Categorical Track

As part of the Categorical Track at Virginia Mason, each resident will participate in inpatient, outpatient and elective experiences that will teach the skills and knowledge needed to pursue any path in internal medicine, whether it be fellowship, hospital medicine or primary care. As compared to the primary care track, categorical residents will spend more months on inpatient services.

Every categorical and primary care resident has a primary care continuity clinic throughout all three years of residency, either at a Virginia Mason clinic or at the Eastgate Public Health Center. In addition to the inpatient medicine services and continuity clinic, there are opportunities to participate in a variety of electives, both outpatient and inpatient based. Overall, our goal is to provide residents with a wealth of varied experiences that are customizable, so that each resident has the opportunity to focus on a particular path within internal medicine. As an example, a resident intent on hospital medicine might decide to pursue inpatient-based electives such as inpatient neurology, where the resident works one-on-one with a neurohospitalist.

The first year of the categorical Internal Medicine Residency is an intensive introduction to both inpatient and outpatient internal medicine. This year exposes new residents to patients with complex medical presentations, and provides both breadth and depth in the ascertainment of new medical knowledge. Note that this year also has the fewest blocks available for elective time, and this is the most inpatient-heavy year of the residency program. Residents complete this year with the skills necessary to be well prepared to lead teams as senior residents in their R2 year.

First year residents’ schedules break down in general as follows:

• Wards: 20 weeks
• ICU: 8 weeks
• Night Float: 4 weeks
• Outpatient General Internal Medicine: 4 weeks
• Emergency Medicine: 4 weeks
• Electives: 8-12 weeks
• Continuity Clinic: 2-4 full days per month, with the exception of months on ICU and Night Float rotations, during which there is no continuity clinic scheduled.

The second year allows residents to take the reins and begin to lead inpatient wards teams as senior residents. It also provides an increased amount of time to explore both personal and professional goals, with more time allocated to elective rotations, scholarly research time, and networking opportunities.

Second year residents’ schedules break down in general as follows:

• Wards: 8-12 weeks
• ICU: 4-8 weeks
• Night Float: 4-8 weeks
• Outpatient General Internal Medicine: 0-4 weeks
• Electives: 20-24 weeks
• Continuity Clinic: 2-4 full days per month, with the exception of months on ICU and Night Float rotations, during which there is no continuity clinic scheduled

The third and final year of the categorical track solidifies residents’ knowledge base in both inpatient and outpatient internal medicine and prepares them for their ensuing careers. The goal of this year is to tie together both clinical and leadership skills, and allows for time for career development (preparation and application for fellowship, career networking events, a larger number of rotations with increasing amounts of independence).

The R3 schedule generally mirrors the second year schedule:

• Wards: 8-12 weeks
• ICU: 4-8 weeks
• Night Float: 4-8 weeks
• Outpatient General Internal Medicine: 0-4 weeks
• Electives: 20-24 weeks
• Continuity Clinic: 2-4 full days per month, with the exception of months on ICU and Night Float rotations, during which there is no continuity clinic scheduled

In July 2019 Virginia Mason transitioned to a unit-based care model. This means patients with similar disease manifestations reside on the same floors. We have found this increases efficiency for the physician, ensures optimal communication with our nursing and care managers, and allows us to be more present throughout the day for family discussions or other needs which may arise. From an educational viewpoint, this has allowed us to immerse ourselves in specific topics during our inpatient months. While there are still many disease processes on each floor, the resident rotates through the telemetry unit, progressive care (ICU step-down unit), and a med/surg hematology-oncology unit. Because of this geographic structure, we have been able to engage our sub-specialist colleagues for frequent teaching during the month centered on patient-specific presentations, review of echocardiograms, physical examination rounds, oncologic emergencies, palliative care rounds, and a variety of other learning modalities which enhance our residency experience.

• Teams consist of varying compositions of seniors and interns, providing a range of opportunities for teaching and practicing more autonomously. These rotations provide the backbone of our inpatient clinical education and allow for the development of diagnostic and patient care skills. While on wards, residents are immersed in the culture of continual improvement that defines Virginia Mason as an institution.
   
• Teams will utilize, depending on their floors’ needs, both traditional rounds as well as our innovative “one-piece flow” rounding system, which increases efficiency and patient safety, and exemplifies the Lean principles and practice for which Virginia Mason is nationally recognized. The rounding teams rotate as the daytime cross-cover and Code Blue team. Night float team provides cross-cover and admits for the resident teams overnight. All residents have one day off per week while on inpatient services except for Day Admit when every weekend is off.
   
• Shifts on rounding teams usually run from 7 a.m. to 7 p.m. when a team is code/cross-cover, though residents are usually able to leave earlier on non-code days.
    
• Rounding teams will admit patients if the team has a sufficiently low enough census.
   
• Teaching occurs during rounds on a daily basis as well as outside of rounds with talks from attendings and residents to supplement topics seen on the floor.

Level 8: This is the team for our Telemetry floor who care for our patients admitted for cardiac issues, such as ACS and heart failure. The team consists of a senior resident with two interns and an attending hospitalist who oversees the team.

• As part of being on this team, residents undergo a series of didactics focused on-based management of these conditions and weekly teaching sessions with our cardiologists to improve their understanding and capacity to manage these issues.
    
• Goal census for the team: 14-18 patients split between the 2 interns with senior oversight.

Level 9: This is our Progressive Care floor, which is our step-down unit, where patients have either improved enough to leave the ICU or require close monitoring. This floor has robust learning with an emphasis on sepsis and respiratory failure. The team consists of two senior residents and two interns working together to care for their patients, supervised by an attending hospitalist.

• While on this rotation, residents work through a set of didactics on conditions typically seen on this floor, such as alcohol withdrawal and sepsis, as well as having weekly teaching sessions with our pulmonologists.
   
• Goal census for team: 14-18 patients split between the 2 interns and 2 seniors.

Level 18: This is an oncology-focused medical/surgical floor where residents receive training on common malignancy-related complications and conditions. The team consists of 2 interns and a supervising attending hospitalist. There is a senior on the unit for first 2 months of intern year after which interns have increased autonomy and work directly with an attending hospitalist.

• Residents will review didactics on topics such as neutropenic fever and other common presentations seen on the floor, as well as having weekly didactic sessions with our oncologists and Palliative Care team.
    
• Goal census for team: 16 patients split between 2 interns.

Day Admit Team: This team admits medicine patients throughout the hospital (excluding MICU). The team consists of 1 senior resident, 2 interns and a supervising attending hospitalist.

• Shifts are M-F, starting at 10 a.m. and usually finishing with admissions by 10 p.m. Weekends are off on this rotation.
    
• Each intern admits a maximum of 4 patients per shift with oversight from a senior resident. On intern clinic days, the senior oversees the other intern while performing their own admissions.

Medical Intensive Care Unit (MICU)

In addition to teaching the skills necessary for the care of the complex, critically ill patient, our MICU rotation emphasizes leadership, interdisciplinary collaboration and end-of-life care. Our award-winning ICU is staffed by board-certified subspecialists who are passionate about resident education.

• The critical care team consists of two senior residents, four interns, a daytime intensivist, and an ICU night hospitalist. The four interns are split between the day and night shifts, and they switch halfway through the rotation.
    
• Interns work approximately 11 night shifts and 11 day shifts, with six days off per rotation. Senior residents do not work any night shifts and have five days off over the rotation.
    
• Rounds are attended by a multidisciplinary team that includes not only the residents and attending, but also nurses, pharmacists, respiratory therapists, and patients with their families.

Night Float

Our night float rotation emphasizes the development of autonomous decision making, efficiency and communication. It is instrumental in training interns to admit patients in an organized, comprehensive and efficient manner, while balancing the demands of cross-cover.

• The night float team consists of two interns, two senior residents, and a nocturnist attending. Each Tuesday and Wednesday night the interns are off, and the two senior residents will run the show.
    
• The night float shift is from 7 p.m. - 7:30 a.m.
    
• Interns work five nights in a row and then have two nights off per week, and senior residents work nine nights in a row and then have five nights off.

Emergency Medicine

Our emergency medicine rotation allows residents to hone their skills in the initial workup and management of patients with a wide range of diseases. Like all departments at Virginia Mason, our Emergency Department (ED) is designed to maximize patient safety and quality care, while minimizing cost and unnecessary testing.

• Residents work one-on-one with board-certified emergency medicine physicians.
    
• During the block, interns work 16 shifts, consisting of day, evening and night shifts.

Elective Hospitalist Float Rotation

The resident on the hospitalist elective works one-on-one with a Virginia Mason hospitalist faculty to care for six to eight patients without a larger intern team. The resident rounds independently, checking in with the attending throughout the day. This rotation emphasizes autonomy and advanced clinical decision-making skills and is a good option for those interested in a hospitalist career.

• Chosen as an elective by second- or third-year residents.
• 7 a.m. to 7 p.m. Monday through Sunday, every other week.
• In the off weeks, the resident has two days of continuity clinic each week and is otherwise free.
• Residents continue to attend conferences and didactic sessions when they are in the hospital.

Other than the hospitalist float rotation, all other elective rotations are Monday through Friday, though residents may be called to work as inpatient as back up during their assigned weeks on these rotations. Over the course of three years, residents complete the core electives needed for their track (categorical or primary care) and will be able to customize a schedule of electives that will best prepare them for their future career.

During these rotations, residents work directly with the specialists in caring for patients to learn more about the breadth of each of these fields as well as more in depth in how to diagnose and manage the conditions that these providers specialize in. Our specialists help residents focus on not only the knowledge needed for boards but also improving their exam techniques and understanding of conditions so they are better able to evaluate and manage patients for a wide variety of conditions prior to referral.

Elective Options

Electives in bold are required for completion of Categorical and Primary Care Programs. 

• Allergy and Immunology
• Anesthesiology (Moderate sedation certification, optional)
• Away rotation (another institution, rural, or international)
• Cardiology
• Dermatology — Required for Primary Care
• Endocrinology
• ENT — Recommended for Primary Care
• Float Hospitalist Rotation
• Gastroenterology
• General Internal Medicine I
• General Internal Medicine II – Required for R1 Primary Care
• General Internal Medicine – Advanced – Required for Primary Care, R2 and R3
• Geriatrics — Required as R2
• Gynecology — Required for Primary Care
• Hematology/Oncology
• Hyperbaric Medicine — Recommended for Primary Care
• Infectious Diseases
• Inpatient Glycemic Control
• Inpatient Neurohospitalist
• Inpatient Oncology
• Inpatient Psychiatry
• Nephrology
• Neurology
• Obesity Medicine
• Ophthalmology — Recommended for Primary Care
• Orthopedics/Sports Medicine/PMR/Podiatry (Musculoskeletal) — Required for Primary Care
• Palliative Care
• Pathology
• Physical Medicine and Rehabilitation
• Procedures (R2 and R3 only)
• Pulmonology
• Radiology (R3 option, upon approval by department)
• Rheumatology
• Scholarly
• Sleep Medicine
• Systems-Based Practice
• Surgery — Outpatient — Required for Primary Care
• Urology — Outpatient — Required for Primary Care
      

Each available elective usually has a predominant outpatient or inpatient focus. However, each elective can be molded based on your interest to have more outpatient or inpatient experience based on your interests and future career goals.

The rotations with inpatient predominant experiences are:

• Float Hospitalist
• Infectious Diseases
• Inpatient Glycemic Control-Endocrinology
• Inpatient Neurohospitalist
• Inpatient Oncology
• Inpatient Psychiatry
• Nephrology

On each of these rotations, you work one-on-one with an attending, seeing new patient consults and follow-up patients. On the float service, senior residents have the opportunity to work aside an independent hospitalist, managing patients and getting a feel for the life of a hospitalist. The schedule for elective inpatient rotations are typically Monday-Friday, with weekends off!

At Virginia Mason, there are plenty of opportunities to connect with categorical graduates of the program and attending physicians. Every year, we host a variety of career nights including hospital medicine, primary care and fellowship panels. There is a wealth of information that we have gained from our alum, many of whom have stayed at Virginia Mason after residency, or come back post-fellowship!

As a Virginia Mason resident, you are exposed to a wide variety of patients with a range of backgrounds, medical issues and economic circumstances. Residents are exposed to diversity both within the Virginia Mason health system and through our community partners.

The Virginia Mason Health System includes both the main hospital and outpatient clinics in downtown Seattle, as well as eight medical pavilions. About 15 percent to 20 percent of our patients identify as a racial minority, and we are a tertiary referral center where patients from community hospitals or other states are referred for specialty care. About half of our patients in the hospital have commercial insurance, while the other half is a mix of Medicare, Medicaid and uninsured. This creates a rich learning environment for our residents to gain experience in not only a diversity of medical conditions but also work with patients facing a variety of socioeconomic challenges.

Many residents have continuity clinic at Eastgate Public Health, which is a King County Public Health clinic. At this clinic, residents are able to practice many aspects of medicine and care for a diverse group of patients. Most of the patients are uninsured or underinsured, and there is a small minority who are homeless. Many of the patients have lived in other countries, which means that their medical issues can range from common chronic conditions such as diabetes to infectious diseases less commonly seen. In addition, most of the patients do not speak English, but speak most commonly Spanish and Urdu, among others. This clinic site offers the opportunity to work with an underserved population who often present with complex medical conditions.