Mission

To educate and develop the next generation of physicians in clinical care excellence, scholarship, leadership, preparing trainees to meet tomorrow’s challenges in military and civilian health care.

Vision

Madigan transitional year physician graduates understand and exhibit the unique values and specialized knowledge to lead and deliver highly reliable care in complex and unpredictable environments.

Aims

• Promote individual development of the unique values and specialized knowledge to lead and deliver highly reliable care in complex, variable, and unpredictable environments.
• Educate and develop the next generation of physicians in clinical care excellence, scholarship, leadership, and resiliency, preparing trainees to meet tomorrow's challenges in military and civilian health care.
• Foster an inclusive work environment where all individuals are respected as members of the health care team.
• Reinforce a culture of commitment to patient safety and continuous quality improvement.

Didactic sessions correspond to resident clinical rotations and complement and enhance the clinical experience. Didactic sessions include multidisciplinary conferences; morbidity and mortality conferences; journal or evidence-based reviews; case-based planned didactic experiences; seminars and workshops to meet specific competencies; computer- aided instruction; grand rounds; quality improvement and safety; and one-on-one instructions. Resident attendance and participation in didactic experiences is monitored using a residency management software verification form completed by the resident after each rotation. Additionally, the program holds regular meetings twice a month every other Tuesday from 12 -1 p.m. covering additional topics such as evidence-based medicine, high value care, diversity equity and inclusion initiatives, patient safety/quality improvement, wellness/resiliency, and other military specific topic relevant to their level of training/expertise.

The transitional year program consists of twelve months of training divided into 13 four-week blocks. There are eight required rotations and five elective rotations. All rotations are four weeks in duration.

The eight required rotations are outlined below.

• Intensive Care Unit (inpatient): Caring for critically ill hospitalized patients.
• General Inpatient Medicine (inpatient): Two rotations of caring for hospitalized adult patients.
• Obstetrics and Gynecology (outpatient): Ambulatory care of gynecology and obstetrical triage patients.
• Pediatrics (outpatient): Caring for well and sick children and adolescents in clinic.
• Family Medicine (outpatient): Two rotations providing ambulatory care to adults and a family medicine patient population at both the MAMC family medicine and Okubo clinics family medicine clinics. This includes training in common outpatient procedures, exposure to sick-call, and soldier-centered medical care.
• Emergency Medicine (outpatient): Ambulatory care of patients presenting to the emergency department. This includes 144-160 hours of emergency medicine experience seeing all acuity levels of adult and pediatric patients.

TY residents choose five elective rotations based on their pre-selected specialty or specialty goals. One of these electives must be a surgical elective and at least two need to involve direct patient care. Incoming residents complete a survey to choose their electives prior to arrival. Available electives for the transitional year program are listed in the table below.

• Allergy-Immunology
• Adolescent Medicine
• Anesthesia
• Cardiac Care Unit
• Cardiology Clinic
• Dermatology
• Diagnostic Services (Rads/Path)
• Emergency Medicine
• Endocrinology
• Family Medicine Clinic
• Family Medicine Inpatient team
• Gastroenterology Clinic
• General Surgery
• Geriatrics
• Gynecology
• Gynecology-Oncology
• Gynecology-Urology
• Infectious Disease
• Intensive Care Unit
• Internal Medicine Consult Clinic
• Internal Medicine Wards
• Labor and Delivery
• Neonatal ICU
• Nephrology
• Neurology
• Neurosurgery
• Nuclear Medicine
• Obstetrics
• Operational Medicine
• Ophthalmology
• Orthopaedic Surgery Ward
• Otolaryngology
• Pathology
• Pediatric Inpatient Service
• Pediatric Subspecialty electives
• Physical Medicine
• Plastic Surgery
• Preventive Medicine
• Psychiatry
• Pulmonary Clinic
• Radiology (diagnostic or interventional)
• Rheumatology
• Thoracic Surgery
• Urology
• Vascular Surgery

Transitional Year residents only take call during the following inpatient rotations: internal medicine wards, and ICU. During the ICU, TY residents are on call during the day for any new admissions or consults to the ICU under the supervision of their higher-level resident and attending physician. ICU interns do not take overnight call on this rotation. Additionally, residents are on call during their long call day for any new admissions or consults to the internal medicine wards under the supervision of their higher-level resident and attending physician. During one of their internal medicine rotations, TY residents will spend seven consecutive days on a night-float AMOD (cross-cover) schedule where they will respond to any urgent or acute clinical issue with any patient admitted to the adult internal medicine ward service. The program has no 24-hour call responsibilities on any of its required rotations.

Mandatory Intern Lecture Series

(All TY residents complete)

All TY residents will attend the mandatory intern lectures that occur on ten Fridays throughout the academic year from 1200-1300. These lectures are run by the Director of the Central GME Curriculum and cover a variety of topics to include: military medicine, officer professional development, finance, and military topics. These didactics serve as a practice management lecture series and will cover pertinent topics to prepare residents to be medical officers.

Chemical, Biological, Radiological, Nuclear and High Explosive (CBRNE) Training

(All TY residents complete)

CBRNE training is an online course designed to increase the residents’ knowledge of how to prepare and respond to terrorist attacks involving CBRNE agents.

Combat Casualty Care Course (C4)

(All TY residents who did not attend the Bushmaster course at USUHS will complete.)

The C4 course is a 9-day course at Fort Sam Houston which is a requirement for those who did not attend USUHS. ATLS training, deployment medicine, and management of casualties are taught during the course.

Graduate Capstone Course

(All TY residents going out as GMOs and those selected for residency outside of Madigan will complete.)

All TY residents going out as general medical officers or attending residency at an institution other than MAMC, will attend this week-long seminar in May prior to graduation. The course is designed to help graduates transition to military medicine outside of residency training. It includes leadership topics, medical liability and patient safety, and the role of service chiefs in the management of personnel and quality patient care.

• Military Medical Humanitarian Assistance Course
• CITI Training and/or the Applied Research Training (ART) at Madigan

Residents will participate in a variety of simulation activities designed to both teach residents and assess their competence in a variety of skills and procedures. Residents will complete the simulation activities below:

OB/GYN Procedure Training

(4-hour session for all TY residents).

All TY residents will complete training on placement and removal of Nexplanons/IUD by trained and certified staff at MAMC. This training will incorporate education on indications and complications of this procedure. This training is fundamental to TY interns, especially those going out as GMOs.

Central Venous Catheter (CVC) Placement

All TY residents will complete training on how to place a central line under ultrasound (US) guidance. This is included in FCCS training during intern orientation. Residents will first complete the online training through the University of Washington and then complete a four-hour class at the simulation center which includes didactics, use of an US machine, and hands-on training using simulation. This training is required for all Madigan residents rotating through the intensive care unit. A copy of the curriculum and evaluation form can be found on the TY SharePoint site.

Intravenous Access

Residents will receive training on gaining intravenous access during FCCS training during intern orientation. Didactics and hands-on experience will take place while residents wait to do their hands-on CVC test.

Management of Medical Emergencies

(3-hour sessions for up to six residents per session).

All TY residents will complete this training in groups of five or six residents. Emergency scenarios will be given to one of the residents who will be the team leader and work with his or her peers to manage the patient’s condition. This allows residents the opportunity to practice team crisis management skills including individual role assignments, effective closed-loop communication, and techniques for effective code leadership. A TY faculty member will conduct an interactive debriefing after each scenario to discuss key points and give feedback. A copy of the curriculum is located on the TY SharePoint site.

Suturing and Skin Procedures

(One 4-hour session for all TY residents).

Residents will learn about common skin disorders and procedures. Reading material is posted on the TY SharePoint site to review prior to the workshop. The workshop will consist of didactics, videos, and hands-on training performing procedures. Residents will learn how to counsel patients regarding skin procedures, understand potential risks, manage local anesthesia, and perform shave biopsies, punch biopsies, excisional biopsies, suturing, and cryotherapy. A copy of the curriculum is located on the TY SharePoint site.

Arthrocentesis and the Musculoskeletal Examination

(One 4-hour session for all TY residents).

Residents will learn to diagnose common knee and shoulder problems using historical clues and physical exam maneuvers and perform shoulder and knee arthrocentesis. Residents will review reading material prior to the workshop, participate in didactics, and get hands-on training doing musculoskeletal examinations and simulated arthrocentesis.

Standardized Patient Evaluation

(Two 30-minute sessions for all TY residents). Residents will evaluate two standardized patients presenting with challenging inter-personal dilemmas common in the inpatient and outpatient services. TY residents will evaluate each standardized patient and receive formative feedback on their performance from faculty members within the program. This is a low-stakes training event meant to help improve their inter-personal communication and professionalism skills.

The Transitional residency program does not have any unique leadership training opportunities not already outlined in this document. However, during intern orientation, two TY reps are selected from their peers and are responsible for organizing the TY program annual educational retreat, holiday party, graduation celebration, and multiple fifth Friday team-building events fostering camaraderie and facilitating structured annual program evaluation policies.

The Madigan Transitional Year curriculum advances residents’ knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care. Madigan and the program allocate adequate educational resources to facilitate resident involvement in scholarly activities as follows. The ACGME requirement is that TY resident participation in scholarly activity includes presentation of a case report or a presentation to colleagues on a subject of interest, and/or development of a research or quality improvement project. Madigan TY residents exceed the scholarly activity requirement by resident involvement in the following required and optional activities:

Case Reports/Group Presentation

Residents present a case report, morning report, or presentation to colleagues on a patient or subject of interest while on their medicine ward, ICU, or other rotations. These presentations are used to educate other residents and faculty on interesting aspects of a patient the resident cared for while on the rotation.

Quality Improvement Project

All residents complete the quality improvement and patient safety curriculum as outlined below. Each resident will present a mistake and lead a quality improvement. discussion during a TY resident meeting. All residents will also participate in a group quality improvement project using the FOCUS-PDCA model as outlined below.

Research Training Course

Residents are required to either attend the two day Applied Research Training (ART) Course offered at Madigan each year OR complete the online Collaborative Institutional Training Initiative (CITI) research course.

Interaction with Faculty

Residents interact with faculty who participate in original research, present at national conferences, produce publications, and offer guidance and technical support in their area of research.

Madigan Research Day Presentations

Residents may submit an abstract regarding a case report or research project for Madigan Research Day. If selected, residents will present their scholarly activity either as a main stage presentation or a poster presentation.

Research Elective

Completion of a research project is not required during the transitional year; although, a research elective is available as part of the curriculum. If TY residents request a research elective, they must meet the following criteria: must associate the elective with a rotation where the research is being done to allow for didactics; must have a research mentor; and must have an approved IRB original research project prior to the start date of the elective. Research electives are not allowed for case reports or research planning.

Recognition for Scholarly Work

The TY program encourages research and publication. The program submits an Army award for those residents who go above and beyond the scholarly activity requirements and publish a peer-reviewed manuscript. Awards will be submitted for residents who either publish a peer-reviewed manuscript during the TY year or publish a manuscript after the TY year that was based on research conducted during the TY year.

Institutional Resources

Madigan’s Department of Clinical Investigation has personnel to assist with research planning, statistical analysis, and funding of research and outside presentations.

Making mistakes while practicing medicine will always happen, especially at the PGY-1 level when young physicians are making daily decisions about patient care. It is important for new physicians to understand that mistakes happen, admit their mistakes, realize how mistakes occur, and use the lessons learned to make sure they and others do not repeat the same mistake again. The Madigan TY program is committed to promoting patient safety through a comprehensive quality improvement and patient safety curriculum. Residents learn and are able report errors, adverse events, unsafe conditions, and near misses in a protected manner that is free from reprisal. The curriculum is also designed to allow residents to contribute to inter-professional root cause analysis and other risk reduction teams.

PGY-1 Orientation

Prior to starting the transitional year, residents receive a variety of lectures and workshops that focus on patient safety and quality improvement during their intern orientation. They are introduced to ACGME requirements for patient safety, national patient safety goals, risk management and sentinel events, the quality improvement cycle, and the hospital method of reporting of patient safety concerns through a secure SharePoint site.

Root Cause Analysis Training

During intern orientation, each transitional year resident completes the Department of Defense Patient Safety Program Root Cause Analysis (RCA) eLearning Course. This online course provides comprehensive training on the RCA process.

My Mistake Project

My Mistake is a tool that is used to help residents understand how their interactions in the medical system can affect and improve patient care. As mistakes are encountered, transitional year residents will prepare one type-written page to reflect on the experience using an established format in the My Mistake curriculum. Each resident will present this mistake and lead a class discussion at one of the TY resident meetings which occur every other Tuesday at noon in the TY resident workroom. Useful recommendations from this meeting are relayed to the appropriate hospital committee or department when applicable.

Other Quality Improvement Projects

Several formal quality improvement group projects will be performed during the year. Topic will be chosen by the residents and TY leadership, and residents are broken into several groups for each topic. Each group will work through the performance improvement process together under the supervision of a TY faculty member using the Madigan standard FOCUS-PDCA model. Residents will systematically analyze their practice using quality improvement methods and implement changes with the goal of practice improvement. All residents will be involved in the project and will document the process. Up to two residents will be chosen or may volunteer to lead the process under supervision of the faculty.

Required for all Transitional Year Residents

Lack of military mentorship is a leading contributor of why officers leave the Medical Corps. TY residents will be assigned the requirements below to be completed during the first half of the academic year. These requirements were added to the curriculum to help develop TY residents professionally and set them on a successful path as they progress through their careers and ensure clearer communication with HRC for future potential assignments. Links to lectures, handouts, and other information pertinent to the items below can be found on the TY SharePoint site under “Professional Development” in the left margin. Residents will receive a lecture on the items below during one of their mandatory intern lectures and/or TY didactic lectures at noontime.

Integrated Personnel and Pay System

Army (IPPS-A) and Soldier Talent Brief (STB): TY residents will understand how to navigate IPPS-A and items to review/update on their current STB. A “Preparing for Promotion” lecture handout is available on the TY SharePoint site to assist.

Official Military Personnel File (OMPF)

TY residents must make sure their OMPF is up to date. See promotion handout for instructions.

Department of the Army (DA) Photo

TY residents must take their DA photo in the Army Service Uniform (blues) on post.

Curriculum Vitae

TY residents will create a CV using the American Association of Medical Colleges (AAMC) format. See guidance on TY SharePoint site.

• Bremerton Naval Hospital
• Joint Base Lewis-McChord

The TY program does not host rotations for medical students.  

The program does not conduct formal interviews for individuals participating in the Joint Services GME Selection Board process. However, the TY leadership is available to answer any questions about the program throughout the academic year.

Transitional Year residents are not required to take a specialty board examination.  

During inpatient medicine and ICU rotations, TY residents have the opportunity to supervise and mentor medical students from the USUHS and the University of Washington. TY residents also have the opportunity to present didactic sessions at either morning report or during other informal times during their rotations.

Our TY Leadership have a diverse background encompassing many surgical, medical, and support services within the Sponsoring Institution. In addition, TY residents interact with many faculty members in a broad range of specialties during assigned and elective clinical rotations.

Each Associate Program Director is assigned up to 11 TY residents and serves as their mentor during their transitional year. This faculty member is responsible for answering any professional development and/or career related questions during the year, serving as a resident advocate to the program, conducting TY quarterly counseling sessions, serving as a Rater for resident Officer Evaluation Reports, and submitting Army awards for those residents who go above and beyond the educational requirements of the program.