Primary Medical Education residents rotate every 3 months throughout the year in 2 teams. For 6 months each year, PRIME residents perform the typical inpatient duties of an internal medicine house officer. While on outpatient block, the typical weekly PRIME schedule is a mix of 3 half days of primary care clinic, 3 to 4 half days of subspecialty elective clinics, 2 half days of didactic time, and 1–2 half days of research time. PRIME residents become well known to the physician staff at the San Francisco VA Medical Center and are heavily relied upon for staffing (with appropriate attending supervision) of both our primary and subspecialty clinics. Our residents see a large volume of patients seeking primary and specialty care, and serve an important role in access to care for our veterans. The clinical relationships built with generalist and specialist attendings have frequently led to research projects and career mentoring.
Didactic time is divided evenly between clinical outpatient topics, behavioral medicine, and epidemiology/research methods training. Our clinical didactics cover the ACGME recommended core topics that are not covered in other learning opportunities provided by the residency. The behavioral medicine program, run by Drs. Calvin Chou and Kewchang Lee, focuses on important skills for improving patient care and utilizes videotaped and interactive group feedback sessions.
The epidemiology/research methods section of the PRIME didactic curriculum has 4 components that we repeat in different forums to reinforce the key concepts of EBM. The curriculum is a synthesis of the Advanced Training in Clinical Research (ATCR) research training program available to clinical fellows at UCSF, with curriculum used by the Robert Wood Johnson Clinical Scholars Program Fellowship at the University of Washington. The first component is the epidemiology didactic lecture series. This 12 seminar series is provided in consecutive weekly 90-minute sessions. Concepts are presented practically, augmented with assigned reading from the chosen textbook5
and reinforced with short homework assignments. The curriculum sequentially introduces key concepts in a practical manner building from the basics to progressively more difficult concepts as listed in .
The PRIME Epidemiology Curriculum
This lecture series is repeated twice yearly, every year, to ensure all the residents have the opportunity to participate. The seminar leaders are members of our clinical investigator faculty. This interaction early in the year fosters future collaborations between residents and faculty. In later blocks other research topics are presented to the residents depending upon their needs. Topics that have been covered in past years include: power calculations, qualitative research methods, survey research, decision analysis and treatment thresholds, cost-effectiveness analysis, use of standardized patients in research, community-based research and process evaluation, international research, administrative data utilization, and deciphering a spreadsheet.
The second component of our EBM/clinical research program is weekly afternoon small group journal clubs. This curriculum reinforces the concepts from the didactic seminar series by discussing the full range of common clinical research study types. During the first half of the year, diagnostic test evaluation, case-control studies, cohort studies, randomized control trials, meta-analysis, decision analysis, cost-effectiveness analysis, practice guidelines, and clinical overviews are covered. The second half of the year, we move to weekly “classic” journal clubs where residents choose articles that they frequently hear quoted on the medical wards. After reading the article the residents evaluate the quality of the “classic” to understand if and how they should apply the study in daily practice.
This journal club series has assigned background reading on the various epidemiology study types. Each week, a resident leads the seminar and prepares a 15-minute presentation that highlights the key learning points for each study type. The discussion is led on their chosen article to reinforce the key points that have been presented. We use a journal club format with a list of questions to be addressed as described in . We find this format useful as it is simple to remember, easy to apply, and applicable to each study type we review. The journal clubs are precepted by a program director to help with the flow of the session, and to answer questions that arise.
Simplified Criteria for Journal Article Reviews
The third component involves presentation of the “PRIME projects.” Residents present their projects quarterly in 90-minute work-in-progress sessions that are attended by the residents on outpatient block, the 2 program directors and a rotating member of the GIM clinician-investigator faculty. These sessions are similar to those utilized by research divisions across the academic community. They are collegial, interactive seminars where group effort is used to improve the individual's project ideas.
The final component of the PRIME curriculum is mentorship. The section of General Internal Medicine at the San Francisco VA Medical Center is vital to the success of the program, as are many specialist faculties at the San Francisco VA Medical Center. The clinician investigators and the educators of the division have rallied together to the support of the program. Each part of the division takes pride in the accomplishments of the PRIME program, as does the leadership of the medical center. Participation is almost universal at evening journal clubs, seminar leadership, career guidance, clinical teaching, or project mentoring sessions. The work is spread evenly throughout the section so that each individual participates willingly to a manageable extent.
Most faculty involved in mentoring PRIME residents give several lectures each year (2–4 1-hour lectures), participate in work-in-progress sessions (2 to 4 1-hour sessions), and actively supervise 1–2 PRIME residents on research projects, which typically involves 1–2 1-hour meetings per month in addition to reviewing and editing drafts of proposals and manuscripts. The time expenditure for faculty members varies from week to week, but results in approximately 1 to 2 hours of dedicated time per week. Because faculty members are matched with residents sharing an interest in their area of expertise, the PRIME projects are often complementary to their own work and fulfill part of their academic mission to provide teaching to students at the university. Because the PRIME residents have the explicit expectation that they will publish their research findings, faculty members are more willing to invest the time as mentors.
Residents are steered by the program directors to an appropriate mentoring relationship at the VA, or 1 of the other UCSF affiliated hospitals. Residents interact frequently with the program directors either in the group didactic sessions or during office hours. The primary duty of the program directors is to oversee the direction of the resident to find a project that meets his/her needs. We believe that this model is replicable within many academic GIM sections across the country.