140_InternalMedicine

ACGME Program Requirements for

Graduate Medical Education

in Internal Medicine

Definitions

For more information, see the ACGME Glossary of Terms.

Core Requirements: Statements that define structure, resource, or process elements

essential to every graduate medical educational program.

Detail Requirements: Statements that describe a specific structure, resource, or

process, for achieving compliance with a Core Requirement. Programs and

sponsoring institutions in substantial compliance with the Outcome Requirements may

utilize alternative or innovative approaches to meet Core Requirements.

Outcome Requirements: Statements that specify expected measurable or observable

attributes (knowledge, abilities, skills, or attitudes) of residents or fellows at key stages

of their graduate medical education.

Osteopathic Recognition

For programs with or applying for Osteopathic Recognition, the Osteopathic Recognition

Requirements also apply (www.acgme.org/OsteopathicRecognition).

Revision Information

ACGME-approved Focused Revision: February 7, 2022; effective July 1, 2022

Updated to include revised Common Program Requirements, effective July 1, 2023

Internal Medicine

Contents

Introduction ................................................................................................................................. 3

Int.A. Definition of Graduate Medical Education ............................................................................ 3

Int.B. Definition of Specialty ........................................................................................................... 3

Int.C. Length of Educational Program ............................................................................................ 4

I. Oversight .............................................................................................................................. 5

I.A. Sponsoring Institution ............................................................................................................ 5

I.B. Participating Sites ................................................................................................................... 5

I.C. Workforce Recruitment and Retention ................................................................................. 6

I.D. Resources ................................................................................................................................ 6

I.E. Other Learners and Health Care Personnel ......................................................................... 8

II. Personnel ............................................................................................................................. 9

II.A. Program Director ..................................................................................................................... 9

II.B. Faculty .................................................................................................................................... 15

II.C. Program Coordinator ............................................................................................................ 22

II.D. Other Program Personnel .................................................................................................... 25

III. Resident Appointments .................................................................................................... 25

III.A. Eligibility Requirements ....................................................................................................... 25

III.B. Resident Complement .......................................................................................................... 26

III.C. Resident Transfers ................................................................................................................ 26

IV. Educational Program ......................................................................................................... 26

IV.A. Educational Components ..................................................................................................... 27

IV.B. ACGME Competencies ......................................................................................................... 28

IV.C. Curriculum Organization and Resident Experiences ........................................................ 34

IV.D. Scholarship ............................................................................................................................ 40

V. Evaluation ........................................................................................................................... 42

V.A. Resident Evaluation .............................................................................................................. 42

V.B. Faculty Evaluation ................................................................................................................ 45

V.C. Program Evaluation and Improvement ............................................................................... 46

VI. The Learning and Working Environment ........................................................................ 49

VI.A. Patient Safety, Quality Improvement, Supervision, and Accountability ......................... 50

VI.B. Professionalism..................................................................................................................... 53

VI.C. Well-Being .............................................................................................................................. 55

VI.D. Fatigue Mitigation ................................................................................................................. 57

VI.E. Clinical Responsibilities, Teamwork, and Transitions of Care ........................................ 58

VI.F. Clinical Experience and Education ..................................................................................... 59

Internal Medicine

ACGME Program Requirements for Graduate Medical Education

in Internal Medicine

Common Program Requirements (Residency) are in BOLD

Where applicable, text in italics describes the underlying philosophy of the requirements in that

section. These philosophic statements are not program requirements and are therefore not

citable.

Introduction

Int.A. Definition of Graduate Medical Education

Graduate medical education is the crucial step of professional

development between medical school and autonomous clinical practice. It

is in this vital phase of the continuum of medical education that residents

learn to provide optimal patient care under the supervision of faculty

members who not only instruct, but serve as role models of excellence,

compassion, cultural sensitivity, professionalism, and scholarship.

Graduate medical education transforms medical students into physician

scholars who care for the patient, patient’s family, and a diverse

community; create and integrate new knowledge into practice; and educate

future generations of physicians to serve the public. Practice patterns

established during graduate medical education persist many years later.

Graduate medical education has as a core tenet the graded authority and

responsibility for patient care. The care of patients is undertaken with

appropriate faculty supervision and conditional independence, allowing

residents to attain the knowledge, skills, attitudes, judgment, and empathy

required for autonomous practice. Graduate medical education develops

physicians who focus on excellence in delivery of safe, equitable,

affordable, quality care; and the health of the populations they serve.

Graduate medical education values the strength that a diverse group of

physicians brings to medical care, and the importance of inclusive and

psychologically safe learning environments.

Graduate medical education occurs in clinical settings that establish the

foundation for practice-based and lifelong learning. The professional

development of the physician, begun in medical school, continues through

faculty modeling of the effacement of self-interest in a humanistic

environment that emphasizes joy in curiosity, problem-solving, academic

rigor, and discovery. This transformation is often physically, emotionally,

and intellectually demanding and occurs in a variety of clinical learning

environments committed to graduate medical education and the well-being

of patients, residents, fellows, faculty members, students, and all members

of the health care team.

Int.B. Definition of Specialty

Internal Medicine

Internists are specialists who care for adult patients through comprehensive,

clinical problem solving. They integrate the history, physical examination, and all

available data to deliver, direct, and coordinate care across varied clinical

settings, both in person and remotely through telemedicine. Internists are

diagnosticians who manage the care of patients who present with

undifferentiated, complex illnesses, and comorbidities; promote health and health

equity in communities; collaborate with colleagues; and lead, mentor, and serve

multidisciplinary teams. Internists integrate care across organ systems and

disease processes throughout the adult lifespan. They are expert

communicators, creative and adaptable to the changing needs of patients and

the health care environment. They advocate for their patients within the health

care system to achieve the patient’s and family’s care goals. Internists embrace

lifelong learning and the privilege and responsibility of educating patients,

populations, and other health professionals. The discipline is characterized by a

compassionate, cognitive, scholarly, relationship-oriented approach to

comprehensive patient care.

The successful, fulfilled internist maintains this core function and these core

values. Internists find meaning and purpose in caring for individual patients with

increased efficiency through well-functioning teams, and are equipped and

trained to manage change effectively and lead those teams. They understand

and manage the business of medicine to optimize cost-conscious care for their

patients. They apply data management science to population and patient

applications and help solve the clinical problems of their patients and their

community. Internists communicate fluently and are able to educate and clearly

explain complex data and concepts to all audiences, especially patients. They

collaborate with patients to implement health care ethics in all aspects of their

care. Internists display emotional intelligence in their relationships with

colleagues, team members, and patients, maximizing both their own and their

teams’ well-being. They are dedicated professionals who have the knowledge,

skills, and attitudes to effectively use all available resources, and bring

intellectual curiosity and human warmth to their patients and community.

Specialty-Specific Background and Intent: The Review Committee developed this definition

to clearly articulate the core functions and values of internal medicine and describe what is

needed to move the specialty forward through program requirements. They express what

the Review Committee aspires to see in the graduates of internal medicine residency

programs, faculty members, and the broader internal medicine community.

Int.C. Length of Educational Program

An accredited residency program in internal medicine must provide 36 months of

supervised graduate medical education.

(Core)

Specialty-Specific Background and Intent: While internal medicine residency must be

completed within a 36-month supervised educational framework (barring remediation and

extended leaves), the requirements were written to be flexible and allow program directors

the opportunity to create more individualized educational experiences for residents who have

achieved, or are on a trajectory to achieve, competence in the foundational areas of internal

medicine. This was a guiding principle for the revision process. The requirements for the

Internal Medicine

foundational areas of internal medicine and individualized educational experiences are

located in Section IV.C.: Curriculum Organization and Resident Experiences.

I. Oversight

I.A. Sponsoring Institution

The Sponsoring Institution is the organization or entity that assumes the

ultimate financial and academic responsibility for a program of graduate

medical education, consistent with the ACGME Institutional Requirements.

When the Sponsoring Institution is not a rotation site for the program, the

most commonly utilized site of clinical activity for the program is the

primary clinical site.

Background and Intent: Participating sites will reflect the health care needs of the

community and the educational needs of the residents. A wide variety of organizations

may provide a robust educational experience and, thus, Sponsoring Institutions and

participating sites may encompass inpatient and outpatient settings including, but not

limited to a university, a medical school, a teaching hospital, a nursing home, a school

of public health, a health department, a public health agency, an organized health care

delivery system, a medical examiner’s office, an educational consortium, a teaching

health center, a physician group practice, federally qualified health center, or an

educational foundation.

I.A.1. The program must be sponsored by one ACGME-accredited

Sponsoring Institution.

(Core)

I.B. Participating Sites

A participating site is an organization providing educational experiences or

educational assignments/rotations for residents.

I.B.1. The program, with approval of its Sponsoring Institution, must

designate a primary clinical site.

(Core)

I.B.1.a) The program, in partnership with its Sponsoring Institution, must

ensure that there is a reporting relationship between the internal

medicine subspecialty programs and the residency program

director.

(Core)

I.B.2. There must be a program letter of agreement (PLA) between the

program and each participating site that governs the relationship

between the program and the participating site providing a required

assignment.

(Core)

I.B.2.a) The PLA must:

I.B.2.a).(1) be renewed at least every 10 years; and,

(Core)

Internal Medicine

I.B.2.a).(2) be approved by the designated institutional official

(DIO).

(Core)

I.B.3. The program must monitor the clinical learning and working

environment at all participating sites.

(Core)

I.B.3.a) At each participating site there must be one faculty member,

designated by the program director as the site director, who

is accountable for resident education at that site, in

collaboration with the program director.

(Core)

Background and Intent: While all residency programs must be sponsored by a single

ACGME-accredited Sponsoring Institution, many programs will utilize other clinical

settings to provide required or elective training experiences. At times it is appropriate

to utilize community sites that are not owned by or affiliated with the Sponsoring

Institution. Some of these sites may be remote for geographic, transportation, or

communication issues. When utilizing such sites, the program must ensure the quality

of the educational experience.

Suggested elements to be considered in PLAs will be found in the Guide to the

Common Program Requirements. These include:

• Identifying the faculty members who will assume educational and supervisory

responsibility for residents

• Specifying the responsibilities for teaching, supervision, and formal evaluation

of residents

• Specifying the duration and content of the educational experience

• Stating the policies and procedures that will govern resident education during

the assignment

I.B.4. The program director must submit any additions or deletions of

participating sites routinely providing an educational experience,

required for all residents, of one month full time equivalent (FTE) or

more through the ACGME’s Accreditation Data System (ADS).

(Core)

I.C. Workforce Recruitment and Retention

The program, in partnership with its Sponsoring Institution, must engage in

practices that focus on mission-driven, ongoing, systematic recruitment

and retention of a diverse and inclusive workforce of residents, fellows (if

present), faculty members, senior administrative GME staff members, and

other relevant members of its academic community.

(Core)

Background and Intent: It is expected that the Sponsoring Institution has, and

programs implement, policies and procedures related to recruitment and retention of

individuals underrepresented in medicine and medical leadership in accordance with

the Sponsoring Institution’s mission and aims.

I.D. Resources

Internal Medicine

I.D.1. The program, in partnership with its Sponsoring Institution, must

ensure the availability of adequate resources for resident education.

(Core)

I.D.1.a) The program, in partnership with its Sponsoring institution, must:

I.D.1.a).(1) provide the broad range of facilities and clinical support

services necessary to provide comprehensive and timely

care of adult patients;

(Core)

I.D.1.a).(2) ensure that the program has adequate space available,

including meeting rooms, classrooms, examination rooms,

computers, visual and other educational aids, and office

space;

(Core)

I.D.1.a).(3) ensure that appropriate in-person or remote/virtual

consultations, including those done using

telecommunication technology, are available in settings in

which residents work;

(Core)

I.D.1.a).(4) provide access to an electronic health record; and,

(Core)

Specialty-Specific Background and Intent: An electronic health record (EHR) can include

electronic notes, orders, and lab reporting. Such a system also facilitates data reporting

regarding the care provided to a patient or a panel of patients. It may also include systems for

enhancing the quality and safety of patient care. An EHR does not have to be present at all

participating sites and does not have to include every element of patient care information.

However, a system that simply reports laboratory or imaging results does not meet the

definition of an EHR.

I.D.1.a).(5) provide residents with access to training using simulation

to support resident education and patient safety.

(Core)

Specialty-Specific Background and Intent: The Review Committee does not expect each

program to own a simulator or to have a simulation center. “Simulation” is used broadly to

mean learning about patient care in settings that do not include actual patients. This could

include objective structured clinical examinations (OSCEs), standardized patients, patient

simulators, or electronic simulation of resuscitation, procedures, and other clinical scenarios.

I.D.1.b) The program must provide residents with a patient population

representative of both the broad spectrum of clinical disorders and

medical conditions managed by internists, and of the community

being served.

(Core)

I.D.2. The program, in partnership with its Sponsoring Institution, must

ensure healthy and safe learning and working environments that

promote resident well-being and provide for:

I.D.2.a) access to food while on duty;

(Core)

Internal Medicine

I.D.2.b) safe, quiet, clean, and private sleep/rest facilities available

and accessible for residents with proximity appropriate for

safe patient care;

(Core)

Background and Intent: Care of patients within a hospital or health system occurs

continually through the day and night. Such care requires that residents function at

their peak abilities, which requires the work environment to provide them with the

ability to meet their basic needs within proximity of their clinical responsibilities.

Access to food and rest are examples of these basic needs, which must be met while

residents are working. Residents should have access to refrigeration where food may

be stored. Food should be available when residents are required to be in the hospital

overnight. Rest facilities are necessary, even when overnight call is not required, to

accommodate the fatigued resident.

I.D.2.c) clean and private facilities for lactation that have refrigeration

capabilities, with proximity appropriate for safe patient care;

(Core)

Background and Intent: Sites must provide private and clean locations where residents

may lactate and store the milk within a refrigerator. These locations should be in close

proximity to clinical responsibilities. It would be helpful to have additional support

within these locations that may assist the resident with the continued care of patients,

such as a computer and a phone. While space is important, the time required for

lactation is also critical for the well-being of the resident and the resident's family, as

outlined in VI.C.1.c).(1).

I.D.2.d) security and safety measures appropriate to the participating

site; and,

(Core)

I.D.2.e)

accommodations for residents with disabilities consistent

with the Sponsoring Institution’s policy.

(Core)

I.D.3. Residents must have ready access to specialty-specific and other

appropriate reference material in print or electronic format. This

must include access to electronic medical literature databases with

full text capabilities.

(Core)

I.E. Other Learners and Health Care Personnel

The presence of other learners and other health care personnel, including

but not limited to residents from other programs, subspecialty fellows, and

advanced practice providers, must not negatively impact the appointed

residents’ education.

(Core)

Background and Intent: The clinical learning environment has become increasingly

complex and often includes care providers, students, and post-graduate residents and

fellows from multiple disciplines. The presence of these practitioners and their

learners enriches the learning environment. Programs have a responsibility to monitor

the learning environment to ensure that residents’ education is not compromised by

the presence of other providers and learners.

Internal Medicine

II. Personnel

II.A. Program Director

II.A.1. There must be one faculty member appointed as program director

with authority and accountability for the overall program, including

compliance with all applicable program requirements.

(Core)

II.A.1.a) The Sponsoring Institution’s GMEC must approve a change in

program director and must verify the program director’s

licensure and clinical appointment.

(Core)

Background and Intent: While the ACGME recognizes the value of input from

numerous individuals in the management of a residency, a single individual must be

designated as program director and have overall responsibility for the program. The

program director’s nomination is reviewed and approved by the GMEC.

II.A.1.b) The program must demonstrate retention of the program

director for a length of time adequate to maintain continuity

of leadership and program stability.

(Core)

Background and Intent: The success of residency programs is generally enhanced by

continuity in the program director position. The professional activities required of a

program director are unique and complex and take time to master. All programs are

encouraged to undertake succession planning to facilitate program stability when

there is necessary turnover in the program director position.

II.A.2. The program director and, as applicable, the program’s leadership

team, must be provided with support adequate for administration of

the program based upon its size and configuration.

(Core)

II.A.2.a) At a minimum, the program director must be provided with the

dedicated time and support specified below for administration of

the program:

(Core)

Number of Approved

Resident Positions

Minimum Support

Required (FTE)

0.2

7-10

0.4

>10

0.5

II.A.2.b) Programs with more than 15 residents must appoint an associate

program director(s). The associate program director(s) must be

provided with support equal to a dedicated minimum time for

administration of the program as follows:

(Core)

Number of Approved

Resident Positions

Minimum Support

Required (FTE)

<15

Internal Medicine

Number of Approved

Resident Positions

Minimum Support

Required (FTE)

16-20

0.1

21-25

0.2

26-30

0.3

31-35

0.4

36-40

0.5

41-45

0.6

46-50

0.7

51-55

0.8

56-60

0.9

61-65

1.0

66-70

1.1

71-75

1.2

76-80

1.3

81-85

1.4

86-90

1.5

91-95

1.6

96-100

1.7

101-105

1.8

106-110

1.9

111-115

2.0

116-120

2.1

121-125

2.2

126-130

2.3

131-135

2.4

136-140

2.5

141-145

2.6

146-150

2.7

151-155

2.8

156-160

2.9

161-165

3.0

166-170

3.1

171-175

3.2

176-180

3.3

181-185

3.4

186-190

3.5

191-195

3.6

196-200

3.7

201-205

3.8

206-210

3.9

211-215

4.0

216-220

4.1

221-225

4.2

226-230

4.3

Background and Intent: To achieve successful graduate medical education, individuals

Internal Medicine

serving as education and administrative leaders of residency programs, as well as

those significantly engaged in the education, supervision, evaluation, and mentoring of

residents, must have sufficient dedicated professional time to perform the vital

activities required to sustain an accredited program.

The ultimate outcome of graduate medical education is excellence in resident

education and patient care.

The program director and, as applicable, the program leadership team, devote a

portion of their professional effort to the oversight and management of the residency

program, as defined in II.A.4.-II.A.4.a).(12). Both provision of support for the time

required for the leadership effort and flexibility regarding how this support is provided

are important. Programs, in partnership with their Sponsoring Institutions, may provide

support for this time in a variety of ways. Examples of support may include, but are not

limited to, salary support, supplemental compensation, educational value units, or

relief of time from other professional duties.

Program directors and, as applicable, members of the program leadership team, who

are new to the role may need to devote additional time to program oversight and

management initially as they learn and become proficient in administering the

program. It is suggested that during this initial period the support described above be

increased as needed.

In addition, it is important to remember that the dedicated time and support

requirement for ACGME activities is a minimum, recognizing that, depending on the

unique needs of the program, additional support may be warranted. The need to

ensure adequate resources, including adequate support and dedicated time for the

program director, is also addressed in Institutional Requirement II.B.1. The amount of

support and dedicated time needed for individual programs will vary based on a

number of factors and may exceed the minimum specified in the applicable

specialty/subspecialty-specific Program Requirements. It is expected that the

Sponsoring Institution, in partnership with its accredited programs, will ensure support

for program directors to fulfill their program responsibilities effectively.

Specialty-Specific Background and Intent: For instance, a program with an approved

complement of 36 residents is required to have 50% FTE support for the program director

and 50 percent FTE support for the associate program director(s). The Review Committee

decided not to specify how the support should be distributed among associate program

directors to allow programs, in partnership with their sponsoring institution, to allocate the

support as they see fit. Further, the program could redistribute the FTE back to the program

director; for example, in this instance, the associate program director(s) could receive 25

percent FTE support and the program director could receive 75 percent FTE support (50

percent plus the remaining 25 percent from the associate program director FTE support).

II.A.3. Qualifications of the program director:

II.A.3.a) must include specialty expertise and at least three years of

documented educational and/or administrative experience, or

qualifications acceptable to the Review Committee;

(Core)

Internal Medicine

Background and Intent: Leading a program requires knowledge and skills that are

established during residency and subsequently further developed. The time period

from completion of residency until assuming the role of program director allows the

individual to cultivate leadership abilities while becoming professionally established.

The three-year period is intended for the individual's professional maturation.

The broad allowance for educational and/or administrative experience recognizes that

strong leaders arise through diverse pathways. These areas of expertise are important

when identifying and appointing a program director. The choice of a program director

should be informed by the mission of the program and the needs of the community.

In certain circumstances, the program and Sponsoring Institution may propose and the

Review Committee may accept a candidate for program director who fulfills these

goals but does not meet the three-year minimum.

II.A.3.b) must include current certification in the specialty for which

they are the program director by the American Board of

Internal Medicine (ABIM) or by the American Osteopathic

Board of Internal Medicine (AOBIM), or specialty qualifications

that are acceptable to the Review Committee;

(Core)

II.A.3.b).(1) The Review Committee only accepts current certification in

internal medicine from the ABIM or AOBIM.

(Core)

II.A.3.c) must include ongoing clinical activity.

(Core)

Background and Intent: A program director is a role model for faculty members and

residents. The program director must participate in clinical activity consistent with the

specialty. This activity will allow the program director to role model the Core

Competencies for the faculty members and residents.

II.A.3.d) must have experience working as part of an interdisciplinary, inter-

professional team to create an educational environment that

promotes high-quality care, patient safety, and resident well-being.

(Core)

II.A.4. Program Director Responsibilities

The program director must have responsibility, authority, and

accountability for: administration and operations; teaching and

scholarly activity; resident recruitment and selection, evaluation,

and promotion of residents, and disciplinary action; supervision of

residents; and resident education in the context of patient care.

(Core)

II.A.4.a) The program director must:

II.A.4.a).(1) be a role model of professionalism;

(Core)

Internal Medicine

Background and Intent: The program director, as the leader of the program, must serve

as a role model to residents in addition to fulfilling the technical aspects of the role. As

residents are expected to demonstrate compassion, integrity, and respect for others,

they must be able to look to the program director as an exemplar. It is of utmost

importance, therefore, that the program director model outstanding professionalism,

high quality patient care, educational excellence, and a scholarly approach to work.

The program director creates an environment where respectful discussion is welcome,

with the goal of continued improvement of the educational experience.

II.A.4.a).(2) design and conduct the program in a fashion

consistent with the needs of the community, the

mission(s) of the Sponsoring Institution, and the

mission(s) of the program;

(Core)

Background and Intent: The mission of institutions participating in graduate medical

education is to improve the health of the public. Each community has health needs that

vary based upon location and demographics. Programs must understand the structural

and social determinants of health of the populations they serve and incorporate them

in the design and implementation of the program curriculum, with the ultimate goal of

addressing these needs and eliminating health disparities.

II.A.4.a).(3) administer and maintain a learning environment

conducive to educating the residents in each of the

ACGME Competency domains;

(Core)

Background and Intent: The program director may establish a leadership team to

assist in the accomplishment of program goals. Residency programs can be highly

complex. In a complex organization, the leader typically has the ability to delegate

authority to others, yet remains accountable. The leadership team may include

physician and non-physician personnel with varying levels of education, training, and

experience.

II.A.4.a).(4) have the authority to approve or remove physicians

and non-physicians as faculty members at all

participating sites, including the designation of core

faculty members, and must develop and oversee a

process to evaluate candidates prior to approval;

(Core)

Background and Intent: The provision of optimal and safe patient care requires a team

approach. The education of residents by non-physician educators may enable the

resident to better manage patient care and provides valuable advancement of the

residents’ knowledge. Furthermore, other individuals contribute to the education of

residents in the basic science of the specialty or in research methodology. If the

program director determines that the contribution of a non-physician individual is

significant to the education of the residents, the program director may designate the

individual as a program faculty member or a program core faculty member.

II.A.4.a).(5) have the authority to remove residents from

supervising interactions and/or learning environments

that do not meet the standards of the program;

(Core)

Internal Medicine

Background and Intent: The program director has the responsibility to ensure that all

who educate residents effectively role model the Core Competencies. Working with a

resident is a privilege that is earned through effective teaching and professional role

modeling. This privilege may be removed by the program director when the standards

of the clinical learning environment are not met.

There may be faculty in a department who are not part of the educational program, and

the program director controls who is teaching the residents.

II.A.4.a).(6) submit accurate and complete information required

and requested by the DIO, GMEC, and ACGME;

(Core)

Background and Intent: This includes providing information in the form and format

requested by the ACGME and obtaining requisite sign-off by the DIO.

II.A.4.a).(7) provide a learning and working environment in which

residents have the opportunity to raise concerns,

report mistreatment, and provide feedback in a

confidential manner as appropriate, without fear of

intimidation or retaliation;

(Core)

II.A.4.a).(8) ensure the program’s compliance with the Sponsoring

Institution’s policies and procedures related to

grievances and due process, including when action is

taken to suspend or dismiss, or not to promote or

renew the appointment of a resident;

(Core)

Background and Intent: A program does not operate independently of its Sponsoring

Institution. It is expected that the program director will be aware of the Sponsoring

Institution’s policies and procedures, and will ensure they are followed by the

program’s leadership, faculty members, support personnel, and residents.

II.A.4.a).(9) ensure the program’s compliance with the Sponsoring

Institution’s policies and procedures on employment

and non-discrimination;

(Core)

II.A.4.a).(9).(a) Residents must not be required to sign a non-

competition guarantee or restrictive covenant.

(Core)

II.A.4.a).(10) document verification of education for all residents

within 30 days of completion of or departure from the

program;

(Core)

II.A.4.a).(11) provide verification of an individual resident’s

education upon the resident’s request, within 30 days;

and,

(Core)

Internal Medicine

Background and Intent: Primary verification of graduate medical education is

important to credentialing of physicians for further training and practice. Such

verification must be accurate and timely. Sponsoring Institution and program policies

for record retention are important to facilitate timely documentation of residents who

have previously completed the program. Residents who leave the program prior to

completion also require timely documentation of their summative evaluation.

II.A.4.a).(12) provide applicants who are offered an interview with

information related to their eligibility for the relevant

specialty board examination(s).

(Core)

II.B. Faculty

Faculty members are a foundational element of graduate medical education

– faculty members teach residents how to care for patients. Faculty

members provide an important bridge allowing residents to grow and

become practice-ready, ensuring that patients receive the highest quality of

care. They are role models for future generations of physicians by

demonstrating compassion, commitment to excellence in teaching and

patient care, professionalism, and a dedication to lifelong learning. Faculty

members experience the pride and joy of fostering the growth and

development of future colleagues. The care they provide is enhanced by

the opportunity to teach and model exemplary behavior. By employing a

scholarly approach to patient care, faculty members, through the graduate

medical education system, improve the health of the individual and the

population.

Faculty members ensure that patients receive the level of care expected

from a specialist in the field. They recognize and respond to the needs of

the patients, residents, community, and institution. Faculty members

provide appropriate levels of supervision to promote patient safety. Faculty

members create an effective learning environment by acting in a

professional manner and attending to the well-being of the residents and

themselves.

Background and Intent: “Faculty” refers to the entire teaching force responsible for

educating residents. The term “faculty,” including “core faculty,” does not imply or

require an academic appointment.

II.B.1. There must be a sufficient number of faculty members with

competence to instruct and supervise all residents.

(Core)

II.B.1.a) Faculty members with credentials appropriate to the care setting

must supervise all clinical experiences.

(Core)

II.B.1.a).(1) There must be physicians with certification in internal

medicine by the ABIM or AOBIM to teach and supervise

internal medicine residents while they are on internal

medicine inpatient and outpatient rotations.

(Core)

Internal Medicine

Specialty-Specific Background and Intent: The Review Committee believes the best role

models for internal medicine residents are internal medicine physicians with certification in

internal medicine from the ABIM or AOBIM. Providing such faculty members ensures

specialty-specific educators with significant experience managing and providing

comprehensive patient care to complex patients. However, the Review Committee recognizes

there are circumstances and clinical settings in which a non-internist who has been approved

by the program director would be an appropriate supervisor. Examples include but are not

limited to the following:

• On inpatient medicine ward rotations, it is appropriate for an ABFM- or AOBFP- certified

physician with extensive experience in caring for inpatient adults to teach and supervise

internal medicine residents, provided they are approved by the site director and the

program director. Working as an adult hospitalist for at least three years would be one

way to demonstrate such extensive experience.

• On inpatient medicine rotations in the critical care setting, it would be appropriate for a

non-internist who has been approved by the program director and the medical intensive

care unit director to teach and supervise internal medicine residents. For example, it

would be appropriate for emergency medicine physicians with certification in internal

medicine-critical care medicine to supervise internal medicine residents on critical care

medicine rotations. It is also appropriate for physicians with certification in critical care

from other disciplines to teach and supervise in limited circumstances, such as evening or

weekend cross-coverage.

• On outpatient medicine rotations/experiences, it is appropriate for a non-internist with

documented expertise (e.g., a family medicine physician with extensive

outpatient/ambulatory experience or procedural proficiency) to teach and supervise

internal medicine residents provided the non-internist is approved by the site director and

the program director.

II.B.1.a).(2) Physicians certified by the ABIM or the AOBIM in the

relevant subspecialty must be available to teach and

supervise internal medicine residents while they are on

internal medicine subspecialty rotations.

(Core)

II.B.1.a).(3) Physicians certified by an ABMS or AOA board in the

relevant subspecialty should be available to teach and

supervise internal medicine residents while they are on

multidisciplinary subspecialty rotations.

(Core)

Specialty-Specific Background and Intent: For example, it would be appropriate for a faculty

member certified in geriatric medicine by the ABIM, AOBIM, American Board of Family

Medicine, or American Osteopathic Board of Family Medicine to teach and supervise internal

medicine residents on geriatric medicine rotations.

II.B.1.a).(4) Physicians certified by an ABMS or AOA board in the

relevant specialty should be available to teach and

supervise internal medicine residents while they are having

non-internal medicine experiences.

(Core)

Specialty-Specific Background and Intent: For example, it would be appropriate for a faculty

member certified in neurology by the American Board of Psychiatry and Neurology or the

Internal Medicine

American Osteopathic Board of Neurology and Psychiatry to teach and supervise internal

medicine residents on neurology rotations.

II.B.2. Faculty members must:

II.B.2.a) be role models of professionalism;

(Core)

II.B.2.b) demonstrate commitment to the delivery of safe, equitable,

high-quality, cost-effective, patient-centered care;

(Core)

Background and Intent: Patients have the right to expect quality, cost-effective care

with patient safety at its core. The foundation for meeting this expectation is formed

during residency and fellowship. Faculty members model these goals and continually

strive for improvement in care and cost, embracing a commitment to the patient and

the community they serve.

II.B.2.c) demonstrate a strong interest in the education of residents,

including devoting sufficient time to the educational program

to fulfill their supervisory and teaching responsibilities;

(Core)

II.B.2.d) administer and maintain an educational environment

conducive to educating residents;

(Core)

II.B.2.e) regularly participate in organized clinical discussions,

rounds, journal clubs, and conferences; and,

(Core)

II.B.2.f) pursue faculty development designed to enhance their skills

at least annually:

(Core)

Background and Intent: Faculty development is intended to describe structured

programming developed for the purpose of enhancing transference of knowledge, skill,

and behavior from the educator to the learner. Faculty development may occur in a

variety of configurations (lecture, workshop, etc.) using internal and/or external

resources. Programming is typically needs-based (individual or group) and may be

specific to the institution or the program. Faculty development programming is to be

reported for the residency program faculty in the aggregate.

II.B.2.f).(1) as educators and evaluators;

(Detail)

II.B.2.f).(2) in quality improvement, eliminating health inequities,

and patient safety;

(Detail)

II.B.2.f).(3) in fostering their own and their residents’ well-being;

and,

(Detail)

II.B.2.f).(4) in patient care based on their practice-based learning

and improvement efforts.

(Detail)

Background and Intent: Practice-based learning serves as the foundation for the

practice of medicine. Through a systematic analysis of one’s practice and review of the

Internal Medicine

literature, one is able to make adjustments that improve patient outcomes and care.

Thoughtful consideration to practice-based analysis improves quality of care, as well

as patient safety. This allows faculty members to serve as role models for residents in

practice-based learning.

II.B.2.g) There must be a subspecialty education coordinator (SEC) in

each of the subspecialties of internal medicine and in the

multidisciplinary subspecialty of geriatric medicine.

(Core)

Specialty-Specific Background and Intent: An SEC is necessary in each of the following

subspecialties of internal medicine: cardiovascular disease; critical care medicine;

endocrinology, diabetes, and metabolism; gastroenterology; hematology; infectious disease;

nephrology; medical oncology; pulmonary disease; and rheumatology.

II.B.2.g).(1) Each SEC must be accountable to the program director for

coordination of all educational experiences in the

subspecialty area.

(Core)

II.B.2.g).(2) Each SEC must be certified in the relevant subspecialty by

the ABIM or the AOBIM, except that the geriatric medicine

SEC must be certified in the subspecialty by the relevant

ABMS member board or AOA certifying board.

(Core)

Specialty-Specific Background and Intent: SECs are responsible for developing the

educational content and curriculum for the subspecialty area. An associate program director

or core faculty member can also function as an SEC with adequate additional administrative

resources. Double-boarded SECs can act as education coordinators for two specialties (e.g.,

hematology-medical oncology and pulmonary disease-critical care medicine). The SEC for

geriatric medicine can be certified by the ABIM, the AOBIM, the American Board of Family

Medicine, or the American Osteopathic Board of Family Medicine. The Review Committee

encourages programs that cannot identify an SEC for a particular subspecialty area to

consider the option of sharing one with a program that does have one. The SEC can be

remotely located and associated with multiple residency programs.

II.B.2.h) There must be faculty members with expertise in the analysis and

interpretation of practice data, data management science and

clinical decision support systems, and managing emerging health

issues.

(Core)

Specialty-Specific Background and Intent: Advances in technology are likely to significantly

impact and redefine patient care, and this requirement is intended to ensure that residents

are provided with access to faculty members with knowledge, skills, or experience in the

analysis and interpretation of practice data, and who are able to analyze and evaluate the

validity of decisions from advanced data management and clinical decision support systems.

Faculty members with expertise in this area can be physicians or non-physicians, core or

non-core faculty members. Institutions may already have such experts assisting programs in

meeting the Common Program Requirement to systematically analyze practice data to

improve patient care [IV.B.1.d).(1).(d)]. The Review Committee encourages programs that

cannot identify an existing internal candidate with expertise in this area to consider the option

Internal Medicine

of sharing one with a program that does. The faculty member can be remotely located and

associated with multiple residency programs.

II.B.2.i) Faculty members must have experience working in

interdisciplinary, interprofessional team-based health care delivery

models.

(Core)

Specialty-Specific Background and Intent: The Review Committee believes that

interdisciplinary, interprofessional, team-based care is the foundation of care delivery.

Individuals working within such teams are essential to resident education.

II.B.3. Faculty Qualifications

II.B.3.a) Faculty members must have appropriate qualifications in

their field and hold appropriate institutional appointments.

(Core)

II.B.3.b) Physician faculty members must:

II.B.3.b).(1) have current certification in the specialty by the

American Board of Internal Medicine or the American

Osteopathic Board of Internal Medicine, or possess

qualifications judged acceptable to the Review

Committee.

(Core)

II.B.4. Core Faculty

Core faculty members must have a significant role in the education

and supervision of residents and must devote a significant portion

of their entire effort to resident education and/or administration, and

must, as a component of their activities, teach, evaluate, and

provide formative feedback to residents.

(Core)

Background and Intent: Core faculty members are critical to the success of resident

education. They support the program leadership in developing, implementing, and

assessing curriculum, mentoring residents, and assessing residents’ progress toward

achievement of competence in and the autonomous practice of the specialty. Core

faculty members should be selected for their broad knowledge of and involvement in

the program, permitting them to effectively evaluate the program. Core faculty

members may also be selected for their specific expertise and unique contribution to

the program. Core faculty members are engaged in a broad range of activities, which

may vary across programs and specialties. Core faculty members provide clinical

teaching and supervision of residents, and also participate in non-clinical activities

related to resident education and program administration. Examples of these non-

clinical activities include, but are not limited to, interviewing and selecting resident

applicants, providing didactic instruction, mentoring residents, simulation exercises,

completing the annual ACGME Faculty Survey, and participating on the program’s

Clinical Competency Committee, Program Evaluation Committee, and other GME

committees.

Internal Medicine

II.B.4.a) Core faculty members must complete the annual ACGME

Faculty Survey.

(Core)

II.B.4.b) In addition to the program director and associate program

director(s), programs must have the minimum number of ABIM- or

AOBIM-certified core faculty members based on the number of

approved resident positions, as follows.

(Core)

II.B.4.c) At a minimum, the required core faculty members, in aggregate

and excluding program leadership, must be provided with support

equal to an average dedicated minimum of 0.1 FTE for

educational and administrative responsibilities that do not involve

direct patient care.

(Core)

Number of Approved

Resident Positions

Minimum Number of

ABIM- or AOBIM-

certified Core Faculty

Members

<30

30-39

40-49

50-59

60-69

70-79

80-89

90-99

100-109

110-119

120-129

130-139

140-149

150-159

160-169

170-179

180-189

190-199

200-209

Specialty-Specific Background and Intent: The Review Committee specified the minimum

required number of ABIM- or AOBIM-certified internal medicine core faculty, but did not

specify how the aggregate FTE support should be distributed to allow programs, in

partnership with their sponsoring institution, to allocate the support as they see fit. For

instance, a program with an approved complement of 36 residents is required to have a

minimum of four ABIM- or AOBIM-certified core faculty members and a minimum aggregate

FTE of 40 percent. The program could choose to operationalize this as four ABIM- or AOBIM-

certified faculty members each with 10 percent FTE support, but it could also have eight

members each with five percent FTE support, or one member with twenty percent FTE and

four members with five percent each.

Internal Medicine

The duties of the program director, associate program director(s), and internal medicine core

faculty members are separate and distinct. As such, the minimum required internal medicine

core faculty members are in addition to the program director and the associate program

director(s). One individual cannot “count” as both an associate program director and internal

medicine core faculty member.

The requirement related to support for core internal medicine faculty members is intended to

ensure these faculty members have sufficient protected time to meet the following

educational responsibilities:

• Membership on the Clinical Competency Committee

• Participation in the annual program review as Chair or member of the Program

Evaluation Committee

• Implementation and analysis of the outcome of action plans developed by the

Program Evaluation Committee

• Significant participation in recruitment and selection, including efforts related to the

program’s commitment to diversity

• Advising, mentoring, and coaching residents (co-creating, implementing, and

monitoring individualized learning plans)

• Designing and overseeing remediation plans

• Supporting/overseeing residents in the development/assessment of quality

improvement/patient safety projects

• Supporting/overseeing residents in the conduct of their scholarly work, including the

dissemination of such work through presentations, posters/abstracts, and peer-

reviewed publications

• Significant participation in educational activities (didactics, lab, or simulation)

• Overseeing faculty development for the program’s faculty members

• Designing and implementing simulation and/or standardized patients for teaching and

assessment

• Developing, implementing, and assessing one or more of the major components of the

curriculum, such as patient safety, quality, health disparities, or core didactics

• Designing and implementing the program’s assessment strategies, making certain

there are robust methods used to assess each competency, and ensuring they

provide meaningful information by which the Clinical Competency Committee can

judge resident performance on the Milestones

• Leading the program’s efforts related to resident and faculty member well-being

Each core faculty member does not need to participate in every listed educational

responsibility.

Background and Intent: Provision of support for the time required for the core faculty

members’ responsibilities related to resident education and/or administration of the

program, as well as flexibility regarding how this support is provided, are important.

Programs, in partnership with their Sponsoring Institutions, may provide support for

this time in a variety of ways. Examples of support may include, but are not limited to,

salary support, supplemental compensation, educational value units, or relief of time

from other professional duties.

It is important to remember that the dedicated time and support requirement is a

minimum, recognizing that, depending on the unique needs of the program, additional

Internal Medicine

support may be warranted. The need to ensure adequate resources, including

adequate support and dedicated time for the core faculty members, is also addressed

in Institutional Requirement II.B.2. The amount of support and dedicated time needed

for individual programs will vary based on a number of factors and may exceed the

minimum specified in the applicable specialty-/ subspecialty-specific Program

Requirements.

II.B.5. Associate Program Directors

Associate program directors assist the program director in the

administrative and clinical oversight of the educational program.

II.B.5.a) Associate program directors must:

II.B.5.a).(1) have current certification from the ABIM or AOBIM in either

internal medicine or a subspecialty of internal medicine;

(Core)

II.B.5.a).(2) report directly to the program director;

(Core)

II.B.5.a).(3) participate in academic societies and in educational

programs designed to enhance their educational and

administrative skills; and,

(Core)

II.B.5.a).(4) take an active role in curriculum development, resident

teaching and evaluation, continuous program

improvement, and faculty development.

(Core)

II.C. Program Coordinator

II.C.1. There must be a program coordinator.

(Core)

II.C.2. The program coordinator must be provided with dedicated time and

support adequate for administration of the program based upon its

size and configuration.

(Core)

II.C.2.a) At a minimum, the program coordinator must be provided with the

dedicated time and support specified below for administration of

the program. Additional administrative support must be provided

based on the program size as follows:

(Core

)

Number of Approved

Resident Positions

Minimum FTE Required

for Coordinator Support

Additional Aggregate FTE

Required for Administration

of the Program

0.5

7-10

0.5

0.2

10-15

0.5

0.3

16-20

0.5

0.4

21-25

0.5

26-30

0.5

0.6

Internal Medicine

Number of Approved

Resident Positions

Minimum FTE Required

for Coordinator Support

Additional Aggregate FTE

Required for Administration

of the Program

31-35

0.5

0.7

36-40

0.5

0.8

41-45

0.5

0.9

46-50

0.5

1.0

51-55

0.5

1.1

56-60

0.5

1.2

61-65

0.5

1.3

66-70

0.5

1.4

71-75

0.5

1.5

76-80

0.5

1.6

81-85

0.5

1.7

86-90

0.5

1.8

91-95

0.5

1.9

96-100

0.5

2.0

101-105

0.5

2.1

106-110

0.5

2.2

111-115

0.5

2.3

116-120

0.5

2.4

121-125

0.5

2.5

126-130

0.5

2.6

131-135

0.5

2.7

136-140

0.5

2.8

141-145

0.5

2.9

146-150

0.5

3.0

151-155

0.5

3.1

156-160

0.5

3.2

161-165

0.5

3.3

166-170

0.5

3.4

171-175

0.5

3.5

176-180

0.5

3.6

181-185

0.5

3.7

186-190

0.5

3.8

191-195

0.5

3.9

196-200

0.5

4.0

201-205

0.5

4.1

206-210

0.5

4.2

211-215

0.5

4.3

216-220

0.5

4.4

221-225

0.5

4.5

226-230

0.5

4.6

Background and Intent: The requirement does not address the source of funding

required to provide the specified salary support.

Internal Medicine

Each program requires a lead administrative person, frequently referred to as a

program coordinator, administrator, or as otherwise titled by the institution. This

person will frequently manage the day-to-day operations of the program and serve as

an important liaison and facilitator between the learners, faculty and other staff

members, and the ACGME. Individuals serving in this role are recognized as program

coordinators by the ACGME.

The program coordinator is a key member of the leadership team and is critical to the

success of the program. As such, the program coordinator must possess skills in

leadership and personnel management appropriate to the complexity of the program.

Program coordinators are expected to develop in-depth knowledge of the ACGME and

Program Requirements, including policies and procedures. Program coordinators

assist the program director in meeting accreditation requirements, educational

programming, and support of residents.

Programs, in partnership with their Sponsoring Institutions, should encourage the

professional development of their program coordinators and avail them of

opportunities for both professional and personal growth. Programs with fewer

residents may not require a full-time coordinator; one coordinator may support more

than one program.

The minimum required dedicated time and support specified in II.C.2.a) is inclusive of

activities directly related to administration of the accredited program. It is understood

that coordinators often have additional responsibilities, beyond those directly related

to program administration, including, but not limited to, departmental administrative

responsibilities, medical school clerkships, planning lectures that are not solely

intended for the accredited program, and mandatory reporting for entities other than

the ACGME. Assignment of these other responsibilities will necessitate consideration

of allocation of additional support so as not to preclude the coordinator from devoting

the time specified above solely to administrative activities that support the accredited

program.

In addition, it is important to remember that the dedicated time and support

requirement for ACGME activities is a minimum, recognizing that, depending on the

unique needs of the program, additional support may be warranted. The need to

ensure adequate resources, including adequate support and dedicated time for the

program coordinator, is also addressed in Institutional Requirement II.B.4. The amount

of support and dedicated time needed for individual programs will vary based on a

number of factors and may exceed the minimum specified in the applicable

specialty/subspecialty-specific Program Requirements. It is expected that the

Sponsoring Institution, in partnership with its accredited programs, will ensure support

for program coordinators to fulfill their program responsibilities effectively.

Specialty-Specific Background and Intent: For instance, a program with an approved

complement of 36 residents is required to have 130 percent FTE for coordinator support. The

Review Committee decided not to specify how the support should be distributed to allow

programs, in partnership with their Sponsoring Institution, to allocate the support as they see

fit.

Internal Medicine

II.D. Other Program Personnel

The program, in partnership with its Sponsoring Institution, must jointly

ensure the availability of necessary personnel for the effective

administration of the program.

(Core)

Background and Intent: Multiple personnel may be required to effectively administer a

program. These may include staff members with clerical skills, project managers,

education experts, and staff members to maintain electronic communication for the

program. These personnel may support more than one program in more than one

discipline.

III. Resident Appointments

III.A. Eligibility Requirements

III.A.1. An applicant must meet one of the following qualifications to be

eligible for appointment to an ACGME-accredited program:

(Core)

III.A.1.a) graduation from a medical school in the United States or

Canada, accredited by the Liaison Committee on Medical

Education (LCME) or graduation from a college of

osteopathic medicine in the United States, accredited by the

American Osteopathic Association Commission on

Osteopathic College Accreditation (AOACOCA); or,

(Core)

III.A.1.b) graduation from a medical school outside of the United

States or Canada, and meeting one of the following additional

qualifications:

(Core)

III.A.1.b).(1) holding a currently valid certificate from the

Educational Commission for Foreign Medical

Graduates (ECFMG) prior to appointment; or,

(Core)

III.A.1.b).(2) holding a full and unrestricted license to practice

medicine in the United States licensing jurisdiction in

which the ACGME-accredited program is located.

(Core)

III.A.2. All prerequisite post-graduate clinical education required for initial

entry or transfer into ACGME-accredited residency programs must

be completed in ACGME-accredited residency programs, AOA-

approved residency programs, Royal College of Physicians and

Surgeons of Canada (RCPSC)-accredited or College of Family

Physicians of Canada (CFPC)-accredited residency programs

located in Canada, or in residency programs with ACGME

International (ACGME-I) Advanced Specialty Accreditation.

(Core)

III.A.2.a) Residency programs must receive verification of each

resident’s level of competency in the required clinical field

using ACGME, CanMEDS, or ACGME-I Milestones evaluations

from the prior training program upon matriculation.

(Core)

Internal Medicine

Background and Intent: Programs with ACGME-I Foundational Accreditation or from

institutions with ACGME-I accreditation do not qualify unless the program has also

achieved ACGME-I Advanced Specialty Accreditation. To ensure entrants into ACGME-

accredited programs from ACGME-I programs have attained the prerequisite

milestones for this training, they must be from programs that have ACGME-I Advanced

Specialty Accreditation.

III.B. Resident Complement

The program director must not appoint more residents than approved by

the Review Committee.

(Core)

III.B.1.a) There must be a sufficient number of residents to allow peer-to-

peer interaction and learning.

(Core)

III.B.1.a).(1) The program should offer a minimum of nine positions.

(Detail)

Specialty-Specific Background and Intent: The Review Committee believes that peer-to-peer

interactions and learning are extremely important components of residency education and

has set the minimum number of residents to nine. While three residents per educational year

is suggested, it is not required as long as there is relative balance per level. To ensure that

resident education is not compromised by having too few residents, the number of residents

in a program will be monitored at each review, particularly for those programs with significant

decreases in complement. However, this requirement is categorized as a “detail” as there

may be programs that have specific circumstances that allow them to function with a smaller

resident complement. This categorization allows the establishment of residency education

programs in rural and medically underserved areas and populations when the Review

Committee determines that the program has sufficient resources to ensure substantial

compliance with accreditation requirements.

Background and Intent: Programs are required to request approval of all complement

changes, whether temporary or permanent, by the Review Committee through ADS.

Permanent increases require prior approval from the Review Committee and temporary

increases may also require approval. Specialty-specific instructions for requesting a

complement increase are found in the “Documents and Resources” page of the

applicable specialty section of the ACGME website.

III.C. Resident Transfers

The program must obtain verification of previous educational experiences

and a summative competency-based performance evaluation prior to

acceptance of a transferring resident, and Milestones evaluations upon

matriculation.

(Core)

IV. Educational Program

Internal Medicine

The ACGME accreditation system is designed to encourage excellence and

innovation in graduate medical education regardless of the organizational

affiliation, size, or location of the program.

The educational program must support the development of knowledgeable, skillful

physicians who provide compassionate care.

It is recognized that programs may place different emphasis on research,

leadership, public health, etc. It is expected that the program aims will reflect the

nuanced program-specific goals for it and its graduates; for example, it is

expected that a program aiming to prepare physician-scientists will have a

different curriculum from one focusing on community health.

IV.A. Educational Components

The curriculum must contain the following educational components:

IV.A.1. a set of program aims consistent with the Sponsoring Institution’s

mission, the needs of the community it serves, and the desired

distinctive capabilities of its graduates, which must be made

available to program applicants, residents, and faculty members;

(Core)

IV.A.2. competency-based goals and objectives for each educational

experience designed to promote progress on a trajectory to

autonomous practice. These must be distributed, reviewed, and

available to residents and faculty members;

(Core)

Background and Intent: The trajectory to autonomous practice is documented by

Milestones evaluations. Milestones are considered formative and should be used to

identify learning needs. Milestones data may lead to focused or general curricular

revision in any given program or to individualized learning plans for any specific

resident.

IV.A.3. delineation of resident responsibilities for patient care, progressive

responsibility for patient management, and graded supervision;

(Core)

Background and Intent: These responsibilities may generally be described by PGY

level and specifically by Milestones progress as determined by the Clinical

Competency Committee. This approach encourages the transition to competency-

based education. An advanced learner may be granted more responsibility

independent of PGY level and a learner needing more time to accomplish a certain task

may do so in a focused rather than global manner.

IV.A.4. a broad range of structured didactic activities; and,

(Core)

IV.A.4.a) Residents must be provided with protected time to participate

in core didactic activities.

(Core)

Internal Medicine

Background and Intent: It is intended that residents will participate in structured

didactic activities. It is recognized that there may be circumstances in which this is not

possible. Programs should define core didactic activities for which time is protected

and the circumstances in which residents may be excused from these didactic

activities. Didactic activities may include, but are not limited to, lectures, conferences,

courses, labs, asynchronous learning, simulations, drills, case discussions, grand

rounds, didactic teaching, and education in critical appraisal of medical evidence.

IV.A.5. formal educational activities that promote patient safety-related

goals, tools, and techniques.

(Core)

IV.B. ACGME Competencies

Background and Intent: The Competencies provide a conceptual framework describing

the required domains for a trusted physician to enter autonomous practice. These

Competencies are core to the practice of all physicians, although the specifics are

further defined by each specialty. The developmental trajectories in each of the

Competencies are articulated through the Milestones for each specialty.

IV.B.1. The program must integrate the following ACGME Competencies

into the curriculum:

IV.B.1.a) Professionalism

Residents must demonstrate a commitment to

professionalism and an adherence to ethical principles.

(Core)

IV.B.1.a).(1) Residents must demonstrate competence in:

IV.B.1.a).(1).(a) compassion, integrity, and respect for others;

(Core)

IV.B.1.a).(1).(b) responsiveness to patient needs that

supersedes self-interest;

(Core)

IV.B.1.a).(1).(c) cultural humility;

(Core)

IV.B.1.a).(1).(d) respect for patient privacy and autonomy;

(Core)

IV.B.1.a).(1).(e) accountability to patients, society, and the

profession;

(Core)

IV.B.1.a).(1).(f) respect and responsiveness to diverse patient

populations, including but not limited to

diversity in gender, age, culture, race, religion,

disabilities, national origin, socioeconomic

status, and sexual orientation;

(Core)

IV.B.1.a).(1).(g) ability to recognize and develop a plan for one’s

own personal and professional well-being; and,

(Core)

Internal Medicine

IV.B.1.a).(1).(h) appropriately disclosing and addressing

conflict or duality of interest.

(Core)

Background and Intent: This includes the recognition that under certain

circumstances, the interests of the patient may be best served by transitioning care to

another practitioner. Examples include fatigue, conflict or duality of interest, not

connecting well with a patient, or when another physician would be better for the

situation based on skill set or knowledge base.

IV.B.1.b) Patient Care and Procedural Skills

Background and Intent: Quality patient care is safe, effective, timely, efficient, patient-

centered, equitable, and designed to improve population health, while reducing per

capita costs. In addition, there should be a focus on improving the clinician’s well-

being as a means to improve patient care and reduce burnout among residents,

fellows, and practicing physicians.

IV.B.1.b).(1) Residents must be able to provide patient care that is

patient- and family-centered, compassionate,

equitable, appropriate, and effective for the treatment

of health problems and the promotion of health.

(Core)

IV.B.1.b).(1).(a) Residents must demonstrate the ability to manage

the care of patients:

IV.B.1.b).(1).(a).(i) using clinical skills of interviewing and

physical examination;

(Core)

IV.B.1.b).(1).(a).(ii) in a variety of roles within a health system

with progressive responsibility, including

serving as the direct provider, a member, or

leader of an interprofessional team of

providers; as a consultant to other

physicians; and as a teacher to the patient,

the patient’s family, and other health care

workers;

(Core)

IV.B.1.b).(1).(a).(iii) including the prevention, counseling,

detection, diagnosis, and treatment of adult

diseases;

(Core)

IV.B.1.b).(1).(a).(iv) in a variety of health care settings, including

the inpatient ward, critical care units, and

various ambulatory settings;

(Core)

Specialty-Specific Background and Intent: Emerging models of care and needs of populations

served by programs will result in residents having educational experiences in novel or non-

traditional settings. Examples of non-traditional educational settings include rotations on

Internal Medicine

mobile buses that travel to areas of increased need, and “pop-up” health clinics within

community centers.

IV.B.1.b).(1).(a).(v) for whom they have limited or no physical

contact, through the use of telemedicine;

(Core)

IV.B.1.b).(1).(a).(vi) in the subspecialties of internal medicine;

(Core)

IV.B.1.b).(1).(a).(vii) using population-based data;

(Core)

Specialty-Specific Background and Intent: Understanding population health within the context

of prevention is an important competency for the physician practicing medicine in the future.

Residents need experience using, understanding, and analyzing population health data so

that they can develop health care plans to improve health outcomes for their patients. For

instance, residents may be provided experience in analyzing and interpreting data from health

registries, and understanding the local impact of infectious and non-infectious epidemics

(e.g., obesity or opioid) and pandemics, and the important role social determinants of health

have when developing and applying health care and preventive care decisions.

IV.B.1.b).(1).(a).(viii) using critical thinking and evidence-based

tools.

(Core)

IV.B.1.b).(2) Residents must be able to perform all medical,

diagnostic, and surgical procedures considered

essential for the area of practice.

(Core)

IV.B.1.b).(2).(a) Residents must demonstrate the ability to:

IV.B.1.b).(2).(a).(i) use and/or perform point-of-care laboratory,

diagnostic, and/or imaging studies relevant

to the care of the patient;

(Core)

Specialty-Specific Background and Intent: The Review Committee intentionally did not identify

specific laboratory, diagnostic, and/or imaging studies that residents must perform because it

believes that scientific advances will be constant and ongoing, and whatever is codified in the

requirements quickly becomes outdated. Additionally, the decision to not specifically denote

studies in the requirements aligns with the Committee’s overall position that residents should

perform and develop expertise with those procedures appropriate to their future practice

needs, as noted in the requirement below. However, the Committee acknowledges that

offering point-of-care ultrasonography to residents who believe this will be relevant for their

future career practice may be one way to meet the above-mentioned requirement.

IV.B.1.b).(2).(a).(ii) perform diagnostic and therapeutic

procedures relevant to their specific career

paths; and,

(Core)

IV.B.1.b).(2).(a).(iii) treat their patients’ conditions with practices

that are patient-centered, safe, scientifically

Internal Medicine

based, effective, timely, and cost-effective.

(Core)

IV.B.1.c) Medical Knowledge

Residents must demonstrate knowledge of established and

evolving biomedical, clinical, epidemiological, and social-

behavioral sciences, including scientific inquiry, as well as

the application of this knowledge to patient care.

(Core)

IV.B.1.c).(1) Residents must demonstrate a level of expertise in the

knowledge of the broad spectrum of clinical disorders seen

by an internist, including:

(Core)

IV.B.1.c).(1).(a) the core content of general internal medicine, which

includes the internal medicine subspecialties, the

multidisciplinary subspecialties of geriatric

medicine, hospice and palliative medicine and

addiction medicine, and neurology.

(Core)

IV.B.1.c).(2) Residents must demonstrate sufficient knowledge in the

following areas:

IV.B.1.c).(2).(a) evaluation of patients with an undiagnosed and

undifferentiated presentation;

(Core)

IV.B.1.c).(2).(b) pharmacotherapeutic and non-

pharmacotherapeutic treatment of the broad

spectrum of medical conditions and clinical

disorders managed by internists;

(Core)

IV.B.1.c).(2).(c) provision of preventive care;

(Core)

IV.B.1.c).(2).(d) interpretation of clinical tests and images;

(Core)

IV.B.1.c).(2).(e) recognition and initial management of urgent

medical problems; and,

(Core)

IV.B.1.c).(2).(f) application of technology appropriate for the clinical

context, including evolving techniques.

(Core)

Specialty-Specific Background and Intent: Advances in technology will likely continue to make

substantive changes in patient diagnosis and management. This requirement ensures that

residents will be able to gain experience and become familiar with emerging technologies,

such as intensive care units managed remotely or the use of personalized or precision

medicine.

IV.B.1.d) Practice-based Learning and Improvement

Residents must demonstrate the ability to investigate and

evaluate their care of patients, to appraise and assimilate

Internal Medicine

scientific evidence, and to continuously improve patient care

based on constant self-evaluation and lifelong learning.

(Core)

IV.B.1.d).(1) Residents must demonstrate competence in:

IV.B.1.d).(1).(a) identifying strengths, deficiencies, and limits in

one’s knowledge and expertise;

(Core)

IV.B.1.d).(1).(b) setting learning and improvement goals;

(Core)

IV.B.1.d).(1).(c) identifying and performing appropriate learning

activities;

(Core)

IV.B.1.d).(1).(d) systematically analyzing practice using quality

improvement methods, including activities

aimed at reducing health care disparities, and

implementing changes with the goal of practice

improvement;

(Core)

IV.B.1.d).(1).(e) incorporating feedback and formative

evaluation into daily practice; and,

(Core)

IV.B.1.d).(1).(f) locating, appraising, and assimilating evidence

from scientific studies related to their patients’

health problems.

(Core)

IV.B.1.e) Interpersonal and Communication Skills

Residents must demonstrate interpersonal and

communication skills that result in the effective exchange of

information and collaboration with patients, their families,

and health professionals.

(Core)

IV.B.1.e).(1) Residents must demonstrate competence in:

IV.B.1.e).(1).(a) communicating effectively with patients and

patients’ families, as appropriate, across a

broad range of socioeconomic circumstances,

cultural backgrounds, and language

capabilities, learning to engage interpretive

services as required to provide appropriate care

to each patient;

(Core)

IV.B.1.e).(1).(b) communicating effectively with physicians,

other health professionals, and health-related

agencies;

(Core)

IV.B.1.e).(1).(c) working effectively as a member or leader of a

health care team or other professional group;

(Core)

Internal Medicine

IV.B.1.e).(1).(d) educating patients, patients’ families, students,

other residents, and other health professionals;

(Core)

IV.B.1.e).(1).(e) acting in a consultative role to other physicians

and health professionals;

(Core)

IV.B.1.e).(1).(f) maintaining comprehensive, timely, and legible

health care records, if applicable.

(Core)

IV.B.1.e).(2) Residents must learn to communicate with patients

and patients’ families to partner with them to assess

their care goals, including, when appropriate, end-of-

life goals.

(Core)

IV.B.1.f) Systems-based Practice

Residents must demonstrate an awareness of and

responsiveness to the larger context and system of health

care, including the structural and social determinants of

health, as well as the ability to call effectively on other

resources to provide optimal health care.

(Core)

Background and Intent: Medical practice occurs in the context of an increasingly

complex clinical care environment where optimal patient care requires attention to

compliance with external and internal administrative and regulatory requirements.

IV.B.1.f).(1) Residents must demonstrate competence in:

IV.B.1.f).(1).(a) working effectively in various health care

delivery settings and systems relevant to their

clinical specialty;

(Core)

IV.B.1.f).(1).(b) coordinating patient care across the health care

continuum and beyond as relevant to their

clinical specialty;

(Core)

Background and Intent: Every patient deserves to be treated as a whole person.

Therefore it is recognized that any one component of the health care system does not

meet the totality of the patient's needs. An appropriate transition plan requires

coordination and forethought by an interdisciplinary team. The patient benefits from

proper care and the system benefits from proper use of resources.

IV.B.1.f).(1).(c) advocating for quality patient care and optimal

patient care systems;

(Core)

IV.B.1.f).(1).(d) participating in identifying system errors and

implementing potential systems solutions;

(Core)

IV.B.1.f).(1).(e) incorporating considerations of value, equity,

cost awareness, delivery and payment, and

Internal Medicine

risk-benefit analysis in patient and/or

population-based care as appropriate;

(Core)

IV.B.1.f).(1).(f) understanding health care finances and its

impact on individual patients’ health decisions;

and,

(Core)

IV.B.1.f).(1).(g) using tools and techniques that promote patient

safety and disclosure of patient safety events

(real or simulated).

(Detail)

IV.B.1.f).(2) Residents must learn to advocate for patients within

the health care system to achieve the patient's and

patient’s family's care goals, including, when

appropriate, end-of-life goals.

(Core)

IV.C. Curriculum Organization and Resident Experiences

IV.C.1. The curriculum must be structured to optimize resident educational

experiences, the length of the experiences, and the supervisory

continuity. These educational experiences include an appropriate

blend of supervised patient care responsibilities, clinical teaching,

and didactic educational events.

(Core)

IV.C.1.a) Rotations must be of sufficient length to provide longitudinal

relationships with faculty members to allow for meaningful

assessment and feedback.

(Core)

IV.C.1.b) Rotations must be structured to allow residents to function as part

of effective interprofessional teams that work together towards the

shared goals of patient safety and quality improvement.

(Core)

IV.C.1.c) Rotations must be structured to minimize conflicting inpatient and

outpatient responsibilities.

(Core)

Background and Intent: In some specialties, frequent rotational transitions, inadequate

continuity of faculty member supervision, and dispersed patient locations within the

hospital have adversely affected optimal resident education and effective team-based

care. The need for patient care continuity varies from specialty to specialty and by

clinical situation, and may be addressed by the individual Review Committee.

Specialty-Specific Background and Intent: The Review Committee encourages programs to

think of ways to balance the inherent conflicts between inpatient and outpatient

responsibilities, including using an effective hand-off process. For example, programs may

want to consider schedules that allow members of the interprofessional health care team to

provide coverage for the inpatient service when residents are in continuity clinics.

Alternatively, programs may consider creating schedules that either provide more continuity

clinic experiences or an exclusive continuity clinic experience when residents are not on

inpatient rotations to allow them to have less or no clinic during inpatient rotations.

Internal Medicine

IV.C.2. The program must provide instruction and experience in pain

management if applicable for the specialty, including recognition of

the signs of substance use disorder.

(Core)

IV.C.3. The educational program for all residents must include:

(Core)

IV.C.3.a) at least 30 months of clinical experiences;

(Core)

IV.C.3.b) a longitudinal team-based continuity experience for the duration of

the program;

(Core)

IV.C.3.c) foundational experience in internal medicine, including:

IV.C.3.c).(1) at least 10 months of clinical experiences in the outpatient

setting;

(Core)

Specialty-Specific Background and Intent: Clinical experiences in the following settings may

be used to fulfill this requirement: general internal medicine continuity clinics; internal

medicine subspecialty clinics (e.g., HIV clinic); non-medicine clinics (e.g., dermatology or

physical medicine and rehabilitation clinic); walk-in clinics; neighborhood health clinics; home

care visit programs; urgent care clinics; and ambulatory block rotations.

Time devoted to the longitudinal continuity experience can count towards the minimum

required 10 months of foundational experiences in the outpatient setting. For the purposes of

this calculation, a month is equivalent to four weeks, 20 days, or 40 half-days. For example,

40 half-day continuity clinic sessions would equal one month of outpatient experience.

IV.C.3.c).(2) at least 10 months of clinical experiences in the inpatient

and critical care settings;

(Core)

IV.C.3.c).(2).(a) Critical care experiences must be a minimum of two

months and a maximum of six months and must not

occur solely in the PGY-1.

(Core)

IV.C.3.c).(3) clinical experiences in each of the internal medicine

subspecialties; and,

(Core)

Specialty-Specific Background and Intent: Clinical experiences in the each of the

subspecialties can be used to fulfill either the minimum required number of months in the

inpatient or outpatient setting, depending on the setting the experience is provided. For

instance, a month rotation on a hematology-oncology service would count towards meeting

the inpatient minimums whereas a month in an oncology clinic would count towards

outpatient.

IV.C.3.c).(4) clinical experiences in geriatric medicine, hospice and

palliative medicine, addiction medicine, emergency

medicine, and neurology.

(Core)

IV.C.3.d) at least six months of individualized educational experiences to

participate in opportunities relevant to their future practice or to

Internal Medicine

further skill/competency development in the foundational areas.

(Core)

Specialty-Specific Background and Intent: The Review Committee views these four

components of internal medicine residency (at least 30 months of clinical experience,

longitudinal continuity experience, foundational internal medicine experience, and at least six

months of individualized experience) as distinct but overlapping. For example, the longitudinal

continuity experience could be obtained through discrete blocks or interspersed among other

clinical experiences. Time in an outpatient clinic may be part of the continuity experience or

may be part of a subspecialty experience, or both, and it would count towards the minimum

for both foundational outpatient experience and the 30 months of clinical experience.

Additional time in that clinic may be part of a resident’s individualized learning experiences,

which would also count towards the 30-month minimum. The six months of individualized

learning experiences may be all clinical experiences that would count towards the 30-month

minimum, or they may include non-clinical experiences.

The requirements acknowledge that in addition to providing residents with broad foundational

educational experiences in ambulatory and hospital-based internal medicine, programs must

ensure residents have educational experiences that take into account their future plans and

the different paces and trajectories at and on which residents will learn and demonstrate

competence in the foundational areas.

Individualized educational experiences will be determined by the program director and take

into account demonstrated competence in the foundational areas noted above, resources,

program aims, and the residents’ future practice plans. Although six months can be devoted

to individualized experiences, some residents may require more time to achieve competence

in the foundational educational areas, which may result in less time for individualized

educational experiences. Some residents may need to devote the entirety of residency to

achieve competence in the foundational areas. The converse may be possible. Programs

may have the opportunity to allocate more than six months of individualized educational

opportunities for residents who have achieved or are on target to achieve competence in the

foundational areas. These opportunities may include more ambulatory/outpatient experiences

for residents interested in practicing in an outpatient setting after residency, more inpatient

experiences for those interested in hospitalist medicine careers, or more experiences in a

subspecialty for those interested in subspecializing. Individualized educational experiences

may be integrated throughout the 36 months of the educational program and do not need to

be consecutive.

The Review Committee is interested in programs pursuing innovations in internal medicine

training. Additional information on the development of the Program Requirements and the

Review Committee’s interest in exploring innovative proposals that will guide future versions

of the Program Requirements can be found on the Internal Medicine section of the ACGME

website.

IV.C.4. While on inpatient rotations:

IV.C.4.a) residents' responsibilities must be limited to patients for whom the

teaching team has diagnostic and therapeutic responsibility;

(Core)

Internal Medicine

IV.C.4.b) programs must monitor and limit the number of resident-attending

relationships to ensure that communication and education is not

compromised;

(Core)

IV.C.4.c) non-physician faculty members must not supervise internal

medicine residents on inpatient rotations;

(Core)

Specialty-Specific Background and Intent: While it is important for residents to acquire

experience in leading and participating in interprofessional, interdisciplinary health care

teams, the overall supervision of all clinical care provided by residents is the responsibility of

the members of the physician faculty. A physician faculty member may delegate an

appropriately qualified non-physician to assist a resident in discrete activities, such as

performing procedures.

IV.C.4.d) residents from other specialties must not supervise internal

medicine residents on any internal medicine inpatient rotation;

(Core)

IV.C.4.e) the resident team and each attending physician must have the

responsibility to make management rounds on their patients and

communicate effectively with each other at a frequency

appropriate to the changing care needs of the patients;

(Core)

IV.C.4.f) residents must write all orders for patients

under their care, with

appropriate supervision by the attending physician;

(Core)

IV.C.4.f).(1) In those circumstances when another attending physician

or consultant writes an order on a resident's patient, the

attending or consultant must communicate the action to the

resident in a timely manner.

(Core)

IV.C.4.g) PGY-1 residents must not be assigned more than five new

patients per admitting day;

(Core)

IV.C.4.g).(1) an additional two patients may be assigned if they are in-

house transfers from the medical services.

(Core)

IV.C.4.h) PGY-1 residents must not be assigned more than eight new

patients in a 48-hour period;

(Core)

IV.C.4.i) PGY-1 residents must not be responsible for the ongoing care of

more than 10 patients;

(Core)

IV.C.4.j) when supervising more than one PGY-1 resident, the PGY-2 or

PGY-3 supervising resident must not be responsible for the

supervision or admission of more than 10 new patients and four

transfer patients per admitting day or more than 16 new patients in

a 48-hour period;

(Core)

Internal Medicine

IV.C.4.k) when supervising one PGY-1 resident, the PGY-2 or PGY-3

supervising resident must not be responsible for the ongoing care

of more than 14 patients; and,

(Core)

IV.C.4.l) when supervising more than one PGY-1 resident, the PGY-2 or

PGY-3 supervising resident must not be responsible for the

ongoing care of more than 20 patients.

(Core)

Specialty-Specific Background and Intent: The Review Committee cannot prescriptively and

explicitly assign patient census limits for every possible educational scenario or circumstance

given the variability in these settings and the complexity and acuity of the patients. Instead,

the committee asks program and institutional leadership teams to proactively and regularly

monitor the census, complexity, and acuity of patients assigned to resident-comprised health

care teams, and the structure and composition of the team, particularly the knowledge, skills,

and abilities of the team members, to determine the appropriate patient team size for the

situation. Although the Review Committee limits the number of new patients PGY-2 and PGY-

3 residents can be assigned per admitting day (Program Requirements IV.C.4. j)-l)), programs

can exercise flexibility and deviate from these limits for PGY-3 residents who have significant

experience in the inpatient setting and are interested in hospitalist medicine careers in the

future. The leadership team will need to carefully review institutional patient safety outcome

data when determining patient census team limits in such scenarios. The census limits noted

above apply to all inpatient experiences during the 36 months of supervised graduate medical

education regardless of whether an inpatient rotation is part of the foundational educational

experiences in internal medicine or part of the individualized experiences.

IV.C.5. While on outpatient rotations:

IV.C.5.a) residents must have clinical experiences in chronic disease

management, preventive health, patient counseling, and common

acute ambulatory problems; and,

(Core)

IV.C.5.b) residents must have a longitudinal, team-based, continuity

experience for the duration of the educational program through

which they develop a long-term therapeutic relationship with a

panel of patients.

(Core)

Specialty-Specific Background and Intent: The Review Committee believes that residents can

only achieve a long-term therapeutic relationship with a panel of patients if the continuity clinic

experience takes place for the entirety of the educational program. This will allow patients to

understand that the resident is “their” primary care doctor, and residents to see the continuity

clinic patients as “their” patients. While new patients will be added to the panel (and others

will leave) throughout the course of the program, the Review Committee suggests that

residents will remain in the same clinic throughout the 36 months to maintain continuity of

care for their patient panel.

The committee believes this requirement can be best met through assigning residents to a

general internal medicine clinic. However, to allow for residents to pursue post-residency

interests during residency, programs may assign residents to subspecialty or specialized

continuity clinics (e.g., an HIV clinic) if these assignments achieve the desired outcome noted

in the requirement: that residents develop a long-term therapeutic relationship with a panel of

patients.

Internal Medicine

IV.C.5.b).(1) Residents must serve as the primary physician for a panel

of patients, with responsibility for chronic disease

management, management of acute health problems, and

preventive health care for their patients.

(Core)

IV.C.5.b).(2) Residents must participate in the coordination of care of

patients across health care settings and between

outpatient visits.

(Core)

IV.C.5.b).(3) Residents must be supervised and taught by faculty

members with whom they have developed a longitudinal

relationship.

(Core)

IV.C.5.b).(4) Faculty members must maintain a ratio of residents or

other learners to faculty preceptors not to exceed four to

one;

(Detail)

IV.C.5.b).(4).(a) Faculty members must not have other patient care

responsibilities while supervising more than two

residents or other learners.

(Detail)

IV.C.6. Required Didactic Experiences

IV.C.6.a) The educational program must include didactic instruction based

upon the core knowledge content of internal medicine.

(Core)

IV.C.6.a).(1) Residents must participate in diverse teaching conferences

or didactic sessions, including those dedicated to quality

improvement.

(Core)

IV.C.6.a).(2) The program must ensure that residents have the

opportunity to review all knowledge content from

conferences they could not attend.

(Core)

Specialty-Specific Background and Intent: Core knowledge content presented during

conferences will need to be made available for residents who missed the conference due to

clinical responsibilities. This can include repeating the conference, recording and making it

available electronically, or making the content provided during the conference available

electronically.

IV.C.6.a).(3) Residents’ educational experience must include didactic

sessions in which residents interact with other residents

and faculty members.

(Core)

IV.C.6.a).(3).(a) The frequency of these sessions must be sufficient

for peer-to-peer and peer-to-faculty member

interaction.

(Core)

IV.C.6.a).(4) Residents must be provided a patient or case-based

approach to clinical teaching:

Internal Medicine

IV.C.6.a).(4).(a) on all inpatient, outpatient, telemedicine, and

consultative services;

(Core)

IV.C.6.a).(4).(b) with a frequency and duration sufficient to ensure a

meaningful and continuous teaching relationship

between the assigned teaching faculty member and

the resident; and,

(Core)

IV.C.6.a).(4).(c) that includes interactions between resident and the

teaching faculty member, bedside teaching,

discussion of pathophysiology, and the application

of current evidence in diagnostic and therapeutic

decisions.

(Core)

IV.D. Scholarship

Medicine is both an art and a science. The physician is a humanistic

scientist who cares for patients. This requires the ability to think critically,

evaluate the literature, appropriately assimilate new knowledge, and

practice lifelong learning. The program and faculty must create an

environment that fosters the acquisition of such skills through resident

participation in scholarly activities. Scholarly activities may include

discovery, integration, application, and teaching.

The ACGME recognizes the diversity of residencies and anticipates that

programs prepare physicians for a variety of roles, including clinicians,

scientists, and educators. It is expected that the program’s scholarship will

reflect its mission(s) and aims, and the needs of the community it serves.

For example, some programs may concentrate their scholarly activity on

quality improvement, population health, and/or teaching, while other

programs might choose to utilize more classic forms of biomedical

research as the focus for scholarship.

IV.D.1. Program Responsibilities

IV.D.1.a) The program must demonstrate evidence of scholarly

activities consistent with its mission(s) and aims.

(Core)

IV.D.1.b) The program, in partnership with its Sponsoring Institution,

must allocate adequate resources to facilitate resident and

faculty involvement in scholarly activities.

(Core)

IV.D.1.c) The program must advance residents’ knowledge and

practice of the scholarly approach to evidence-based patient

care.

(Core)

IV.D.2. Faculty Scholarly Activity

Internal Medicine

IV.D.2.a) Among their scholarly activity, programs must demonstrate

accomplishments in at least three of the following domains:

(Core)

• Research in basic science, education, translational

science, patient care, or population health

• Peer-reviewed grants

• Quality improvement and/or patient safety initiatives

• Systematic reviews, meta-analyses, review articles,

chapters in medical textbooks, or case reports

• Creation of curricula, evaluation tools, didactic

educational activities, or electronic educational

materials

• Contribution to professional committees, educational

organizations, or editorial boards

• Innovations in education

IV.D.2.b) The program must demonstrate dissemination of scholarly

activity within and external to the program by the following

methods:

Background and Intent: For the purposes of education, metrics of scholarly activity

represent one of the surrogates for the program’s effectiveness in the creation of an

environment of inquiry that advances the residents’ scholarly approach to patient care.

The Review Committee will evaluate the dissemination of scholarship for the program

as a whole, not for individual faculty members, for a five-year interval, for both core

and non-core faculty members, with the goal of assessing the effectiveness of the

creation of such an environment. The ACGME recognizes that there may be differences

in scholarship requirements between different specialties and between residencies and

fellowships in the same specialty.

IV.D.2.b).(1) faculty participation in grand rounds, posters,

workshops, quality improvement presentations,

podium presentations, grant leadership, non-peer-

reviewed print/electronic resources, articles or

publications, book chapters, textbooks, webinars,

service on professional committees, or serving as a

journal reviewer, journal editorial board member, or

editor;

(Outcome)

IV.D.3. Resident Scholarly Activity

IV.D.3.a) Residents must participate in scholarship.

(Core)

IV.D.3.a).(1) A program’s graduates must demonstrate dissemination of

scholarship within or external to the program by any of the

following methods:

(Core)

IV.D.3.a).(1).(a) presenting in grand rounds, poster sessions,

leading conference presentations (journal club,

Internal Medicine

morbidity and mortality, case conferences);

workshops; quality improvement presentations;

podium presentations; grant leadership; non-peer-

reviewed print/electronic resources; articles or

publications; book chapters; textbooks; webinars;

service on professional committees; or serving as a

journal reviewer, journal editorial board member, or

editor.

(Core)

V. Evaluation

V.A. Resident Evaluation

V.A.1. Feedback and Evaluation

Background and Intent: Feedback is ongoing information provided regarding aspects

of one’s performance, knowledge, or understanding. The faculty empower residents to

provide much of that feedback themselves in a spirit of continuous learning and self-

reflection. Feedback from faculty members in the context of routine clinical care

should be frequent, and need not always be formally documented.

Formative and summative evaluation have distinct definitions. Formative evaluation is

monitoring resident learning and providing ongoing feedback that can be used by

residents to improve their learning in the context of provision of patient care or other

educational opportunities. More specifically, formative evaluations help:

• residents identify their strengths and weaknesses and target areas that need

work

• program directors and faculty members recognize where residents are

struggling and address problems immediately

Summative evaluation is evaluating a resident’s learning by comparing the residents

against the goals and objectives of the rotation and program, respectively. Summative

evaluation is utilized to make decisions about promotion to the next level of training, or

program completion.

End-of-rotation and end-of-year evaluations have both summative and formative

components. Information from a summative evaluation can be used formatively when

residents or faculty members use it to guide their efforts and activities in subsequent

rotations and to successfully complete the residency program.

Feedback, formative evaluation, and summative evaluation compare intentions with

accomplishments, enabling the transformation of a neophyte physician to one with

growing expertise.

V.A.1.a) Faculty members must directly observe, evaluate, and

frequently provide feedback on resident performance during

each rotation or similar educational assignment.

(Core)

Background and Intent: Faculty members should provide feedback frequently

throughout the course of each rotation. Residents require feedback from faculty

Internal Medicine

members to reinforce well-performed duties and tasks, as well as to correct

deficiencies. This feedback will allow for the development of the learner as they strive

to achieve the Milestones. More frequent feedback is strongly encouraged for

residents who have deficiencies that may result in a poor final rotation evaluation.

V.A.1.b) Evaluation must be documented at the completion of the

assignment.

(Core)

V.A.1.b).(1) For block rotations of greater than three months in

duration, evaluation must be documented at least

every three months.

(Core)

V.A.1.b).(2) Longitudinal experiences, such as continuity clinic in

the context of other clinical responsibilities, must be

evaluated at least every three months and at

completion.

(Core)

V.A.1.c) The program must provide an objective performance

evaluation based on the Competencies and the specialty-

specific Milestones, and must:

(Core)

V.A.1.c).(1) use multiple evaluators (e.g., faculty members, peers,

patients, self, and other professional staff members);

and,

(Core)

V.A.1.c).(2) provide that information to the Clinical Competency

Committee for its synthesis of progressive resident

performance and improvement toward unsupervised

practice.

(Core)

V.A.1.d) The program director or their designee, with input from the

Clinical Competency Committee, must:

V.A.1.d).(1) meet with and review with each resident their

documented semi-annual evaluation of performance,

including progress along the specialty-specific

Milestones;

(Core)

V.A.1.d).(2) assist residents in developing individualized learning

plans to capitalize on their strengths and identify areas

for growth; and,

(Core)

V.A.1.d).(3) develop plans for residents failing to progress,

following institutional policies and procedures.

(Core)

Background and Intent: Learning is an active process that requires effort from the

teacher and the learner. Faculty members evaluate a resident's performance at least at

the end of each rotation. The program director or their designee will review those

evaluations, including their progress on the Milestones, at a minimum of every six

months. Residents should be encouraged to reflect upon the evaluation, using the

information to reinforce well-performed tasks or knowledge or to modify deficiencies in

Internal Medicine

knowledge or practice. Working together with the faculty members, residents should

develop an individualized learning plan.

Residents who are experiencing difficulties with achieving progress along the

Milestones may require intervention to address specific deficiencies. Such

intervention, documented in an individual remediation plan developed by the program

director or a faculty mentor and the resident, will take a variety of forms based on the

specific learning needs of the resident. However, the ACGME recognizes that there are

situations which require more significant intervention that may alter the time course of

resident progression. To ensure due process, it is essential that the program director

follow institutional policies and procedures.

V.A.1.e) At least annually, there must be a summative evaluation of

each resident that includes their readiness to progress to the

next year of the program, if applicable.

(Core)

V.A.1.f) The evaluations of a resident’s performance must be

accessible for review by the resident.

(Core)

V.A.1.g) The program must assess residents’ skills in data gathering and

analysis, physical examination, clinical reasoning, patient

management, and procedures in all clinical settings.

(Core)

V.A.2. Final Evaluation

V.A.2.a) The program director must provide a final evaluation for each

resident upon completion of the program.

(Core)

V.A.2.a).(1) The specialty-specific Milestones, and when applicable

the specialty-specific Case Logs, must be used as

tools to ensure residents are able to engage in

autonomous practice upon completion of the program.

(Core)

V.A.2.a).(2) The final evaluation must:

V.A.2.a).(2).(a) become part of the resident’s permanent record

maintained by the institution, and must be

accessible for review by the resident in

accordance with institutional policy;

(Core)

V.A.2.a).(2).(b) verify that the resident has demonstrated the

knowledge, skills, and behaviors necessary to

enter autonomous practice; and,

(Core)

V.A.2.a).(2).(c) be shared with the resident upon completion of

the program.

(Core)

V.A.3. A Clinical Competency Committee must be appointed by the

program director.

(Core)

Internal Medicine

V.A.3.a) At a minimum, the Clinical Competency Committee must

include three members of the program faculty, at least one of

whom is a core faculty member.

(Core)

V.A.3.a).(1) Additional members must be faculty members from

the same program or other programs, or other health

professionals who have extensive contact and

experience with the program’s residents.

(Core)

Background and Intent: The requirements regarding the Clinical Competency

Committee do not preclude or limit a program director’s participation on the Clinical

Competency Committee. The intent is to leave flexibility for each program to decide the

best structure for its own circumstances, but a program should consider: its program

director’s other roles as resident advocate, advisor, and confidante; the impact of the

program director’s presence on the other Clinical Competency Committee members’

discussions and decisions; the size of the program faculty; and other program-relevant

factors. Inclusivity is an important consideration in the appointment of Clinical

Competency Committee members, allowing for diverse participation to ensure fair

evaluation. The program director has final responsibility for resident evaluation and

promotion decisions.

The program faculty may include more than the physician faculty members, such as

other physicians and non-physicians who teach and evaluate the program’s residents.

There may be additional members of the Clinical Competency Committee. Chief

residents who have completed core residency programs in their specialty may be

members of the Clinical Competency Committee.

V.A.3.b) The Clinical Competency Committee must:

V.A.3.b).(1) review all resident evaluations at least semi-annually;

(Core)

V.A.3.b).(2) determine each resident’s progress on achievement of

the specialty-specific Milestones; and,

(Core)

V.A.3.b).(3) meet prior to the residents’ semi-annual evaluations

and advise the program director regarding each

resident’s progress.

(Core)

V.B. Faculty Evaluation

V.B.1. The program must have a process to evaluate each faculty

member’s performance as it relates to the educational program at

least annually.

(Core)

Background and Intent: The program director is responsible for the educational

program and all educators. While the term “faculty” may be applied to physicians

within a given institution for other reasons, it is applied to residency program faculty

members only through approval by a program director. The development of the faculty

improves the education, clinical, and research aspects of a program. Faculty members

have a strong commitment to the resident and desire to provide optimal education and

Internal Medicine

work opportunities. Faculty members must be provided feedback on their contribution

to the mission of the program. All faculty members who interact with residents desire

feedback on their education, clinical care, and research. If a faculty member does not

interact with residents, feedback is not required. With regard to the diverse operating

environments and configurations, the residency program director may need to work

with others to determine the effectiveness of the program’s faculty performance with

regard to their role in the educational program. All teaching faculty members should

have their educational efforts evaluated by the residents in a confidential and

anonymous manner. Other aspects for the feedback may include research or clinical

productivity, review of patient outcomes, or peer review of scholarly activity. The

process should reflect the local environment and identify the necessary information.

The feedback from the various sources should be summarized and provided to the

faculty on an annual basis by a member of the leadership team of the program.

V.B.1.a) This evaluation must include a review of the faculty member’s

clinical teaching abilities, engagement with the educational

program, participation in faculty development related to their

skills as an educator, clinical performance, professionalism,

and scholarly activities.

(Core)

V.B.1.b) This evaluation must include written, anonymous, and

confidential evaluations by the residents.

(Core)

V.B.2. Faculty members must receive feedback on their evaluations at least

annually.

(Core)

V.B.3. Results of the faculty educational evaluations should be

incorporated into program-wide faculty development plans.

(Core)

Background and Intent: The quality of the faculty’s teaching and clinical care is a

determinant of the quality of the program and the quality of the residents’ future

clinical care. Therefore, the program has the responsibility to evaluate and improve the

program faculty members’ teaching, scholarship, professionalism, and quality care.

This section mandates annual review of the program’s faculty members for this

purpose, and can be used as input into the Annual Program Evaluation.

V.C. Program Evaluation and Improvement

V.C.1. The program director must appoint the Program Evaluation

Committee to conduct and document the Annual Program

Evaluation as part of the program’s continuous improvement

process.

(Core)

V.C.1.a) The Program Evaluation Committee must be composed of at

least two program faculty members, at least one of whom is a

core faculty member, and at least one resident.

(Core)

V.C.1.b) Program Evaluation Committee responsibilities must include:

V.C.1.b).(1) review of the program’s self-determined goals and

progress toward meeting them;

(Core)

Internal Medicine

V.C.1.b).(2) guiding ongoing program improvement, including

development of new goals, based upon outcomes;

and,

(Core)

V.C.1.b).(3) review of the current operating environment to identify

strengths, challenges, opportunities, and threats as

related to the program’s mission and aims.

(Core)

Background and Intent: To achieve its mission and educate and train quality

physicians, a program must evaluate its performance and plan for improvement in the

Annual Program Evaluation. Performance of residents and faculty members is a

reflection of program quality, and can use metrics that reflect the goals that a program

has set for itself. The Program Evaluation Committee utilizes outcome parameters and

other data to assess the program’s progress toward achievement of its goals and aims.

The Program Evaluation Committee advises the program director through program

oversight.

V.C.1.c) The Program Evaluation Committee should consider the

outcomes from prior Annual Program Evaluation(s),

aggregate resident and faculty written evaluations of the

program, and other relevant data in its assessment of the

program.

(Core)

Background and Intent: Other data to be considered for assessment include:

• Curriculum

• ACGME letters of notification, including citations, Areas for Improvement, and

comments

• Quality and safety of patient care

• Aggregate resident and faculty well-being; recruitment and retention; workforce

diversity, including graduate medical education staff and other relevant

academic community members; engagement in quality improvement and patient

safety; and scholarly activity

• ACGME Resident and Faculty Survey results

• Aggregate resident Milestones evaluations, and achievement on in-training

examinations (where applicable), board pass and certification rates, and

graduate performance.

• Aggregate faculty evaluation and professional development

V.C.1.d) The Program Evaluation Committee must evaluate the

program’s mission and aims, strengths, areas for

improvement, and threats.

(Core)

V.C.1.e) The Annual Program Evaluation, including the action plan,

must be distributed to and discussed with the residents and

the members of the teaching faculty, and be submitted to the

DIO.

(Core)

V.C.2. The program must complete a Self-Study and submit it to the DIO.

(Core)

Internal Medicine

Background and Intent: Outcomes of the documented Annual Program Evaluation can

be integrated into the accreditation Self-Study process. The accreditation Self-Study is

an objective, comprehensive evaluation of the residency program, with the aim of

improving it. Underlying the accreditation Self-Study is this longitudinal evaluation of

the program and its learning environment, facilitated through sequential Annual

Program Evaluations that focus on the required components, with an emphasis on

program strengths and self-identified areas for improvement. Details regarding the

timing and expectations for the accreditation Self-Study are provided in the ACGME

Manual of Policies and Procedures. Additionally, a description of the

accreditation

Self-Study process is available on the ACGME website.

V.C.3. One goal of ACGME-accredited education is to educate physicians

who seek and achieve board certification. One measure of the

effectiveness of the educational program is the ultimate pass rate.

The program director should encourage all eligible program

graduates to take the certifying examination offered by the

applicable American Board of Medical Specialties (ABMS) member

board or American Osteopathic Association (AOA) certifying board.

V.C.3.a) For specialties in which the ABMS member board and/or AOA

certifying board offer(s) an annual written exam, in the

preceding three years, the program’s aggregate pass rate of

those taking the examination for the first time must be higher

than the bottom fifth percentile of programs in that specialty.

(Outcome)

V.C.3.b) For specialties in which the ABMS member board and/or AOA

certifying board offer(s) a biennial written exam, in the

preceding six years, the program’s aggregate pass rate of

those taking the examination for the first time must be higher

than the bottom fifth percentile of programs in that specialty.

(Outcome)

V.C.3.c) For specialties in which the ABMS member board and/or AOA

certifying board offer(s) an annual oral exam, in the preceding

three years, the program’s aggregate pass rate of those

taking the examination for the first time must be higher than

the bottom fifth percentile of programs in that specialty.

(Outcome)

V.C.3.d) For specialties in which the ABMS member board and/or AOA

certifying board offer(s) a biennial oral exam, in the preceding

six years, the program’s aggregate pass rate of those taking

the examination for the first time must be higher than the

bottom fifth percentile of programs in that specialty.

(Outcome)

V.C.3.e) For each of the exams referenced in V.C.3.a)-d), any program

whose graduates over the time period specified in the

requirement have achieved an 80 percent pass rate will have

Internal Medicine

met this requirement, no matter the percentile rank of the

program for pass rate in that specialty.

(Outcome)

Background and Intent: Setting a single standard for pass rate that works across

specialties is not supportable based on the heterogeneity of the psychometrics of

different examinations. By using a percentile rank, the performance of the lower five

percent (fifth percentile) of programs can be identified and set on a path to curricular

and test preparation reform.

There are specialties where there is a very high board pass rate that could leave

successful programs in the bottom five percent (fifth percentile) despite admirable

performance. These high-performing programs should not be cited, and V.C.3.e) is

designed to address this.

V.C.3.f) Programs must report, in ADS, board certification status

annually for the cohort of board-eligible residents that

graduated seven years earlier.

(Core)

Background and Intent: It is essential that residency programs demonstrate knowledge

and skill transfer to their residents. One measure of that is the qualifying or initial

certification exam pass rate. Another important parameter of the success of the

program is the ultimate board certification rate of its graduates. Graduates are eligible

for up to seven years from residency graduation for initial certification. The ACGME

will calculate a rolling three-year average of the ultimate board certification rate at

seven years post-graduation, and the Review Committees will monitor it.

The Review Committees will track the rolling seven-year certification rate as an

indicator of program quality. Programs are encouraged to monitor their graduates’

performance on board certification examinations.

In the future, the ACGME may establish parameters related to ultimate board

certification rates.

VI. The Learning and Working Environment

Residency education must occur in the context of a learning and working

environment that emphasizes the following principles:

• Excellence in the safety and quality of care rendered to patients by residents

today

• Excellence in the safety and quality of care rendered to patients by today’s

residents in their future practice

• Excellence in professionalism through faculty modeling of:

• Appreciation for the privilege of providing care for patients

• Commitment to the well-being of the students, residents, faculty members, and

all members of the health care team

Internal Medicine

VI.A. Patient Safety, Quality Improvement, Supervision, and Accountability

VI.A.1. Patient Safety and Quality Improvement

VI.A.1.a) Patient Safety

VI.A.1.a).(1) Culture of Safety

A culture of safety requires continuous identification

of vulnerabilities and a willingness to transparently

deal with them. An effective organization has formal

mechanisms to assess the knowledge, skills, and

attitudes of its personnel toward safety in order to

identify areas for improvement.

VI.A.1.a).(1).(a) The program, its faculty, residents, and fellows

must actively participate in patient safety

systems and contribute to a culture of safety.

(Core)

VI.A.1.a).(2) Patient Safety Events

Reporting, investigation, and follow-up of safety

events, near misses, and unsafe conditions are pivotal

mechanisms for improving patient safety, and are

essential for the success of any patient safety

program. Feedback and experiential learning are

essential to developing true competence in the ability

to identify causes and institute sustainable systems-

based changes to ameliorate patient safety

vulnerabilities.

VI.A.1.a).(2).(a) Residents, fellows, faculty members, and other

clinical staff members must:

VI.A.1.a).(2).(a).(i) know their responsibilities in reporting

patient safety events and unsafe

conditions at the clinical site, including

how to report such events; and,

(Core)

VI.A.1.a).(2).(a).(ii) be provided with summary information

of their institution’s patient safety

reports.

(Core)

VI.A.1.a).(2).(b) Residents must participate as team members in

real and/or simulated interprofessional clinical

patient safety and quality improvement

activities, such as root cause analyses or other

activities that include analysis, as well as

formulation and implementation of actions.

(Core)

Internal Medicine

VI.A.1.a).(3) Quality Metrics

Access to data is essential to prioritizing activities for

care improvement and evaluating success of

improvement efforts.

VI.A.1.a).(3).(a) Residents and faculty members must receive

data on quality metrics and benchmarks related

to their patient populations.

(Core)

VI.A.2. Supervision and Accountability

VI.A.2.a) Although the attending physician is ultimately responsible for

the care of the patient, every physician shares in the

responsibility and accountability for their efforts in the

provision of care. Effective programs, in partnership with

their Sponsoring Institutions, define, widely communicate,

and monitor a structured chain of responsibility and

accountability as it relates to the supervision of all patient

care.

Supervision in the setting of graduate medical education

provides safe and effective care to patients; ensures each

resident’s development of the skills, knowledge, and attitudes

required to enter the unsupervised practice of medicine; and

establishes a foundation for continued professional growth.

VI.A.2.a).(1) Residents and faculty members must inform each

patient of their respective roles in that patient’s care

when providing direct patient care.

(Core)

VI.A.2.a).(1).(a) This information must be available to residents,

faculty members, other members of the health

care team, and patients.

(Core)

Background and Intent: Each patient will have an identifiable and appropriately

credentialed and privileged attending physician (or licensed independent practitioner

as specified by the applicable Review Committee) who is responsible and accountable

for the patient’s care.

VI.A.2.a).(2) The program must demonstrate that the appropriate

level of supervision in place for all residents is based

on each resident’s level of training and ability, as well

as patient complexity and acuity. Supervision may be

exercised through a variety of methods, as appropriate

to the situation.

(Core)

Background and Intent: Appropriate supervision is essential for patient safety and

high-quality teaching. Supervision is also contextual. There is tremendous diversity of

resident-patient interactions, training locations, and resident skills and abilities, even

Internal Medicine

at the same level of the educational program. The degree of supervision for a resident

is expected to evolve progressively as the resident gains more experience, even with

the same patient condition or procedure. The level of supervision for each resident is

commensurate with that resident’s level of independence in practice; this level of

supervision may be enhanced based on factors such as patient safety, complexity,

acuity, urgency, risk of serious safety events, or other pertinent variables.

VI.A.2.b) Levels of Supervision

To promote appropriate resident supervision while providing

for graded authority and responsibility, the program must use

the following classification of supervision:

VI.A.2.b).(1) Direct Supervision:

VI.A.2.b).(1).(a) the supervising physician is physically present

with the resident during the key portions of the

patient interaction; or,

VI.A.2.b).(1).(a).(i) PGY-1 residents must initially be

supervised directly, only as described in

VI.A.2.b).(1).(a).

(Core)

VI.A.2.b).(1).(a).(i).(a) A supervising physician must be

immediately available to be

physically present for PGY-1

residents on inpatient rotations who

have demonstrated the skills

sufficient to progress to indirect

supervision.

(Core)

VI.A.2.b).(1).(b) the supervising physician and/or patient is not

physically present with the resident and the

supervising physician is concurrently

monitoring the patient care through appropriate

telecommunication technology.

VI.A.2.b).(2) Indirect Supervision: the supervising physician is not

providing physical or concurrent visual or audio

supervision but is immediately available to the

resident for guidance and is available to provide

appropriate direct supervision.

VI.A.2.b).(3) Oversight – the supervising physician is available to

provide review of procedures/encounters with

feedback provided after care is delivered.

VI.A.2.c) The program must define when physical presence of a

supervising physician is required.

(Core)

Internal Medicine

VI.A.2.d) The privilege of progressive authority and responsibility,

conditional independence, and a supervisory role in patient

care delegated to each resident must be assigned by the

program director and faculty members.

(Core)

VI.A.2.d).(1) The program director must evaluate each resident’s

abilities based on specific criteria, guided by the

Milestones.

(Core)

VI.A.2.d).(2) Faculty members functioning as supervising

physicians must delegate portions of care to residents

based on the needs of the patient and the skills of

each resident.

(Core)

VI.A.2.d).(3) Senior residents or fellows should serve in a

supervisory role to junior residents in recognition of

their progress toward independence, based on the

needs of each patient and the skills of the individual

resident or fellow.

(Detail)

VI.A.2.e) Programs must set guidelines for circumstances and events

in which residents must communicate with the supervising

faculty member(s).

(Core)

VI.A.2.e).(1) Each resident must know the limits of their scope of

authority, and the circumstances under which the

resident is permitted to act with conditional

independence.

(Outcome)

Background and Intent: The ACGME Glossary of Terms defines conditional

independence as: Graded, progressive responsibility for patient care with defined

oversight.

VI.A.2.f) Faculty supervision assignments must be of sufficient

duration to assess the knowledge and skills of each resident

and to delegate to the resident the appropriate level of patient

care authority and responsibility.

(Core)

VI.B. Professionalism

VI.B.1. Programs, in partnership with their Sponsoring Institutions, must

educate residents and faculty members concerning the professional

and ethical responsibilities of physicians, including but not limited

to their obligation to be appropriately rested and fit to provide the

care required by their patients.

(Core)

Background and Intent: This requirement emphasizes the professional responsibility

of residents and faculty members to arrive for work adequately rested and ready to

care for patients. It is also the responsibility of residents, faculty members, and other

members of the care team to be observant, to intervene, and/or to escalate their

Internal Medicine

concern about resident and faculty member fitness for work, depending on the

situation, and in accordance with institutional policies. This includes recognition of

impairment, including from illness, fatigue, and substance use, in themselves, their

peers, and other members of the health care team, and the recognition that under

certain circumstances, the best interests of the patient may be served by transitioning

that patient’s care to another qualified and rested practitioner.

VI.B.2. The learning objectives of the program must:

VI.B.2.a) be accomplished without excessive reliance on residents to

fulfill non-physician obligations;

(Core)

Background and Intent: Routine reliance on residents to fulfill non-physician obligations

increases work compression for residents and does not provide an optimal educational

experience. Non-physician obligations are those duties which in most institutions are

performed by nursing and allied health professionals, transport services, or clerical

staff. Examples of such obligations include transport of patients from the wards or units

for procedures elsewhere in the hospital; routine blood drawing for laboratory tests;

routine monitoring of patients when off the ward; and clerical duties, such as

scheduling. While it is understood that residents may be expected to do any of these

things on occasion when the need arises, these activities should not be performed by

residents routinely and must be kept to a minimum to optimize resident education.

VI.B.2.b) ensure manageable patient care responsibilities; and,

(Core)

Background and Intent: The Common Program Requirements do not define

“manageable patient care responsibilities” as this is variable by specialty and PGY

level. Review Committees will provide further detail regarding patient care

responsibilities in the applicable specialty-specific Program Requirements and

accompanying FAQs. However, all programs, regardless of specialty, should carefully

assess how the assignment of patient care responsibilities can affect work

compression, especially at the PGY-1 level.

VI.B.2.c) include efforts to enhance the meaning that each resident

finds in the experience of being a physician, including

protecting time with patients, providing administrative

support, promoting progressive independence and flexibility,

and enhancing professional relationships.

(Core)

VI.B.3. The program director, in partnership with the Sponsoring Institution,

must provide a culture of professionalism that supports patient

safety and personal responsibility.

(Core)

Background and Intent: The accurate reporting of clinical and educational work hours,

patient outcomes, and clinical experience data are the responsibility of the program

leadership, residents, and faculty.

VI.B.4. Residents and faculty members must demonstrate an understanding

of their personal role in the safety and welfare of patients entrusted

Internal Medicine

to their care, including the ability to report unsafe conditions and

safety events.

(Core)

VI.B.5. Programs, in partnership with their Sponsoring Institutions, must

provide a professional, equitable, respectful, and civil environment

that is psychologically safe and that is free from discrimination,

sexual and other forms of harassment, mistreatment, abuse, or

coercion of students, residents, faculty, and staff.

(Core)

Background and Intent: Psychological safety is defined as an environment of trust and

respect that allows individuals to feel able to ask for help, admit mistakes, raise

concerns, suggest ideas, and challenge ways of working and the ideas of others on the

team, including the ideas of those in authority, without fear of humiliation, and the

knowledge that mistakes will be handled justly and fairly.

The ACGME is unable to adjudicate disputes between individuals, including residents,

faculty members, and staff members. However, information that suggests a pattern of

behavior that violates the requirement above will trigger a careful review and, if

deemed appropriate, action by the Review Committee and/or ACGME, in accordance

with ACGME Policies and Procedures.

VI.B.6. Programs, in partnership with their Sponsoring Institutions, should

have a process for education of residents and faculty regarding

unprofessional behavior and a confidential process for reporting,

investigating, and addressing such concerns.

(Core)

VI.C. Well-Being

Psychological, emotional, and physical well-being are critical in the

development of the competent, caring, and resilient physician and require

proactive attention to life inside and outside of medicine. Well-being

requires that physicians retain the joy in medicine while managing their

own real-life stresses. Self-care and responsibility to support other

members of the health care team are important components of

professionalism; they are also skills that must be modeled, learned, and

nurtured in the context of other aspects of residency training.

Residents and faculty members are at risk for burnout and depression.

Programs, in partnership with their Sponsoring Institutions, have the same

responsibility to address well-being as other aspects of resident

competence. Physicians and all members of the health care team share

responsibility for the well-being of each other. A positive culture in a

clinical learning environment models constructive behaviors, and prepares

residents with the skills and attitudes needed to thrive throughout their

careers.

VI.C.1. The responsibility of the program, in partnership with the

Sponsoring Institution, must include:

VI.C.1.a) attention to scheduling, work intensity, and work

compression that impacts resident well-being;

(Core)

Internal Medicine

VI.C.1.b) evaluating workplace safety data and addressing the safety of

residents and faculty members;

(Core)

Background and Intent: This requirement emphasizes the responsibility shared by the

Sponsoring Institution and its programs to gather information and utilize systems that

monitor and enhance resident and faculty member safety, including physical safety.

Issues to be addressed include, but are not limited to, monitoring of workplace injuries,

physical or emotional violence, vehicle collisions, and emotional well-being after safety

events.

VI.C.1.c) policies and programs that encourage optimal resident and

faculty member well-being; and,

(Core)

Background and Intent: Well-being includes having time away from work to engage with

family and friends, as well as to attend to personal needs and to one’s own health,

including adequate rest, healthy diet, and regular exercise. The intent of this

requirement is to ensure that residents have the opportunity to access medical and

dental care, including mental health care, at times that are appr

opriate to their individual

circumstances. Residents must be provided with time away from the program as needed

to access care, including appointments scheduled during their working hours.

VI.C.1.c).(1) Residents must be given the opportunity to attend

medical, mental health, and dental care appointments,

including those scheduled during their working hours.

(Core)

VI.C.1.d) education of residents and faculty members in:

VI.C.1.d).(1) identification of the symptoms of burnout, depression,

and substance use disorders, suicidal ideation, or

potential for violence, including means to assist those

who experience these conditions;

(Core)

VI.C.1.d).(2) recognition of these symptoms in themselves and how

to seek appropriate care; and,

(Core)

VI.C.1.d).(3) access to appropriate tools for self-screening.

(Core)

Background and Intent: Programs and Sponsoring Institutions are encouraged to review

materials to create systems for identification of burnout, depression, and substance use

disorders. Materials and more information are available in Learn at ACGME

(

https://dl.acgme.org/pages/well-being-tools-resources).

Individuals experiencing burnout, depression, a substance use disorder, and/or suicidal

ideation are often reluctant to reach out for help due to the stigma associated with these

conditions and may be

concerned that seeking help may have a negative impact on their

career. Recognizing that physicians are at increased risk in these areas, it is essential

that residents and faculty members are able to report their concerns when another

resident or faculty member displays signs of any of these conditions, so that the

Internal Medicine

program director or other designated personnel, such as the department chair, may

assess the situation and intervene as necessary to facilitate access to appropriate care.

Residents and faculty members must know which personnel, in addition to the program

director, have been designated with this responsibility; those personnel and the

program director should be familiar with the institution’s impaired physician policy and

any employee health, employee assistance, and/or wellness/well-being programs within

the institution. In cases of physician impairment, the program director or designated

personnel should follow the policies of their institution for reporting.

VI.C.1.e) providing access to confidential, affordable mental health

assessment, counseling, and treatment, including access to

urgent and emergent care 24 hours a day, seven days a week.

(Core)

Background and Intent: The intent of this requirement is to ensure that residents have

immediate access at all times to a mental health professional (psychiatrist,

psychologist, Licensed Clinical Social Worker, Primary Mental Health Nurse

Practitioner, or Licensed Professional Counselor) for urgent or emergent mental health

issues. In-person, telemedicine, or telephonic means may be utilized to satisfy this

requirement. Care in the Emergency Department may be necessary in some cases, but

not as the primary or sole means to meet the requirement.

The reference to affordable counseling is intended to require that financial cost not be a

barrier to obtaining care.

VI.C.2. There are circumstances in which residents may be unable to attend

work, including but not limited to fatigue, illness, family

emergencies, and medical, parental, or caregiver leave. Each

program must allow an appropriate length of absence for residents

unable to perform their patient care responsibilities.

(Core)

VI.C.2.a) The program must have policies and procedures in place to

ensure coverage of patient care and ensure continuity of

patient care.

(Core)

VI.C.2.b) These policies must be implemented without fear of negative

consequences for the resident who is or was unable to

provide the clinical work.

(Core)

Background and Intent: Residents may need to extend their length of training

depending on length of absence and specialty board eligibility requirements.

Teammates should assist colleagues in need and equitably reintegrate them upon

return.

VI.D. Fatigue Mitigation

VI.D.1. Programs must educate all residents and faculty members in

recognition of the signs of fatigue and sleep deprivation, alertness

management, and fatigue mitigation processes.

(Detail)

Internal Medicine

Background and Intent: Providing medical care to patients is physically and mentally

demanding. Night shifts, even for those who have had enough rest, cause fatigue.

Experiencing fatigue in a supervised environment during training prepares residents for

managing fatigue in practice. It is expected that programs adopt fatigue mitigation

processes and ensure that there are no negative consequences and/or stigma for using

fatigue mitigation strategies.

Strategies that may be used include but are not limited to strategic napping; the

judicious use of caffeine; availability of other caregivers; time management to maximize

sleep off-duty; learning to recognize the signs of fatigue, and self-monitoring

performance and/or asking others to monitor performance; remaining active to promote

alertness; maintaining a healthy diet; using relaxation techniques to fall asleep;

maintaining a consistent sleep routine; exercising regularly; increasing sleep time

before and after call; and ensuring sufficient sleep recovery periods.

VI.D.2. The program, in partnership with its Sponsoring Institution, must

ensure adequate sleep facilities and safe transportation options for

residents who may be too fatigued to safely return home.

(Core)

VI.E. Clinical Responsibilities, Teamwork, and Transitions of Care

VI.E.1. Clinical Responsibilities

The clinical responsibilities for each resident must be based on PGY

level, patient safety, resident ability, severity and complexity of

patient illness/condition, and available support services.

(Core)

VI.E.1.a) Programs must ensure that residents’ clinical responsibilities on

inpatient rotations are consistent with the requirements in IV.C.4.

(Core)

Background and Intent: The changing clinical care environment of medicine has meant

that work compression due to high complexity has increased stress on residents.

Faculty members and program directors need to make sure residents function in an

environment that has safe patient care and a sense of resident well-being. It is an

essential responsibility of the program director to monitor resident workload. Workload

should be distributed among the resident team and interdisciplinary teams to minimize

work compression.

VI.E.2. Teamwork

Residents must care for patients in an environment that maximizes

communication and promotes safe, interprofessional, team-based

care in the specialty and larger health system.

(Core)

VI.E.2.a) The program must provide educational experiences that allow

residents to interact with and learn from other health care

professionals, including physicians in other specialties, advanced

practice providers, nurses, social workers, physical therapists,

case managers, language interpreters, and dieticians, in order to

Internal Medicine

achieve effective, interdisciplinary, and interprofessional team-

based care.

(Core)

Specialty-Specific Background and Intent: Physician and non-physicians, core and non-core

faculty members, are part of the different teams that form depending on the health care

situation and on patients’ health status and circumstances. The intent of the requirement is to

ensure that residents will have access to the appropriate health care personnel as defined by

the circumstances, and that interdisciplinary, interprofessional teams will be constituted as

appropriate and as needed.

Background and Intent: Effective programs will have a structure that promotes safe,

interprofessional, team-based care. Optimal patient safety occurs in the setting of a

coordinated interprofessional learning and working environment.

VI.E.3. Transitions of Care

VI.E.3.a) Programs must design clinical assignments to optimize

transitions in patient care, including their safety, frequency,

and structure.

(Core)

VI.E.3.b) Programs, in partnership with their Sponsoring Institutions,

must ensure and monitor effective, structured hand-off

processes to facilitate both continuity of care and patient

safety.

(Core)

VI.E.3.c) Programs must ensure that residents are competent in

communicating with team members in the hand-off process.

(Outcome)

VI.F. Clinical Experience and Education

Programs, in partnership with their Sponsoring Institutions, must design

an effective program structure that is configured to provide residents with

educational and clinical experience opportunities, as well as reasonable

opportunities for rest and personal activities.

Background and Intent: The terms “clinical experience and education,” “clinical and

educational work,” and “clinical and educational work hours” replace the terms “duty

hours,” “duty periods,” and “duty.” These terms are used in response to concerns that

the previous use of the term “duty” in reference to number of hours worked may have

led some to conclude that residents’ duty to “clock out” on time superseded their duty

to their patients.

VI.F.1. Maximum Hours of Clinical and Educational Work per Week

Clinical and educational work hours must be limited to no more than

80 hours per week, averaged over a four-week period, inclusive of all

in-house clinical and educational activities, clinical work done from

home, and all moonlighting.

(Core)

Internal Medicine

Background and Intent: Programs and residents have a shared responsibility to ensure

that the 80-hour maximum weekly limit is not exceeded. While the requirement has been

written with the intent of allowing residents to remain beyond their scheduled work

periods to care for a patient or participate in an educational activity, these additional

hours must be accounted for in the allocated 80 hours when averaged over four weeks.

Work from Home

While the requirement specifies that clinical work done from home must be counted

toward the 80-hour maximum weekly limit, the expectation remains that scheduling be

structured so that residents are able to complete most work on site during scheduled

clinical work hours without requiring them to take work home. The requirements

acknowledge the changing landscape of medicine, including electronic health records,

and the resulting increase in the amount of work residents choose to do from home. The

requirement provides flexibility for residents to do this while ensuring that the time

spent by residents completing clinical work from home is accomplished within the 80-

hour weekly maximum. Types of work from home that must be counted include using an

electronic health record and taking calls from home. Reading done in preparation for t

following day’s cases, studying, and research done from home do not count toward the

80 hours. Resident decisions to leave the hospital before their clinical work has been

completed and to finish that work later from home should be made in consultation with

the resident’s supervisor. In such circumstances, residents should be mindful of their

professional responsibility to complete work in a timely manner and to maintain patient

confidentiality.

Residents are to track the time they spend on clinical work from home and to report that

time to the program. Decisions regarding whether to report infrequent phone calls of

very short duration will be left to the individual resident. Programs will need to factor in

time residents are spending on clinical work at home when schedules are developed to

ensure that residents are not working in excess of 80 hours per week, averaged over

four weeks. There is no requirement that programs assume responsibility for

documenting this time. Rather, the program’s responsibility is ensuring that residents

report their time from home and that schedules are structured to ensure that residents

are not working in excess of 80 hours per week, averaged over four weeks.

VI.F.2. Mandatory Time Free of Clinical Work and Education

VI.F.2.a) Residents should have eight hours off between scheduled

clinical work and education periods.

(Detail)

Background and Intent: There may be circumstances when residents choose to stay to

care for their patients or return to the hospital with fewer than eigh

t hours free of clinical

experience and education. This occurs within the context of the 80-hour and the one-

day-off-in-seven requirements. While it is expected that resident schedules will be

structured to ensure that residents are provided with a minimum of eight hours off

between scheduled work periods, it is recognized that residents may choose to remain

beyond their scheduled time, or return to the clinical site during this time-off period, to

care for a patient. The requirement preserves the flexibility for residents to make those

choices. It is also noted that the 80-hour weekly limit (averaged over four weeks) is a

deterrent for scheduling fewer than eight hours off between clinical and education work

Internal Medicine

periods, as it would be difficult for a program to design a schedule that provides fewer

than eight hours off without violating the 80-hour rule.

VI.F.2.b) Residents must have at least 14 hours free of clinical work

and education after 24 hours of in-house call.

(Core)

Background and Intent: Residents have a responsibility to return to work rested, and

thus are expected to use this time away from work to get adequate rest. In support of

this goal, residents are encouraged to prioritize sleep over other discretionary activities.

VI.F.2.c) Residents must be scheduled for a minimum of one day in

seven free of clinical work and required education (when

averaged over four weeks). At-home call cannot be assigned

on these free days.

(Core)

Background and Intent: The requirement provides flexibility for programs to distribute

days off in a manner that meets program and resident needs. It is strongly

recommended that residents’ preference regarding how their days off are distributed be

considered as schedules are developed. It is desirable that days off be distributed

throughout the month, but some residents may prefer to group their days off to have a

“golden weekend,” meaning a consecutive Saturday and Sunday free from work. The

requirement for one free day in seven should not be interpreted as precluding a golden

weekend. Where feasible, schedules may be designed to provide residents with a

weekend, or two consecutive days, free of work. The applicable Review Committee will

evaluate the number of consecutive days of work and determine whether they meet

educational objectives. Programs are encouraged to distribute days off in a fashion that

optimizes resident well-being, and educational and personal goals. It is noted that a day

off is defined in the ACGME Glossary of Terms as “one (1) continuous 24-hour period

free from all administrative, clinical, and educational activities.”

VI.F.3. Maximum Clinical Work and Education Period Length

VI.F.3.a) Clinical and educational work periods for residents must not

exceed 24 hours of continuous scheduled clinical

assignments.

(Core)

VI.F.3.a).(1) Up to four hours of additional time may be used for

activities related to patient safety, such as providing

effective transitions of care, and/or resident education.

Additional patient care responsibilities must not be

assigned to a resident during this time.

(Core)

Background and Intent: The additional time referenced in VI.F.3.a).(1) should not be

used for the care of new patients. It is essential that the resident continue to function as

a member of the team in an environment where other members of the team can assess

resident fatigue, and that supervision for post-call residents is provided. This 24 hours

and up to an additional four hours must occur within the context of 80-hour weekly limit

averaged over four weeks.

VI.F.4. Clinical and Educational Work Hour Exceptions

Internal Medicine

VI.F.4.a) In rare circumstances, after handing off all other

responsibilities, a resident, on their own initiative, may elect

to remain or return to the clinical site in the following

circumstances: to continue to provide care to a single

severely ill or unstable patient; to give humanistic attention to

the needs of a patient or patient’s family; or to attend unique

educational events.

(Detail)

VI.F.4.b) These additional hours of care or education must be counted

toward the 80-hour weekly limit.

(Detail)

Background and Intent: This requirement is intended to provide residents with some

control over their schedules by providing the flexibility to voluntarily remain beyond the

scheduled responsibilities under the circumstances described above. It is important to

note that a resident may remain to attend a conference, or return for a conference later

in the day, only if the decision is made voluntarily. Residents must not be required to

stay. Programs allowing residents to remain or return beyond the scheduled work and

clinical education period must ensure that the decision to remain is initiated by the

resident and that residents are not coerced. This additional time must be counted

toward the 80-hour maximum weekly limit.

VI.F.4.c) A Review Committee may grant rotation-specific exceptions

for up to 10 percent or a maximum of 88 clinical and

educational work hours to individual programs based on a

sound educational rationale.

The Review Committee for Internal Medicine will not consider

requests for exceptions to the 80-hour limit to the resident work

week.

VI.F.5. Moonlighting

VI.F.5.a) Moonlighting must not interfere with the ability of the resident

to achieve the goals and objectives of the educational

program, and must not interfere with the resident’s fitness for

work nor compromise patient safety.

(Core)

VI.F.5.b) Time spent by residents in internal and external moonlighting

(as defined in the ACGME Glossary of Terms) must be

counted toward the 80-hour maximum weekly limit.

(Core)

VI.F.5.c) PGY-1 residents are not permitted to moonlight.

(Core)

Background and Intent: For additional clarification of the expectations related to

moonlighting, please refer to the Common Program Requirement FAQs (available at

http://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements).

VI.F.6. In-House Night Float

Internal Medicine

Night float must occur within the context of the 80-hour and one-

day-off-in-seven requirements.

(Core)

VI.F.6.a) Residents must not be assigned more than two months of night

float during any year of the educational program, or more than

four months of night float during the course of the residency.

(Core)

VI.F.6.b) Residents must not be assigned to more than one month of

consecutive night float rotation.

(Core)

Specialty-Specific Background and Intent: Night float rotations are designed to either

eliminate in-house call or to assist other residents during the night. Residents assigned to

night float are assigned on-site duty during evening/night shifts and are responsible for

admitting or cross-covering patients until morning and will not have daytime assignments or

ongoing primary responsibility for these patients. The Committee has limited the number a

program can assign because it believes too many such rotations can negatively affect

resident well-being and contribute to burnout and fatigue. Overnight shifts occurring during

critical care rotations (in the medical intensive care unit or the critical care unit) do not count

towards night float, but towards the maximum six months of required critical care time.

Overnight emergency medicine assignments do not count towards night float.

VI.F.7. Maximum In-House On-Call Frequency

Residents must be scheduled for in-house call no more frequently

than every third night (when averaged over a four-week period).

(Core)

VI.F.8. At-Home Call

VI.F.8.a) Time spent on patient care activities by residents on at-home

call must count toward the 80-hour maximum weekly limit.

The frequency of at-home call is not subject to the every-

third-night limitation, but must satisfy the requirement for one

day in seven free of clinical work and education, when

averaged over four weeks.

(Core)

VI.F.8.a).(1) At-home call must not be so frequent or taxing as to

preclude rest or reasonable personal time for each

resident.

(Core)

Background and Intent: As noted in VI.F.1., clinical work done from home when a

resident is taking at-home call must count toward the 80-hour maximum weekly limit.

This acknowledges the often significant amount of time residents devote to clinical

activities when taking at-home call, and ensures that taking at-home call does not result

in residents routinely working more than 80 hours per week. At-home call activities that

must be counted include responding to phone calls and other forms of communication,

as well as documentation, such as entering notes in an electronic health record.

Activities such as reading about the next day’s case, studying, or research activities do

not count toward the 80-hour weekly limit.

Internal Medicine

In their evaluation of residency/fellowship programs, Review Committees will look at the

overall impact of at-home call on resident/fellow rest and personal time.