Graduate Medical Education - Residencies and Fellowships

 

 Overview

 
  • ​NMCSD is the largest military medical facility in the United States. It serves as the tertiary care referral center for military members and their families from the Southwestern United States, and the entire Pacific Rim as far as Southeast Asia. Most medical staff hold faculty appointments at University of California San Diego and the Uniformed Services University of Health Sciences, and are nationally recognized for their clinical research and teaching expertise.

    Program Description

    The Internal Medicine Residency program at the Naval Medical Center San Diego is one of the premier residency programs in the Department of Defense. The residency program typically matches 20 PGY1 learners, and 11 residents to both the PGY2 and PGY3 classes. The program provides all clinical and leadership opportunities and experiences required for success in General Internal Medicine around the globe. Graduates of the program are currently serving in every facet of Navy Medicine, to include executive medicine, academic medicine, and operational medicine.

    Program Aim

    Graduates of the NMCSD Internal Medicine Residency program will be well prepared to begin the practice of general internal medicine in any environment with the additional capabilities expected of those serving in the armed forces. Trainees represent communities and cultures from across the United State that, upon graduation, will practice in operational, inpatient, outpatient, research, and academic settings and potentially participate in additional subspecialty training. Additionally, graduates will serve a diverse group of active duty service members, dependents, and retirees in addition to potentially treating foreign nationals and citizens of foreign countries. Residents will gain patient-based educational experience that emphasizes the knowledge and skills needed to manage patients with both acute and chronic diseases common to internal medicine in a wide variety of national and international settings.

 

 Program History

 
  • ​The Internal Medicine residency at Naval Medical Center San Diego (NMCSD) has been fully accredited and operating since December 1, 1958, and accredited to train up to 44 residents. It is the largest Navy Internal Medicine residency program and graduates 10-11 general internists per year. The program has a three-year 96% American Board of Internal Medicine (ABIM) pass rate (2015-2017).

    Program graduates continue their military career by serving as General Internists at Naval Hospitals around the globe, ship board, operational Marine Forces, and fellowship training programs.

    Recent graduates are currently serving in the following commands and fellowship programs:

    Naval Hospital, Camp Pendleton

    Naval Hospital, Guam

    Naval Hospital, Pensacola

    Naval Hospital, 29 Palms

    Naval Medical Center, San Diego

    Naval Hospital, Okinawa

    Naval Hospital, Yokosuka

    Naval Hospital, Guantanamo Bay

    Naval Hospital, Lemoore

    Operational Forces (shipboard and US Marine Corps)

    Fellowship training: Pulmonary/Critical Care, Cardiovascular Disease, Infectious Disease, Gastroenterology, Allergy/Immunology, Nephrology, Hematology/Oncology, Rheumatology, or Endocrinology

     

    Institutional Highlights

    NMCSD is a tertiary referral center providing care for more than 250,000 active duty, retired military, and family members in San Diego County, as well as patients referred from the entire Pacific Rim. Our patients are multiethnic, ranging in age from young adults to centurions. We are the most technologically advanced Navy medical treatment facility offering state-of-the-art imaging, surgical suites, and cardiac catheterization labs. NMCSD sponsors 25 GME programs ranging from anesthesiology to urology. There are multiple research opportunities available throughout the Department of Medicine.
 

 Academics

 
  • ​The program has a structured academic schedule, with a year-long curriculum designed to highlight both high-yield topics as well as operationally relevant medicine topics.

    Training Mission Statement

    Each physician studying internal medicine at NMCSD will acquire:

    Knowledge to identify and treat uncommon and rare conditions

    Skills to manage patients with diseases and problems common to internal medicine

    Ability to provide acute and comprehensive care to the seriously ill adult in both the inpatient and outpatient settings

    The attitude to advance into subspecialty training with a thorough grounding in internal medicine.

     

    Conferences:

     

    Daily Academics

    0730-0800: Brief topic/skill development (i.e. CXR Rounds, EKG Rounds) - once weekly

    0800-0830: Morning Report: Attended by faculty; formal presentation of a recent patient admission and discussion of the case

    0830-0900: Staff Lecture Series: Faculty presentation on a specific topic (i.e. glomerulonephritis)

     

    Monthly Academics

    Thursday 1200-1300: Morbidity and Mortality Conference, Journal Club, or Formal Senior Resident Presentation

    Friday 1300-1600: Ambulatory week workshop. Afternoon workshop for the group of residents on their ambulatory week, with a focus on pertinent outpatient IM topics (HTN, DMII, Geriatrics)

     

    Simulator Training

    Mock codes and procedural training built into specific rotation curriculum (i.e. MICU schedule). Required mock code training one cycle per academic year in the PGY-2 and PGY-3 years. In addition, annual communication training with standardized patients for medical error disclosure, end-of-life discussion, and other challenging communication challenges is performed.

 

 Curriculum

 
  • PGY-1: Rotations are scheduled in 4-week blocks (13 rotations)

    • Rotations are scheduled in 3-week blocks followed by 1 week of ambulatory medicine (13 blocks)
    • Internal Medicine wards at NMCSD and heme-onc service (4-5 blocks)
    • Internal Medicine wards at Scripps Green La Jolla (1 block possible)
    • Inpatient Cardiology (1 block)
    • Medical Intensive Care Unit (1 block)
    • Emergency Medicine (1 block)
    • Neurology (1 block)
    • Obstetrics and Gynecology (2 weeks)
    • Psychiatry (2 weeks)
    • Unrestricted Elective (1-2 block)
    • Ambulatory week is divided between one day of outpatient cardiology, one day of subspecialty clinic, and 3 days IM continuity clinic

    PGY-2/PGY-3: Rotations are scheduled in 3-week blocks followed by 1 week continuity clinic with minimum requirements:

    • Internal Medicine wards (5 blocks) including 1 block of Hematology/Oncology wards
    • Medical Intensive Care Unit (2 blocks)
    • Inpatient Cardiology – CCU (2 blocks)
    • Night float (1 block)
    • Subspecialty electives
    • Inpatient Internal Medicine Consult Service (1 block)
    • Geriatrics (2 weeks)
    • Allergy (2 weeks)
    • Physical Medicine and Rehabilitation (2 weeks)
    • Pulmonary and Sleep Medicine (1 block)

    Required Rotations

    • Inpatient Cardiology/CCU: A three week inpatient rotation in which you learn the inpatient management of common cardiac diseases such as decompensated heart failure, myocardial infarctions and arrhythmias. PGY1-3 residents will take overnight call. Outpatient Cardiology: Work one-on-one with attending physicians in the cardiology clinic caring for patients with coronary artery disease, congestive heart failure, arrhythmias, and syncope.
    • Dermatology: Trainees work with senior dermatology residents and gain exposure to common and uncommon dermatologic diseases. Residents can become certified in skin and punch biopsy during this rotation.
    • Emergency Medicine: A four week rotation consisting of approximately sixteen 8-hour shifts in which you learn the management of patients in an acute care setting, working with EM residents and staff.
    • Hematology/Oncology Wards: A three week inpatient rotation learning the management of hematologic and oncologic conditions. The ward team consists of one resident and one intern who admit every day.
    • ICU: The MICU team consists of 3 residents and 4-5 interns who take call daily and manage critically ill patients. MICU PGY-1-3 residents take overnight call. The ICU is a combined unit (MICU/SICU) to better prepare the IM graduates for practice in the Navy, where IM physicians are frequently required to provide surgical critical care.
    • Internal Medicine Wards: A three week inpatient rotation in which you learn management of medical diseases. There are three resident teams consisting of one resident and two or three interns. Teams admit on a “drip” system, 2 out of 3 days. PGY1 residents will have one overnight shift every 9 days.
    • Night Float: A three week inpatient rotation from 1800-0700. The night float handles overnight admissions and cross-coverage on medicine patients. The team consists of one PGY2-3 resident and two PGY-1 residents. Usually the IM PGY1 resident overnight is on the IM wards rotation (overnight call every 9th day)
    • OB-GYN: A two week rotation in which you learn the management of common obstetric and gynecologic diseases. Internal medicine interns are commonly assigned to round on hospitalized complicated obstetric patients in addition to rotating through a variety of outpatient and acute care settings.
    • Orthopedic Surgery or Sports Medicine: A two week outpatient rotation designed to teach the appropriate management of common orthopedic issues including fractures, strains and sprains.
    • Electives

      Internal Medicine Residents choose electives from the internal medicine subspecialties or other related specialties. These rotations are either an outpatient clinic, inpatient consult service, or a combination of both. Electives may include Endocrinology, Nephrology, Infectious Diseases, Rheumatology, Gastroenterology, Research, Anesthesiology, Radiology, Pathology.
    • Continuity Clinic

      Each PGY1 is assigned a 30-40 patient panel, and will perform all duties of a primary care doctor for these patients. Each PGY2 resident is assigned approximately 100 patients. The majority of face-to-face care is provided during the ambulatory week, however all residents provide longitudinal care for their patients over the year by handling phone calls, lab and radiology results, and other patient care concerns that arise between ambulatory weeks.
    • Military Unique Curriculum

      Graduates of our program will be well prepared to begin the practice of general internal medicine in any environment with the additional capabilities expected of those serving in the armed forces. Trainees represent communities and cultures from across the United States that, upon graduation, will practice in operational, inpatient, outpatient, research and academic settings and potentially participate in additional subspecialty training.
      Graduates will serve a diverse group of active duty service members, dependents, and retirees in addition to potentially treating foreign nationals and citizens of foreign countries. Residents will gain patient-based educational experience that emphasizes the knowledge and skills needed to manage patients with both acute and chronic diseases common to internal medicine in a wide variety of national and international settings.
 

 Faculty

 
  • ​NMCSD Internal Medicine and its subspecialties is comprised of 56 staff physicians.

    Department Chairman: Commander Jennifer A. Curry MD, MPH, FACP, FIDSA
     
    Program Director: Commander Mark P. Tschanz, DO, MACM, FACP
     

    A native of Chicago, Illinois, CDR Tschanz graduated from the University of Illinois with a Bachelor of Science degree in bioengineering before pursuing his medical degree from Kirksville College of Osteopathic Medicine in Kirksville, Missouri. He was commissioned 2002 after accepting a Health Professions Scholarship Program (HPSP) scholarship, and was promoted to Lieutenant after graduation from medical school with the degree of Doctor of Osteopathic Medicine. In addition to his medical degree, he earned a Master’s Degree in Academic Medicine from the University of Southern California (USC) in 2015.

    CDR Tschanz completed his training in Internal Medicine at the Naval Medical Center San Diego (NMCSD), followed by a one-year tour as the Chief of Residents. He remained at the medical center as a staff Internist and Associate Program Director for the Internal Medicine Residency after his Chief tour. While at NMCSD, he founded the annual Primary Care Symposium, which continues to be the largest military conference for Primary Care providers in Southern California, and served as the clerkship site director for the USUHS Internal Medicine clerkship. In 2010 he was deployed to Camp Bastion Hospital, Helmand Province, Afghanistan, where he served as the US Intensive Care Physician at the multi-national trauma hospital during the troop surge in 2010.

    CDR Tschanz transferred to the USS ESSEX (LHD 2) in 2012, where he served as the Senior Medical Officer, overseeing the large medical and surgical departments on the large amphibious assault ship. During his sea tour, ESSEX received the largest overhaul of a surface ship in Naval history, with complete renovation and upgrade of all of the medical spaces to include six operating rooms, a 16-bed intensive care unit, and 45-bed ward. He also coordinated medical efforts for multiple surface platforms during RIMPAC 2012 and Seattle Sea Fair 2014 exercises.

    CDR Tschanz returned to NMCSD in 2014 as an Internist and Associate Program Director for the Internal Medicine Residency, becoming Program Director in 2017. He is Board Certified in Internal Medicine, is a Fellow of the American College of Physicians (FACP), and serves as the Governor for the Navy Chapter of the American College of Physicians. He has special interests in hypertension and diabetes management, resident evaluation, and burnout. CDR Tschanz is an Associate Professor of Medicine at the Uniformed Services University of Health Sciences.

    Scholarly Activity

    Abstract/Poster Submissions for 2018-2019 Regional Meetings:
    Septic thrombophlebitis of the portal vein with Pseudomonas bacteremia in a returning traveler
    Delayed diagnosis of Brucella bacteremia
    The great imitator returns: syphilitic hepatitis masquerading as isotretinoin hepatotoxicity
    HIV infection and syphilitic lymphadenitis of the neck
    Mediastinal abscess in an immunocompetent patient; combined EBUS/EUS case
    Acute bladder perforation presenting as pseudo-AKI
    Leriche Syndrome (Aortoiliac Occlusive Disease): A Community Ambulator with Hyperreflexia & Ataxia with a Normal Spinal Cord
    Why is that diabetic patient waving at me? A case of nonketotic hyperglycemic hemiballism.
    Functional Neurologic Disorder: A must-know diagnosis for internists.
    Brugada and STEMI findings in patient who presented with cardiac arrest
    6 year survival in a patient with metastatic pancreatic cancer: FOLFIRI + medicinal marijuana
    Incidental pulmonary aplasia in an active duty service member (great
    Cryptogenic concentric bronchiolitis (pathologically proven - very rare
    20 Years of Missed Diagnosis:A Case of Cryopyrin-Associated Periodic Syndrome
    "I am allergic to everything" - Mast Cell Activation Syndrome and Response to Omalizumab
    Neiseria Meningitis in 2 Marine Recruits: Evaluation for complement deficiency in the age of Vaccination for Neisseria
    Penicillin Delabeling in a Military Treatment Facility
    Malignancy Masquerading as Sinusitis - A Case of DLCBL

 

 scholarly activity

 
  • ​Research is a required component of the 3-year Internal Medicine residency experience. Many residents fulfill this requirement by participating in the Associate’s Abstract Competition at the annual Navy and Southern California American College of Physician’s meeting. Many others publish original articles in journals of note or participate in full original research protocols that they themselves have designed. The opportunities are abundant for motivated physician scientists or those seeking to become more involved in research. There is a research tract available for PGY 2-3 residents who are in good academic standing and have interest in clinical research.
    Quality Improvement:
    Many ongoing resident projects including:
    Lean Six Sigma Project - Discharge PlanningGoal to streamline inpatient discharge processes to prevent bed capacity limitations during peak hours.
    VTE Quality ImprovementPerform audit of inpatient VTE screening and prescribing practices.
    Cancer CQTPoint person for IFOB roll-out to augment colonoscopy to improve CRC screening throughout USN clinics in the area (plan to propagate in late Jan16); also slated to do lymphoma project (awaiting hem-onc provision of data)
    NoV outbreak aboard USNS Mercy during Pacific Partnership 2015Outbreak investigation
    Cardiovascular risk factors observed in active duty service members presenting with ACSRetrospective cohort
    Quality of discharge summaries for patients admitted to CCUAssess, identify areas of improvement, train, and re-assess quality of discharge summaries for patient admitted to inpatient cardiology.
    Reducing Medication ErrorsMultidisciplinary team with primary objective of reducing errors on the inpatient medicine ward.
    Mental Health CQTGoal to improve HEDIS measures regarding anti-depressant medication administration as well as post-hospitalization follow-up for patients admitted for mental health diagnoses.
    Weight loss outcomes after liver biopsyWeight loss outcomes after liver biopsy in patients with nonalcoholic fatty liver disease; weight loss outcomes after liver biopsy in patients with nonalcoholic fatty liver disease. Letter to the Editor Digestive and Liver Disease 46 (2014) 1134-1138
    Inadvertent Sedation / Safe use of opioids & benzodiazepines in the inpatientReviewed NMCSD RRT events likely related to opioids, BZDs, anticholinergics, etc. Created educational intervention for NMCSD providers (RNs, Physicians, etc.) of all levels. Plan to implement education and re-assess rate of events.
    Phase-out of ammonia inhalantsUse of ammonia inhalants is not evidence-based and involves theoretical risks. Removal of AIs from NMCSD & surrounding clinic stocks will eliminate unnecessary use by untrained providers as well as reduce costs.
    Abstract/Poster Submissions for 2016 Regional Meetings
    DRESS - Clinical Vignette
    An Uncommon Proteinuria - Clinical Vignette
    Development of Hepatocellular Carcinoma in a Patient on Tacrolimus Following Renal Transplantation - Clinical Vignette
    Mast Cell Activation Syndrome (Recurrent Anaphylaxis) - Clinical Vignette
    A Rare Case of Ileitis as a Manifestation of Hereditary Angioedema - Clinical Vignette
    Prolonged Anaphylaxis Following Tattoo - Clinical Vignette
    Urticaria Associated with Pernicious Anemia - Clinical Vignette
    Autoimmune Progesterone Dermatitis - Clinical Vignette
    Sweet Syndrome/Neutrophillic Dermatitis - Clinical Vignette
    Hypereosinophili/Churg Strauss - Clinical Vignette
    Iatrogenic Adrenal Insufficiency in Patient Treated for Cushing's Disease with RU-486 - Clinical Vignette
    Non-conventional Imaging in Infective Endocarditis - Clinical Vignette
    Listeria Septic Arthritis - Clinical Vignette
    Small Bowel Obstruction from Peritoneal Tuberculosis - Clinical Vignette
    IgA Bullous Dermatosis/Ulcerative Proctitis - Clinical Vignette
    A Case of Chagas Cardiomyopathy - Clinical Vignette
    Calciphylaxis - Clinical Vignette
    Lupus Cardiomyopathy - Clinical Vignette
    Diagnosis of MTB Complex - Clinical Vignette
    Paradoxical Systemic Emboli Presenting as Renal Infarcts - Clinical Vignette
    Groans and Moans: An Interesting Presentation of IRIS Induced Hypercalcemia - Clinical Vignette
    A Positive Synthetic Cannabinoid Test Result in an E-cigarette User - Clinical Vignette
    Primary CNS Vasculitis - Clinical Vignette
    Acute Rheumatic Fever - Clinical Vignette
    Idiopathic Hemopericardium - Clinical Vignette