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GUIDELINES FOR COMBINED TRAINING
IN DERMATOLOGY AND INTERNAL MEDICINE

GENERAL REQUIREMENTS

Combined training in dermatology and internal medicine must include at least five years of coherent training integral to residencies in the two disciplines that meets the program requirements for accreditation by the Residency Review Committee for Internal Medicine and the Residency Review Committee for Dermatology.

Combined training must be conducted under the auspices of the Committee on Graduate Medical Education within a single institution and its affiliated hospitals. Documentation of the unqualified commitment of the hospital/s and faculty to the institutional goals for the combined training must be available in signed agreements. Affiliated institutions must be located close enough to facilitate cohesion among the house staff, attendance of trainees at weekly continuity clinics and integrated conferences, and faculty exchanges relating to the curriculum, evaluation of trainees, administration of the program, and related matters.

Ideally, one resident should be enrolled in combined training each year. A combined training program with no trainees for a period of five years cannot continue to be approved. The American Board of Dermatology (ABD) and the American Board of Internal Medicine (ABIM) will only approve a combined training program intended to be offered to residents annually and not a training track for a single resident.

At the conclusion of 60 months of training in internal medicine and dermatology, the resident should have had experience and instruction in the prevention, detection, and treatment of acute and chronic illness, the ethical care of patients, the team approach to medical care, and the effects of illnesses on the socioeconomic status of patients.

While residents are on internal medicine rotations, their training is the responsibility of internal medicine faculty, and while they are on dermatology rotations, it is the responsibility of the dermatology faculty. Vacations, leave, and meeting time will be taken from the training time in each discipline, on an equal basis. Absences from training (vacation, leave) exceeding five months of the 60 months must be made up.

Except for the following provisions, combined residencies must conform to the Program Requirements for accreditation of residencies in internal medicine and dermatology.

CORE CURRICULUM REQUIREMENTS

A clearly described written curriculum must be available to the residents, faculty, and the Residency Review Committees of both Internal Medicine and Dermatology. The curriculum must assure a cohesive, systematic and progressive educational experience, not simply comprise a series of rotations between the two specialties. Duplication of clinical experiences between the two specialties should be avoided, and periodic reviews of the program curriculum must be performed. These reviews must include the training directors from both departments in consultation with faculty and residents. Combined training must not interfere with or compromise the training of the general residents in either field.

Program directors may choose from either of two structures/models of the combined internal medicine/dermatology program, depending on which model works best in their setting.

(1) During the first year (PGY-1), the resident must have at least ten months of training in internal medicine. During the second year (PGY-2), the resident must have at least 10 months of training in dermatology. In each of the remaining three years (PGY-3, 4, and 5), the resident shall have six months of training in internal medicine and six months of training in dermatology. Rotations of shorter duration, but not less than three months, are also acceptable. During these last three years, it is important that program directors make certain that in the PGY-3, -4, and 5 years, each resident will have 18 months of training in each specialty.

(2) The second alternative is PGY-1 and PGY-2 mostly internal medicine including all or almost all the ward and unit assignments; PGY-3 mostly dermatology; and PGY-4 and 5 nine months of dermatology and three months of internal medicine with the internal medicine being predominantly outpatient rotations, such as rheumatology, infectious disease, medical oncology, endocrinology, gastroenterology, etc. but also including emergency room, neurology, medical consults and geriatrics.

In both models, the total number of months in the program is the same: 30 months of internal medicine and 30 months of dermatology. The only difference between these two models is when the rotations are taken.

REQUIREMENTS FOR DERMATOLOGY

During the 30 months of dermatology training, 28 months (full-time equivalent) must be spent in clinical dermatology with the primary responsibility in patient care. This must include at least 25 months (full-time equivalent) of experience in clinical dermatology, which must be primarily in the care of outpatients but will include consultations and appropriate inpatient rotations as well. In addition, each resident must obtain three months of experience in dermatologic surgery under the supervision of a dermatologic surgeon or Board-certified dermatologist with surgical experience, and two months of dermatopathology under the supervision of a dermatopathologist who is Board certified in this subspecialty. Indeed, continuity of training in dermatopathology should be sustained throughout the dermatology residency, in lectures, conferences, and as residents follow their patients in clinics and in the hospital.

Residents must learn the basic sciences on which clinical dermatology is founded, including cutaneous pharmacology, molecular biology, genetics, immunology, epidemiology, and statistics. Elective time in one of these areas is encouraged and should be for a minimum of two months, which may be substituted for time in the 25-month segment of clinical dermatology.

Residents must regularly attend seminars and conferences in general dermatology. There must be clinical pathological conferences. Residents must learn about major developments in both the basic and clinical sciences relating to dermatology and must attend seminars, journal clubs, lectures in basic sciences, didactic courses, and meetings of local and national dermatologic societies.

REQUIREMENTS FOR INTERNAL MEDICINE

During the 30 months of training in internal medicine, each resident must have 20 months of direct responsibility for patients with illnesses in the domain of internal medicine.

Each resident must have a one-month experience during the first or second year in emergency medicine, having first contact responsibility for the diagnosis and management of adults.

Each resident must be assigned to the care of patients in a medical intensive care unit for 3-4 weeks in the first year and again, at least on one four-week rotation, during the months of internal medicine training in years PGY-3, PGY-4, or PGY-5.

At least 20% of the 30 months of internal medicine experience must involve non-hospitalized patients (6 months of dermatology is credited for 13% of the ambulatory requirement). This must include a continuity experience for each resident in a half-day per week continuity-care clinic for 36 consecutive months and block experience in ambulatory medicine for at least two months. Ambulatory experience may include subspecialty clinics, walk-in clinics, and brief rotations for appropriate interdisciplinary experience in areas such as office gynecology and ENT. Residents will be encouraged to follow their continuity clinic patients during the course of the patients' hospitalization. During the internal medicine phase of training, subspecialty experience must be provided to every resident for at least four months. Some of this experience must include a role as a consultant. Subspecialty experience may be inpatient, outpatient, or a combination thereof. Significant exposure to geriatrics, infectious disease and outpatient rheumatology and endocrinology is necessary.

When on internal medicine rotations, residents must regularly attend morning report, medical grand rounds, work rounds, and mortality and morbidity conferences.

CERTIFICATION

To meet the eligibility requirements for the certification processes in internal medicine and dermatology, the resident must satisfactorily complete 60 months of combined training as verified by the director and associate director or the co-directors of these combined training programs