach Junior Chief)
• All residents are scheduled to develop and present evidence-based medicine presentations (using the PICO format in R-1 year), deliver "Updates in Subspecialty" morning report using EBM principles to curate and deliver content (R-2 year), and participate in EBM "debate" structured on answering a debated topic in medicine using the best available evidence to argue their assigned stance (R-2 and R-3 years)
• Throughout the academic year, residents have the opportunity to design and deliver other educational sessions in lecture or small group format.
• Residents plan and lead simulation training for our family medicine resident colleagues every month.
• Any trainee in residency training may sign up to earn a Certificate in Health Professions Education from the Uniformed Services University.
• Senior residents may participate in a two —or four-weeklong faculty development rotation to hone their skills as clinician educators and academic medical professionals.
• Medical students are encouraged (but not required) to participate in academics by joining their ward teams in gathering content for and delivering morning report lectures, delivering medical student lectures, and giving chalk talks to their respective ward teams.

Faculty supporting the Internal Medicine Residency program have a wide range of subspecialty representation, including:

• Critical Care
• Cardiology
• Hematology Oncology
• Endocrinology
• Rheumatology
• Pulmonary
• Nephrology
• Allergy Immunology
• Gastroenterology
• Neurology
• Dermatology
• Infectious Disease
• Palliative Care
• Geriatrics
• Faculty Development
• Ultrasound (Point-of-care)
• Emergency Medicine
• Radiology
• Ophthalmology
• Anesthesia

Internal Medicine Clinic (IMC) Advisor Program

Each internal medicine resident is assigned a general primary care-focused internist on arrival to the program, who will serve as their IMC advisor throughout their three-year residency. This IMC advisor will also frequently be assigned with the resident as a preceptor during their continuity clinic to provide consistent supervision and care. The advisor will often see and take care of acute issues in patients assigned to that resident’s continuity panel when that individual is unavailable due to residency rotation requirements, leave, or TDY. This individual will also review and cosign telephone consults the resident completes addressing patient issues not otherwise associated with a clinic visit staffed with another faculty member.

Faculty and Resident Mentor Programs

The internal medicine mentorship programs consist of first assigning each incoming PGY-1 a PGY-3 mentor with whom guidance regarding PCS, scheduling, required training, house/apartment hunting, etc., is solicited, in addition to overall questions about the program, and any specific advice that can be shared. In addition, every incoming intern will identify and solicit mentorship from a faculty member with whom they are most likely to benefit regarding career guidance, personal coaching, research interests, or fellowship aspirations. Residents are expected to meet with their mutually agreed upon mentors biannually to monitor progress on specific goals set at their initial encounter and subsequent encounters. PGY-1s are strongly encouraged to seek professional guidance early in their career to succeed in academic and military medicine.

The Madigan Internal Medicine Residency Program and its leadership are fully committed to the wellness of residents and strive to foster a positive, safe, collaborative, and effective learning environment that centers the needs of patients and residents alike. The service of residents cannot and does not take precedence over learning. The program leadership is committed to addressing and using resident feedback and concerns to make program changes and adjustments as needed to be expedited.

Formal wellness initiatives include:

• Fifth Fridays (any resident on outpatient rotation during a month with five Fridays sees the final Friday of the month excused from clinical responsibilities and will join in a wellness committee voted on event outside the hospital)
• Intern welcome picnic
• Holiday party
• Medical student receptions during interview season
• Medical student “Who-Am-I” events at morning report to introduce rotators to the residents
• Medical student outings organized by outreach junior chief
• Annual resident retreat
• End-of-year banquet and awards ceremony
• Off-site rotator check-ins and care packages by chief residents
• Chief resident “candy rounds"
• Residency kudos (Kudos recipients receive $5 Starbucks gift cards)
• Open-door chief resident and program director policy for any questions/comments/concerns/feedback

The program and institution have a rich array of resources available for trainees to help support their health and wellness including a peer support program, behavioral health resources, financial planning resources, chaplain services, and military and family life counseling.

Beyond the academic rigor, varied and vast clinical experiences, opportunities for research, and fellowship competitiveness, perhaps the most revered aspect of the program is our resident camaraderie and mutual adoration and respect for one another. Residents create and maintain lifelong friendships in the program – we are a close-knit community within our residency and amongst other programs in the hospital as evidenced by our vast array of interdisciplinary lectures and grand rounds. All of us have a deep concern for our patients and each other and our rotating medical students – so please come rotate with us, we’d love to have you!