The FCIM Task Force believes that its report can achieve several aims. First, the report centers internal medicine in the field of adult primary care. Other specialties share that field, and the boundaries of internal medicine extend beyond primary care. However, the message of the FCIM report is clear: Residencies in internal medicine should prepare residents to be experts in the care of adult patients, including care that takes place in the home, office, hospital, and long-term care facility.

Second, the resource guide delineates the integrative disciplines that general internists should master (Table 1). The integrative disciplines are the cross-cutting areas of competence that effective internists use as they bring their knowledge of disease to bear upon patients and clinical problems. The resource guide presents the integrative disciplines in three tiers. Uppermost are the competencies that describe the underlying and most fundamental values and attitudes of the medical profession: humanism, ethics, and professionalism. Next are the specific characteristics, or salient professional behaviors, of general internists. These include lifelong learning, the clinical method, clinical epidemiology and quantitative reasoning, and quality management. Last are important domains of clinical practice in which internists use these disciplines. These domains include nursing home care, occupational and environmental medicine, physical therapy and rehabilitation, and systems for practice and information management. In many ways, these integrative disciplines, even more than the clinical competencies, define internal medicine and distinguish internists from other medical professionals. No other field has quite the same core values and attitudes; no other branch of medicine has the same commitments to learning, to science, to the clinical method, and to clinical reasoning; and no other form of practice includes the same range of concerns and sites of practice (Table 1). For each integrative discipline, the resource guide presents core competencies in a worksheet format to help program directors and local curriculum committees assign responsibility for providing learning experiences and deciding which instructional methods are most appropriate for each integrative competency.

Third, the resource guide identifies the core knowledge of and skills in the clinical topics that internists need to practice adult primary care (Table 2). Each topic corresponds to a clinical field and includes a list of items that residents should master, including common clinical presentations, important diagnostic tests and procedures, and specific diseases. A worksheet (Figure 1) for each clinical topic allows local curriculum committees to note the rotations on which teaching about these problems and diseases is most likely to occur. Space is allotted for writing in the lectures and other didactic experiences that can provide knowledge that may not be gained from clinical experience. The intent is to allow local curriculum committees to decide on the relative importance of a venue or rotation on the basis of the volume of core competencies that residents are likely to achieve there. From this information, the committees can apportion residents' time in order to increase the likelihood of exposure to clinical cases that represent the core knowledge of internal medicine. The worksheet approach is also designed to help curriculum committees identify a list of competencies that can be assigned to each rotation. The faculty of each rotation can then shape the residents' clinical experiences and their didactic programs to create, in effect, a mini-curriculum for the rotation and a system to ensure that the residents are exposed to essential topics.

View larger version (21K): [in this window] [in a new window]   Figure 1. Sample grid for assigning clinical competencies to specific training venues. Worksheets allow program directors and local curriculum committees to endorse or revise the competencies identified by the Federated Council of Internal Medicine (FCIM) Task Force for each clinical area and to prioritize them. Priority 1 indicates that a condition should be learned through direct responsibility for patients; priority 2 indicates that other forms of patient-based learning, such as learning in groups, are appropriate; and priority 3 indicates that the condition is important but may be learned in other ways, such as through conferences or assigned reading. The worksheets then allow the program director or local committee to check off the site at which each competency is most likely to be encountered and to decide whether and how that competency should be addressed in the program's didactic (non-patient-based) learning experiences.

Fourth, the resource guide describes the critical determinants of success for each of the most important rotations (Table 3). It may be true that learning happens, but it is more likely to happen in a setting that is well-equipped and, indeed, well-organized for that purpose. To this end, the resource guide identifies facilities, faculty roles, team structure, and evaluation systems. It also describes the role of formal didactic programs for each type of rotation.

Fifth, the resource guide offers three sample solutions to the challenge of developing a competency-based curriculum within a 36-month program. The FCIM Task Force does not claim to provide empirically derived, tested formulas. Rather, the solutions illustrate how curriculum committees at different institutions might arrive at rational but different solutions to the same problem. No single solution is recommended by the FCIM Task Force. The resource guide provides a nationally derived, consensus-based core that identifies what all residents should learn, but it defers to local faculty with regard to decisions about how, where, and when that learning should take place.

Explicit recommendations do, however, appear at the conclusion of the resource guide. These recommendations underscore the importance of curriculum in an era of change. The FCIM Task Force encourages programs to relocate training to ambulatory sites, develop curricula based on educational content rather than service requirements, emphasize the integrative disciplines, and enhance training in continuity practice. More broadly, the FCIM Task Force urges program directors to consider the practice requirements of the internists of tomorrow when making the curricular decisions of today. In its conclusion, the resource guide identifies several important challenges, including coordinating residency and medical student curricula, expanding programs for faculty development, developing better systems of evaluation, and securing the resources needed to set up a learning-centered residency program.

To understand the resource guide, the reader must understand what the guide is not. It is not a one-size-fits-all curriculum. Defining the curriculum for a residency program is the work of a curriculum committee, which must prescribe the day-to-day, week-to-week experiences with faculty, colleagues, students, and patients. Nor is the guide a vague call for curricular reform. Rather, it attempts to move programs in a specific direction: toward the education of the expert in adult primary care. It provides signposts that point out the directions in which local curriculum efforts might head, each in its own way.

Local committees, of course, do not have free rein to determine their curricula. Residency programs are not unregulated, nor should they be. The Accreditation Council on Graduate Medical Education, through its discipline-specific Residency Review Committees (RRCs) (which include an RRC for internal medicine [RRC-IM]), sets standards for the accreditation of training programs. The American Board of Internal Medicine, by overseeing a certification process, determines the standards for Board-eligible trainees. All of the organizations of internal medicine have a huge investment in the residency training process, and all of them have championed graduate medical education, often in an environment of fiscal constraint and state and federal regulation.

In the 1995 iteration of the Special Essentials for Internal Medicine, the RRC-IM imposed a requirement for a written curriculum and listed some of the areas that the curriculum should address. The FCIM resource guide should assist program directors in meeting the RRC-IM requirements for a written curriculum, but it should also do much more. It should help program directors assess the content of their programs according to how well the program exposes residents to opportunities from which they can acquire competencies important for general internists. The FCIM Task Force hopes that this resource guide will inform the blueprint of the American Board of Internal Medicine Certifying Examination and the In-Training Examinations prepared by the American College of Physicians, the Association of Professors of Medicine, and the Association of Program Directors in Internal Medicine. Although the FCIM Task Force sees a direct role for this resource guide in the process of Board certification, it does not intend the contents of this guide to become the accreditation requirements for residency training programs. Specifying programmatic requirements at the level of experience with individual diseases, particularly for internal medicine, would be ill advised.

Will this resource guide stifle innovation? The FCIM Task Force expects the opposite result. Identifying core competencies for trainees should stimulate institutions to experiment with and share models of program structure and teaching. Comparing different instructional models will be easier when those models address an identifiable core.

And finally, this report should not be the FCIM's last word on curriculum. If internal medicine views its residency curriculum as an important statement about the values and skills of internists, then internal medicine must periodically revise this statement to keep pace with changes in the nature of disease, the environment of practice, and the expectations of the public.

In referring to medical education reports of the past, Samuel Bloom concluded that the history of medical education is the "history of reform without change" [1]. Will the report of the FCIM Task Force make a difference? In some ways, it already has. The challenge of defining the competencies of the general internist has brought the internal medicine community together, to speak with a single voice about internal medicine's commitment to residents, patients and society. The FCIM has taken a significant first step. Will internal medicine follow? We think it will.

Appendix

The members of the FCIM Task Force on Graduate Medical Education are Francois Abboud, MD; Susan Deutsch, MD; Jack Ende, MD; Mark Kelley, MD; Paul Ramsey, MD; Richard Ruppert, MD; Harold Sox, MD (Chair); Beverly Woo, MD; and Richard Wright, MD.

The FCIM resource guide has been published as a monograph titled Graduate Education in Internal Medicine: A Resource Guide to Curriculum Development. Copies ($18.00 for FCIM members; $25.00 for nonmembers) can be obtained from Customer Service Center, American College of Physicians, Independence Mall West, Sixth Street at Race, Philadelphia, PA 19106-1572; telephone 215-351-2600 or 800-523-1546, extension 2600.

Dr. Kelley: University of Pennsylvania Health System, 21 Penn Tower, Philadelphia, PA 19104-4385.

Dr. Sox: Department of Medicine, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756.