Residency in Primary Care and Population Medicine

BWH Residency Program in Primary Care and Population Medicine at
Harvard Vanguard Medical Associates and the Department of Population Medicine,
Harvard Medical School and Harvard Pilgrim Health Care Institute

The BWH Residency Program in Primary Care and Population Medicine offers distinctive training to develop superb generalist physicians who can provide outstanding clinical care, as well as leadership in health systems and policy, and in the improvement of the health of populations.

Primary care faces major challenges.  To meet these challenges, tomorrow’s physician leaders require both outstanding clinical training and the skills to contribute to improvements in population health.  Acquiring an understanding of health systems and health policy, the evidence base of practice, clinical preventive services, and the role of public health systems will help tomorrow’s physicians improve care at multiple levels and address pressing issues in quality, access, cost, and disparities in health care. 

The goals of this residency program are:

  1. To provide comprehensive inpatient and outpatient clinical training of the highest quality for general internists;
  2. To develop a broad understanding of the determinants of population health and its relation to medical practice, and the analytical and management skills required to improve care, lead health systems, and develop sound health policy;
  3. To enhance leadership and management skills through mentorship, seminars and other curricula, and progressively increasing responsibility for those components of the program of particular relevance to the residents’ interests and developing goals.

 

Our Partnering Institutions:
This program is based on a unique and innovative 20-year collaboration among four institutions: 

  • Brigham and Women’s Hospital’s Department of Medicine; http://www.brighamandwomens.org/Departments_and_Services/medicine/medical_professionals/residency/Medical/primaryCare.aspx?sub=1
  • Harvard Pilgrim Health Care (HPHC) http://www.harvardpilgrim.org is a not-for-profit health plan nationally recognized as a leader in health care quality and noted for innovation in disease management and its diverse delivery models.  The Harvard Pilgrim Health Care Institute (HPHCI) is committed to research in quality improvement, patient outcomes, and clinical practices, and has active collaborations with investigators at Harvard’s Medical School and School of Public Health, as well as HMS-affiliated hospitals.
  • Harvard Vanguard Medical Associates (HVMA) http://www.harvardvanguard.org, a non-profit multispecialty group practice nationally recognized for excellence in patient care, quality improvement, and the use of cutting-edge technology in care management.  As a major teaching affiliate of Harvard Medical School, Harvard Vanguard has a long-standing mission in clinical education and scholarship focused on improving clinical practice and outcomes. 

Each of our partnering organizations brings its expertise in clinical care, academic medicine, population health, and health systems and policy to our program, providing residents boundless opportunities for clinical education in general medicine and primary care, and for broader training in all the elements of population health.

Program Structure and Curriculum:
The BWH Residency Program in Primary Care and Population Medicine has several features in its structure and curricula that make it distinctive: 

  • Size:  We are a small program within the larger Brigham Internal Medicine Residency family.  There are 12 residents in our program, 4 residents in each year.  Our small size affords opportunities for intensive small-group learning and great flexibility and responsiveness to resident initiatives in our program-specific curriculum.
  • Cohort Structure:  Residents in PGY-1, PGY-2, and PGY-3 are scheduled to participate in outpatient-based blocks simultaneously to allow for intensive, interactive small-group learning.  This structure is explicitly used to foster professional growth and the development of leadership skills. 
  • Our Preceptor Model:  Each of our residents is paired with one preceptor with whom he or she works throughout the three years of residency.  This is a defining (and popular!) feature of our program.
  • Broad Educational Mission:  Our program provides both outstanding clinical training in the care of individual patients and the skills and knowledge to contribute to improving the health of populations.
  • Leadership Development:  As residents progress through the program they take on greater responsibility for program leadership, working with the Program Director and faculty in developing and implementing curriculum, electives, and project opportunities.  Residents in PGY-3 take on many of the responsibilities traditionally assumed by chief residents.
  • Collaboration:  In addition to their access to faculty and the educational activities of the Department of Population Medicine and Harvard Vanguard, our residents work and learn with their peers and faculty in the DGM and categorical programs at Brigham and Women’s Hospital.  Schedules are designed to allow participation in the broad array of educational activities offered by the Department of Medicine at the Brigham.

Clinical Training:
Inpatient rotations occur at Brigham and Women’s Hospital (BWH), Faulkner Hospital (FH), and West Roxbury/Veterans Affairs Medical Center (WRVAMC); during inpatient rotations no distinctions exist between residents in our program and other residents in internal medicine at the Brigham.  Ambulatory training in primary care is based at Harvard Vanguard Medical Associates (HVMA).  Subspecialty training occurs primarily at HVMA and BWH, with electives at other institutions devised to meet residents’ individualized learning agenda.

Each resident manages his or her own primary care practice, partnered with a superb clinician-educator at one of HVMA’s health centers in the metropolitan Boston area.  This one-on-one relationship between each resident and his or her clinical preceptor is a unique feature of this residency.  Each resident practices side-by-side with his or her preceptor during the entire three years of residency, gaining valuable insight into longitudinal care and practice management.  Sessions with BWH and HVMA subspecialists are integrated into the outpatient rotations so that all graduates are exposed to the full spectrum of outpatient management and learn advanced techniques in the care of complex patients.  Throughout residency, the diverse patient population within HVMA provides residents with a full range of clinical training opportunities in a highly developed practice setting. 

Ambulatory Blocks:
During ambulatory blocks, residents practice at their clinics 3-4 times per week and attend longitudinal seminars and faculty-led didactic sessions three mornings per week.  The remaining time is spent at subspecialty clinics, electives, or in independent project work. 

Typical outpatient schedules for each year are:

PGY-1:  10 weeks outpatient; includes primary care practice, subspecialty care, and longitudinal seminars in clinical epidemiology, the patient-doctor relationship, health policy and systems, social justice and determinants of health, communication skills, and a rotation in geriatrics.  

PGY-2:  6 months outpatient; includes primary care practice, subspecialty care, and seminars in clinical epidemiology, the patient-doctor relationship, health policy and systems, social justice and determinants of health, communication skills, leadership and management, and rotations in palliative care.  Each resident acquires knowledge and skills in seminars and in independent sessions with mentorship to develop an individual project that will culminate in a presentation at the end of PGY-3.

PGY-3:  6 months outpatient; includes primary care practice, subspecialty care, seminars in clinical epidemiology, the patient-doctor relationship, health policy and systems, social justice and determinants of health, communication skills, and leadership and management.  Each resident has significant flexibility in scheduling to pursue individual goals.  These include the development of particular areas of clinical expertise based on choice of subspecialty and other electives, and mentored research or a management project with a health plan or organizational leader, and/or international work.  Mentorship and dedicated time for each resident’s project increase as each resident brings his or her project to fruition at the conclusion of the program.

Longitudinal Seminar Curriculum:
A core element of this training program is a series of small-group seminars during outpatient blocks that develop the residents’ competencies in primary care internal medicine, while augmenting their academic and leadership abilities to make improvements in population health.  The curriculum is continually reviewed, renewed, and updated, with residents playing a central role in curriculum development and delivery.   The current core seminars are:

  • Clinical Epidemiology and Preventive Medicine: Led by William Taylor, MD. (weekly; 6 months/year, all years)

A longitudinal seminar in which residents become highly skilled in interpreting the medical literature and applying evidence to clinical practice.  With faculty guidance, residents choose topics, develop relevant teaching approaches, and lead each session.

  • Psychosocial Medicine and Communication Skills (aka “Patient/Doctor”): Led by Jim Sabin, MD and Kathy Rexrode, MD (weekly; 6 months/year, all years)

A longitudinal discussion about residents’ experiences as physicians taking care of patients. Content arises from patients and situations that the residents encounter in their clinical practices.

  • Population Health: Systems and Policy: Led by Gordon Moore, MD and invited faculty from DPM, HPHC, BWH, and other institutions.  (Policy: 4-6 sessions; 1  month, all years; Systems:  4-6 sessions; 1  month, all years)

This interactive case-based series examines policy and the structure of health systems in the U.S. and, by comparison with other countries, models for reform, the financing of medical services in the U.S., and healthcare quality measurement and improvement. 

  • Sign Out Rounds: Led by Howard Lewine, MD and invited faculty from BWH, DPM, HVMA, and other institutions. (weekly; 6 months/year, all years)

A weekly review of residents’ clinical cases.  Designed to be a forum for exploring patient management issues that are not addressed elsewhere in the formal curriculum.

  • Faculty Didactics on Topics in Ambulatory Medicine:  Given by invited faculty from BWH, DPM, HVMA and other institutions (1-2 weekly: 6 months/year, all years).
  • Resident Didactics on Topics in Ambulatory Medicine:  Given by residents (1 weekly: 6 months/year, all years).
  • Leadership and Management Skills:  (6-8 sessions; 1 month, all years):  Led by faculty from DPM, HPHC, BWH, HVMA, and industries outside of healthcare.

The series, drawn from the Leadership Academy curriculum developed by HVMA for their top leaders, is designed to prepare residents for their future roles as leaders and team members in tomorrow’s primary care and population health environments.  During junior and senior years, residents have the opportunity to partner with senior mentors in institutional leadership roles to develop project-based solutions to health systems problems and may also participate in the Brigham’s Management and Leadership Track. 

  • Social Determinants of Health / Disparities: Led by residents and invited faculty from DPM, BWH, HVMA, and other institutions.  (4-6 sessions; 1 month, all years).

This series examines current theory and evidence on the broader social determinants of health and how social factors influence health outcomes.  Particular focus is given to specific health disparities within our community through didactics and visits to community health centers. 

  • Communication: Led by invited faculty from BWH, DPM, HVMA, HPHC, and other institutions.  (4-6 sessions; longitudinal, all years).

This practicum-based curriculum, offered throughout the academic year, is designed to develop critical skills in physician-patient communication and effective public speaking.  Topics include counseling patients on behavioral change, strategic messaging for advocacy, and addressing difficult situations in the clinical encounter. 

  • Care at the End of Life: Led by Muriel Gillick, MD.  (1 month, junior year).

This series provides an introduction to the unique aspects of care at the end of life, with didactics and experiences at a hospice.

  • Care of the Elderly Patient:  Led by Eliza Shulman, DO (1 month, intern year).

This series provides an introduction to primary care for older adults, incorporating didactic sessions, experience at an extended care facility, and precepted home visits with the residents’ patients.

The Resident as Teacher:   Much of the content in the curriculum is developed with active involvement of the residents.  Residents are mentored in their teaching skills, and progressively take on responsibility for the teaching of individual components of the curriculum under the supervision of the faculty.  Peer education across all three years greatly enriches the curriculum by focusing on residents’ learning needs, and by developing residents’ abilities as educators and as leaders.  The residents’ schedules are designed to allow participation with fellow residents and faculty in the broad array of educational activities offered by the Department of Medicine at Brigham and Women’s Hospital,  and in seminars and other educational activities of the Department of Population Medicine.  Interested residents can serve as seminar leaders and take other educational roles in teaching courses at Harvard Medical School, with full participation in the faculty development programs offered at HMS.

Mentorship:   Beginning in the first year of the program, each resident has a BWH mentor and two faculty mentors at DPM to help the resident with career planning, project selection, and the development of skills in research and population health.  The program director matches each incoming resident with faculty preceptors in DPM based on the resident’s professional interests.

The program director and other faculty throughout DPM and BWH are actively involved in mentoring each resident. The program director meets with each resident often, and faculty mentors are available throughout the year.  In addition, our unique one-on-one precepting model provides residents consistent feedback, mentoring, and role modeling in the clinical setting throughout their entire residency.  Residents are also encouraged to seek out mentoring relationships with faculty members throughout DPM, BWH and HMS.

Research and Elective Opportunities:  All residents have dedicated time for a longitudinal project chosen by the resident with faculty input and guidance.  Residents often chose topics that focus on the care of defined populations.  Residents take primary responsibility for choosing their topic, and are closely mentored by faculty drawn from the Department of Population Medicine, Harvard Vanguard Medical Associates, Harvard Pilgrim Health Care, and Brigham and Women’s Hospital.  These activities can help define career interests, and can facilitate entry into positions of academic, organizational and clinical leadership.

During either their junior or senior years, residents may spend up to one month away on an elective, either in the U.S. or abroad.  These electives are scheduled during selected times in ambulatory blocks, with approval by the program director.  All residents may also pursue other elective opportunities during ambulatory block time allocated to subspecialty or individual project work.

Summary:  The BWH Residency Program in Primary Care and Population Medicine is designed to be comprehensive and flexible to offer distinctive training for future leaders in general internal medicine.  Through its innovative design, educational curriculum and unique organizational affiliations, the program provides opportunities for residents to explore interests and develop competencies in the multiple domains of primary care and population health, including clinical practice, teaching, research, and organizational leadership.  Graduates of this program are prepared to make contributions as superb clinicians, as academic physicians and researchers, and as leaders able to improve systems of care for populations.