Id P&P 2010 2011 1

UCSF Fresno
Infectious Diseases
Fellowship
Policy & Procedure

Manual
2010/2011
Revised July 20010
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INFECTIOUS DISEASE FELLOWSHIP
INTRODUCTION
Infectious Diseases remain a major cause of morbidity and mortality. New organisms have been
emerging, older pathogens re-emerging and the specter of bioterrorism requires a broad range of
knowledge. The fellowship program’s purpose is to train the Infectious Disease specialist to
treat and manage patients with Infectious diseases in a changing world.
The Infectious Disease Medicine division is proud to welcome you into our fellowship training
program. Enclosed in this notebook you will find the outline of your 2-year curriculum and
general guidelines for your entire fellowship program.
It is expected that each fellow attend all conferences that are listed on the monthly-published
calendar. Twice yearly individual evaluations of fellow performance will be conducted by the
program director. You will also be expected to evaluate the faculty and the training program.
Over the 2-year period of training, fellows will be expected to have increasing responsibility for
patient care and involvement in administrative tasks.
Infectious Disease Fellows are expected to exhibit the highest level of professionalism at all
times.
Research is a core component to the training program. Each fellow must identify a research
mentor early in the program and develop a substantive research project. A careful evaluation
process will also guide the research aspect of the program.
Please review the entire contents of this notebook and refer to it as needed throughout your
training.
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FELLOW SUPERVISION POLICY
Infectious Diseases Fellowship
The Program Director, with the assistance of attending physicians, assures that fellows are
appropriately supervised. Fellows are permitted to take on progressively greater responsibility
throughout the course of the fellowship, consistent with individual growth in clinical experience,
judgment, knowledge, and technical skill. Fellows are supervised by attending physicians so that
the fellows assume progressively increasing responsibility according to their level of education,
ability, and experience.
The Program Director, with the assistance of attending physicians, will assess fellows’
competence as the basis for determining the minimum level of supervision required for different
activities. The objective criteria used to evaluate the fellow’s progressive ability, and which will
be consistently applied, is contained in evaluation forms; program director review of fellow
competency / feedback form; procedure logs; Competency-based curriculum and objectives. This
assessment includes the evaluation of the fellow’s technical, patient management, and
communication skills and capacity to perform as required. The Program Director communicates
the assessment of the fellow’s competence to the fellow and supervising attending physician at
least annually and when significant progress or deficiencies are noted.
On-call schedules for attending physicians shall provide for supervision, that is readily available
to a fellow, on duty 24 hours per day, 7 days per week. Under circumstances in which urgent
judgments by highly experienced physicians are typically required, attending physicians must be
immediately available on site at all times. Under other circumstances, attending physicians can
provide adequate supervision off site as long as their physical presence within a reasonable time
can be assured in case of need. The Program Director assures that a schedule with the name and
contact number of the responsible attending physician is available at all times to program
fellows.
All patients seen by a fellow on an outpatient basis must be seen by, discussed with, or reviewed
by the responsible attending physician
General Attending Physician Responsibilities
An attending physician is responsible for and actively involved in the care provided to each
patient, both inpatient and outpatient.
An attending physician directs the care of each patient and provides the appropriate level of
supervision for a fellow, based on the nature of the patient's condition, the likelihood of major
changes in the management plan, the complexity of care, and level of education, ability,
experience, and judgment of the fellow being supervised.
The attending physician, in consultation with the program director, accords a fellow progressive
responsibility for the care of the patient, based on the fellow’s clinical experience, judgment,
knowledge, technical skill, and capacity to function.
The attending physician advises the program director if he/she believes a change in the level of
the fellow’s responsibility and supervision should be considered. The overriding consideration
must be the safe and effective care of the patient that is the personal responsibility of the
attending physician.
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The attending physician fosters an environment that encourages questions and requests for
support or supervision from the fellow, and encourages the fellow to call or inform the attending
physician of significant or serious patient conditions or significant changes in patient condition.
Fellow Responsibilities and Requirements
The fellow must be aware of his/her level of training, his/her specific clinical experience,
judgment, knowledge, and technical skill, and any associated limitations. The fellow must not
independently perform procedures or treatments, or management plans that he/she is
unauthorized to perform or lacks the skill and training to perform.
The fellow is responsible for communicating to the attending physician any significant issues
regarding patient care.
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Duty Hours
Resident duty hours are governed by ACGME guidelines and are monitored by the Graduate
Medical Education Committee via its Duty Hours Subcommittee and individual programs. All
efforts should be made to maximize educational opportunities while minimizing fatigue and
service requirements via the individual training programs and the Duty Hours Sub-Committee,
the GMEC is responsible for monitoring resident duty hours.
All schedules for the fellows are designed in a yearly format, taking into consideration all the
work hour rules. The schedule is posted in advance on a web based program (Amion.com). Any
necessary schedule changes are posted immediately to Amion.com – this program is designed to
stay within all duty hour rules. To ensure the fellow is in compliance with all duty hours
regulations, he or she will be responsible for entering their hours daily on the duty hours module
of a web based product: E Value. E-Value is set up to send email reminders to the fellows if
they do not log their hours. The program will also notify the Program Director of any duty hours
violations, or of any fellows not reporting their hours. Any duty hours violations will be reported
to the Program Director and the Program Director will work with the fellow to correct the issues
involved
Moonlighting Policy
The Internal Medicine Department of UCSF Fresno and the UCSF Fresno Infectious Diseases
Fellowship endorses the ACGME and the UCSF Fresno GMEC policy on Moonlighting.
The Moonlighting Policy, which my also be found in the UCSF Fresno Resident handbook, is as
follows:
¾ The resident’s primary responsibility is to fulfill the education expectation of the

program. Outside work (moonlighting) cannot interfere with this primary responsibility.
¾ No resident on probation or remediation may participate in moonlighting.
¾ All moonlighting activities must e requested in writing using the UCSF Fresno
“moonlighting request” form available in the Department Office.
¾ All moonlighting activities must be approved by the Program Director in writing.
¾ Approval of the Program Director does not provide malpractice coverage for this activity
that is outside the scope of the educational process.
¾ Failure to follow this policy can result in suspension from the training program.
The term “resident” denotes all levels of trainees in the UCSF Fresno Medical Education
programs.
(The department office has these forms)
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Vacation Policy
Fellows are entitled to 3 weeks of vacation and 1 week of continuing medical education activity
per year.
It is requested that the fellows work out their plans with each other regarding coverage and
present their requests to the Program Director.
VACATION/CONFERENCE REQUEST FORM
NAME:___________________________________________DATE___________
DATES REQUESTED_______________________________________________
NUMBER OF WEEK DAYS__________
NAME OF CONFERENCE____________________________________________
ROTATION________________________________________________________
SIGNATURE OF COVERING FELLOW________________________________
SIGNATURE OF PROGRAM DIRCTOR_______________________
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We take the issue of fellow stress very seriously. We discuss these issues with the
fellows at orientation, and address it in our lecture series throughout the year. Fellows
are able to access (free of charge) our Employee Assistance Program, and both health
plans offered have covered services for mental or emotional issues. The Program
Director and the faculty monitor fellows for unusual behavior that could signal
impairment. In addition, UCSF Fresno has the Impaired Residents/ Fellow Policy listed
below:
POLICY: Impaired Residents / Fellows

PURPOSE: To provide a guide to prevent or minimize the occurrence of impairment by resident* physicians. *For
the sake of this policy resident also refers to fellows
Policy:
Impairment of performance by resident physicians places patients at risk. Impairment may result
from depression or other mental health/behavioral disorders, physical conditions, medical
illnesses, and substance abuse and subsequent chemical dependency. Impairment in resident
physicians will be recognized and managed as a medical/behavioral illness. This concept of
impairment allows for diagnosis, opportunity for treatment, and, with a successful recovery, an
opportunity to return to training in an appropriate capacity. This policy is written to ensure
optimal patient care, excellence in medical education, and to prevent or eliminate, to the extent
possible, impaired resident physicians.
The goals of this policy are:

1. To prevent or minimize the occurrence of impairment, including substance abuse, among
resident physicians at the UCSF Fresno Medical Education Program and its affiliated
medical centers.
2. To protect patients from risks associated with care given by an impaired resident
physician.
3. To compassionately confront problems of impairment to effect diagnosis, relief from
patient care responsibilities if necessary, treatment as indicated, and appropriate
rehabilitation.
In achieving these goals, several principles are involved:

1. The safety of both the impaired individual and of patients is of prime importance.
2. The privacy and dignity of the affected individual will be maintained to the extent
possible.
3. To the extent that its resources allow, the UCSF Fresno Wellness Committee will
facilitate education, preliminary assessment, diagnostic evaluation, and work with the
State Diversion Program.
Procedure:
Diagnosis of Impairment
The following are signs and symptoms of impairment. Isolated instances of any of these signs
and symptoms may not impair ability to perform adequately, but if they are noted on a continual
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basis or if multiple signs are observed, any individual action may be at risk. Warning signs and
symptoms of impaired functioning may include:
1. Physical signs such as fatigue, deterioration in personal hygiene and appearance, multiple
physical complaints, accidents, eating disorders.
2. Disturbances in personal and professional relationships.
3. Social withdrawal and isolation from peers, inappropriate behavior in the professional
setting, unpredictable behavior, increased argumentativeness, and aggressive behavior.
4. Changes in professional behavior patterns such as unexplained absences, tardiness,
decreasing quality and interest in work, and inadequate professional performance.
5. Drug use indicators such as excessive agitation or edginess, dilated or pinpoint pupils,
noticeable odor of alcohol or cannabis.
Access and Reporting Process
1. If a resident physician is observed to be impaired/disabled while engaged in the
performance of his/her duties, the course of action shall be as follows The observer shall
report his/her concern immediately to a responsible supervisor, and ultimately to the
Program Director.
2. The Program Director will notify the HR Manager who will assemble the Wellness
Committee if needed. If further evaluation is thought to be warranted, the resident will
be sent for an evaluation by the addiction specialist for Fresno County. The addiction
specialist will report to the State Medical Board should that be necessary. The diversion
services of the Board will arrange appropriate treatment and monitor resident compliance.
3. The Program Director and the HR Manager will discuss the resident’s options regarding
any leave of absence and/or suspension from the Medical Education Program in
accordance with the UCSF Fresno Due Process Policy. If a leave of absence is indicated,
the resident will be informed of the decision to require a LOA as soon as possible.
4. The need for reporting to the State of California Licensing Board will be made with
consultation with the Board and University Legal Counsel and the evaluating physician.
5. Should the evaluating physician recommend a level of treatment that can be addressed
locally, the HR Manager will assist the resident in obtaining local mental health/treatment
services.
6. Should a resident about whom the concern has been expressed be determined not to be
impaired, any mention of the concern will be removed from his/her file and the individual
will be allowed to return to the Medical Education program without prejudice.
7. Appropriate and complete documentation of the events shall be performed.
Follow-up
The HR Manager will serve as liaison with the Diversion Board. When it is determined by the
Board that the resident is ready to re-enter the Medical Education Program, the HR Manager will
assist the resident in the re-entry to the Medical Education Program.
Prevention and Education Services
1. Each year during New House staff Orientation, an educational component addressing
Resident Physician Impairment policies and services will be presented.
2. Seminars addressing the Impaired Physician will be presented at least yearly in the UCSF
Fresno Wednesday Special Lecture series. This lecture series is open to all housestaff
and faculty.
3. At departmental request, a designated representative will be available to provide

educational lectures addressing Impaired Physician issues.
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Daily rounds
CRMC
ROTATION Monday Tuesday Wednesday Thursday Friday
Pgy 5 ID Clinic HIV clinic
Pgy 4 ID Clinic HIV clinic Hep clinic
Lecture noon noon noon noon noon
Grand HIV Case Conf ID case conf ID Core Lecture UCSF 301
Rounds UMC – 12-1 Rm 333 Rm 301 Board Review
Rounds
CRMC - daily
Microbiology 7:30-11:30 7:30-11:30 7:30-11:30
ETC 3RD Thursday,

7:30am- ID
present Chest C
Journal club noon
th
4 Friday
UCSF 301
IM Fellows 7:30am – IM 12:30 - 4th
Research Research Meeting Thursday .
Conference UCSF 108
VA
ROTATION Monday Tuesday Wednesday Thursday Friday

ID Clinic 1:00 pm 1:00 pm
Rounds- daily
Committee 10:00 am
4th Friday
Inf. Control
Lectures Please See Schedule above
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Evaluations:
Fellows;
We follow similar policies already in effect for the Internal Medicine Residency Program. We
utilize a web based evaluation program called E-Value. Fellows will be evaluated on each
rotation by the faculty, and fellows will evaluate their attending each rotation. Peer evaluations
are also sent out to fellows, both fellow to fellow and resident to fellow. Nursing personnel also
use E-Value to evaluate fellows. All evaluations are based on the core competencies. The
evaluations are sent out by email, with reminders until the evaluations are complete. The system
also has “on the fly” evaluations which allow for concern or praise cards of either fellows or
faculty. These evaluations go directly to the Program Director. The system is also set up to send
a notice immediately both to the fellow’s mentor and Program Director if a fellow receives a less
than satisfactory score in any area of his / her evaluation. The participating hospitals send out
patient evaluations, and this information is shared on a regular basis with the Program Director.
The fellows do a complete written survey of the program once a year.
The fellows meet as a group with the Fellowship Program Director every 4 months and as
needed. During those meetings all aspects of the fellowship program are open for discussion and
critical review is encouraged. Problems delineated from those discussions are then addressed by
the Program Director until they are resolved satisfactorily.
Two times per year, the Fellowship Program Director meets with each individual fellow and
solicits from the fellow their observations and recommendations for improvements in the
program.
Issues which require general consideration are presented at the Division’s Bi-monthly Faculty
Meeting for discussion by the entire Division faculty.
Conference attendance is expected to be 100%, with vacations as the only excuse to not attend.
Attendance record is kept in the Fellowship office.
Faculty;
At least annually, the program must evaluate faculty performance as it relates to the educational
program.
These evaluations should include a review of the faculty’s clinical teaching abilities,
commitment to the educational program, clinical knowledge, professionalism, and scholarly
activities.
The evaluation must include at lest annual written confidential evaluations by fellows. Fellows
should evaluate the faculty’s effectiveness as teacher, the effectiveness of rotation or assignment
in achieving the goals and objectives identified in the curriculum for that rotation.
The fellows must have the opportunity to assess formally the effectiveness of ambulatory
teaching on an ongoing basis.
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GRADED RESPONSIBILITY
Fellows are assigned incrementally increasing responsibility and independence during their
training appropriate for their demonstrated level of competency and professional development
(as assessed by the supervising physicians), according to a three-tiered format as shown below.
Level of responsibility/ independence by proficiency level*

Function/ activity Beginning Developing Proficient
Clinical data collection independent, with staff independent, with staff independent, with selective staff
supplementation confirmation confirmation
Formulation of clinical jointly with staff independent, with staff independent, with selective staff
assessments/ plans confirmation confirmation
Communication of after discussion with preliminary, independent, with selective staff
recommendations to 10 staff independent; final, after confirmation
teams/ referring MDs discussion with staff
Antibiotic approvals after discussion with independent, with staff independent, with selective staff
staff confirmation confirmation
Case conference jointly with staff independent, with staff independent, with selective staff
preparation confirmation confirmation
Supervision of jointly with staff independent, with staff independent, with selective staff
students/ residents review review
Research directed background execution of existing analysis and presentation of
reading, tutored skill projects with staff results, new project
development oversight development, independent
conduct of research with
selective staff review
*As assessed by supervising faculty based on observation of fellow’s performance. Clinical
proficiency levels correspond approximately with the first, second, and third 4-month blocks of
clinical experience, but individual fellows move through the levels at different rates depending
on their rate of developing the relevant competencies.
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ROTATION TEMPLATES - CONSULTS
First year
Average Average Frequency

Duration number of number of of
of hours on full days in house
experience Frequency duty off night
Rotation Institution/Site (weeks or of Nights per week per week call (e.g.,
Name/Year 1 (F1) months) On-Call (including during this Q3,
ID Inpatient Consult CRMC 24 wks 2/wk 50 1 0
VA ID Inpatient VA 12 wks 2/wk 50 1 0
Pediatric ID Consult CHILDREN’S 4 wks 2/wk 50 1 0
Kaiser ID Consult KAISER 4 wks 2/wk 50 1 0
Microbiology CRMC 4 wks 0 40 2 0
Second year
Average Average Frequency

Duration number of number of of
of hours on full days in house
experience Frequency duty off night
Rotation Institution/Site (weeks or of Nights per week per week call (e.g.,
Name/Year 2 (F2) months) On-Call (including during this Q3,
CRMC ID Consult CRMC 12 wks 1/wk 50 1 0
VA ID Consult VA 4 wks 1/wk 50 1 0
UCSF Transplant UCSF 4 wks 1/wk 50 1 0
Research (required) CRMC/VA 20 wks 0 0 2 0
CONTINUITY CLINIC EXPERIENCE:
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Duration ½ day sessions Average patients
Name of Experience ID (months) per week seen per session
Special Services Clinic (HIV) CRMC 18 1 6
Other Ambulatory Experience:
½ day Average
Duration sessions patients seen
Name of Experience ID (months) per week per session
ID Clinic CRMC 18 1 12
ID Clinic VA 5 1 5
ID Clinic (elective) CHILDRENS 1 1 10
ID Clinic (elective) KAISER 1 1 12
CORE CURRICULUM
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REQUIRED CLINICAL COMPETENCIES IN INFECTIOUS DISEASES
Infections and other complications in patients with HIV/AIDS

Cardiovascular and endovascular infections
Central nervous system infections
Gastrointestinal, intra-abdominal, and hepatobilliary infections
Skin and soft tissue infections
Bone and joint infections
Infections of prosthetic devices
Infections related to trauma
Sepsis syndromes
Nosocomial infections
Urinary tract infections
Infections in the immunosuppressed host, other than HIV
Infections in international and returning travelers
Antibiotic use and utilization management
Clinical microbiology and parasitology
Infections of the eyes, ear, nose and throat
Infections in the elderly and geriatric population
Sexually-transmitted infections
Immunizations
Bioterrorism
Zoonotic infections
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Teaching conferences
Fellows are expected to present at the weekly Case Management conference as
well as the monthly Journal Club and M & M., and the weekly ID Core
conference, Chest conference, and Medicine Grand Rounds.
100% attendance is expected, vacation being the only excuse for absence.
Core Curriculum:
Conferences are held once each week, discussing each topic, one time per year.
1. The febrile patient
2. URI
3. Pleuropulmonary Infections
4. Urinary Tract Infections
5. Intra-Abdominal Infection
6. Cardiovascular Infection
7. Central Nervous System Infection
8. Skin and Soft Tissue Infection
9. Infections Related to Trauma(including bites and burns)
10. GI Infections and food poisoning
11. Bone and Joint Infections (including Prosthetic device and joint infections)
12. Infections of Reproductive Organs
13. Sexually Transmitted Diseases
14. Infections of the Eye
15. Viral hepatitis
16. Sepsis Syndromes
17. Nosocomial Infections
18. HIV Infections and its Complications
19. Infections in Neuropenic Hosts
20. Infections in Patients with Leukemia and Lymphoma
21. Infections in Marrow Transplant Patients
22. Infections in Solid Organ Transplants
23. Infections in Geriatric Patients
24. Infections in Travelers
25. Infections in Parenteral Drug Users
26. Antimicrobial Therapy – (7 sub topics)
27. Bioterrorism
28. Catheter Related Infections
29. Emerging infectious diseases and pathogens
30. Fungal Infections (7 sub topics)
31. Anaerobic infections
32. Anthrax
33. Helicobacter pylori
34. herpes viruses
35. Immunizations
36. infection control
37. influenza
38. lyme disease
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ROTATION SPECIFIC CURRICULUM
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Name of rotation: General ID Consultation Service
Division: Infectious Diseases Average Number of Months
Fellows at Hospital
Course Director: Robert Libke, M.D.
F1 F2 F3
Site(s):Fresno-CRMC 6 6
Duration of rotation: [x] one month
General description of the rotation including educational purpose, rationale or value:

Fresno CRMC is an academic center which has 457 licensed beds with expansion to about 700 beds
underway. Approximately 80 beds are dedicated for the ICU, and the hospital currently serves an average
of 332 inpatients a day. It houses Central California's only burn and Level 1 trauma center, the UCSF
Fresno Medical Education Program (residencies in Internal medicine, Family Practice, Surgery,
Pediatrics, Oral Surgery, OBGYN, and Psychiatry and Fellowships in Cardiology, Pulmonary Medicine
and Gastroenterology) and specialty programs such as general, orthopedic, gynecological, urological,
vascular, neurological, trauma, burn and ENT surgery. New innovations in cardiac, vascular and
neurological surgery are offered, including a hyperbaric chamber, robotic surgery such as CyberKnife, the
da Vinci Surgical System, laser transmyocardial revascularization, aortic and peripheral vascular stent
placement and prostate brachytherapy.
The infectious diseases consult team includes the ID attending physician, 1 to 3 residents and medical
students, an ID pharmacist and pharmacy resident and students. The general infectious diseases
consultative service at the CRMC sees a mix of both primary and tertiary care patients with a variety of
acute and chronic infectious disease problems, both in the intensive care units and on the general
medical/surgical wards. Approximately 60% of all consults are men and 40% are women. Our fellows
will see an average of 50 to 60 consultations per month covering patients across a wide range of services
including Medicine, HIV, Surgery, post transplant medicine, Neurosurgery, Ophthalmology, Ob-Gyn,
ENT, etc., as well as patients with varying degrees of severity of illness including intensive care patients.
Common presentations include: fever of unknown origin, bacteremia, infectious endocarditis, pneumonia,
empyema, meningitis, brain abscess, osteomyelitis, and urinary tract infections, to name a few. Emphasis
will be placed on generating a strong database including history, physical examination and laboratory
values including microbiology, antibiotic levels, and radiology. These data will be used to make initial
treatment plans and subsequent day-to-day treatment decisions.
CRMC has an antimicrobial management program to ensure the appropriate utilization of

antibiotic therapy. It will allow the fellows to acquire expertise and knowledge in the appropriate
utilization and management of antimicrobial agents in order to optimize patient care, minimize
toxicities, minimize the development of resistant nosocomial pathogens and practice cost
effective medicine. The “Antibiotic” pager receives calls for all restricted antimicrobials. This
pager is required to be on and available 24/7, staffed by the Infectious Diseases fellows on
clinical rotations at CRMC. It is expected that calls are returned as soon as possible where
practical. The pager will be supervised by the attending on the consult service. The fellow should
only carry the pager for no longer than 24 hours during a workday week and only one weekend a
month. This is worked out with the other fellows to coordinate with their days off of their
concurrent clinical rotation. There is no in-house call.
CRMC has a large full-service microbiology lab. The fellows will have frequent interaction with
the microbiology laboratory personnel through their clinical rotations and the clinical
microbiology rounds, which occur almost daily. All first year fellows spend several days during
the 2 week orientation learning the basics of the clinical microbiology laboratory. Subsequently
through the rest of the year, all fellows on clinical rotations have clinical microbiology rounds
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almost daily in the microbiology lab. These rounds include acquiring knowledge of all aspects of
microbiology including: basic culture techniques, other diagnostic techniques, and appropriate
cost-effective utilization of the microbiology lab.
Fellow responsibilities:
a. The fellow will develop the on-call schedule for him/herself and for the rotating residents
j. The fellow will take first call regarding antimicrobial approvals.

k. The fellow will be responsible for management of the patients
i. Assigning new consultations to students and residents rotating on the
consultation service.
ii. Determining the appropriate strategy for diagnosis and treatment of the patient.
iii. Providing a link between the inpatient consultation service and the outpatient
clinic in order to maintain continuity and prevent medical errors.
iv. Suggest appropriate times to sign off of patients
l. The fellow will supervise all the residents and medical students on the service.
i. Confirm the history and physical examination
ii. Help the student develop a plan for the management of the patient.
iii. Provide education and references to the students and residents
iv. Allow residents to go to clinic and conferences in a timely manner
i. Provide constructive feedback to the students and residents.
m. The fellow will present cases to the faculty physician.
n. The fellow will confer with the attending physician if difficulties are encountered in
running the service.
o. The fellow will be responsible for organizing and presenting cases at the weekly case
conferences.
p. The fellow will be responsible for interaction with the requesting services.
q. The fellow will take call two of the four weekends per block making certain to maintain 1
day off in every 7 averaged over 30 days.
r. The fellow on service should be available 24 hours per day by telephone except during
the weekend off or when being covered by a colleague.
Educational Objectives: An expanded version of the competencies is listed under Core

Competencies in Internal Medicine. Those listed here are specific to this rotation and pertain to
fellows at all levels of training.
Patient Care
1. Develop expertise in the epidemiology as well as in the clinical and microbiological diagnosis of
infectious diseases.
2. Read and interpret gram stains, AFB smears, fungal stains, and understand the general
principles of obtaining and interpreting microbiologic cultures and sensitivity reports.
3. Develop expertise in the management of infectious diseases.
4. Understand and utilize the principles of anti-infective management to maximize treatment
effectiveness while at the same time minimizing side effects, preventing emergence of resistant
pathogens, and promoting cost effectiveness.
Medical Knowledge
1. Discuss the major classes of antibiotics, their appropriate use, and important side effects.
2. Demonstrates knowledge of the application of microbiologic laboratory tests and their clinical
application
3. Discuss differential diagnoses for common infectious disease problems encountered in the large referral
hospital setting
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4. Demonstrates knowledge of the pharmacology, spectrum of activity, toxicities, limitations and drug
interactions of antimicrobials utilized in treating infections, including an understanding of the
mechanisms of resistance.
5. Discuss the epidemiology and pathophysiology of common infectious diseases encountered in the
referral hospital setting.
6. Discuss the issues surrounding indications for testing, appropriate laboratory tests, and pre- and post-
test counseling for communicable infectious diseases such as TB, HIV and other sexually transmitted
diseases.
7. Discuss the basic principles guiding hospital epidemiology and infection control in the referral hospital
setting.
Practice-Based Learning
1. Perform literature searches, read textbooks and journal articles pertinent to the infectious diseases’
cases that are being seen on service.
Interpersonal and Communication Skills – See Core Competencies
1. Examines personal attitudes toward sexuality, intravenous drug abuse, cultural differences,
communicable diseases and death.
2. Recognizes the importance of quality-of-life issues.
3. Demonstrates compassion and objectivity when dealing with patients who have a chronic and
potentially life-threatening illness.
4. Appreciates the importance of support from family members and others.
5. Awareness of community and cultural attitudes toward the illness and the need for confidentiality
Professionalism – See Core Competencies
System-Based Practice – See Core Competencies
1. Practice cost-effective health care and resource allocation that does not compromise quality of care.
2. Advocate for quality patient care and assist patients in dealing with system complexities.
3. Apply principles of infection control and hospital epidemiology to the inpatient units
Check all principle teaching methods used during this rotation:

[x ] Attending teaching rounds [ ] Interdisciplinary rounds
[x ] Patient management discussions [x ] Small group discussions
[x] Conferences specific to rotation [x ] Bedside clinical rounds
[ ] Individual instruction of procedures [x ] Review of diagnostic studies,
[x ] Other: Clinical Microbiology Rounds including radiology
Principal ancillary education materials used:

[ ] Reading lists [x ] Pathologic material
[x ] Radiologic studies [ ] Other noninvasive studies
[x ] Handouts on relevant topics [x ] Articles from the literature
[x ] Other: Small group discussion of [x ] Case studies
prepared cases
Methods used to evaluate the resident and the rotation:

[x ] Evaluation of fellow performance and professionalism
[x ] Evaluation of attending teaching skills and other attributes
[x ] Rotation assessment by fellow
[x ] Observation of fellow's clinical competency
[x ] Observation of fellow's leadership and teaching skills
[x ] Review of the fellow's history/physical exam, progress notes and documentation
of procedures in the chart
[x ] Fellow's attendance of rounds and conferences monitored
[ ] Other: ________________________
Conferences or Attending/Patient Care Rounds: (Journal club, division rounds, etc.)
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Fellows are expected to attend the following conferences while on this rotation. This is in addition to
attending/patient care rounds as outline above under fellow responsibilities.
Rev. 5/09
Name Location Day Time

ID Clinical Conference UCSF Building Tues 1200-1300
ID Didactic Lectures UCSF Building Wed 1200-1300
HIV Case Conference Cedar Campus Tues 1200-1300
ID Board Review UCSF Building Fridays 1200-1300
Journal Club UCSF Building 4th Friday 1200-1300
Microbiology Rounds CRMC Lab Wed 1000-1100
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Name of rotation: General ID Consultation Average Number of Months
Service Fellows at Hospital
Division: Infectious Diseases F1 F2 F3
Site(s): Fresno VA
3 4 Required
Course Director:, Shobha Sharma, D.O.
Elective
Duration of rotation: [x] one month

The fellowship rotation at the Veterans Affairs Central California Health Care System (VACCHCS)
facility will include both inpatient and outpatient experiences. The fellows will learn to work in the
unique system of health care that has been developed for veterans and participate in health care using a
mature integrated electronic records system that has been a model for other health care systems.
VACCHCS serves veterans throughout Central California. It has 53 acute care beds with 12 ICU -
telemetry beds and 60 geriatrics extended care unit beds. On Average 30-50 inpatient infectious disease
consultation are provided per month. The inpatient ID consultative service includes patients from a
number of services including Medicine, Surgery (general surgery, orthopedics, urology, etc), and
intensive care. Patients are seen with a variety of presentations including bacteremia, infectious
endocarditis, pneumonia, empyema, meningitis, brain abscess, osteomyelitis, and urinary tract infections.
Infectious diseases more commonly seen in the veteran population and especially those in the geriatric
unit will be emphasized.
While at the VACCHCS, the fellows will have an opportunity to participate in quality improvement
measures related to infection control issues such as wound infection, ventilator associated pneumonia and
methicillin resistant Staph aureus. In addition, efforts to improve outcomes in community acquired
pneumonia and antibiotic use will be part of the experience.
The Fresno VACCHCS has an active outpatient program, including an ambulatory infectious diseases
program that will provide experience for the fellows during the rotations at the medical center. The
ambulatory experience will include providing medical care to veterans with a variety of acute and chronic
infectious diseases, diabetic complications, and other immune-compromising settings.
There are on-site microbiology and pathology labs which process cultures and biopsy specimens. Fellows
will have the chance to interact closely with microbiology and pathology staff.
a) The fellow will perform all of the Infectious Diseases consultations requested.
b) The fellow will present cases to the faculty physician on clinical rounds
c) Interesting cases from the VA should be incorporated into the weekly case
conference.
d) The fellow will review all laboratory results and work with the attending physician to
appropriately act to provide patient care.
e) The fellow will take call two of the four weekends per block making certain to
maintain 1 day off in every 7 averaged over 30 days.

Competencies in Internal Medicine. Those listed here are specific to this rotation.
All objectives pertain to first and second year fellows (PGY-4,5). It is expected that the
achievement and mastery of these objectives will occur over multiple rotations.
Patient Care
76
pathogens, promoting cost effectiveness.
Medical Knowledge
application
hospital setting
diseases.
setting.
1. Perform literature searches, read textbooks and journal articles pertinent to the infectious disease cases
that are being seen on service.
Interpersonal and Communication Skills – See master list for these competencies.
Professionalism – See master list for these competencies.
System-Based Practice
1. Practice cost-effective health care and resource allocation that does not compromise
quality of care.
3. Apply principles of infection control and hospital epidemiology to the Fresno VA inpatient units

[x] Other: Optional Clinical Microbiology rounds including radiology
Check the principal ancillary education materials used:

[ ] Reading lists [ ] Pathologic material
[x] Radiologic studies [ ] Other noninvasive studies
77
[x] Handouts on relevant topics [x] Articles from the literature
[x] Other: Small group discussion of prepared [x] Case studies
cases

[ ] Other: ________________________

Rev 5//09

78
Name of rotation: Pediatric Infectious Diseases Consultation Service
Division: Infectious Diseases
Site(s): Children’s Hospital of Central California, Madera, CA
Course Directors: David Pugash, M.D. & James McCarty, M.D.
Duration of rotation: [x] one month Average Number of Months

Fellows at Hospital
F1 F2 F3
Required
1 Elective
The Children’s Hospital of Central California has 255 beds. On average 25-30 inpatient infectious disease
consultations are provided per month. The fellowship elective rotation at Children’s Hospital of Central
California will include both inpatient and outpatient experiences. The fellows will experience the practice
of the specialty of Pediatric Infectious Diseases in a medical center that serves both as a primary care
facility and as a referral center for the care of children.
The inpatient ID consultative service includes patients from a number of services including pediatric
medicine, cardiology, surgery (general surgery, orthopedics, urology, etc), intensive care, oncology and
neurologic services. Patients are seen with an array of acute and chronic infections. Infectious diseases
more commonly seen in the pediatric population and especially those related to immunologic and genetic
disorders will be emphasized. Educational experiences in dealing with viral illness and prevention of
infectious illnesses by vaccination will be prominent during this rotation.
The Pediatric Infectious Diseases rotation includes an active ambulatory pediatric infectious disease
experience for the fellows during their time at that medical center. The clinic experience will include
providing medical care to children with HIV disease and with a mixture of acute and chronic infectious
diseases such as coccidioidomycosis, osteomyelitis, infections in compromised pediatric hosts, and a
variety of viral illnesses.
f) The fellow will perform all of the Infectious Diseases consultations requested.
g) The fellow will present cases to the faculty physician on clinical rounds
h) Interesting cases from the Children’s Hospital should be incorporated into the weekly
case conference.
i) The fellow will review all laboratory results and work with the attending physician to

Patient Care
1. Develop knowledge in the epidemiology as well as in the clinical and microbiological diagnosis of
pediatric infectious diseases.
3. Develop knowledge in the management of pediatric infectious diseases.
79
4. Understand and utilize the principles of anti-infective management in pediatric patients to maximize
treatment effectiveness while at the same time minimizing side effects, preventing emergence of resistant
Medical Knowledge
application
3. Discuss differential diagnoses for common pediatric infectious disease problems encountered in the
large referral hospital setting
5. Discuss the epidemiology and pathophysiology of common pediatric infectious diseases encountered in
the referral hospital setting.
test counseling for communicable infectious diseases such as TB and HIV.
setting.
1. Perform literature searches, read textbooks and journal articles pertinent to the pediatric infectious
disease cases that are being seen on service.
quality of care.
3. Apply principles of infection control and hospital epidemiology to the Children’s Hospital inpatient
units

[x] Other: including radiology

cases

80
[ ] Other: ________________________

Rev: 5/09

HIV Case Conference Cedar Campus tues 1200-1300
81
Name of rotation: General Infectious Diseases Service
Course Director: Dee A. Lacy, MD, Ph.D.
Site(s): Kaiser Permanente Fresno Medical Center

Fellows at Hospital
F1 F2 F3
Required
1 Elective

Kaiser Permanente Fresno Medical Center has 189 beds. On Average 25-30 inpatient infectious disease
consultations are provided per month. The ID services at Fresno Kaiser Permanente Medical Center
includes a wide range of services with both inpatient and outpatient coverage. Inpatient consultative
service includes patients on Medicine, Surgery, Oncology, Neurology, Neurosurgery, OB/GYN, and ENT,
with patients demonstrating varying degrees of severity of illness including intensive care patients.
Common presentations include prolonged fever, bacteremia and sepsis, infectious endocarditis, pneumonia,
empyema, meningitis, brain abscess, osteomyelitis, urinary tract infections, and surgical site infections to
name a few.
The Infectious Disease Fellows will provide first contact for requested consultations and will be supervised
by Board Certified Infectious Disease faculty members who are experienced Kaiser medical staff
physicians. Emphasis will be placed on generating a strong database including history, physical
examination and laboratory values including microbiology, antibiotic levels, and radiology. These data
will be used to make initial treatment plans and subsequent day-to-day treatment decisions.
The Fellows will also have a rich ambulatory experience with an opportunity to see, again on a first contact
basis, a variety of infectious disease problems in a busy Infectious Diseases Clinic. The patients include
those with fungal infections (especially coccidioidomycosis), HIV infection, osteomyelitis, mycobacterial
infections, and chronic pulmonary infections.
The Fellows will have an opportunity to participate in a mix of quality improvement activities in the
Kaiser system, including infection control and epidemiology with monitoring of ventilator associated
pneumonia, as well as surgical site , blood stream and urinary tract infections. They will also participate
in antibiotic use and monitoring and the surveillance of daily microbiologic reports.
j) The fellow will perform all of the Infectious Diseases consultations requested.
k) The fellow will present cases to the faculty physician on clinical rounds
l) Interesting cases from the Kaiser Hospital should be incorporated into the weekly
case conference.
m) The fellow will review all laboratory results and work with the attending physician to

Patient Care
82
Medical Knowledge
application
hospital setting
diseases.
setting.
quality of care.
3. Apply principles of infection control and hospital epidemiology to the Kaiser Hospital inpatient units

[x] Other: including radiology

83
cases

[ ] Other: ________________________

Rev. 5/09

Journal Club UCSF Building 4h Friday 1200-1300
84
Name of rotation: Transplant Infectious Diseases Service
Site(s): University of California, San Francisco Moffitt Hospital
Course Director: Peter Chin-Hong, MD

Fellows at Hospital
F1 F2 F3
1 Required
Elective

The goal of this mandatory rotation is to provide the fellow with the skills necessary to understand the
unique infectious complications in transplant patients and to learn the appropriate evaluations required for
diagnosis and treatment of these infections. The fellows will join the ID consultative service at UCSF-
Moffett Hospital in San Francisco and participate by both seeing the transplant patients as primary
consultative contact and by supervising residents making primary contact. They will be supervised by the
Infectious Disease Specialist attending on the ID transplant service and will be monitored by the site
director. During the rotation they will not only learn the diagnostic and treatment skills required for
transplant patients, but also gain knowledge on the indications and approach to infection prophylaxis.
They will also learn how to assess the literature relative to infections in the transplant patients and be
prepared to discuss key articles.
a. The patients to be managed on the transplantation service include solid organ and bone
marrow transplants.
b. The fellow receives the calls for consultations and he/she will then evaluate the patient.
c. The patient will be presented to the transplant attending for teaching and review of the
plan of management.
d. The fellow will then be involved in the discussions with the primary service regarding the
final plan of action.
e. The fellows will participate in ID transplant rotation conferences
f. Interesting cases from the San Francisco Moffitt Hospital should be incorporated into the
weekly case conference.
g. The fellow will take call two of the four weekends per block making certain to maintain 1
day off in every 7 averaged over 30 days.

Patient Care
infectious diseases in immunosuppressed patients.
3. Develop expertise in the management of transplant infectious diseases.
85
pathogens, and promoting cost effectiveness.
Medical Knowledge
application in transplant patients.
3. Discuss differential diagnoses for transplant-related infectious disease problems encountered in
the large referral hospital setting
4. Demonstrates knowledge of the pharmacology, spectrum of activity, toxicities and limitations of
antimicrobials utilized in treating infections, including an understanding of the mechanisms of
resistance.
5. Understand adverse reactions and drug-to-drug interactions of commonly used post-transplant
immuosuppressive agents
6. Discuss the epidemiology and pathophysiology of common transplant-related infectious diseases
encountered in the referral hospital setting.
7. Discuss the basic principles guiding hospital epidemiology and infection control in the referral
hospital setting.
quality of care.
3. Apply principles of infection control and hospital epidemiology to the Fresno VA inpatient units

[x] Other: Optional rounds with oncology team including radiology

86
cases

[ ] Other: ________________________

We will need to get the conf schedule @ San Francisco Moffitt Hospital
87
Name of rotation: Special Services Clinic (HIV) Division: Infectious Diseases
Course Director: Simon Paul, MD Site(s): CRMC, Cedar Campus
Duration of rotation: [x ] longitudinal

The Special Care Clinic (HIV) at CRMC provides care to over 700 active patients who span the spectrum
of disease from acute to far advanced infection. In addition, 25-30 pediatric patients are cared for by the
HIV clinic. The clinic also provides primary care for 15-20 HIV-infected pregnant women every year.
There will be one clinic per week for the 24 months of the fellowship program in order to
provide continuity of care. Each fellow will be assigned a panel of 50 patients for their
longitudinal continuity care clinic. The clinic session will be 4 hours once per week. With
dieticians, pharmacists, social workers and nurses all working in the clinics, fellows are exposed
to an inter-disciplinary approach to patient care. In addition, the inpatient consult service
provides at least 3 HIV consults/week which allows the fellow to focus on the inpatient HIV-
related complications and to gain in depth knowledge of the acute care aspect of these
immunosupressed patients. .
d. The fellow will see and evaluate patients sent to Special Services clinic. This clinic will
serve as the continuity clinic. There may also be consultations performed.
e. The fellow will present all patients to the attending physician for teaching and
development of a plan of management.
f. The fellow is responsible for following up labs and phone calls for their patients. They
will also provide prescription refills for their patients.
g. The fellow is responsible for all paperwork for their patients including Ryan White
forms.
Educational objectives: An expanded version of the competencies is listed under Core

During this rotation the first year fellow (PGY-4) will:

Patient Care
1. Gather essential and accurate information about the patient.
2. Evaluate not fewer than 3 or greater than 6 patients per scheduled 1/2-day session when averaged over
the year.
4. Make informed diagnostic and therapeutic decisions based on patient information, current
scientific evidence, clinical judgment, and patient preference.
5. Carry out patient management plans, including appropriate follow up of all diagnostic tests
ordered.
6. Demonstrate ability to diagnose, evaluate and manage patients with broad ID problems, HIV and
Hepatitis C.
7. Accurately document information gathered from as well as given to each patient.
8. Provide effective health maintenance and anticipatory guidance.
Medical Knowledge
1. Discuss the diagnosis and treatment of common infectious disease and internal medicine problems,
including HIV and Hepatitis C, encountered in an outpatient clinic.
2. Demonstrate an investigatory and analytic approach to clinical problem solving and knowledge
acquisition.
3. Demonstrate knowledge of the basic evaluation, treatment and management of patients with HIV and
Hepatitis C.
88
1. Develop and maintain a willingness to learn from errors.
2. Locate, appraise and assimilate evidence from scientific studies related to their patients’ health
problems.
Interpersonal and Communication Skills
1. Demonstrate the ability to create and maintain a therapeutic relationship with patients and
families.
2. Communicate effectively and respectfully with the referring physician and other members of the health
care team.
1. Demonstrate commitment to the practice of cost-effective medical care.
2. Anticipate problems patients/care givers may face in negotiating the health care system and
advocate on the patient’s behalf.
3. Identify and work with other health care professionals and organizations that may assist in a
patient’s care.
4. Partner with members of the health-care team to manage complex patient issues.
During this rotation the second year fellows (PGY-5) will:

Patient Care
2. Evaluate not fewer than 4 or greater than 8 patients per scheduled 1/2-day session
when averaged over the year.
ordered.
6. Demonstrate ability to diagnose, evaluate and manage patients with HIV and Hepatitis C.
Medical Knowledge
1. Continue to expand expertise regarding infectious disease and internal medicine problems, including
HIV and Hepatitis C, encountered in an outpatient clinic.
acquisition.
3. Demonstrate knowledge of the basic evaluation, treatment and management of patients with HIV and
Hepatitis C.
problems.
3. Assess practice style; identify areas requiring improvement and implement changes accordingly.
1. Demonstrate the ability to create and maintain a therapeutic relationship with patients and families.
2. Communicate effectively and respectfully with other members of the health care team.
patient’s care.
4. Function as the coordinator of a health-care team to manage complex patient issues.

[ ] Attending teaching rounds [x ] Interdisciplinary rounds
89
[x ] Individual instruction of procedures [x ] Review of diagnostic studies,
[ ] Other: ________________________ including radiology

[x ] Reading lists [ ] Pathologic material
[ ] Other: ________________________ [x ] Case studies
Methods used to evaluate the fellow and the rotation:

[x ] Review of the fellow's history/physical exam, progress notes and documentation of
procedures in the chart
[x ] Other: Evaluation of interviewing skills and approach to psychosocial problems

Rev. 5/09

Board Review UCSF Building Fridays 1200-1300
90
General Clinic Organization, HIV
Scheduling:
General stuff:
--Clinic starts at 8:30 (first patient is scheduled at 8:15 and should be registered, vital signs done
by 8:30).
--after having their vital signs done, patients wait in the clinic waiting room. When you are ready
to see the patient, get them from the waiting room, introduce yourself if they do not already
know who you are, and take them to the exam room you will be using.
--If the patient is not in the waiting room they may be meeting with their case manager
somewhere. Unless you are very short of time, try not to interrupt their meeting but wait until the
case manager finishes and then go get the patient from the waiting room. The case managers try
to work around the provider’s schedule, so this doesn’t happen often.
--when you are done seeing the patient, send them back to the waiting room. That’s where their
case manager will look for them and that’s where the nursing staff will look for them if they need
any vaccines/injections etc.
--It’s fine to use the computers in the exam room, but make sure to close windows etc. if patients
can view the screen so as to protect other patient’s confidentiality. If you are using the computer
in the exam room be very careful about leaving patients alone in the room when you are not there
(i.e. don’t). You can click on the encentuate icon in the lower right corner of the toolbar to close
all windows and lock the computer if you need to.
Scheduling:
--New patients and your own patients will be added to your schedule without contacting you if
there is an available appointment.
--Case managers will check with you first prior to adding on any: same-day add-on
appointments, overbooked patients, or to have you see another provider’s patient.
--If you do not have an appointment slot available, case managers will contact you to get your
OK for your patient to see another provider (vs. waiting to be seen by you if that’s a reasonable
alternative).
--Canceling clinics/vacation dates: please give six weeks notice to cancel a clinic date. If you
need to cancel a clinic with less than six weeks notice then provide an alternate clinic session for
the patients to be moved to. Email all schedule change requests to Karla
(kvilla@communitymedical.org) and me as well.
Paper flow:
--We do not use the med sheet in the medical paper chart. Instead we print out the active
medications at each appointment, the provider signs off on that list, and the front desk staff adds
that current med list to the paper chart.
--Labtracker IS NOT the official medical record, so anything that needs to be in the medical
record has to be printed out and sent off for filing….
--return the billing sheet, order sheet (either orders on the progress note or the separate sheet with
instructions), labsheet, and prescriptions to the front desk staff. They will give everything to the
patient when they give them their next appointment date.
Labtracker:
(Detailed instructions regarding how to do these things are attached below)
--Prescriptions: ALL prescriptions need to be entered in labtracker. This includes rx’s such as
narcotics that have to be written by hand
--clinic visit notes: you can type these in labtracker OR write your note by hand and enter a 2-3
sentence summary in labtracker so that covering providers/case managers know what’s going on
--health maintenance: this screen also has to be updated. Case managers also help update these
fields, but ultimately it’s the primary provider’s responsibility to document that health
maintenance has been completed. Our performance reporting to the federal gov’t is extracted
91
automatically from the health maintenance screen so it’s critical this be updated: writing that
something was done in your progress note isn’t enough.
Health Maintenance:
As we are the patient’s primary care provider, all recommended health maintenance for all
conditions/age/sex that’s indicated should of course be done. Specific to HIV, the things we care
about are:
--Baseline labs get done (including hep serologies, lipids, repeat HIV ab test if not in chart, u/a,
gc/Chlamydia, toxo IgG, cmv ab, cd4/hiv vl)
--PAP Smears: at least yearly
--PPD or quantiferon yearly
--VDRL q 6 months
--Adherence counseling
--assessment of drug use, risk assessment/prevention/safe sex
If you want to know if your patient is due for anything, click on the “decision support” box that
is on the main patient screen when you first select your patient from the active patient list. (note:
check with the patient before ordering anything. Sometimes it will say a ppd is due, but actually
they have had a +PPD in the past and they really just need questioning re if they have
symptoms/signs of active tb as their particular yearly tb screening)
The specific health maintenance outcomes that we monitor at present and our minimum
acceptable levels are:
PPD: at least 40% of active patients should be up to date (last ppd within 12 mo)
PAP: at least 40% of active patients should be up to date (last pap within 12 mo)
RPR: at least 50% of active patients should be up to date (last vdrl within 12 mo)
Conferences:
Each Tuesday at noon we have the clinic case conference. The first Tuesday of the month we go
over patients in the MediCal Waiver/CMP intensive case management program. The other
Tuesdays we go over the previous week’s patients that came to clinic. Each week we also try and
go over new patients that will be coming in the next week, and any inpatients on the HIV service.
The primary purpose of this conference is to coordinate care between the various providers, case
managers, and clinic staff.
The current format is for the casemanager to present first, then the physician or psychiatrist. It’s
helpful for people to know a few basic things about where you patient is at clinically, where they
are going and any new/unusual issues that came up. For example: “has a low cd4 count but is
planning to begin arv’s at their next visit. They were hospt for pcp but currently they feel fine…”
LabTracker Orientation:
Entering Medications:
1. Find patient in patient list, select patient
2. click on “medication” tab, med list should appear (note you can select “all meds” or “active
meds” and various other options from the combo box near the top of the med list)
3. to add a new medication click on “new med”
3a. search for the med in the search box, click on the name once it appears
92
3b. enter a dose in the first box (has to include a number)
3c. select a dosing interval (i.e “bid”) in the next box
3d. click on done
Reactivating an inactive med:

Sometimes when you go to add a new medication you will get a “patient already has this
medication” box. If you don’t see the medication on their list, probably you are looking at their
“active med” list, and you need to change to “all meds” list.
Once you are at the “all meds” list, click on the square box under the heading “click for more
date”. A new screen for just that medication will appear. Enter a new start date, dose, interval,
then click done…
Inactivating a medication:
Just enter a date in the “end date” window for that medication. You can enter a reason if you feel
like it in the next box over…
Reason for Drug:

For antiretroviral meds that you enter, click on the box in the first column under “reason for
drug” and select “treat” for antiretroviral meds and “prophylaxis” for oi prophylaxis meds. This
helps us report what percent of our patients are on appropriate medications, so even though it
may seem obvious from the drug name that the patient is on antiretrovirals this box is still
important…
Health Maintenance:
This section is kind of a pain, but here are some tips:
If a test already has info recorded (i.e. a ppd was done 16 months ago), just click on the box in
the “click for more dates” column and go with whatever it asks for in the next window.
If no info has ever been entered for that test, if you click on that box, you will get a message
about “adding a new test”. That doesn’t mean adding a new test to labtracker, it just means that
you are adding new test info for that patient! So click on the “new test/imm” box near the top left
and select a test that is already on the list in the window that will appear. Do not click on the
“new test” option at that point as that option is for adding a completely new test that labtracker
has never heard of before...
Visits:
Often by the time you get around to writing your note, the front desk staff will have already
entered the visit date and possibly visit type/provider info. If not, here’s what needs to be
entered:
Go to the “Visits” tab (top right area when you have selected a patient),
Click on “new visit date” and enter a date
Click on “visit type” and select “routine clinic visit”
Select your name under “provider”
Enter a time, length of visit (ballpark), and select “attended”
If you asked the patient about adherence, click on the “y” box over on the left under adherence
and fill in that pop up window.
Once you have done the above, you can either write a quick summary in the “visit comments”
box (2-3 sentences) and initial that (and write a regular progress note by hand), OR, click on
“edit soap” and write your note in labtracker (easier than it sounds once you figure out how to
enter them). If you write your note in labtracker you need to print it out and sign it to go off to
the paper chart.
93
LabTracker Orientation:
Entering Medications:
1. Find patient in patient list, select patient
2. click on “medication” tab, med list should appear (note you can select “all meds” or “active
meds” and various other options from the combo box near the top of the med list)
3. to add a new medication click on “new med”
3a. search for the med in the search box, click on the name once it appears
3b. enter a dose in the first box (has to include a number)
3c. select a dosing interval (i.e “bid”) in the next box
3d. click on done
Reactivating an inactive med:

Sometimes when you go to add a new medication you will get a “patient already has this
medication” box. If you don’t see the medication on their list, probably you are looking at their
“active med” list, and you need to change to “all meds” list.
Once you are at the “all meds” list, click on the square box under the heading “click for more
date”. A new screen for just that medication will appear. Enter a new start date, dose, interval,
then click done…
Inactivating a medication:
Just enter a date in the “end date” window for that medication. You can enter a reason if you feel
like it in the next box over…
Reason for Drug:

For antiretroviral meds that you enter, click on the box in the first column under “reason for
drug” and select “treat” for antiretroviral meds and “prophylaxis” for oi prophylaxis meds. This
helps us report what percent of our patients are on appropriate medications, so even though it
may seem obvious from the drug name that the patient is on antiretrovirals this box is still
important…
Health Maintenance:
This section is kind of a pain, but here are some tips:
If a test already has info recorded (i.e. a ppd was done 16 months ago), just click on the box in
the “click for more dates” column and go with whatever it asks for in the next window.
If no info has ever been entered for that test, if you click on that box, you will get a message
about “adding a new test”. That doesn’t mean adding a new test to labtracker, it just means that
you are adding new test info for that patient! So click on the “new test/imm” box near the top left
and select a test that is already on the list in the window that will appear. Do not click on the
“new test” option at that point as that option is for adding a completely new test that labtracker
has never heard of before...
Visits:
Often by the time you get around to writing your note, the front desk staff will have already
entered the visit date and possibly visit type/provider info. If not, here’s what needs to be
entered:
Go to the “Visits” tab (top right area when you have selected a patient),
Click on “new visit date” and enter a date
94
Click on “visit type” and select “routine clinic visit”
Select your name under “provider”
Enter a time, length of visit (ballpark), and select “attended”
If you asked the patient about adherence, click on the “y” box over on the left under adherence
and fill in that pop up window.
Once you have done the above, you can either write a quick summary in the “visit comments”
box (2-3 sentences) and initial that (and write a regular progress note by hand), OR, click on
“edit soap” and write your note in labtracker (easier than it sounds once you figure out how to
enter them). If you write your note in labtracker you need to print it out and sign it to go off to
the paper chart.
95
Name of rotation: Infectious Diseases Outpatient Clinic
Course Director: Robert Libke, MD

Site(s): CRMC, Cedar Campus
Duration of rotation: [x ] longitudinal

The weekly Infectious Diseases Clinic provides both follow up consultations to patient seen in
the inpatient setting and new patient consultations. Approximately 60% of all consults are men
and 40% are women. Patients have a wide range of infectious diseases, with emphasis on long-
term care for patients with coccidioidomycosis, because of its high endemicity in the California
Central Valley. We hope for the fellows to achieve an appreciation for the natural history of
infectious diseases and familiarity with common problems encountered in the outpatient practice
of infectious diseases.
a) The fellow will see and evaluate patients referred to the clinic for consultation.
b) The fellow will present the patients to the faculty physician to develop the plan for
management.
c) The fellow will review the laboratory and radiology results returned to the clinic that are not
on the EMR and address those results that require immediate action while forwarding others
to the appropriate provider.
d) The fellow will be responsible for prescription refills for their own patients and if there is no
assigned attending physician. The one exception is pain medications and other controlled
substances.
e) The fellow will be primarily responsible for answering phone consultations by outside
physicians and discuss them with the attending physician as required.
Educational objectives: An expanded version of the competencies is listed under Core

During this rotation the first year fellow (PGY-4) will:

Patient Care
2. Evaluate not fewer than 3 or greater than 6 patients per scheduled 1/2-day session when averaged over
the year.
ordered.
6. Demonstrate ability to diagnose, evaluate and manage patients with broad ID problems emphasis on
long-term care for patients with coccidioidomycosis.
Medical Knowledge
1. Discuss the diagnosis and treatment of common infectious disease and internal medicine problems
encountered in an ID outpatient clinic.
acquisition.
3. Demonstrate knowledge of the basic evaluation, treatment and management of patients with
coccidioidomycosis.
96
problems.
1. Demonstrate the ability to create and maintain a therapeutic relationship with patients and
families.
2. Communicate effectively and respectfully with the referring physician and other members of the health
care team.
patient’s care.
4. Partner with members of the health-care team to manage complex patient issues.
During this rotation the second year fellows (PGY-5) will:

Patient Care
2. Evaluate not fewer than 4 or greater than 8 patients per scheduled 1/2-day session
when averaged over the year.
ordered.
6. Demonstrate ability to diagnose, evaluate and affectively manage patients with coccidioidomycosis.
Medical Knowledge
1. Continue to expand expertise regarding infectious disease and internal medicine problems, encountered
in an outpatient clinic.
acquisition.
3. Demonstrate knowledge of the basic evaluation, treatment and management of patients with
coccidioidomycosis.
problems.
3. Assess practice style; identify areas requiring improvement and implement changes accordingly.
1. Demonstrate the ability to create and maintain a therapeutic relationship with patients and families.
2. Communicate effectively and respectfully with other members of the health care team.
patient’s care.
4. Function as the coordinator of a health-care team to manage complex patient issues.

[ ] Attending teaching rounds [ ] Interdisciplinary rounds
[x ] Patient management discussions [ ] Small group discussions
97
[x ] Individual instruction of procedures [x ] Review of diagnostic studies,
[ ] Other: ________________________ including radiology

[ ] Other: ________________________ [x ] Case studies
Methods used to evaluate the fellow and the rotation:

[x ] Review of the fellow's history/physical exam, progress notes and documentation of
procedures in the chart
[x ] Other: Evaluation of interviewing skills and approach to psychosocial problems

Rev: 5/09

Board Review UCSF Building Fridays 1200-1300
98
Research
In the Second year of the fellowship, the majority of the time will be spent in Research
Fellows must demonstrate evidence of recent research productivity in the scholarship of

discovery, as evidenced by peer-reviewed funding or by publication of original research in a
peer-reviewed journal, or the scholarship of dissemination, as evidenced by review articles or
chapters in textbooks, or application as evidenced by the publication or presentation of case
reports, abstracts, or clinical series at national or international specialty society meetings. The
Review Committee defines acceptable Fellow publications as:
1. Publication of original research

2. Review article
3. Editorial in a peer-reviewed (indexed) journal or a funded
peer-reviewed grant
4. Book chapter in a medical textbook
5. Abstracts published
6. Abstracts presented at national specialty meeting.
As research director for the internal medicine residency program, Dr. Simon Paul has been very
involved in teaching research methods. In the year 2008, we began an interactive research design
workshop for fellows in specialty training; this course is required for infectious disease fellows.
This research course assists fellows in developing their research projects by providing training in
research design, data analysis and statistics and also by providing exposure to basic science
methodologies. The bi-monthly course also provides a forum for fellows in training to present
their ongoing research projects.
Our program has developed a broad range of research interests that will provide a foundation for
fellows in infectious disease to gain research training. Dr. Simon Paul is the Principal
Investigator of an NIHfunded study using exercise testing and isotopic tracers to study the
effects of antiretroviral therapy on glucose and lactate metabolism. He plans to go forward with
this methodology in the future to study more broadly the effects of infections on metabolism and
mitochondrial function. Dr. Paul has also served as the local PI for an NIH funded multi-center
study validating in Spanish an adolescent risk for HIV infection survey. In addition Dr. Paul has
received funding to establish an internet based patient education center in the HIV clinic and is
currently mentoring internal medicine residents studying the effectiveness of this approach.
Our HIV program also served as a site for the CPCRA SMART study of structured treatment
interruptions for antiretroviral therapy and has participated in several industry-funded clinical
trials, thus providing opportunities for fellows training in infectious disease to participate in
multi-center clinical trials.
Fungal meningitis is also an area of active investigation. Dr. Paul has also collaborated with Dr.
Roger Mortimer in a study of risk factors for cryptococcal meningitis in HIV infected patients.
Dr. Robert Libke is studying the epidemiology of coccidioidal meningitis and Dr. Tanya
Warwick of neurology is studying the use of transcranial doppler for prediction of complications
of fungal meningitis.
Dr Muhammed Sheikh, Chief of the Gastroenterology Fellowship, is actively involved in

multiple studies of different treatment modalities in HCV. Fellows are expected to attend his
99
weekly HCV clinic and participate in evaluating and initiating HCV treatment as outlined in
these studies.
Participating Institutions:
1.Community Regional Medical Center: (CRMC)
Site Director, Robert Libke, M.D.
2823 Fresno Street – Main Campus
See page 57 for Specific Rotation Information
Cedar Campus
Site Director, HIV, Simon Paul, M.D.
445 South Cedar - Clinic Campus
2. Veterans Affairs Central California Health Care System (VACCHCS)

Site Director, Shobha Sharma, D.O.
2615 E. Clinton - 2nd Campus 1.5 miles
3. Kaiser Permanente Fresno Medical Center

Site Director, Dee Lacy, M.D.
7300 N. Fresno - 1 month, 1st year 6 miles
4. Children’s Hospital of Central California

Site Director, James McCarty, M.D.
1 month, 1st year
9300 Valley Children’s Blvd. Madera 10 miles
5. . University of California, San Francisco Moffitt Hospital 1 month 2nd year

Site Director, Peter Chinn Hong, M.D.
505 Parnassus SF 180 Miles
100
Faculty requirements:
In addition to the program director, each program must have two key clinical faculty. Key
clinical faculty are attending physicians who dedicate, on average, 10 hours per week throughout
the year to the training program.
Qualifications: The key faculty must:

1. be active clinicians with broad knowledge of experience with and commitment to
Internal medicine/Infectious Diseases as a discipline, and
2. have current certification in Infectious Diseases or possess qualifications judged
by the Review Committee to be acceptable.
In addition to the responsibilities of all individual faculty, the key clinical faculty with the
Program director, are responsible for the planning implementation, monitoring and evaluation of
the fellows’ clinical and research training.
Some members of the faculty should also demonstrate scholarship by one or more of the
following:
1. peer-reviewed funding
2. publication of original research or review articles in peer reviewed journals or
chapters in textbooks.
3. publication or presentation of case reports or clinical series at local, regional, or
national professional and scientific society meetings; or,
4. participate in national committees or educational organizations.
5. faculty should encourage and support fellows in scholarly activities.
At each participating site, there must be a sufficient number of faculty with documented
qualifications to instruct and supervise all fellows at that location. They must:
1. devote sufficient time to the educational program to fulfill their supervisory and
Teaching responsibilities and to demonstrate strong interest in the education
2. administer and maintain an educational environment conductive to educating the
Fellows
The nonphysician faculty must have appropriate qualifications in their field and hold appropriate
institutional appointments.
The faculty must establish and maintain an environment of inquiry and scholarship with an
active research component.
The faculty must regularly participate in organized clinical discussions, rounds, journal clubs and
conferences.
101
Facilities and Resources
The institution and the program must jointly ensure the availability of adequate resources
for fellow education, as defined in the specialty program requirements.
Fellows must have clinical experiences in efficient, effective ambulatory and inpatient care
settings.
There must be space and equipment for the educational program, including meeting rooms,
classrooms, examination rooms, computers, visual and other educational aids, and work/study
space.
Fellows must have lounge and food facilities during assigned duty hours.
Medical Records:
Clinical records that document both inpatient and ambulatory care must be readily
available at all times.
Patient Population:
The inpatient and ambulatory care population must provide experience with patients
whose illnesses are encompassed by, and help to define, the fellowship.
There must be patients of both sexes with a broad age range, including geriatric patients.
A sufficient number of patients must be available to ensure adequate inpatient and

ambulatory experience for each subspecialty fellow.
All deaths of patients who received care by fellows must be reviewed.
Support Services:
Administrative support must include adequate secretarial and administrative staff and
technology to support the program director.
Inpatient clinical support services must be available on a 24 hour basis to meet

Reasonable and expected demands, including intravenous services, phlebotomy
Services, messenger/transporter services and laboratory and radiologic information
Retrieval systems that allow prompt access to results.
Medical Information Access:

Fellows must have ready access to specialty-specific and other appropriate reference
material in print or electronic format. Electronic medical literature databases with
search capabilities should be available.
102
39. malaria
40. parasites
41. parvovirus
42. rabies
43. SARS
44. Septic Shock
45. Small Pox
46. Zoonosis
20
Curriculum for Fellowship Training in Clinical Infectious Diseases
UCSF-Fresno MEP
Educational Purpose
Infectious Diseases remain a major cause of morbidity and mortality. In addition, new
organisms have been emerging, older pathogens have been re-emerging and the specter of
bioterrorism requires a broad range of knowledge for physicians practicing clinical infectious
diseases. The purpose of the fellowship program at UCSF-Fresno is to broadly train our fellows
to treat and manage patients with infectious diseases in a changing world. The fellows serve as
consultants in the hospital as well as in the outpatient setting. For patients with HIV, hepatitis C
and other chronic infections, the fellows follow the patients longitudinally and commonly serve
as the primary care providers. Upon completion of training the fellows are required to be
competent specialists in our field. Demonstration of competency will be evaluated by using the
following competencies.
Core Competencies
1. Patient Care
a. Clinical skills needed to achieve competency include: ability to obtain an accurate
history focusing on the issues of particular interest to infectious diseases and
perform a complete and accurate physical exam. The fellow must also
demonstrate the ability to accurately review medical records.
b. Patient management skills are necessary to achieve competency. The skills to be
evaluated are: the ability to synthesize patient data and the literature to come to an
accurate differential diagnosis, demonstration of sound clinical judgment,
appropriately use antimicrobial agents and other approaches to therapy, and
incorporation of the patient preferences into the final plan.
2. Medical Knowledge
a. The fellow must demonstrate a mastery of the literature in Infectious Diseases.
b. Understanding etiologic agents and the pathogenesis of diseases is a required skill
to achieve competency.
c. The appropriate use of antimicrobial agents is an important skill that must be
mastered.
d. Access and critically evaluate the medical literature. This will demonstrate
evidence of independent scholarship.
e. Apply an open minded and analytical approach to acquiring new knowledge.
23
CORE CURRICULUM
CORE COMPETENCIES
3. Practice-Based Learning and Teaching

a. The fellow must be able to critique his/her own performance.
b. The fellow must be receptive to constructive criticism.
c. The fellow should learn from his/her own errors and errors of colleagues.
d. Actively educate colleagues, patients and self with a variety of sources of
information.
e. Perform research or other creative activity that will enhance learning and
teaching.
4. Interpersonal and Communication Skills

a. Develop a good working relationship and rapport and communicate clearly to
other physicians, other healthcare workers and patients.
b. Present cases in a concise and focused manner. Understand what information is
required to make an accurate and complete presentation (pertinent positives and
negatives).
c. Maintain comprehensive, timely and legible medical records.
d. Develop an approach to appropriately and accurately perform patient handoffs.
5. Professionalism
a. The fellow is expected to demonstrate respect, compassion and integrity when
working with patients and families.
b. The fellow is expected to demonstrate respect and integrity with fellow physicians
and healthcare providers.
c. The fellow is required to adhere to HIPAA standards for patient confidentiality.
d. The fellow is expected to adhere to principles of scientific and academic integrity.
e. The fellow should demonstrate the ability to recognize and identify deficiencies in
peer performance in a constructive manner.
f. The fellow must take responsibility for providing quality patient care.
g. The fellow must acknowledge mistakes without being defensive.
6. System-Based Practice
a. Be able to work at all medical facilities understanding the systems available for
patient care.
b. Identify the infectious diseases that are reportable to state and county health
departments.
c. Work within regional and national medical systems to deliver optimal medical
care.
d. Participate in quality improvement activities to optimize patient care.
e. Maintain credentials to be an active member of the medical staff.
f. If performing clinical research, maintain certification to achieve the expected
completion of the clinical projects.
g. Appropriate use of on-line resources to access information.
24
CORE CURRICULUM
Teaching Methods
The primary method of teaching is at the patient’s bedside. The fellow evaluates the
patient and the faculty member supervises and helps direct the clinical practice. A basic science
series, journal club, case conference, and core curriculum lectures provide didactic teaching.
The fellows participate in these conferences by providing some of the teaching through their
reading and evaluation of the literature. Self-directed learning by reading textbooks and current
literature is an expectation.
Goals and Objectives

1. The fellow must be able to evaluate a patient with an infectious disease and determine
the diagnosis and a plan for management.
2. The fellow must be able to effectively manage patients with chronic infectious
diseases such as HIV infection and hepatitis C infection.
3. The fellow must understand the principles and practice of healthcare epidemiology
and infection control.
4. The fellow must have physical access and be able to effectively use the Clinical
Microbiology Laboratory, other pathology laboratories and radiology and understand
the results provided.
5. The fellow must understand the correct use of antimicrobial drugs and the utility of
antimicrobial formularies. The fellow will interact with the pharmacy and other
healthcare providers in order to optimally utilize these important drugs as part of the
Antimicrobial Stewardship Program.
6. The fellow must be able to critically interpret the medical literature and research data.
List of Rotations
x Inpatient Consultation Service at Fresno Community Regional Medical Center
x Inpatient Consultation Service at the Fresno VA Hospital
x Outpatient ID Clinic at Community Regional Medical Centers, Cedar campus
x Outpatient (Continuity) Clinic at Special services Clinic (HIV) Community Regional
Medical Centers, Cedar campus
x Infectious Diseases Outpatient Clinic at the Fresno VA Hospital
x Clinical Microbiology Rotation at Community Regional Medical Centers, Infection
Control at Community Regional Medical Centers
x Research
x Inpatient Transplant Infectious Diseases Services at UCSF Campus
x Inpatient Consultation Service, Kaiser Hospital, Fresno (Elective)
x Inpatient Consultation Service, Children’s Hospital, Fresno (Elective)
25
CORE CURRICULUM
VI. Responsibilities of the Fellow

1. The fellow will be physically present at the appropriate site for the rotation.
The fellow will be provided 2 weekends free from clinical service while on the 4-week
consultation service block so that there is one day off in every seven averaged over 30
days. The fellow will also work no more than 80 hours in a week and there will be a
minimum of 10 hours off between shifts The fellow must inform the program director
regarding any schedule change.
2. Inpatient Consultation Service at Fresno Community Regional Medical Center

a. The fellow will develop the on-call schedule for self and the rotating residents
b. The fellow will take first call regarding antimicrobial approvals.

c. The fellow will be responsible for management of the patients
i. Assigning new consultations to students and residents rotating on the
consultation service.
ii. Determining the appropriate strategy for diagnosis and treatment of the
patient.
iii. Providing a link between the inpatient consultation service and the
outpatient clinic in order to maintain continuity and prevent medical
errors.
iv. Suggest appropriate times to sign off of patients
d. The fellow will supervise the residents and medical students on the service.
i. Confirm the history and physical examination
ii. Help the student develop a plan for the management of the patient.
iii. Provide education and references to the students and residents
iv. Allow residents to go to clinic and conferences in a timely manner
v. Provide constructive feedback to the students and residents.
e. The fellow will present cases to the faculty physician.
f. The fellow will confer with the attending physician if difficulties are encountered
in running the service.
g. The fellow will be responsible for organizing and presenting cases at the weekly
case conferences.
h. The fellow will be responsible for interaction with the requesting services.
i. The fellow on service should be available 24 hours per day by telephone except
during the weekend off or when being covered by a colleague.
3 Inpatient Consultation Service at the Fresno VA Hospital
b. The fellow will perform all of the Infectious Diseases consultations requested.
c. The fellow will present cases to the faculty physician on clinical rounds
26
CORE CURRICULUM
RESPONSIBILITIES OF FELLOW
d. Interesting cases from the VA should be incorporated into the weekly case
conferences.
e. The fellow will review all laboratory results and work with the attending
physician to appropriately act to provide patient care.
f. The fellow will take call 2 of the 4 weekends per block making certain to
maintain 1 day off in every 7 averaged over 30 days.
4. ID Outpatient Clinic at Community Regional Medical Centers, Cedar campus

a. The fellow will see and evaluate patients referred to the clinic for consultation.
b. The fellow will present the patients to the faculty physician to develop the plan
for management.
c. The fellow will review the laboratory and radiology results returned to the clinic
that are not on the EMR and address those results that require immediate action
while forwarding others to the appropriate provider.
d. The fellow will be responsible for prescription refills for their own patients and if
there is no assigned attending physician. The one exception is pain medications
and other controlled substances.
e. The fellow will be primarily responsible for answering phone consultations by
outside physicians and discuss them with the attending physician as required.
5. Special Services Clinic (HIV) Community Regional Medical Centers, Cedar campus
There will be one clinic per week for the 24 months of the fellowship program in
order to provide continuity of care.
a. The fellow will see and evaluate patients sent to Special Services Clinic. This
clinic will serve as the continuity clinic. There may also be consultations
performed.
b. The fellow will present all patients to the attending physician for teaching and
development of a plan of management.
c. The fellow is responsible for following up labs and phone calls for their patients.
They will also provide prescription refills for their patients.
d. The fellow is responsible for all paperwork for their patients including Ryan
White forms.
6. Outpatient Clinic at the VA

a. The fellow will attend one outpatient clinic at the VA Hospital during the months
that they serve on the inpatient rotation. .
b. The patients will be seen and evaluated by the fellow who will then present the
case to an Attending physician to review the plan of management.
c. The fellow is responsible for following labs, radiology and paperwork related to
their patients.
d. Transplantation Service at UCSF Campus
27
CORE CURRICULUM
RESPONSIBILITIES OF FELLOW
e. The patients to be managed on the transplantation service include solid organ

transplants (kidney, liver, lung and heart) and bone marrow (stem cell)
transplants.
f. The fellow receives the calls for consultations and he/she will then evaluate the
patient.
g. The patient will be presented to the transplant attending for teaching and review
of the plan of management.
h. The fellow will then be involved in the discussions with the primary service
regarding the final plan of action.
7. Clinical Microbiology Laboratory

a. This rotation occurs for a total of one month during the first year of the
fellowship.
b. The fellow will report to a designated educator (Director or supervising
technologist) who is responsible for their experience.
c. The fellow will rotate to the different benches in the microbiology lab learning the
methods used and how to interpret these tests.
d. They will learn to read gram stains as part of the bacteriology. They will rotate
through mycology, virology, molecular diagnostics and mycobacteriology.
8. Infection Control
a. Due to time constraints it is often difficult for the fellow to spend much time at
CRMC in Infection Control. Therefore, all fellows are sent to the CDC/SHEA
Infection Control training course.
b. At CRMC the fellow on the consultation service is expected to help with
tuberculosis management by evaluating patients regarding necessity for isolation.
c. The fellow on the consultation service is responsible for addressing bloodborne
pathogen exposures on off-hours (5:00 PM through 7:00 AM).
VII. Responsibilities of the Faculty
1. The faculty is assigned to the Inpatient Consultation Service in 4-week blocks. Some
of the faculty are also assigned to one Infectious Diseases Clinic at CRMC.
Responsibility as the teaching attending at CRMC-HIV clinic is shared by faculty
assigned to Special Services Clinic.
2. The faculty member is expected to be present for rounds on the consultation service
and in the clinic to staff the patients.
3. On the consultation service the faculty member is expected to perform teaching
rounds daily.
4. In the clinic the faculty member is expected to see and evaluate all of the fellows
patients and participate in the development of a plan of action (Please see the Graded
Responsibility Document).
5. The faculty member is expected to provide an environment conducive to learning.
6. The faculty member is expected to respond to questions appropriately.
28
CORE CURRICULUM
7. The faculty member is expected to participate in weekly conferences such as journal

club, case conference, and core curriculum lectures.
8. The faculty member must provide goals and objectives at the beginning of the
rotation and verbal feedback to the fellow at the end of each rotation.
9. The faculty member must provide written evaluations at the end of each rotation for
the consultation service and quarterly evaluations for the clinic rotations using E-
value.
VIII. Role of the Program Director
1. The program director is responsible for organizing the curriculum..
2. The program director is responsible for the schedules of the fellows

guaranteeing adherence to all work hour rules.
3. The program director is responsible for providing an environment conducive to

learning.
4. The program director is responsible for reviewing all evaluations and meeting with
the fellow quarterly to review their progress.
5. The program director is responsible for the final evaluation and determining whether
the fellow has met the criteria for advancement and are competent to practice
Infectious Diseases and qualified to sit for the board examination.
IX. Contents of The Infectious Diseases Rotations (Goals and Objectives)
A. CRMC and VA Inpatient Consultation Service and

General Infectious Diseases Curriculum
General
a. Learn how to obtain relevant information for the solution of problems presented by infectious diseases
b. Learn to do a directed history and physical examination

c. Learn to collect relevant laboratory data
d. Evaluate results of microbiological data including susceptibility testing
e. Assess the risks and benefits of relevant diagnostic procedures
2. Understand the rationale for selection and use of antimicrobials on the CRMC
hospital formulary
i. Select antibiotics and usual dosing regimens based on the hospital
formulary
ii. Learn how to interpret the antibiogram in the selection of empiric and
directed antimicrobial therapy.
29
CORE CURRICULUM
CONSULTATION SERVICE
iii. Participate in the discussions of antibiotic pharmacology on consultation

rounds, in case conferences, and in lectures provided by the Infectious
Diseases pharmacy specialist
iv. Participate in the Antibiotic Subcommittee Meetings
3. Understand the role of the consultant, including the importance of

communication and clarity of recommendations
4. Master the physical diagnostic skills necessary to be an effective Infectious

Diseases physician
B. Understand Mechanisms of Action and Resistance Mechanisms of

Anti-Infectives
1. Understand the Mechanisms of Action and Resistance of Anti-Infective Agents

a. Antimicrobial dosing
b. Principles of pharmacokinetics and pharmacodynamics
c. Drug-drug interactions
d. The role of bactericidal vs. bacteriostatic agents
e. Monitoring of drug concentrations
2. Antivirals (other than antiretrovirals)

¾ Amantadine and Rimantadine
Understand the limited spectrum of activity and the limited time
window for use
Understand the mechanism of action, resistance and toxicity
¾ Oseltamivir and Zanamivir
Understand the spectrum of activity and the limited time window
for use
Understand the mechanism of action, resistance and toxicity
¾ Acyclovir, Valacyclovir; Penciclovir, Famciclovir, Ganciclovir and
Valganciclovir
Understand the relationship among this class of antivirals in
relationship to their structure and function, resistance mechanisms,
and toxicities
¾ Foscarnet
Understand its place in the sequence of treatment of viral disease
and its structure and function in relation to its toxicity
¾ Cidofovir
Define the role of cidofovir for the treatment of CMV infection as
well as for adenovirus and papovavirus infections.
¾ Interferon
Understand this class’s broad spectrum of activity, mechanisms of
action
Understand the different dosing regimens for different viruses and
the different delivery mechanisms
¾ Ribavirin
30
CORE CURRICULUM
ANTIRETROVIRALS
Understand the mechanism of action, spectrum of activity

Understand the dosing regimens
Understand potential drug interactions
Competency Requirement The fellow will provide advice to

consulting physicians regarding use of
antiviral medications.
Competency Measurement The fellow will review the use of these
medications with the attending on the
consultation service. The evaluation will
be based on appropriate use. These drugs
will also be discussed in the core
curriculum lecture series.
References Mandell, et al. Principles and practices of

Infectious Diseases, 6th Ed.
Jefferson T, et al.Lancet. 2006;367303-13
Erik De Clercq. Antiviral agents active

against influenza A viruses Nature Reviews
Drug Discovery 5, 1015-1025 (December
2006)
3. Antibacterials
Competency Requirement Fellows will participate in the approval restricted
antibacterials in accordance with institutional
formulary and guidelines as well as approve restricted
antibacterials appropriate to specific ID indications.
Competency Measurement Fellows will review approval of restricted
antibacterials with the attending on the ID Consult
Service.
References x Mandell, et al. Principles and practices of
Infectious Diseases, 6th Ed.
x Guidelines: Antimicrobial Stewardship
x CID 2007; 44: 159-77.
x PNAS 1999; 96: 1152-56
x CID 2005; 41: 435-40.
x CID 2005; 41: 441-9
x AJIC 2006; 34; S64-73.
x Steven J. Brickner. J. Med. Chem., 2008, 51
(7),1981–90
31
D. KarageorgopoulosJournal of Antimicrobial
Chemotherapy 2008 62(1):45-55
Alan R. Hauser Antibiotics Basics For Clinicians:

Choosing the Right Antibacterial Agent 2008
AJ O'Neill. Expert Opinion on Investigational Drugs

March 2008, Vol. 17, No. 3, Pages 297-302
Peterson l. International Journal of Antimicrobial

Agents Volume 32, Supplement 4, December 2008,
Pages S215-S222
Hawser S. Biochemical Pharmacology

Volume 71, Issue 7, 30 March 2006, 941-948
Kluytmans J. BMJ 2009;338:b364
a. Fellows must have a good understanding of all the major

antibacterial agents used in clinical practice. The fellow
must have knowledge of the mechanisms of action, correct dosing,
resistance profiles, major mechanisms of resistance, toxicity of
medications and when they occur.
CORE CURRICULUM
ANTIBACTERIALS
b. Understand the concept of an antibiotic formulary and
appropriate use of medications within it’s context.
c. Penicillins
¾ Understand the difference between the agents in this class.
¾ Basic understanding of pharmacokinetics, toxicities and

management of these problems including desensitization of
allergies.
¾ Knowledge of pharmacodynamics and the role of continuous

infusions is necessary.
¾ Antistaphylococcal agents - dicloxacillin, methicillin,
oxacillin/nafcillin
¾ Aminopenicillins- ampicillin, amoxicillin
¾ Beta-lactam, beta-lactamase inhibitors – amoxicillin/clavulanic
acid, ampicillin/sulbactam and piperacillin/tazobactam
¾ Antipseudomonal – piperacillin, ticarcillin, and these drugs
combined with tazobactam or clavulanate.
d. Cephalosporins
¾ Understand the differences and similarities between the
cephalosporins including spectrum of activity and toxicities.
o 1st generation-cefazolin
o 2nd generation-cefotetan, cefoxitin, cefuroxime
o 3rd generation-cefotaxime, ceftriaxone, ceftazidime
32
o 4th generation-cefepime
e. Monobactams
¾ Understand the role of aztreonam in the treatment of gram-
negative bacterial infections.
¾ Understand the nature of cross-reaction regarding beta-lactam
allergies.
f. Carbapenems
¾ Understand the mechanism of action, antibacterial spectrum, basic
pharmacology and adverse reactions of the members of this group
of drugs.
¾ Differentiate imipenem, meropenem, doripenem and ertapenem and
identify the role each plays in the treatment of infectious diseases.
g. Glycopeptides - vancomycin
¾ Understand mechanism of action, antibacterial spectrum, and
mechanisms of resistance. Additionally understand the pathogens
that are resistant to vancomycin including VRE and VRSA.
¾ Learn the appropriate manner of dosing this medication
understanding the monitoring of blood concentrations and interaction
of these parameters with toxicity and efficacy.
¾ Management of drug toxicities
h. Streptogramins
CORE CURRICULUM
ANTIBACTERIALS
¾ Understand the role of this class in relation to other agents with

similar spectrum of activity
¾ know the adverse effects of this class of drugs and the
management of side effects.
i. Lipopeptides (Daptomycin)
¾ Understand the dosing and pharmacodynamics of the drug in
different disease states.
¾ Understand the possible molecular interactions with
glycopeptides.
j. Oxazolidinones
¾ Understand the mechanism of action, antibacterial spectrum
and mechanism of resistance.
¾ Understanding the dosing, pharmacokinetics and
pharmacodynamics of the drug in different disease states.
¾ Understand the toxicities and drug interactions of the agent.
k. Aminoglycosides
¾ Gentamicin, tobramycin, streptomycin, and amikacin
¾ Learn the spectrum of these antibiotics for gram-negative
infections and their use for synergy in the treatment of serious
gram-positive bacterial infections.
33
¾ Knowledge of basic pharmacokinetics and pharmacodynamics to
direct the appropriate dosing schedules
¾ Understanding the appropriate monitoring of patients receiving
treatment with these medications
l. Tetracycline, Glycylcyclines and Chloramphenicol
¾ Learn mechanism of action, basic pharmacology, and relevant
toxicity issues. Learn the appropriate use of these drugs in
pregnancy, children and unusual infections.
¾ Tetracycline, doxycycline, minocycline, tigecycline and
chloramphenicol
m. Macrolides and Clindamycin
¾ Learn mechanism of action, antibacterial spectrum, therapeutic
uses, toxicity and issues of resistance.
o In particular, understand the role of the D-test in identifying
inducible MLS resistance via the ermB gene.
¾ Erythromycin, clarithromycin, azithromycin, clindamycin
n. Fluoroquinolones
¾ Learn mechanism of action, drug spectrum, drug interactions and
therapeutic uses of this class of drug.
o Understand the difference in spectrum with the traditional
fluoroquinolones like ciprofloxacin and the respiratory
fluoroquinolones like moxifloxacin.
o Understand the role in treatment of mycobacterial
infections.
CORE CURRICULUM
ANTIBACTERIALS
¾ Understand drug toxicity in both healthy individuals and in

patients with underlying disease states i.e. diabetes.
¾ Understand the importance of resistance to this class of drugs and
the role utilization plays in development of resistance.
¾ Ciprofloxacin, levofloxacin, and moxifloxacin
o. Sulfonamides and Trimethoprim
¾ Understand the mechanism of action, antimicrobial spectrum,

toxicity, drug interactions and therapeutic uses of this class of
drug.
¾ Combination preparation – trimethoprim/sulfamethoxazole
p. Rifamycins
¾ Understand the mechanism of action of the rifamycins (rifampin)
¾ Understand the ease that resistance can develop when treating a
bacterial infection with rifampin.
¾ Understand the pharmacokinetics and pharmacodynamics of these
agents.
¾ Role in treatment of staphylococcal infections
¾ Role in treatment of mycobacterial infections.
¾ Understand the role of rifabutin and rifaximin in treatment of
infectious diseases
q. Other antimicrobials
34
¾ Understand the “niche” for other antimicrobials used in inpatient
infectious diseases setting
o
o Metronidazole
o
o Nitrofurantoin
o Topical antibiotics
r. Antimycobacterials – see tuberculosis and other mycobacterial
pathogens
s. Antibiotics and pregnancy
¾ Know the drugs that would be contraindicated for treatment of
infections in pregnant women.
¾ Understand the pharmacokinetics of antimicrobials in pregnant
women.
t. Antimicrobial Resistance
- Develop an understanding of methods to limit development of
resistant pathogens by understanding mechanisms of resistance
- Understand the relevance of resistance in clinical practice.
- Comprehend the mechanisms of resistance
¾ Enzymatic inhibition
¾ i.e. Beta-lactamasesBypass of
antibiotic inhibition
¾ Membrane permeability
¾ Promotion of antibiotic efflux
CORE CURRICULUM
ANTIFUNGALS
¾ Alteration of target enzymes
4. Antifungals (systemic)
¾ Amphotericin B Deoxycholate and the Lipid Formulations

Understand the mechanism of action, spectrum of activity, toxicity,
methods to prevent toxicity, and dosing
Develop knowledge of the different lipid formulations in terms of

dosing and toxicity and the unique advantages to the different
formulations
¾ Flucytosine
Understand its limited role in the treatment of fungal infections and
the dosing adjustments in relation to toxicity
¾ Azoles
Ketoconazole
Understand the spectrum of activity, dosing in relation to toxicity,
and the unique toxicities of this class of antifungals
Triazoles
(Fluconazole, Itraconazole, Voriconazole and Posaconazole)
Understand the spectrum of activity, the limits of the clinical trials
data, dosing, and toxicities
¾ Echinocandins
Caspofungin, Micafungin and Anidulafungin
35
Understand the spectrum of activity, dosing and toxicities.
Understand the potential role of this class of antifungals in
combination therapy
Competency Requirement Demonstrate knowledge of antifungal

agents based on the performance of
consultations. Thecurrent policy requires
consultation for any restricted antifungal
agent.
Competency Measurement Appropriate utilization of the antifungal
agent will be demonstrated by
recommendations and presentation to the
faculty consulting physician.
References Nagappan V, Deresinski S. Clin Infect Dis.
2007;45:1610-7.
Kanafani ZA, Perfect JR. Clin Infect Dis.

2008;46:120-8.
Dodds E. CID 2006; 43:S28–39
CORE CURRICULUM
C. Diagnosis and Management of Major Clinical Syndromes
1. Meningitis
a. Recognize clinical presentation of acute meningitis. Understand
causative agents, diagnostic tools available and treatment.
¾ Causative agents include bacterial, viral, fungal, rickettsiae,
spirochetes, protozoa, other pathogens, and non- infectious causes.
¾ Diagnosis - Interpretation of the CSF cell formula, cultures, and
serologic evaluation.
¾ Understand the issues regarding treatment including empiric

therapy, organism directed treatment, adjunctive therapy such as
the use of steroids, postexposure prophylaxis, and the infection
control aspects of this infection.
b. Understand major causes of chronic and recurrent meningitis.
Grasp the role of careful history, physical exam and the utility of
laboratory/radiologic diagnostic tests.
¾ Know the major causes including tuberculosis, fungi, Lyme
disease (neuroborreliosis), and Herpes simplex virus (Mollaret’s
meningitis).
c. Recognize the differences in etiology and presentation in
immunocompromised hosts.
36
2. Encephalitis, myelitis, and neuritis.
a. Understand clinical presentation of these syndromes.
b. Learn the relevant laboratory workup to define an etiologic
diagnosis.
c. Understand the most common causes of these syndromes including
enterovirus, tick-borne pathogens, and mosquito-borne pathogens
including West Nile Virus, mumps, and herpes viruses.
d. Understand therapeutic strategies for the management of these
patients.
3. Brain Abscess
a. Understand basic epidemiology.
b. Know the causative agents and clinical manifestations.
¾ Bacterial- i.e. Streptococcus anginosus group, Bacteroides sp. and
mixed infections
¾ Fungal including Candida sp., Aspergillus sp. and Zygomycetes
¾ Protozoan/helminthic-i.e. Toxoplasmosis
c. Diagnosis and management
¾ CT vs. MRI vs. SPECT
¾ Appropriate surgical intervention
¾ Brain abscess and HIV infection
d. Antimicrobial Therapy
¾ Empiric vs. culture driven
¾ Duration of therapy
CORE CURRICULUM
MAJOR CLINICAL SYNDROMES
Competency Requirement Fellows will diagnose and manage patients

with central nervous system infections
including meningitis, encephalitis and brain
abscess.
Competency Measurement Appropriate management of the patients
will include obtaining appropriate clinical
samples (cultures, antigen or PCR testing),
and recommending the appropriate
antimicrobial therapy where indicated.
References N Engl J Med 2006;354:1429-1432
Lancet. 2002;359:507-13
Am J Med 2003; 115:143-146
van de Beek D. Cochrane Database of
Systematic Reviews 2007, Issue 1. Art.
No.: CD004405
Journal of Intensive Care Medicine, Vol.
22, No. 4, 194-207 (2007)
NEUROLOGY 2008;70:943-947
BMJ 2008;336:36-40
Expert Opinion on Pharmacotherapy
July 2007, Vol. 8, No. 10, Pages 1493-
1504
N Engl J Med 2010;362:146-154
Clinical Microbiology Reviews, July 2008,
37
p. 519-537, Vol. 21, No. 3
4. Sepsis
a. Recognize clinical and physiologic manifestations of sepsis.
b. Learn a thoughtful approach to discovering cause of the sepsis
syndrome.
c. Understand the appropriate use of antimicrobials in the septic
patient.
d. Learn the use of adjunctive therapies in the patient with sepsis.
Competency Requirement Fellows will diagnose and manage patients

with sepsis.
Competency Measurement Appropriate management will include

obtaining appropriate cultures and
recommending appropriate antimicrobial
therapy and duration.
References Wheeler AP. Chest. 2007; 132:1967-76
Critical Care 2008, 12:213
Am J Respir Crit Care Med
181;2010:A5802
5. Enteric Infections
a. Acute diarrhea
¾ Understand concept of noninflammatory, inflammatory and
invasive diarrhea.
¾ Understand common causes of enteric infections.
o Bacterial causes of diarrhea including E. coli 0157:H7,
Salmonella, Shigella and Campylobacter
o The role of antimicrobial use with O1 57:H7 and the
development of HUS.
o
Antibiotic associated diarrhea including C. difficile
associated diarrhea
o
Viral causes of diarrhea
¾ Develop a systemic approach to all patients with enteric infections.
¾ Understand prevention and control of infections.
o Public health implications
CORE CURRICULUM
b. Chronic Diarrhea
¾ Develop an approach for the diagnosis and management of patients
with chronic diarrhea.
Competency Requirement Fellows will help manage difficult cases of

diarrhea with particular focus on
Clostridium difficile infection.
Competency Measurement Management of a variety of cases of
diarrhea. Understanding the role of
38
antimicrobial therapy and the appropriate
drugs of choice for the different pathogens.
Reference Zar FA, et al. Clin Infect Dis. 2007;
45(3):302-7.
Am J Gastroenterol 2009; 104:S10–S16
Aliment Pharmacol Ther 30, 187–196
Current Opinion in Gastroenterology: 2009
Volume 25 - Issue 1 - p 1-7
6. Urinary Tract Infections
Competency Requirement Fellows will diagnose and manage difficult cases of

urinary tract infections on the ID consult services.
Competency Measurement Fellows will manage a variety of cases of UTI’s
during fellowship. Appropriate management will
include ensuring appropriate cultures obtained,
selection of antimicrobial and de-escalation and
duration of therapy
References CID 1999; 29: 745-58
CID 2007; 44: 769-74
CID 2001; 33: 615-21
Ann Intern Med. 2006;144:116-126
Infect Control Hosp Epidemiol 2008;29:S41–S50
Clinical Infectious Diseases 2008;46:251–253
Clinics in Geriatric Medicine Volume 25, Issue 3,
August 2009, Pages 423-436
CID 2010;50:625–663
a Know the predisposing pathophysiology, relevant host

factors, and route of infection.
b. Identify common organisms with characteristic epidemiologic
factors and microbiologic factors that may allow differentiation of
these organisms.
c. Learn to identify and manage bacteruria in all patient groups.
d. Understand spectrum of illness
¾ Pyelonephritis, cystitis, prostatitis, abscess
e. Know appropriate management issues in relation to the treatment
and prevention of UTIs.
6. Skin and Soft Tissue Infections

a. Understand spectrum of illness including cellulitis, erysipelas,
fasciitis, furunculosis, folliculitis and impetigo. Define the likely
pathogen for each of these syndromes.
c. Toxic shock syndrome including streptococcal and staphylococcal toxic shock
syndrome.
d. Necrotizing fasciitis and clostridial myonecrosis
CORE CURRICULUM
39
¾ Know clinical manifestations, predisposing host factors, classic

exposures, and appropriate treatment.
Competency Requirement The fellows will help manage difficult

cases of skin infections including recurrent
infections with MRSA. (See
Staphylococcus aureus)
Competency Measurement Fellows will see a variety of cases with
skin and soft tissue infections. They
will demonstrate expertise in the use of
antimicrobial therapy and prevention of
recurrent disease based on
presentations to the faculty.
References Stevens DL, et al. Clin Infect Dis.
2005;41:1373-406.
N Engl J Med 2007;357:380-90.
CID 2007;44:777–784
CID 2008;46:S368–S377
7. Pneumonia
Competency Requirement Fellows will diagnose and manage difficult cases of
pneumonia on the ID consult services.
Competency Measurement Fellows will see cases of pneumonia due to various
pathogens during fellowship. They will demonstrate
expertise by the antimicrobial choices and duration of
therapy recommended. The fellow must manage
CAP, VAP and pneumonia in compromised hosts.
References CID 1999; 29: 745-58
CID 2007; 44: 769-74
CID 2001; 33: 615-21
Critical Care Medicine. 36(1):1-7, January 2008
Critical Care 2008, 12:R56
Cochrane Database of Systematic Reviews 2009, Issue
4. Art. No.: CD002109
a. Understand the body’s host defenses and the pathogenesis of

infection
b. Learn to perform a physical exam to support the diagnosis of this
infection
c. Develop knowledge of diverse epidemiological exposures and
associations with different pathogens.
d. Develop knowledge of different bacterial, viral, fungal causes of
pneumonia
8 Endocarditis and intravascular infections
40
a. Understand the epidemiology in relation to etiologic agents and
risk factors
b. Learn to perform a physical exam to identify the clinical
manifestations of disease
c. Learn the utility and limitations of various diagnostic tests
including echocardiogram.
CORE CURRICULUM
d. Apply the modified Duke Criteria to help in determining the

diagnosis
e. Be able to diagnose culture negative endocarditis and know the
pathogens responsible.
Competency Requirement The fellow will manage patients with

blood stream infections including
endocarditis.
Competency Measurement Competency will be defined by
knowledge of appropriate microbiology
testing to make the appropriate
diagnosis. Additionally the fellow will
appropriately manage the patients
including correct antimicrobials and
duration.
Fowler VG Jr et al.; S. aureus

References Endocarditis and Bacteremia Study
Group. N Engl J Med. 2006;355:653-
65.
Guidelines - American Heart

Association; Infectious Diseases
Society of America.
Circulation. 2005;111:e394-434.
Erratum in: Circulation.
2005;112:2373. Circulation.
2007;115:e408. Circulation.
2007;116:e547.
Albrich WC, et al. Lancet Infect Dis.

2004;4:777-84
Cochrane Database of Systematic
Reviews 2008, Issue 4. Art. No.:
CD003813
Am J Health-Syst Pharm. 2009; 66:82-
98
Eur J Clin Microbiol Infect Dis (2007)
26:849–856
41
9. Bone and Joint Infections
a. Infectious Arthritis
¾ Understand the different mechanisms of pathogenesis of infectious
arthritis
¾ Recognize the important historical clues to etiology, physical exam
and laboratory findings of infectious arthritis
¾ Recognize the various etiologies of infectious arthritis: bacterial,
viral, mycobacterial
¾ Understand the role of surgical and medical management in
treatment of patients.
b. Osteomyelitis and Prosthetic Joint Infections
¾ Understand the pathogenesis of osteomyelitis
CORE CURRICULUM
¾ Recognize the common bacterial pathogens associated with

osteomyelitis
¾ Understand the utility and pitfalls of the various clinical, laboratory
and imaging modalities used to diagnose and monitor disease
¾ Develop knowledge concerning duration of therapy for
osteomyelitis, based on pathogen, duration of illness and presence
or absence of orthopedic devices
¾ Understand the limitations of chronic suppressive therapy
Competency Requirement Fellows will understand the

pathophysiology of infectious arthritis and
osteomyelitis. They will know the
appropriate approach to treatment.
Competency Measurement The fellows will be responsible for
management of cases of bone and joint
infection.
References Butalia S, et al. JAMA. 2008;299:806-13.
Stengel D, et al. Lancet Infect Dis.
2001;3:175-88
Zimmerli W, et al. JAMA. 1998;279:1537-
41
Arch Intern Med. 2008;168(8):805-819.
Diabetes Metab Res Rev 2008; 24(Suppl
1): S145–S161.
International Journal of Antimicrobial
Agents 29 (2007) 233–239
Infect Control Hosp Epidemiol
2007;28:1290–1298
10. Nosocomial Infections

Competency Requirement Fellows will understand the pathophysiology of
different nosocomial infections.
Know the evidenced based guidelines for prevention
of nosocomial infections
42
Competency Measurement Fellows will perform a system quality improvement
project related to either the prevention, diagnosis, or
management of nosocomial infections.
References 1. ICHE. 2002; 23: S3-S40.
2. ICHE 2003; 24: 362-386.
3. Clin Infect Dis. 2006;43:322-30
Infect Control Hosp Epidemiol 2007;28:1290–1298
Journal of Hospital Infection (2007) 66, 101e108
JAMA. 2008;299(10):1149-1157
a. Be able to define a nosocomial infection
b. Understand the risk factors for nosocomial infections and the
different methods to prevent them, focusing on medical devices.
c. Develop a framework for antimicrobial prophylaxis in the setting
of surgical procedures
¾ Clean Surgery
¾ Clean – Contaminated Surgery
¾ Contaminated Surgery
d. Understand infection control practices in the hospital (see infection
control)
e. Ventilator associated pneumonia
¾ Understand the pathogenesis and methods of prevention including
the IHI bundles.
¾ Understand the criteria for diagnosis
CORE CURRICULUM
NOSOCOMIAL INFECTIONS
¾ Develop knowledge of common bacterial causes and the treatment

¾ Understand how to use the clinical pulmonary infection score
(CPIS) in the management of nosocomial pneumonia
f. Catheter related infections
the IHI bundles.
¾ Understand the differences in efficacy of antiseptic scrub solutions
in performance of sterile procedures
¾ Develop knowledge of methods of treatment based on the etiologic
agent.
¾ Understand utility and importance of removal of the catheter in
clinical management of documented infection and evaluation of
fever.
¾ Understand when to consider preservation of the catheter and use
of antibiotic lock solution
g. Surgical Site infections
the timing of antimicrobial prophylaxis.
¾ Develop knowledge of the common pathogens and treatment

¾ Learn the SCIP measures to monitor hospital compliance with
appropriate practices of prevention of surgical site infections.
They include timing of administration of antimicrobial therapy,
duration of antimicrobial therapy and proscribed medications.
43
h.. Public reporting of nosocomial infections
Understand the background for reporting and the methodology for
obtaining good surveillance data
D. Management of Specific Microbes
1. Bacteria
a. Staphylococcus aureus
¾ Learn how the organism is identified in the Microbiology Laboratory by
morphology, biochemical and other tests.
¾ Understand the epidemiology and pathogenesis of different clinical
syndromes caused by S. aureus, especially ones listed below
o Localized infection
o Localized infection with diffuse skin rash
o Bacteremia and endocarditis
o Toxic Shock Syndrome
o Osteomyelitis, septic arthritis, and pyomyositis
o Staphylococcal food poisoning
¾ Understand the treatment using the most active drug based on
susceptibility of methicillin-susceptible (MSSA), methicillin-resistant
CORE CURRICULUM
MANAGEMENT OF SPECIFIC MICROBES
¾ (MRSA), vancomycin-intermediate (VISA) and vancomycin-resistant

(VRSA) Staphylococcus aureus
¾ Understand the concept of heteroresistance
¾ Understand the differences in epidemiology between hospital-associated
and community-acquired MRSA
Competency Requirement The fellow must be able to appropriately

diagnose and manage patients with serious
S. aureus infections.
Competency Measurement The fellow will be evaluated on the
management of patients through
interaction with faculty (e-value or mini-
CEX)
References Deresinski S. Clin Infect Dis 2005;40:563-
573.
Fowler VG et al. N Engl J Med.
2006;355:653-65
Sievert DM, et al.Clin Infect Dis.
2008;4:668-74.
Expert Review of Anti-Infective Therapy,

Volume 6, Number 3, June 2008 , pp. 299-
307(9)
b. Enterococcus species
44
¾ Learn to identify by morphology and biochemical tests
¾ Understand the pathogenesis of the different manifestations of infection
¾ Understand the risk factors for colonization or infection with vancomycin-
resistant enterococci (VRE)
¾ Develop knowledge of different antibiotics used for treatment and
understand when treatment is necessary
Competency Requirement The fellow must be able to appropriately

diagnose and manage patients with
enterococcal infections.
Competency Measurement The fellow will be evaluated based on
management of patients through interaction
with faculty.
References Zirakzadeh A, Patel R. Mayo Clin Proc.
2006;81:529-36
Gavaldà J, et al. Ann Intern Med.
2007;146:574-9
J Infect. 2007 June; 54(6): 567–571.
Expert Opinion on Investigational Drugs
July 2009, Vol. 18, No. 7, Pages 921-944
Current Opinion in Microbiology 2007,
10:436–440
JAC 2008 62(Supplement 1):i17-i28
Ann Intern Med. 2007;146:574-579.
c. Pseudomonas aeruginosa
¾ Understand basic microbiology, epidemiology and pathogenesis of this
organism.
¾ Know classic clinical manifestations of syndromes caused by this
organism, host factors that put patients at risk, and treatment.
o Infections of interest include endocarditis, hospital acquired
pneumonia, ear infections, respiratory tract infections in patients
with cystic fibrosis.
CORE CURRICULUM
o The role of multidrug resistance in the management of infections

caused by P. aeruginosa.
o Pseudomonas and HIV
¾ Understand the role of antimicrobial resistance in the management of
bacterial infections
o Stenotrophomonas maltophilia Acinetobacter baumannii and
Burkholderia cepacia.
o The role of extended-spectrum beta-lactamases (ESBL) and class I
chromosomal beta-lactamases (AmpC) in the treatment of serious
infections with gram-negative bacteria.
Competency Requirement The fellow will be responsible for the

knowledge of infections due to gram-
negative bacteria. The particular focus is
45
resistant organisms including Pseudomonas
aeruginosa
Competency Measurement Competency will be measured by
observations on rounds and evaluation.
Also presentations at Case Conference
and the Basic Science Conference will
demonstrate competency.
Patterson JE. Infect Control Hosp
Epidemiol. 2006;27:889-92.
References
Paterson DL, Bonomo RA. Clin Microbiol
Rev. 2005 Oct;18(4):657-86.
Current Opinion in Microbiology 2007,

10:436–440
JAC doi:10.1093/jac/dkm357
Drugs, Volume 67, Number 3, 2007 , pp.

351-368(18)
2. Fungi
a. Candida species
¾ Understand microbiology, pathogenesis, and pathologic findings.
¾ Learn spectrum of clinical manifestations.
o Thrush, esophagitis, cutaneous syndromes, fungemia and deep
organ manifestations.
o Know appropriate management of infections with Candida sp. as
determined by cultures of blood or sterile body fluids.
x Endocarditis, line infections and peritonitis
o Understand relationship between different species particularly the
non-albicans candida and antifungal agents.
Competency Requirement Fellow will be required to demonstrate the
knowledge of diagnosis and management of candidal
infections
Competency Measurement The fellow will be evaluated while on clinical service
using e-value. Antifungal therapy for candidal
infections is part of the antimicrobial approval
process.
CORE CURRICULUM
References Pfaller MA, Diekema DJ. Clin Microbiol Rev.
2007;20:133-63.
Pappas PG. Infect Dis Clin North Am. 2006;20:485-

506.
46
Medical Mycology June 2007, 45, 321_346
CID 2007;44:402–409
Drugs, Volume 67, Number 2, 2007 , pp. 269-
298(30)
Infection 2008; 36: 296–313
b. Cryptococcus neoformans (See HIV infection section)

¾ Understand basic mycology, epidemiology, and host factors.
o
¾ Know clinical manifestations of illness.
o HIV infected patients vs non-infected patients
¾ Understand diagnostic work up and treatment options.
c. Aspergillus species
¾ Understand the ecology and epidemiology of different species of
aspergillus
¾ Understand the manifestations of the different syndromes of infection
o Allergic bronchopulmonary aspergillosis
o Aspergilloma
o Invasive Aspergillosis
¾ Be able to identify hyphae as aspergillus-like by microscopy
¾ Determine the role of CT scan and galactomannan assay in the diagnosis

of invasive aspergillosis.
¾ Develop knowledge of the different treatments options for treatment or
prevention of infections.
o Amphotericin B and lipid formulations
o Voriconazole/Posaconazole
o Echinocandins
Competency Requirement Fellow must demonstrate knowledge

regarding the diagnosis and management of
infections with Aspergillus species.
Competency Measurement The fellow will be evaluated on service by
e-value and their role in antimicrobial
approval process.
References Barnes PD, Marr KA. Infect Dis Clin North
Am. 2006;20:545-61.
Infection 2007; 35: 51–58
infection Vol 10 April 2010
JID 2007;195:756–764
d. Zygomycetes
¾ Understand the ecology and epidemiology of different species of
Zygomycetes.
¾ Understand the risk factors for infection with these organisms.
¾ Understand the different clinical manifestations and pathogenesis of
infection
o Rhinocerebral
o Pulmonary
47
CORE CURRICULUM
FUNGI
o Cutaneous
o Gastrointestinal
o Central nervous system
¾ Be able to identify hyphae by microscopy. Differentiate Zygomycetes
from other groups of fungi such as Aspergillus
¾ Understand the importance of surgical vs. medical treatment in the
management of infected patients.
¾ Understand the antifungal agents with activity against these moulds.
o Amphotericin B and lipid formulations
o Posaconazole
Competency Requirement Fellows will be required to understand the

diagnosis and management of patients with
zygomycosis based on management of
cases on the consultation service.
Competency Measurement The fellow will be evaluated on service by
e-value and their role in antimicrobial
approval process..
References Kontoyiannis DP, Lewis RE. Infect Dis
Clin North Am. 2006;20:581-607.
JAC (2008) 61, Suppl. 1, i35–i39
e. Endemic mycoses – Coccidioides immitis, Histoplasma capsulatum,

Blastomycosis dermatitidis, Paracoccidioides
¾ Develop knowledge of the geographic ecology and epidemiology of these
pathogens.
¾ Be able to identify organism by microscopy in tissue and in culture.
¾ Develop knowledge of the different treatment options and the risks and
benefits.
Competency Requirement Fellows will comprehend the management

and diagnosis of endemic mycoses. The
most important is coccidioidomycosis as
we are in an endemic area.
Competency Measurement The fellows will be evaluated on the
consultation service and in the ID clinic by
either e-value or mini-CEX.
References Clin Infect Dis 2000; 30:658–61

Clin Infect Dis 2007; 45:807–25
Clin Infect Dis 2000; 30:679–83
3. Viruses
a. Enterovirus
¾ Understand different species of enterovirus.
48
o Poliovirus, coxsackievirus, echoviruses and other enterovirus species
such as 71.
CORE CURRICULUM
VIRUSES
o Understand the epidemiology, pathology, clinical manifestations, and

management of patients. The primary illness that will likely be treated
is viral meningitis.
b. Human herpes viruses
¾ Herpes Simplex 1 and 2
o Understand the pathogenesis and spectrum of disease
o Understand the various methods of diagnosis and treatment and
prevention
¾ Varicella Zoster Virus
o Understand the pathogenesis and clinical manifestations with primary
infection and reactivation disease
o Identify the distinguishing characteristics from smallpox
o Develop knowledge of the treatment of different clinical syndromes.
o Understand the infection control implications of exposure to varicella
o Understand the use of the varicella virus vaccine and the shingles
vaccine in adults including healthcare providers.
¾ Cytomegalovirus
o Understand the pathogenesis and clinical manifestations in various
hosts including patients with HIV infection, bone marrow and solid
organ transplantation.
o Understand the different techniques for diagnosis including culture
based, immunological and molecular methods.
o Understand the therapeutic and prophylactic options for management
of patients
¾ Epstein Barr Virus

o Understand the epidemiology, pathogenesis and clinical manifestations
o Understand the interpretation of the serology panel for diagnosis of the
various stages of infection: acute, reactivation and past infection
o Develop knowledge of the management of patients with active
infection with EBV including post-transplant lymphoproliferative
disorder and Burkitt’s lymphoma
¾ HHV 6 and 7
o Understand the epidemiology and clinical manifestations
o Understand the diagnosis and treatment
¾ HHV-8 (KS associated Herpes Virus)
o Understand the epidemiology and different clinical syndromes
Kaposi’s sarcoma
Primary effusion lymphoma
Castleman’s disease
o Understand the treatment of visceral disease in HIV
Competency Requirement The fellow will diagnose and manage multiple
patients with serious herpes virus infections.
49
CORE CURRICULUM
Competency Measurement The fellow will be evaluated in the management of

these infections in multiple settings. The consult
service and the transplant service will provide the
source of inpatients. Special Services Clinic and
the ID clinic will be a source of herpes virus
infections in the outpatient setting and in AIDS.
The fellows will be evaluated using e-value in these
settings.
References Legendre C, Pascual M. Clin Infect Dis.
2008;46:732-40.
Smith TF et al. Clin Infect Dis. 2007;45:1056-61.
Oxman MN et al. N Engl J Med. 2005;352:2271-
84.
Whitley RJ, Gnann JW. Lancet. 2002;359:507-13.
c. Human Immunodeficiency Virus (HIV) – see ambulatory curriculum and HIV

specific curriculum (CARES)
4. Agents of Bioterrorism
a. Understand the agents involved in bioterrorism, the clinical presentation and

management.
b. Understand the use of smallpox vaccine, the risks, benefits and complications.
c. Know the infection control issues involved in the management of patients infected
with agents of bioterrorism
d. Be aware of the chain of command if an attack were to occur including the county
and state health officers.
Competency Requirement The fellow will know the agents involved
in bioterrorism. The fellow must
understand the prevention and treatment
approaches.
50
CORE CURRICULUM
MANAGEMENT OF SPECIFIC
BIOTERRORISM
Competency Measure As it is unlikely that management of many
of these infections will be undertaken due
to the rarity of the disease. Therefore, the
competency measure will be didactic
sessions providing information on these
organisms.
References Inglesby TV, et al. JAMA. 2002;287:2236-
52.
Breman JG, Henderson DA. N Engl J Med
2002;346:1300-8.
Clin Microbiol Infect 2009; 15: 700–705
E. Infectious Diseases Ambulatory Clinic Educational Objectives
1. HIV infection (Also see HIV/AIDS Curriculum)

a. Understand the use of serology to establish the diagnosis of HIV infection
b. Understand how to counsel newly infected HIV patients

i. Meaning of HIV test results
ii. Risk of transmission/safer sex and/or safer needle practices
iii. Clinical, viral and immunologic monitoring of HIV infection
iv. Treatment strategies for HIV infection with antiretroviral agents
c. Develop knowledge of recommended immunizations for HIV infected patients
d. Develop knowledge about antiretroviral agents – indications, drug interactions,
common side effects, development of resistance
51
e. Develop knowledge about role of resistance testing, interpretation of genotypic
and phenotypic resistance tests
f. Develop the knowledge of tropism testing for the use of CCR5 inhibitors and the
role of HLA B5701 testing for prevention of abacavir hypersensitivity reactions.
g. Develop knowledge about the clinical presentation, diagnosis and treatment of
opportunistic infections
CORE CURRICULUM
INFECTIOUS DISEASES AMBULATORY CLINIC OBJECTIVES
2. Osteomyelitis (Competency measures noted in “Diagnosis and Management of Major

Clinical Syndromes”)
a. Understand the pathogenesis of osteomyelitis
b. Recognize common bacterial pathogens associated with osteomyelitis
c. Understand diagnostic imaging studies used to diagnose and monitor treatment of
osteomyelitis
d. Develop knowledge about antimicrobial agents used to treat osteomyelitis, their
common side effects and required therapeutic drug monitoring
e. Develop knowledge concerning duration of therapy for osteomyelitis, based on
pathogen and the presence or absence of mechanical devices
3. Traveler’s health
a. Assess traveler’s itinerary for risk of acquiring infectious diseases
b. Assess immunization status of traveler
c. Assess comorbid medical illnesses of traveler
d. Develop plan for preventive therapy and recommended immunizations based on
itinerary, immunization status and comorbid medical illnesses
e. Understand role of CDC Traveler’s Health web site in patient education and
counseling (http://www.cdc.gov/travel/)
f. Develop knowledge about common vaccines and side effects
g. Develop knowledge about preventive therapy options for malaria and their
indications
h. Develop knowledge about non-drug methods to prevent traveler’s diarrhea and
insect bites while traveling abroad
i. Understand the differential diagnosis in the febrile returning traveler.
Competency Requirement The fellow is expected to be competent to
perform an evaluation and treat a traveler
prior to a trip. The fellow must also be
competent in managing the ill returning
traveler
Competency Measurement The fellow will be evaluated by the
attending using e-value and verbal
feedback.
References Hill DR, et al. Clin Infect Dis 2006;
43:1499–1539
Freedman DO,et al. N Engl J Med. 2006
Jan 12;354(2):119-30.
http://wwwn.cdc.gov/travel/default.aspx
4. Infective endocarditis (Competency measures noted in “Diagnosis and Management of

Major Clinical Syndromes”)
52
a. Understand the epidemiology of infective endocarditis, including prosthetic valve
endocarditis, including the common microorganisms involved in this infectious
disease
b. Develop knowledge about the natural history, pathophysiology, diagnosis, clinical
management and antimicrobial treatment of bacterial endocarditis
c. Understand the role of cardiac valve replacement in the management of infective
endocarditis
CORE CURRICULUM
TRAVELERS’ HEALTH
d. Develop knowledge about outpatient management of patients with infective

endocarditis, including recognition of late cardiac and septic complications
5. Coccidioidomycosis (cocci) (Competency measures noted in “Diagnosis and
Management of Major Clinical Syndromes”)
a. Understand the epidemiology of cocci, clinical presentation, diagnosis and
therapeutic management of localized and disseminated cocci.
b. Understand the clinical presentation of localized and disseminated cocci
c. Understand the diagnostic approach to the patient with suspected or proven
disseminated cocci
i. Become proficient in the utilization of cocci complement fixation and
immunodiffusion titers in the diagnosis and follow-up management of
cocci
ii. Understand the role of bone scan, fine needle aspiration of cold abscesses,
chest CT scan and lumbar puncture in the diagnosis of disseminated cocci
d. Understand the principles of antifungal therapy for localized and disseminated
cocci, with an emphasis on the role of triazole agents
e. Develop proficiency in the long-term clinical management of disseminated cocci
6. Lyme disease
Competency Requirement Understand epidemiology, diagnosis and management
of Lyme.
Competency Measurement Fellows will evaluate and manage cases of suspected
Lyme disease in the outpatient clinic. Evaluations will
be based on interaction with attending physician and
evaluations in E*value.
References 1. CID. 2006; 43: 1089-1134.
a. Understand the epidemiology of Lyme disease
b. Understand the clinical presentation of acute and chronic Lyme disease
c. Understand the role of Lyme disease serology, and the significant limitations of
this diagnostic tool
d. Develop familiarity with the IDSA and ACP clinical practice guidelines regarding
diagnosis and treatment of Lyme disease
e. Understand the role of antimicrobial therapy in the management of established
Lyme disease
7. Hepatitis C
a. Understand the epidemiology and natural history of hepatitis C virus
b. Understand the clinical presentation of hepatitis C virus disease
c. Understand the role of the laboratory in the diagnosis and clinical management of
hepatitis C virus infection, with an emphasis on liver biopsy, serology, genotype
and quantitative and qualitative RNA assays
d. Understand the indications for antiviral treatment for hepatitis C virus
53
e. Develop familiarity with antiviral agents and their associated toxicities for
treatment of hepatitis C virus
CORE CURRICULUM
TRAVELERS’ HEALTH
Competency Requirement The fellow will be expected to be able to

diagnose, stage and treat patients with
hepatitis C infection with or without HIV
coinfection.
Competency Measurement The fellow is expected to diagnose and
manage patients with hepatitis C in the VA
clinic setting as well as at Special Services
Clinic and the CRMC Outpatient clinic.
Competency will be measured by the
attending physician evaluation after
reviewing the patients with the fellow.
References Poordad F, et al. Clin Infect Dis.
2008;46:78-84.
Doris B. Strader, et al. Hepatology 2004;
39: 1147-1171
8. Tuberculosis
a. Understand the epidemiology of tuberculosis
b. Understand the pathogenesis, clinical stages (latent versus active disease) and
clinical manifestations of tuberculosis. Understand the role of screening for the
diagnosis of tuberculosis, including interpretation of PPD skin test and interferon J
induction assays.
d. Become familiar with the IDSA/ATS/CDC guidelines on the diagnosis and treatment of
latent and active tuberculosis
e Become familiar with the role of the microbiology laboratory in the diagnosis,
susceptibility testing and follow-up of patients with tuberculosis
f. Become familiar with the use of antimicrobial therapy in the management of latent and
active tuberculosis
i. First line vs. second/third line agents
ii. Common side effects of antituberculous agents
iii. Periodic laboratory tests and clinical exams used to monitor for toxicity of
antituberculous therapy
Competency Requirement The fellow should be able to diagnose and

manage patients with tuberculosis.
The fellow will be evaluated on the

Competency Measurement with faculty (e-value or mini-CEX)
References MMWR 2003; 52 (RR-11)
Am J Respir Crit Care Med2005;
54
172:1169–227
Mazurek GH, Clin Infect Dis.
2007;45:837-45.
MMWR 2003;52(RR-2):15-8.
Ann Intern Med. 2008;149:177-184.
Ann Intern Med. 2008;149:123-134.
Eur Respir J 2009; 33:871-881
CORE CURRICULUM
TRAVELER’S HEALTH
TUBERCULOSIS
9. Mycobacteria Other Than Tuberculosis (MOTT) (Environmental mycobacteria)

f. Understand the epidemiology of the various MOTT pathogens
g. Understand the varied clinical presentations of MOTT in normal and
immunocompromised hosts
h. Understand the diagnostic modalities for MOTT diseases, with an emphasis on
microbiology laboratory tools
i. Become familiar with clinical management of MOTT and the antimycobacterial
agents used in the treatment of MOTT, including their associated side effects and
required monitoring
Competency Requirement The fellow must be able to diagnose and

treat patients with non-tuberculous
mycobacterial infections in normal and
immunocompromised hosts.
Competency Measurement The fellow will be evaluated on the
with faculty (e-value or mini-CEX)
References Griffith DE,et al. Am J Respir Crit Care
Med 2007;175:367–416.
10. Outpatient intravenous antimicrobial therapy management

Competency Requirement Understand the general principles of management of
patients with OPAT
Competency Measurement Fellows will manage patients with OPAT.
Competency will be measured based on management
in the outpatient clinic, in particular looking at
complications that are potentially preventable.
References CID. 2004; 38: 1651-72.
J Clin Oncol 26:606-611
j. Understand the indications for outpatient intravenous antimicrobial therapy

i. Compatible disease states for this treatment modality
ii. Antimicrobial agents commonly used for these diseases
k. Become familiar with the clinical management of percutaneously implanted
central catheters (PICCs) used for this treatment modality
l. Become familiar with required clinical and laboratory monitoring required for
patients receiving potentially toxic antimicrobial therapy in the outpatient setting
55
m. Become facile with the communication skills required to manage patients
receiving this treatment modality, including collaboration with the pharmacy,
home health agency and referring physician
11. Chronic fatigue syndrome (CFS)
n. Understand the IDSA/ACP clinical practice guidelines for diagnosing and
managing CFS
o. Know the differential diagnosis of CFS
p. Become familiar with commonly indicated referrals for specialty evaluation in
patients with CFS, including Psychiatry and Rheumatology
q. Develop communication skills required in long-term management of CFS patients
CORE CURRICULUM
CHRONIC FATIGUE
Competency Requirement The fellow will understand the

differential diagnosis and management
of patients with chronic fatigue
syndrome.
Competency Measurement The fellow will be involved in the
workup and management of patients
with CFS in the outpatient clinic. The
evaluation will be based on discussion
with the attending physician.
References Wessely S. Ann Intern Med. 2001;134:838-
43.
Lerner AM, et al. Clin Infect Dis.
2001;32:1657-8.
PLoS One. 2010; 5(1): e8519.
HIV
F. Curriculum for The Treatment of Patients Infected With The Human Immunodeficiency
Virus (HIV)
Table of Contents
Virology
Epidemiology
Approach to the HIV positive patient
Preventive medical care
Management of other sexually transmitted diseases
Clinical Manifestations of HIV/AIDS
Anti-retroviral Therapy
Issues of adherence
Prophylaxis against opportunistic infections
Resistance testing
Therapeutic drug monitoring
Pharmacodynamics and pharmacokinetic
56
HIV and Hepatitis C co-infection
HIV and Hepatitis B co-infection
Virology
Nomenclature
Direct cell killing
Anti-genetic diversity
Receptor signaling theory
TH1 – TH2 Switch
Viral load and replication kinetics
Concept of long term non-progressors
Concept of virologic controllers
CORE CURRICULUM
HIV
Chemokines as receptor antagonists
Mucosal Immunity
Immune Activation
Epidemiology
Demographic trends
Prevalence
x USA Trends and prevalence
x California Trends and prevalence
x Global prevalence
x Geographic distribution of hiv-1 and hiv-2 infection
x Clades & Distribution
Approach to the HIV positive patient

History
Physical exam
Ordering and interpretation of required laboratories
Patient education
x Safer sex practices
x HIV Super-infection
x Risk / Harm Reduction
x Family Planning
x Adherence, Resistance
x Chronic Disease Self-Management
Preventive medical care
Vaccines
x Pneumococcal vaccine, hepatitis A and B vaccines, influenza vaccines, Tdap
x STD Screening: RPR, and urine tests for C. trachomatis and Neisseria
gonorrhoeae, Q12 mo
Pap smears
PPD tests
Routine dental – Q12 mo.
57
Mammograms, Colorectal CA Screening;
x Ophthalmology in selected populationDiabetes mellitus
CD4 counts FHOOVPP3
Mental Health Issues
x Depression
x Bi-polar Disorder
x Addiction
CORE CURRICULUM
SEXUALLY TRANSMITTED DISEASES
Management of other sexually transmitted diseases

Syphilis
x Screening, diagnosis, clinical manifestations, indications for cerebrospinal fluid

analysis and treatment.
Gonorrhea
x Screening, diagnosis, clinical manifestations and treatment.
Chlamydia
Pelvic inflammatory disease
Herpes simplex virus
Human papillomavirus
Lymphogranuloma venereum
Chancroid
Granuloma inguinale
Clinical Manifestations of HIV/AIDS

Acute retroviral syndrome
Clinical presentations and treatment of opportunistic infections:
x Pneumocystis jiroveci pneumonia
x Mycobacterial infections
o M. tuberculosis
o M. avium complex
o Other environmental mycobacteria
x Protozoan/parasitic infections
o Toxoplasmosis
o Cryptosporidiosis
o Microsporidiosis / Isospora
o Leishmaniasis
58
x Herpes viruses [CMV, HSV, VZV EBV]
x Polyoma virus [PML], BK shedding vs. disease
x Parvovirus B19
x Fungal infections
o Candidiasis
o Cryptococcosis
o Histoplasmosis
o Coccidioidomycosis
o Penicillium marneffei
CORE CURRICULUM
CLINICAL MANIFESTATIONS OF HIV/AIDS
Kaposi’s sarcoma –human herpesvirus 8

HIV Wasting Syndrome
Lymphoma
Neuropathy
x Distal symmetrical Polyneuropathy
x Acute and chronic inflammatory Demyelinating polyneuropathy [AIDP/CIDP]
x CMV polyradiculopathy
Anti-retroviral Therapy
x Mechanisms of action
x Treatment theory
x When to start
x Treatment sequencing
x Treatment naïve patients
x Second Regimen patient
x Treatment experienced patient
x Salvage Therapy
x Acute and long term side-effects of antiretroviral therapy
o NRTI associated
Lipodystrophy
Lactic acidosis,
Neuromuscular weakness syndrome,
Nonalcoholic steatohepatitis
Antiretroviral therapy -induced pancreatitis
Antiretroviral therapy induced peripheral neuropathy
x NNRTI-induced
Hepatotoxicity
Rash
x Special consideration to specific medications:
o Abacavir hypersensitivity syndrome, role of HLA B5701
o Zidovudine associated anemia [acute and latent]
o Stavudine, didanosine, and zalcitabine.
Peripheral neuropathy
Pancreatitis
o Indinavir
59
Retinoid-like cutaneous side effects
o Indinavir and atazanavir – hyperbilirubinemia, nephrolithiasis
o Efavirenz - central nervous system toxicity
o Tenofovir - nephrotoxicity and possible bone effects

x Mineral effects
x Acid reducing agents: IDV, ATV, NFV
x Hyperlipidermia
x Insulin Resistance
Prophylaxis against opportunistic infections [Pneumocystis, Mycobacterium, Toxoplasmosis]
CORE CURRICULUM
ANTI-RETROVIAL THERAPY
x When to start
x Medication options and their side-effects
x When to discontinue
Issues of adherence
x Understanding factors that influence medication compliance
o Positive
o Negative
o Counseling patient’s on adherence
Resistance testing
x Understanding currently available resistance assays –
o Proper use, strengths, and limitations;
o Utility of resistance testing in selecting a drug regimen
Treatment naïve
Treatment experienced
Salvage therapy
Therapeutic drug monitoring

x Understanding its principles and utility
Pharmacodynamics and pharmacokinetic

x Cmin, Cmax, IC 50, area under the curve (AUC), and inhibitory quotient (IQ) and
x Ritonavir’s effect on the pharmacokinetic of anti-retroviral medications
HIV and Hepatitis C co-infection

x Screening
x Evaluation
x Treatment options
x Management of treatment side-effects
HIV and Hepatitis B co-infection

x Screening
60
x Evaluation
x Treatment options
x Management of treatment side-effects
Competency Requirement The fellow is expected to manage patients with HIV infection
in the inpatient setting and provide continuity care in the
outpatient setting.
Competency Measurement The fellow will be evaluated on the management of patients
through interaction with faculty (e-value or mini-CEX)
References Clin Infect Dis 2004; 39:609–29
MMWR 2002; 51(RR-8)
http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf
Antiviral Research 85 (2010) 241–244
Current Infect Dis Report Volume 11, Number 4 / July, 2009
CORE CURRICULUM
TRANSPLANTATION INFECTIOUS DISEASES
G. Curriculum for Transplantation Infectious Diseases
1. Solid organ transplantation

a. Understand the time of occurrence of infections after solid organ
transplantation
b. Be aware of the types of transplants and the different risks and
characteristic infections.
c. Define the sites infection including infections of the surgical site, urinary
tract, respiratory tract, gastrointestinal tract, central nervous system and
bloodstream infections.
d. Understand the common pathogens involved in these infections.
e. Comprehend the opportunistic pathogens most likely to be involved in
solid organ transplantation
¾ Virus infections including herpes simplex virus, cytomegalovirus,
Epstein-Barr virus (post-transplant lymphoproliferative disorder
[PTLD]), parvovirus B19, BK virus and human herpes virus-8
¾ Fungal infections including candidiasis, aspergillosis, zygomycosis,
cryptococcosis and invasive infections with other moulds
¾ Other pathogens such as Pneumocystis jiroveci and Toxoplasma gondii
f. Understand medications used to treat and prevent infections in patients
with solid organ transplants.
g. Understand the medications used to immune suppress patients to prevent
rejection and their role in infectious diseases.
h. Be able to evaluate a patient prior to transplantation to determine risk of
infection and strategies to prevent them.
i. Be able to perform a history and physical examination, use laboratory
testing and imaging to come to a diagnosis in a febrile patient with solid
organ transplantation.
Competency Requirement Have a detailed understanding of the

different kinds of infections in the setting
of solid organ transplantation.
61
Competency Measurement Fellows will manage infectious
complications in patients with solid organ
transplantation
References Infect Dis Clin North Am. 2001;15:901-52
Clin Liver Dis. 2000;4:657-73
2. Bone Marrow Transplantation

Competency Requirement Have a detailed understanding of the different kinds of
infections in the setting of bone marrow
transplantation.
Competency Measurement Fellows will manage infectious complications in
patients with bone marrow transplantation
References 1. MMWR. 2000; 44(R10): 1-128.
CORE CURRICULUM
BONE MARROW TRANSPLANTATION
a. Understand the difference in infection risk posed by autologous bone

marrow transplantation and allogeneic transplantation.
¾ Define the risks posed by the use of immunosuppressive medications
as prophylaxis for graft vs. host disease
b. Define the antimicrobial agents used to prevent infections in the peri
procedure period of bone marrow transplantation.
c. Be aware of unique syndromes in bone marrow transplantation including
graft vs. host disease, veno-occlusive disease, mucositis, idiopathic
pneumonia syndrome, skin rashes and diarrhea.
d. Determine the different infection risks and pathogens at different times
during the procedure, pre-engraftment vs. early post-engraftment vs. late.
¾ Pre-engraftment period pathogens include Herpes simplex virus,
bacteria (gram-positive and gram-negative), Candida spp.,
Aspergillus spp. and respiratory viruses
¾ Early post-engraftment period (4-12 weeks) pathogens include
CMV, BK virus, and Toxoplasma gondii
¾ Late period pathogens (13-52 weeks) include VZV and
encapsulated bacteria.
¾ Other pathogens of interest include mycobacteria, Nocardia spp.,
EBV, HHV-6, Legionella pneumophila and Listeria
monocytogenes.
e. Understand the antimicrobial agents used to treat infections in BMT
patients and duration of therapy
f. Understand the role of the microbiology lab and other diagnostic tests in
the management of patients with bone marrow transplantation
¾ PCR testing for CMV
¾ Galactomannan assay for aspergillosis
¾ Rapid influenza testing
g. Have knowledge of the use of immunoglobulin replacement in bone
marrow transplantation and the use of vaccines once the immune system
has been partially reconstituted.
H. Infectious Diseases Curriculum in Medical Microbiology
62
Competency Requirements The fellow will become knowledgeable
regarding the appropriate use of the
microbiology laboratory and the
interpretation of data provided.
Competency Measurements The fellow will be evaluated by the
preceptor of the microbiology rotation.
Additionally, knowledge will be evaluated
on the clinical service.
References Curr Clin Top Infect Dis. 2001;21:172-89
I. Infection Control Curriculum
a. Understand the epidemiology of nosocomial infections
CORE CURRICULUM
INFECTION CONTROL
¾ Define the infections based on organ systems such as ventilator associated

pneumonia, infections of intravascular devices, urinary tract infections and
others
¾ Define the infections based on the specific pathogens such as MRSA,
VRE, C. difficile and others
¾ Define the infections based on diagnostic and therapeutic procedures
¾ Recognize the use of isolation in the healthcare setting to prevent
transmission of nosocomial infections
¾ Understand the role of standard precautions in prevention of transmission
of nosocomial infections
¾ Define contact, droplet and airborne precautions and understand the role
each plays in the transmission of nosocomial infections
o Know the policies regarding isolation for tuberculosis and
presumed tuberculosis and what criteria are used to take the patient
out of isolation or allow for hospital discharge.
o Understand the role of fit testing in airborne precautions
o Know the policies regarding isolation for meningococcal disease
and the criteria for removal of the patient from isolation.
¾ Understand the policies regarding bloodborne pathogens
¾ Be aware of the criteria for post-exposure prophylaxis of healthcare
workers for exposure to a communicable disease
¾ Define the role of antimicrobial restrictions in the control of antimicrobial
resistant bacterial infections.
¾ Be knowledgeable about hand hygiene and its role in control of
nosocomial infections.
¾ Be knowledgeable about other strategies to control nosocomial infections
¾ Learn how to investigate an outbreak of nosocomial infection in the
hospital
¾ The fellow will be required to participate in a workup of an outbreak
h. Attend monthly Infection Control Committee meetings and when possible
Attend weekly Infection Control Department meetings
63
Competency Requirement The fellow will become knowledgeable in
infection control and healthcare
epidemiology practice.
The fellow will attend the CDC/SHEA
training program. Management of
infection control issues will be evaluated

Competency Measurement
while on service and with phone calls. The
participation in the antimicrobial approval
process is another part of infection control
and is evaluated by reviewing antimicrobial
approvals.
References Mayhall Textbook Hospital Epidemiology
and Infection Control
64
INTERDEPARTMENTAL RELATIONSHIPS
Relationship with Department of Medicine
The ID Program Director reports directly to the Program Director of the Department of
Medicine. The status of clinical services, research programs, faculty development including
promotion and educational activities are reviewed on a regular basis.
The overall performance of the trainees in ID Medicine is reported to the Program Director of the
Department of Medicine on an annual basis. He/She is required to sign all forms indicating
satisfactory performance, completion of training, and eligibility for subspecialty certification. All
offers of appointment for new trainees are issued jointly by the Program Director of Medicine as
well as the ID Medicine program director. The Chairman of Medicine is directly involved in
faculty performance evaluations, advancement and assignment of responsibilities. Trainees in ID
Medicine participate in developing written evaluations of medical residents and students who
have served with them on the ID consultation and clinic.
Policy outlining lines of responsibility between Infectious Diseases residents and Internal
medicine residents
Our policy follows the guidelines established in the UCSF Fresno GMEC policy regarding
resident supervision. When an internal medicine resident is on the infectious diseases elective
he/she will perform the initial consultation and write the preliminary note. The ID fellow will
advise and educate prior to presentation to the attending physician. When the number of cases
increase, the fellow will also perform initial consultations. Should a patient require a procedure,
it is the fellow’s responsibility to obtain informed consent and perform the procedure. When
appropriate, the resident may do the procedure under the fellow’s supervision. The attending
physician will supervise any procedure the fellow is not qualified to perform independently.
6
Leave Policy for Residents/Fellows
Policy: UCSF Fresno supports a work and training environment that offers solutions to the
complex issues individuals face in balancing their work and family commitments. For this
reason UCSF Fresno has adopted the following guidelines regarding leave time for residents,
including leaves of absence. Any leaves of absence identified as a part of the UCSF Fresno
Academic Due Process policy are not covered under this policy.
Specialty Board requirements and RRC requirements should be reviewed prior to granting any
leave by the program director and resident to assure the resident is familiar with the possibility of
having to make up time away from training. Absences/Leaves (including Sick Leave) from the
training program may jeopardize the resident’s approval of credit for training; or additional
training may be required by the specialty Board/RRC. If extended leave results in the
requirement for additional training in order to satisfy specialty Board requirements or RRC
requirements, financial support for the additional training time must be determined when
arrangements are made for the leave and the makeup activity.
At the time each trainee requests a leave of absence, the terms will be put in writing and
signed by the Program Director and the trainee. The trainee will be informed of what
effect the leave will have on the completion of training. A copy of the written consent will
then be sent along with the Personnel Action Form (PAF) to the UCSF Fresno Office of
Medical Education.
Any consecutive leave beyond four (4) calendar months needs to be reviewed and
approved by the Associate Dean.
All leave time is subject to UCSF Fresno department and/or program approval. Paid leave will
be based on the normal academic year. If a resident begins training outside of the normal
academic year, vacation, sick and educational leave will be prorated from the beginning of the
training year to the end of the normal academic year on June 30th. A summary of the leave
policies referred to within this document include:
PAID LEAVE
Vacation/Educational Leave – Leave that is used at the resident’s discretion with program
approval.
Sick Leave – Leave that is used in the event of personal illness or injury; or illness, injury
or death of an immediate family member.
Short Term Military Leave
Jury Duty
Bereavement (sick leave)
UNPAID LEAVE
Medical Leave – leave without pay for illness, including any pregnancy related illness
(includes CFRA & FMLA)
Personal Leave – Leave without pay for any reason.
Extended Term Military Leave
VACATION LEAVE
Vacation leave with compensation shall be fifteen (15) days per academic year. In addition to
any department regulations concerning vacations, all vacation time must be scheduled with the
prior approval of the designated department faculty member and/or Program Director. As a
7
general rule, vacation time does not carry forward from year to year and must be scheduled and
taken in the same academic year the vacation is earned.
EDUCATIONAL LEAVE
Educational leave with compensation shall be five (5) days per academic year. To the extent that
a resident's department does not include educational leave as a portion of the annual vacation
leave, each resident is entitled to use the department educational leave days consistent with the
policies and procedures of the department. Educational time does not carry forward from year to
year and must be scheduled and taken in the same academic year the educational leave is earned.
SICK LEAVE
Sick leave with compensation shall be twelve (12) days per academic year for personal illness,
bereavement or disability. In addition, any remaining educational or vacation leave may be used
to cover illness or disabilities that exceed twelve (12) days of sick leave. Any incidents of sick
leave over 3 consecutive calendar days may require medical certification from the resident’s
health care provider. Programs must notify HR if a resident is on sick leave for 3 consecutive
calendar days or more so that they will receive Family and Medical Leave information that
describes rules and regulations under the policy. Sick leave does not carry forward from year to
year and must be taken in the same academic year the sick leave is earned.
BEREAVEMENT (SICK LEAVE)
Upon the death of an immediate family member (parent, spouse, child, grandparent,
grandchild, sister, brother, mother-in-law, father-in-law, or domestic partner w/affidavit on
file w/UCSF Fresno Human Resources Office), residents may request up to 3 days of
bereavement in the form of sick leave to make arrangements and/or attend the funeral.
Residents must discuss the amount and any additional time needed with their Chief and/or
Program Director.
DISABILITY BENEFITS
Please note that residents are not eligible for, nor covered by the state of California for short-
term disability insurance. However, residents enrolled in the UCSF Housestaff Benefits Plan are
entitled to disability coverage following 30 consecutive days of “total disability.” For more
information, please contact UCSF Fresno Human Resources at (559) 499-6416.
FAMILY & MEDICAL LEAVE ACT (FMLA)
PREGNANCY-RELATED DISABILITY
The California Family Rights Act allows for an additional twelve (12) workweeks of leave after
the birth of a child for pregnancy-related disability. This leave is in addition to the (12)
workweeks of Family and Medical Leave in a twelve-month period. The resident may elect to
use accrued sick leave, vacation leave and educational leave to remain on full pay status for the
initial period of the leave. The total duration of the maternity disability leave (paid and unpaid)
may not exceed 24 calendar weeks.
PATERNITY LEAVE
Paternity leave is covered under the Family and Medical Leave Act (FMLA). Residents
employed by UCSF Fresno for one year, who have worked 1,250 hours in the previous 12
8
months, and have a qualifying status change, are eligible for Family Medical Leave. Residents
who do not qualify for paternity leave may request an unpaid personal leave of absence from
their program. Approvals are subject to the requirements of applicable law, the program, the
appropriate specialty Board and the RRC. If UCSF Fresno employs both parents, UCSF Fresno
reserves the right, if consistent with system-wide University policy, to limit employees to a
combined total of 12 weeks of family leave.
If the event necessitating the leave is based on the expected birth, placement for adoption or
foster care, or planned medical treatment for a serious health condition, the resident must provide
at least 30 days advance notice before leave is to begin. If 30 days notice is not practicable,
notice must be given as soon as practicable. A resident’s request for a leave of absence must be
in writing.
JURY DUTY
A resident called to Jury Duty or to Grand Jury Duty will not suffer a loss of regular pay for
those days when one would otherwise be scheduled to perform their resident duties. A resident is
obligated to keep their department, and appropriate rotation service supervisor apprised of the
status once a jury summons has been received. Only the court pursuant to the procedure outlined
in the Jury Summons Notice can grant deferment or excused absence from jury service.
Deferment or excused absence is generally not granted for inconvenience but may be granted for
reasons of personal health or undue hardship, as determined by the court on a case-by-case basis.
MILITARY LEAVE
Residents are eligible for up to thirty (30) days of military leave with pay while engaged in the
performance of military duty. All benefit coverage will continue during paid military leave.
Absence from the training program to meet military service obligations must be with the
approval of the program director and/or department.
PERSONAL LEAVE
A resident may request from his/her program a personal leave of absence in order to attend to
personal matters of a serious, time consuming nature or if other leaves of absence are not
available. Requests must be in writing. A personal leave, if granted, is unpaid and may follow
the required use of any remaining unused vacation and/or educational leave. The total duration
of the personal leave (including paid and unpaid time) may not exceed four (4) calendar months.
Approval of a personal leave of absence is subject to the needs of the program in addition to the
requirements of the appropriate specialty Board and RRC.
DURATION OF LEAVE
The total length of any leave (paid and unpaid together) may not exceed four (4) calendar months
unless expressly extended in writing by the Program Director with acknowledgement and
approval of the Associate Dean. Consecutive leaves of absences cannot be granted for more than
one (1) year in duration.
BENEFIT STATUS DURING LEAVE

Residents are eligible to maintain insurance coverage during any leave of absence for up to six
(6) months as long as they pay their portion of their premium contribution (if applicable). If the
leave extends beyond six (6) months residents have the option of maintaining insurance coverage
for the remainder of the leave by reimbursing the University the total cost of their insurance
9
coverage (University’s contribution plus the resident premium contribution, if applicable) on a
monthly basis.
Premium payments must be made payable to the “UC Regents” and delivered or mailed to:
UCSF Fresno
Attention: Human Resources
155 N. Fresno Street
Fresno, CA 93701
Any payment covering insurance benefits must be received on the first of the month in which the
coverage is applicable. Late payments will initiate termination of benefits and COBRA
Continuation Coverage information will be forwarded to residents’ address of record. Group
coverage may be continued under COBRA benefits for up to 18 months.
MAKE-UP FOR TIME ON LEAVE

If, as a result of a leave, additional training experiences are necessary in order for the resident to
satisfy Board or RRC requirements, the pay status of the time spent in such make-up training
will be determined by the department prior to the commencement of the make-up activity. The
provision of make-up training is subject to the availability of an appropriate residency position,
the operational needs of the department (including funding constraints) and the requirements of
applicable law and University policy.
(Original signed Policy is available in the UCSF Fresno Office of Medical Education)
Joan L. Voris, M.D., Associate Dean, Co-Chair GMEC
10
ACGME Program Requirements for Graduate Medical Education
in Infectious Diseases
Common Program Requirements are in BOLD
Effective: July 1, 2007
I. Institutions
I.A. Sponsoring Institution
One sponsoring institution must assume the ultimate responsibility for the
program, as described in the Institutional Requirements, and this
responsibility extends to fellow assignments at all participating sites.
The sponsoring institution and program must ensure that the program
director has sufficient protected time and financial support for his or her
educational and administrative responsibilities to the program.
I.A.1. The sponsoring institution must:
I.A.1.a) demonstrate a commitment to education and research sufficient to

support the fellowship program;
I.A.1.b) establish the internal medicine subspecialty fellowship within a

department of internal medicine or an administrative unit whose
primary mission is the advancement of internal medicine
education and patient care;
I.A.1.c) provide fellow compensation and benefits, faculty, facilities, and

resources for education, clinical care, and research required for
accreditation;
I.A.1.d) ensure that adequate salary support is provided to the program

director for the administrative activities of the internal medicine
subspecialty program. The program director must not be required
to generate clinical or other income to provide this administrative
support. It is suggested that this support be 25-50% of the
program director=s salary, depending on the size of the program.
(See Section III.A.4.f)); and,
I.A.1.e) notify the Review Committee within 60 days of changes in

institutional governance, affiliation, or resources that affect the
educational program.
I.A.2. Graduate education in the subspecialties of internal medicine requires a

major commitment to education by the sponsoring institution. Evidence of
such a commitment includes each of the following:
I.A.2.a) The minimum number of fellowship positions supported by the

institution in each training program must not be less than the
Infectious Diseases 1
number of accredited training years in the program.
I.A.2.b) The institution must ensure significant research in each

subspecialty for which it sponsors a training program.
I.B. Participating Sites
Participating sites include both the primary training site and other training sites.
The primary training site is defined as the health-care facility that provides the
required training resources, should be the location of the program director's
major activity, the location where the fellow spends the majority of their clinical
training time, and the primary location of the core program in internal medicine.
I.B.1. There must be a program letter of agreement (PLA) between the

program and each participating site providing a required
assignment. The PLA must be renewed at least every five years.
The PLA should:
I.B.1.a) identity the faculty who will assume both educational and
supervisory responsibilities for fellows;
I.B.1.b) specify their responsibilities for teaching, supervision, and

formal evaluation of fellows, as specified later in this
document;
I.B.1.c) specify the duration and content of the educational

experience; and,
I.B.1.d) state the policies and procedures that will govern fellow
education during the assignment.
I.B.2. The program director must submit any additions or deletions of

participating sites routinely providing an educational experience,
required for all fellows, of one month full time equivalent (FTE) or
more through the Accreditation Council for Graduate Medical
Education (ACGME) Accreditation Data System (ADS).
I.B.3. The Review Committee must give prior approval for participation by any
site providing three months or more of training in a 12 or 24 month
program, or six months or more of training in a 36 month program.
I.B.4. Assignments at participating sites must be of sufficient length to ensure a

quality educational experience and should provide sufficient opportunity
for continuity of care. Although the number of participating sites may vary
with the various specialties= needs, all participating sites must
demonstrate the ability to promote the program goals and educational
and peer activities. Exceptions must be justified and prior-approved by
the Review Committee.
II. Program Personnel and Resources
II.A. Program Director
II.A.1. There must be a single program director with authority and

accountability for the operation of the program. The sponsoring
institution's GMEC must approve a change in program director.
After approval, the program director must submit this change to the
ACGME via the ADS.
II.A.2. The program director should continue in his or her position for a
length of time adequate to maintain continuity of leadership and
program stability.
II.A.3. Qualifications of the program director must include:
II.A.3.a) requisite specialty expertise and documented educational

and administrative experience acceptable to the Review
Committee;
II.A.3.b) current certification in the subspecialty by the American Board

of Internal Medicine, or specialty qualifications acceptable to
the Review Committee; and,
II.A.3.c) current medical licensure and appropriate medical staff

appointment.
II.A.3.d) at least five years of participation as an active faculty member in

an ACGME-accredited internal medicine subspecialty fellowship
program.
II.A.4. The program director must administer and maintain an educational

environment conducive to educating the fellows in each of the
ACGME competency areas. The program director must:
II.A.4.a) oversee and ensure the quality of didactic and clinical

education in all sites that participate in the program;
II.A.4.b) approve a local director at each participating site who is

accountable for fellow education;
II.A.4.c) approve the selection of program faculty as appropriate;
II.A.4.d) evaluate program faculty and approve the continued

participation of program faculty based on evaluation;
II.A.4.e) monitor fellow supervision at all participating sites;
II.A.4.f) prepare and submit all information requested by the ACGME,

including but not limited to the program information forms
and annual program fellow updates to the ADS, and ensure
that the information submitted is accurate and complete;
II.A.4.g) provide each fellow with documented semiannual evaluation
of performance with feedback;
II.A.4.h) ensure compliance with grievance and due process

procedures, as set forth in the Institutional Requirements and
implemented by the sponsoring institution;
II.A.4.i) provide verification of fellowship education for all fellows,

including those who leave the program prior to completion;
II.A.4.j) implement policies and procedures consistent with the

institutional and program requirements for fellow duty hours
and the working environment, including moonlighting, and, to
that end, must:
II.A.4.j).(1) distribute these policies and procedures to the fellows

and faculty;
II.A.4.j).(2) monitor fellow duty hours, according to sponsoring

institutional policies, with a frequency sufficient to
ensure compliance with ACGME requirements;
II.A.4.j).(3) adjust schedules as necessary to mitigate excessive

service demands and/or fatigue; and,
II.A.4.j).(4) if applicable, monitor the demands of at-home call and

adjust schedules as necessary to mitigate excessive
service demands and/or fatigue.
II.A.4.k) monitor the need for and ensure the provision of back up
support systems when patient care responsibilities are
unusually difficult or prolonged;
II.A.4.l) comply with the sponsoring institution’s written policies and

procedures, including those specified in compliance with the
Institutional Requirements, for selection, evaluation and
promotion of fellows, disciplinary action, and supervision of
fellows;
II.A.4.m) be familiar with and comply with ACGME and Review

Committee policies and procedures as outlined in the ACGME
Manual of Policies and Procedures;
II.A.4.n) obtain review and approval of the sponsoring institution’s

GMEC/DIO before submitting to the ACGME information or
requests for the following:
II.A.4.n).(1) all applications for ACGME accreditation of new

programs;
II.A.4.n).(2) changes in fellow complement;
II.A.4.n).(3) major changes in program structure or length of

training;
II.A.4.n).(4) progress reports requested by the Review Committee;
II.A.4.n).(5) responses to all proposed adverse actions;
II.A.4.n).(6) requests for increases or any change to fellow duty

hours;
II.A.4.n).(7) voluntary withdrawals of ACGME-accredited

programs;
II.A.4.n).(8) requests for appeal of an adverse action;
II.A.4.n).(9) appeal presentations to a Board of Appeal or the

ACGME; and,
II.A.4.n).(10) proposals to ACGME for approval of innovative

educational approaches.
II.A.4.o) obtain DIO review and co-signature on all program

information forms, as well as any correspondence or
document submitted to the ACGME that addresses:
II.A.4.o).(1) program citations, and/or
II.A.4.o).(2) request for changes in the program that would have

significant impact, including financial, on the program
or institution.
II.A.4.p) seek the prior approval of the Review Committee for any changes
in the program that may significantly alter the educational
experience of the fellows.
II.A.4.q) be responsible for monitoring fellow stress, including mental or

emotional conditions inhibiting performance or learning, and drug-
or alcohol-related dysfunction. Both the program director and
faculty should be sensitive to the need for timely provision of
confidential counseling and psychological support services to
fellows. Situations that demand excessive service or that
consistently produce undesirable stress on fellows must be
evaluated and modified.
II.A.4.r) dedicate an average of 20 hours per week of his or her

professional effort to the internal medicine subspecialty
educational program, with sufficient time for administration of the
program, and receive institutional support for that administrative
time.
II.A.4.s) participate in academic societies and in educational programs
designed to enhance his or her educational and administrative
skills.
II.A.4.t) implement a program of continuous quality improvement in

medical education for the faculty, especially as it pertains to the
teaching and evaluation of the ACGME Competencies (as outlined
in Section IV of this document).
II.A.4.u) be located at the principal clinical training site.
II.B. Faculty
II.B.1. At each participating site, there must be a sufficient number of

faculty with documented qualifications to instruct and supervise all
fellows at that location.
The faculty must:
II.B.1.a) devote sufficient time to the educational program to fulfill

their supervisory and teaching responsibilities; and to
demonstrate a strong interest in the education of fellows;
and,
II.B.1.b) administer and maintain an educational environment

conducive to educating fellows in each of the ACGME
competency areas.
II.B.2. The physician faculty must have current certification in the

subspecialty by the American Board of Internal Medicine, or possess
qualifications judged to be acceptable by the Review Committee.
II.B.3. The physician faculty must possess current medical licensure and
appropriate medical staff appointment.
II.B.3.a) The physician faculty must meet professional standards of ethical

behavior.
II.B.4. The nonphysician faculty must have appropriate qualifications in

their field and hold appropriate institutional appointments.
II.B.5. The faculty must establish and maintain an environment of inquiry

and scholarship with an active research component.
II.B.5.a) The faculty must regularly participate in organized clinical

discussions, rounds, journal clubs, and conferences.
II.B.5.b) Some members of the faculty should also demonstrate

scholarship by one or more of the following:
II.B.5.b).(1) peer-reviewed funding;
II.B.5.b).(2) publication of original research or review articles in

peer-reviewed journals or chapters in textbooks;
II.B.5.b).(3) publication or presentation of case reports or clinical

series at local, regional, or national professional and
scientific society meetings; or,
II.B.5.b).(4) participation in national committees or educational

organizations.
II.B.5.c) Faculty should encourage and support fellows in scholarly

activities.
II.B.5.d) The majority of faculty must be involved in scholarship as defined

in II.B.5.b.(1), (2), or (3) above.
II.B.5.e) The majority of key clinical faculty must demonstrate evidence of

productivity in the scholarship as defined in II.B.5.b.(1), or (2)
above.
II.B.5.f) At least one faculty member must be active in the scholarship

defined in II.B.5.b.(1) above.
II.C. Other Program Personnel
The institution and the program must jointly ensure the availability of all
necessary professional, technical, and clerical personnel for the effective
administration the program.
II.C.1. Key Clinical Faculty
In addition to the program director, each program must have two key
clinical faculty. Key clinical faculty are attending physicians who dedicate,
on average, 10 hours per week throughout the year to the training
program. For programs with more than five fellows enrolled during the
accredited portion of the training program, a ratio of key clinical faculty to
fellows of at least 1:1.5 must be maintained. (N.B.: The required number
of key clinical faculty may vary by subspecialty.)
II.C.1.a) Qualifications:
The key clinical faculty must:
II.C.1.a).(1) be active clinicians with broad knowledge of, experience

with, and commitment to the internal medicine subspecialty
as a discipline, and
II.C.1.a).(2) have current certification in the subspecialty by the

American Board of Internal Medicine or possess
qualifications judged by the Review Committee to be
acceptable.
II.C.1.b) Responsibilities for the key clinical faculty include:
In addition to the responsibilities of all individual faculty, the key

clinical faculty with the program director, are responsible for the
planning, implementation, monitoring and evaluation of the
fellows’ clinical and research training.
II.C.2. All clinical faculty members should participate in prescribed faculty

development programs designed to enhance the effectiveness of their
teaching.
II.D. Resources
The institution and the program must jointly ensure the availability of
adequate resources for fellow education, as defined in the specialty
program requirements.
II.D.1. Fellows must have clinical experiences in efficient, effective ambulatory

and inpatient care settings.
II.D.1.a) Space and equipment
There must be space and equipment for the educational program,

including meeting rooms, classrooms, examination rooms,
computers, visual and other educational aids, and work/study
space.
II.D.1.b) Facilities
II.D.1.b).(1) Fellows must have lounge and food facilities during

assigned duty hours.
II.D.1.b).(2) When fellows are assigned night duty in the hospital or

called in from home, they must be provided with on-call
facilities that are convenient and that afford privacy, safety,
and a restful environment with a secure space for their
belongings.
II.D.2. Medical Records
Clinical records that document both inpatient and ambulatory care must
be readily available at all times. (See Institutional Requirements, Section
II.D.3.d))
II.D.3. Patient Population
II.D.3.a) The inpatient and ambulatory care population must provide

experience with patients whose illnesses are encompassed by,
and help to define, the subspecialty.
II.D.3.b) There must be patients of both sexes, with a broad age range,
including geriatric patients.
II.D.3.c) A sufficient number of patients must be available to ensure

adequate inpatient and ambulatory experience for each
subspecialty fellow.
II.D.4. Death Reviews and Autopsies
II.D.4.a) All deaths of patients who received care by fellows must be

reviewed and autopsies performed whenever possible.
II.D.4.b) Fellows must receive autopsy reports after autopsies are

completed on their patients.
II.D.5. Support Services
II.D.5.a) Administrative support must include adequate secretarial and

administrative staff and technology to support the program
director.
II.D.5.b) Inpatient clinical support services must be available on a 24-hour

basis to meet reasonable and expected demands, including
intravenous services, phlebotomy services, messenger/transporter
services, and laboratory and radiologic information retrieval
systems that allow prompt access to results.
II.D.5.c) Consultations from other clinical services in the hospital must be

available in a timely manner. All consultations should be
performed by or under the supervision of a qualified specialist.
II.E. Medical Information Access
Fellows must have ready access to specialty-specific and other appropriate

reference material in print or electronic format. Electronic medical literature
databases with search capabilities should be available.
III. Fellow Appointment
III.A. Eligibility Criteria
The program director must comply with the criteria for fellow eligibility as
specified in the Institutional Requirements.
III.B. Number of Fellows
The program director may not appoint more fellows than approved by the
Review Committee, unless otherwise stated in the specialty-specific
requirements. The program’s educational resources must be adequate to
support the number of fellows appointed to the program.
III.C. Fellow Transfer
III.C.1. Before accepting a fellow who is transferring from another program,

the program director must obtain written or electronic verification of
previous educational experiences and a summative competency-
based performance evaluation of the transferring fellow.
III.C.2. A program director must provide timely verification of fellowship

education and summative performance evaluations for fellows who
leave the program prior to completion.
III.D. Appointment of Fellows and Other Students
The presence of other learners (including, but not limited to, residents from
other specialties, subspecialty fellows, PhD students, and nurse
practitioners) in the program must not interfere with the appointed fellows'
education. The program director must report the presence of other learners
to the DIO and GMEC in accordance with sponsoring institution guidelines.
III.E. Fellows responsibilities and professional relationships
Fellows must have clearly defined written lines of responsibility for all clinical
experiences.
III.F. When averaged over any five-year period, a minimum of 75% of fellows in each
subspecialty training program must be graduates of an ACGME accredited
internal medicine training program. Non-ACGME internal medicine trained
fellows must have at least three years of internal medicine training prior to
starting fellowship. Prior to appointment, the program director must inform non-
ACGME trained applicants in writing of the ABIM policies and procedures that
may affect the fellow=s eligibility for ABIM certification. (N.B.: Fellows in the
subspecialty of geriatric medicine may be graduates of an ACGME-accredited
family medicine training program.)
IV. Educational Program
IV.A. The curriculum must contain the following educational components:
IV.A.1. Overall educational goals for the program, which the program must
distribute to fellows and faculty annually;
IV.A.2. Competency-based goals and objectives for each assignment at

each educational level, which the program must distribute to fellows
and faculty annually, in either written or electronic form. These
should be reviewed by the fellow at the start of each rotation;
IV.A.2.a) for each rotation or major learning experience, the written goals
and objectives:
IV.A.2.a).(1) should include the educational purpose; teaching methods;
the mix of diseases, patient characteristics, and types of
clinical encounters, procedures, and services; reading lists,
pathological material, and other educational resources to
be used; and the method for evaluation of fellows’
competence;
IV.A.2.a).(2) must define the level of fellows’ supervision by faculty

members in all patient-care activities; and,
IV.A.2.a).(3) should be reviewed and revised at least every three years

by faculty members and fellows’ to keep the goals and
objectives current and relevant.
IV.A.3. Regularly scheduled didactic sessions; and,
IV.A.4. Delineation of fellow responsibilities for patient care, progressive

responsibility for patient management, and supervision of fellows
over the continuum of the program.
IV.A.5. ACGME Competencies
The program must integrate the following ACGME competencies

into the curriculum:
IV.A.5.a) Patient Care
Fellows must be able to provide patient care that is

compassionate, appropriate, and effective for the treatment of
health problems and the promotion of health. Fellows:
IV.A.5.a).(1) are expected to learn the practice of health promotion,

disease prevention, diagnosis, care, and treatment of men
and women from adolescence to old age, during health
and all stages of illness.
IV.A.5.b) Medical Knowledge
Fellows must demonstrate knowledge of established and

evolving biomedical, clinical, epidemiological and social-
behavioral sciences, as well as the application of this
knowledge to patient care. Fellows:
IV.A.5.b).(1) are expected to learn the scientific method of problem

solving, evidence-based decision making, a commitment to
lifelong learning, and an attitude of caring that is derived
from humanistic and professional values.
IV.A.5.c) Practice-based Learning and Improvement
Fellows must demonstrate the ability to investigate and
evaluate their care of patients, to appraise and assimilate
scientific evidence, and to continuously improve patient care
based on constant self-evaluation and life-long learning.
Fellows are expected to develop skills and habits to be able
to meet the following goals:
IV.A.5.c).(1) identify strengths, deficiencies, and limits in one’s

knowledge and expertise;
IV.A.5.c).(2) set learning and improvement goals;
IV.A.5.c).(3) identify and perform appropriate learning activities;
IV.A.5.c).(4) systematically analyze practice, using quality

improvement methods, and implement changes with
the goal of practice improvement;
IV.A.5.c).(5) incorporate formative evaluation feedback into daily

practice;
IV.A.5.c).(6) locate, appraise, and assimilate evidence from

scientific studies related to their patients’ health
problems;
IV.A.5.c).(7) use information technology to optimize learning; and,
IV.A.5.c).(8) participate in the education of patients, families,

students, fellows and other health professionals.
IV.A.5.d) Interpersonal and Communication Skills
Fellows must demonstrate interpersonal and communication

skills that result in the effective exchange of information and
collaboration with patients, their families, and health
professionals. Fellows are expected to:
IV.A.5.d).(1) communicate effectively with patients, families, and

the public, as appropriate, across a broad range of
socioeconomic and cultural backgrounds;
IV.A.5.d).(2) communicate effectively with physicians, other health

professionals, and health related agencies;
IV.A.5.d).(3) work effectively as a member or leader of a health care

team or other professional group;
IV.A.5.d).(4) act in a consultative role to other physicians and

health professionals; and,
IV.A.5.d).(5) maintain comprehensive, timely, and legible medical

records, if applicable.
IV.A.5.e) Professionalism
Fellows must demonstrate a commitment to carrying out

professional responsibilities and an adherence to ethical
principles. Fellows are expected to demonstrate:
IV.A.5.e).(1) compassion, integrity, and respect for others;
IV.A.5.e).(2) responsiveness to patient needs that supersedes self-

interest;
IV.A.5.e).(3) respect for patient privacy and autonomy;
IV.A.5.e).(4) accountability to patients, society and the profession;

and,
IV.A.5.e).(5) sensitivity and responsiveness to a diverse patient

population, including but not limited to diversity in
gender, age, culture, race, religion, disabilities, and
sexual orientation.
IV.A.5.f) Systems-based Practice
Fellows must demonstrate an awareness of and

responsiveness to the larger context and system of health
care, as well as the ability to call effectively on other
resources in the system to provide optimal health care.
Fellows are expected to:
IV.A.5.f).(1) work effectively in various health care delivery

settings and systems relevant to their clinical
specialty;
IV.A.5.f).(2) coordinate patient care within the health care system

relevant to their clinical specialty;
IV.A.5.f).(3) incorporate considerations of cost awareness and

risk-benefit analysis in patient and/or population-
based care as appropriate;
IV.A.5.f).(4) advocate for quality patient care and optimal patient

care systems;
IV.A.5.f).(5) work in interprofessional teams to enhance patient

safety and improve patient care quality; and,
IV.A.5.f).(6) participate in identifying system errors and

implementing potential systems solutions.
IV.B. Fellows’ Scholarly Activities
IV.B.1. The curriculum must advance fellows’ knowledge of the basic

principles of research, including how such research is conducted,
evaluated, explained to patients, and applied to patient care.
IV.B.2. Fellows should participate in scholarly activity.
IV.B.2.a) Participation in an active research program is an essential

component for fellows enrolled in subspecialty fellowship training
programs of 24 months or greater duration.
IV.B.2.a).(1) The program must ensure a meaningful, supervised

research experience with appropriate protected time for
each fellow—either in blocks or concurrent with clinical
rotations—while maintaining the essential clinical
experience.
IV.B.2.a).(2) Fellows must be advised and supervised by qualified

faculty members in the conduct of research.
IV.B.2.a).(3) Fellows must learn the standards of ethical conduct of

research, design and interpretation of research studies,
responsible use of informed consent, research
methodology, and interpretation of data.
IV.B.2.a).(4) The majority of fellows must demonstrate evidence of

recent research productivity through:
IV.B.2.a).(4).(a) publication (manuscripts or abstracts) in peer-

reviewed journals, or
IV.B.2.a).(4).(b) abstracts presented at national specialty meetings
(N.B.: Training programs in one-year critical care medicine

and internal medicine-geriatric medicine are exempt from
this requirement relative to research productivity by
fellows.)
IV.B.3. The sponsoring institution and program should allocate adequate

educational resources to facilitate fellow involvement in scholarly
activities.
IV.C. Definition and Scope of Specialty
IV.C.1. Subspecialty training in internal medicine is a voluntary component in the

continuum of the educational process; such training should take place
after satisfactory completion of an accredited program in internal
medicine.
IV.C.2. To be eligible for accreditation, a subspecialty program must function as
an integral part of an accredited residency program in internal medicine.
IV.C.3. There must be a reporting relationship, to ensure compliance with the

ACGME accreditation standards, from the program director of the
subspecialty program to the program director of the parent internal
medicine residency program.
IV.C.4. The discipline must be one for which a certificate or a certificate of added
qualifications is offered by the American Board of Internal Medicine. (For
editorial purposes, the term subspecialty is used throughout the
document for both types of training programs.)
IV.C.5. Subspecialty programs must provide advanced training to allow the fellow
to acquire competency in the subspecialty with sufficient expertise to act
as a consultant.
IV.D. Didactics
IV.D.1. Inpatient and Consultation Teaching
IV.D.1.a) Teaching and management rounds are usually combined in

subspecialty training programs. These rounds must be patient-
based sessions in which current cases are presented as a basis
for discussion of such points as interpretation of clinical data,
pathophysiology, differential diagnosis, specific management of
the patient, the appropriate use of technology, the incorporation of
evidence and patient values in clinical decision making, and
disease prevention.
IV.D.1.b) The total teaching time spent in combined management and

teaching rounds must exceed by a minimum of five hours per
week the time required to supervise the care of patients.
IV.D.2. Conferences and Seminars
IV.D.2.a) Conferences must be conducted regularly as scheduled and must

be attended by faculty and fellows. At a minimum, these must
include:
IV.D.2.a).(1) at least one clinical conference weekly,
IV.D.2.a).(2) one literature review conference (journal club) monthly,
IV.D.2.a).(3) one research conference monthly; and,
IV.D.2.a).(4) at least one core curriculum conference weekly, when

averaged over one year.
IV.D.2.a).(4).(a) The core curriculum conference series must include

the basic sciences relevant to the subspecialty;
IV.D.2.a).(4).(b) The core curriculum conference series must cover
the major clinical topics in the subspecialty; and,
IV.D.2.a).(4).(c) The core curriculum conference series must repeat

often enough, or be made available for review on
tape or electronically, to afford each fellow an
opportunity to attend or review most of the core
conference topics.
IV.D.2.b) Fellows must participate in formal review of gross and microscopic

pathological material from patients who have been under their
care.
IV.D.2.c) Fellows must participate in planning and in conducting

conferences.
IV.D.3. Interdisciplinary Topics
IV.D.3.a) Fellows should become proficient in the critical assessment of

medical literature, medical informatics, clinical epidemiology, and
biostatistics.
IV.D.3.b) Educational experiences should include instruction in the

following: clinical ethics, medical genetics, quality assessment,
quality improvement, patient safety, risk management, preventive
medicine, pain management, end-of-life care, and physician
impairment.
IV.E. Clinical
IV.E.1. Ambulatory medicine
IV.E.1.a) There must be on-site faculty whose primary responsibilities must

include the supervision and teaching of fellows.
IV.E.1.b) Fellows must be able to obtain appropriate and timely consultation

from other specialties for their ambulatory patients.
IV.E.1.c) There should be services available from other health-care

professionals such as nurses, social workers, language
interpreters, and dietitians.
IV.E.2. Experience with continuity ambulatory patients
IV.E.2.a) Fellows must have a continuity ambulatory clinic experience a half

day each week to develop a continuous healing relationship with
patients for whom they provide subspecialty care. This continuity
experience should expose fellows to the breadth and depth of the
subspecialty. (N.B.: May vary by subspecialty.)
This may be accomplished by either:
IV.E.2.a).(1) A single continuity clinic for the length of the accredited
fellowship, or
IV.E.2.a).(2) Blocks of at least six months duration for the length of the
accredited fellowship.
IV.E.2.b) Each fellow should, on average, be responsible for four to eight

patients during each half day session.
IV.E.2.c) Over the course of accredited training, each fellow=s panel of

patients must include at least 25% of patients from each gender.
IV.E.2.d) Each fellow=s clinical experiences with ambulatory patients must

provide fellows the opportunity to observe and to learn the course
of disease.
IV.E.2.e) The continuing patient-care experience should not be interrupted

by more than one month, excluding a fellow's vacation.
IV.E.2.f) During the continuity experience, arrangements should be made

to minimize interruptions of the experience by fellows' duties on
inpatient and consultation services.
IV.E.2.g) It is suggested that fellows should be informed of the status of

their continuity patients when they are hospitalized so the fellow
can make appropriate arrangements to maintain continuity of care.
IV.E.3. Procedures
IV.E.3.a) Fellows must develop a comprehensive understanding of

indications, contraindications, limitations, complications,
techniques, and interpretation of results of those diagnostic and
therapeutic procedures integral to the discipline.
IV.E.3.b) Fellows must acquire knowledge of and skill in educating patients

about the rationale, technique, and complications of procedures
and in obtaining procedure-specific informed consent.
IV.E.3.c) Faculty supervision of procedures performed by each fellow must

occur until proficiency has been acquired and documented by the
program director.
IV.E.3.d) Each program must:
IV.E.3.d).(1) identify key procedures;
IV.E.3.d).(2) define a standard for proficiency; and,
IV.E.3.d).(3) document achievement of proficiency.
V. Evaluation
V.A. Fellow
V.A.1. Formative Evaluation
V.A.1.a) The faculty must evaluate fellow performance in a timely

manner during each rotation or similar educational
assignment, and document this evaluation at completion of
the assignment.
V.A.1.a).(1) The faculty must discuss this evaluation with the fellow at
the completion of the assignment.
V.A.1.b) The program must:
V.A.1.b).(1) provide objective assessments of competence in

patient care, medical knowledge, practice-based
learning and improvement, interpersonal and
communication skills, professionalism, and systems-
based practice;
V.A.1.b).(2) use multiple evaluators (e.g., faculty, peers, patients,

self, and other professional staff);
V.A.1.b).(3) document progressive fellow performance

improvement appropriate to educational level; and,
V.A.1.b).(4) provide each fellow with documented semiannual

evaluation of performance with feedback.
V.A.1.b).(4).(a) This includes formal evaluations of knowledge,

skills, and professional growth of fellows and
required counseling by the program director.
V.A.1.c) The evaluations of fellow performance must be accessible for

review by the fellow, in accordance with institutional policy.
V.A.1.d) Permanent records of both the evaluation and counseling

sessions (and any others that occur) for each fellow must be
maintained in the fellow's file and must be accessible to the fellow
and other authorized personnel.
V.A.1.d).(1) The record of evaluation should document the fellow’s

achievement of the competencies using appropriate
evaluation methods.
V.A.1.d).(2) The record of evaluation should document that records

were maintained by documentation logbook or by an
equivalent method to demonstrate that fellows have
achieved competence in the performance of invasive
procedures. These records must state the indications and
complications, and include the names of the supervising
physicians. Such records must be of sufficient detail to
permit use in future credentialing.
V.A.1.d).(3) The record of evaluation should document that fellows

were evaluated in writing and their performance reviewed
with them verbally on completion of each rotation period.
V.A.1.d).(4) The record of evaluation should document that fellows

were evaluated in writing and their performance in
continuity clinic reviewed with them verbally on at least a
semiannual basis.
V.A.2. Summative Evaluation
The program director must provide a summative evaluation for each

fellow upon completion of the program. This evaluation must
become part of the fellow’s permanent record maintained by the
institution, and must be accessible for review by the fellow in
accordance with institutional policy. This evaluation must:
V.A.2.a) document the fellow’s performance during the final period of

education, and
V.A.2.b) verify that the fellow has demonstrated sufficient competence

to enter practice without direct supervision.
V.A.2.b).(1) The program director must also prepare annually a written

summative evaluation of the clinical competence of each
fellow. (N.B.: This summative evaluation is in addition to
the completion of the ABIM tracking form.)
V.A.2.b).(2) The summative evaluation must stipulate the degree to

which the fellow has achieved the level of performance
expected in each Competency (i.e., patient care, medical
knowledge, practice-based learning and improvement,
interpersonal and communication skills, professionalism,
and systems-based practice).
V.B. Faculty
V.B.1. At least annually, the program must evaluate faculty performance as

it relates to the educational program.
V.B.2. These evaluations should include a review of the faculty’s clinical

teaching abilities, commitment to the educational program, clinical
knowledge, professionalism, and scholarly activities.
V.B.3. This evaluation must include at least annual written confidential

evaluations by fellows.
V.B.4. Provision must be made for fellows to confidentially provide written
evaluations of each teaching attending at the end of a rotation, and for the
evaluations to be reviewed annually with faculty.
V.B.5. Fellows should evaluate the faculty’s effectiveness as teachers; fellows

must also evaluate the effectiveness of rotation or assignment in
achieving the goals and objectives identified in the curriculum for that
rotation or assignment.
V.B.6. The fellows must have the opportunity to assess formally the
effectiveness of ambulatory teaching on an ongoing basis.
V.B.7. The results of the evaluations must be used for faculty-member

counseling and for selecting faculty members for specific teaching
assignments.
V.C. Program Evaluation and Improvement
V.C.1. The program must document formal, systematic evaluation of the

curriculum at least annually. The program must monitor and track
each of the following areas:
V.C.1.a) fellow performance;
V.C.1.b) faculty development;
V.C.1.c) graduate performance, including performance of program

graduates on the certification examination; and,
V.C.1.c).(1) At least 80% of those eligible to take an ABIM subspecialty

certifying examination upon completion of their training for
the most recent five year period must have taken an ABIM
subspecialty certifying examination. (Note: Five-year rolling
pass rate for first time takers of the ABIM certifying
examination will be examined at each program review).
V.C.1.d) program quality. Specifically:
V.C.1.d).(1) Fellows and faulty must have the opportunity to

evaluate the program confidentially and in writing at
least annually, and
V.C.1.d).(2) The program must use the results of fellows’

assessments of the program together with other
program evaluation results to improve the program.
V.C.2. If deficiencies are found, the program should prepare a written plan
of action to document initiatives to improve performance in the
areas listed in section V.C.1. The action plan should be reviewed
and approved by the teaching faculty and documented in meeting
minutes.
VI. Fellow Duty Hours in the Learning and Working Environment
VI.A. Principles
VI.A.1. The program must be committed to and be responsible for

promoting patient safety and fellow well-being and to providing a
supportive educational environment.
VI.A.2. The learning objectives of the program must not be compromised by

excessive reliance on fellows to fulfill service obligations.
VI.A.3. Didactic and clinical education must have priority in the allotment of
fellows' time and energy.
VI.A.4. Duty hour assignments must recognize that faculty and fellows
collectively have responsibility for the safety and welfare of patients.
VI.B. Supervision of Fellows
The program must ensure that qualified faculty provide appropriate

supervision of fellows in patient care activities.
VI.C. Fatigue
Faculty and fellows must be educated to recognize the signs of fatigue and
sleep deprivation and must adopt and apply policies to prevent and
counteract its potential negative effects on patient care and learning.
VI.D. Duty Hours (the terms in this section are defined in the ACGME Glossary
and apply to all programs)
Duty hours are defined as all clinical and academic activities related to the
program; i.e., patient care (both inpatient and outpatient), administrative
duties relative to patient care, the provision for transfer of patient care,
time spent in-house during call activities, and scheduled activities, such as
conferences. Duty hours do not include reading and preparation time spent
away from the duty site.
VI.D.1. Duty hours must be limited to 80 hours per week, averaged over a
four-week period, inclusive of all in-house call activities.
VI.D.2. Fellows must be provided with one day in seven free from all
educational and clinical responsibilities, averaged over a four-week
period, inclusive of call.
VI.D.3. Adequate time for rest and personal activities must be provided.
This should consist of a 10-hour time period provided between all
daily duty periods and after in-house call.
VI.E. On-Call Activities
VI.E.1. In-house call must occur no more frequently than every third night,
averaged over a four-week period.
VI.E.1.a) Internal Medicine residency programs are not allowed to average

in-house call over a four-week period.
VI.E.2. Continuous on-site duty, including in-house call, must not exceed 24
consecutive hours. Fellows may remain on duty for up to six
additional hours to participate in didactic activities, transfer care of
patients, conduct outpatient clinics, and maintain continuity of
medical and surgical care.
VI.E.3. No new patients may be accepted after 24 hours of continuous duty.
VI.E.3.a) A new patient is defined as any patient to whom the fellow has not
previously provided care.
VI.E.4. At-home call (or pager call)
VI.E.4.a) The frequency of at-home call is not subject to the every-

third-night, or 24+6 limitation. However at home-call must not
be so frequent as to preclude rest and reasonable personal
time for each fellow.
VI.E.4.b) Fellows taking at-home call must be provided with one day in
day completely free from all educational and clinical
responsibilities, averaged over a four-week period.
VI.E.4.c) When fellows are called into the hospital from home, the
hours fellows spend in-house are counted toward the 80-hour
limit.
VI.F. Moonlighting
VI.F.1. Moonlighting must not interfere with the ability of the fellow to
achieve the goals and objectives of the educational program.
VI.F.2. Internal moonlighting must be considered part of the 80-hour weekly

limit on duty hours.
VI.G. Duty Hours Exceptions
A Review Committee may grant exceptions for up to 10% or a maximum of

88 hours to individual programs based on a sound educational rationale.
VI.G.1. In preparing a request for an exception the program director must

follow the duty hour exception policy from the ACGME Manual on
Policies and Procedures.
VI.G.2. Prior to submitting the request to the Review Committee, the
program director must obtain approval of the institution’s GMEC and
DIO.
VI.G.2.a) The Review Committee for Internal Medicine will not consider
requests for exceptions to the limit to 80 hours per week,
averaged over a four-week period.
VI.H. Service Versus Education
A sponsoring institution must not place excessive reliance on residents to meet

the service needs of the participating training sites.
VI.H.1. Fellows must not be required to provide routine intravenous, phlebotomy,

or messenger/transporter services.
VI.H.2. Fellows' service responsibilities must be limited to patients for whom the
teaching service has diagnostic and therapeutic responsibility
VI.H.3. The admission and continuing care of patients by fellows must be limited
to those patients on the teaching service.
VI.I. Grievance Procedures and Due Process
VI.I.1. In the event of an adverse annual evaluation, a fellow must be offered an

opportunity to address a judgment of academic deficiencies or
misconduct before a formally constituted clinical competence committee.
VI.I.2. There must be a written policy that ensures that academic due process is
provided.
VII. Experimentation and Innovation
Requests for experimentation or innovative projects that may deviate from the
institutional, common and specialty specific program requirements must be
approved in advance by the Review Committee. In preparing requests, the
program director must follow Procedures for Approving Proposals for
Experimentation or Innovative Projects located in the ACGME Manual on Policies
and Procedures. Once a Review Committee approves a project, the sponsoring
institution and program are jointly responsible for the quality of education offered
to fellows for the duration of such a project.
VII.A. Performance Improvement Process
VII.A.1. The program should identify and participate in at least one ongoing
performance improvement activity which relates to the competencies.
VII.A.2. The performance improvement activities must involve both fellows and
faculty in planning and implementing.
VII.A.3. The performance improvement activities should result in measurable
improvements in patient care or residency education.
VIII. Educational Program
VIII.A. A subspecialty educational program in infectious diseases must be organized to

provide training and supervised experience at a level sufficient for the fellow to
acquire the competency of a specialist in the field.
VIII.B. The training program must be 2 years in duration.
VIII.C. A minimum of 12 months must be devoted to clinical experiences.
VIII.D. Ambulatory medicine experience
Continuity ambulatory care experience of 24 months must be included in the

training program. During their ambulatory experience, fellows must have training
in both consultative services and continuing care in infectious disease, including
human immunodeficiency virus (HIV) infection.
IX. Faculty
See Program Requirements for Fellowship Education in the Subspecialties of Internal

Medicine.
X. Facilities and Resources
In addition to the facilities and resources outlined in the Program Requirements for
Fellowship Education in the Subspecialties of Internal Medicine, each of the following
must be present at the primary training site:
X.A. Diagnostic Laboratory Services
Fellows must have convenient access to a laboratory for clinical microbiology,

such that direct and frequent interaction with microbiology laboratory personnel is
readily available. (N.B.: This laboratory does not need to be located at the
primary training site.)
X.B. Imaging
No additional facilities are required.
X.C. Surgery and Pathology
No additional facilities or services are required.
X.D. Other Facilities, Resources, or Support Services
X.D.1. Facilities for the isolation of patients with infectious diseases must be
available.
X.D.2. It is suggested that the training program be conducted in a setting in
which training programs in surgery, obstetrics, gynecology, pediatrics,
and other medical and surgical specialties and subspecialties are
available.
X.E. Patient Population
See Program Requirements for Fellowship Education in the Subspecialties of

Internal Medicine.
XI. Specific Program Content
XI.A. Clinical Experience
XI.A.1. Clinical experience must include opportunities to manage adult and

geriatric patients with a wide variety of infectious diseases in both an
inpatient and ambulatory basis. Such opportunities must encompass
longitudinal experiences in a continuum of care in order to observe the
course of illness and the effects of therapy. Therapeutic modalities should
include management of antibiotic administration in settings such as the
acute care hospital, the office, and in conjunction with the non-acute care
facility or home-care services.
XI.A.2. Experience with pediatric infectious diseases is suggested.
XI.B. Technical and Other Skills
XI.B.1. Fellows must receive formal instruction and gain practical experience in
hospital epidemiology and infection control. This can be accomplished by
didactic or practical experience, as offered through organized
coursework, service on an infection control committee, or by an assigned
rotation on a hospital epidemiology service.
XI.B.2. Fellows must receive formal instruction and gain practical experience in
clinical microbiology.
XI.B.3. Fellows must have clinical experience and demonstrate competence in

the evaluation and management of infections in patients with major
impairments of host defense.
XI.B.3.a) The teaching services on which fellows work must provide an

average of at least 50 consultations per fellow during the period in
which fellows are rotating on these services for their clinical
training.
XI.B.3.b) This experience includes, but is not limited to:
XI.B.3.b).(1) patients who are neutropenic;
XI.B.3.b).(2) patients with leukemia, lymphoma or other malignancies;
XI.B.3.b).(3) patients following solid organ or bone marrow
transplantation; and
XI.B.3.b).(4) patients with HIV/AIDS or patients immunocompromised

by other diseases or medical therapies.
XI.B.3.c) Documentation of the number of consultations above may be

completed for the teaching service overall rather than per fellow, if
these numbers are available for the service; in this case, individual
fellow logs are not necessary. Otherwise, fellows should
document the number of consultations by an individual log.
XI.B.4. Fellows must have formal instruction or clinical experience and must
demonstrate competence in the evaluation and management of the
following disorders:
XI.B.4.a) infections of the reproductive organs;
XI.B.4.b) infections in solid organ transplant patients;
XI.B.4.c) infections in bone marrow transplant recipients;
XI.B.4.d) sexually transmitted diseases;
XI.B.4.e) viral hepatitis, including hepatitis B and C; and
XI.B.4.f) infections in travelers.
XI.B.5. Consultation Experience
The inpatient teaching services on which fellows work must provide an

average of at least 250 consultations per fellow during the period the
fellows are rotating on these services for their clinical training. These
consultations must be provided in a variety of clinical settings, including:
XI.B.5.a) Inpatient General Medical and Surgical Wards, and Intensive Care
Units
In these settings, fellows must have clinical experience and must

demonstrate competence in the evaluation and management of
patients with the following disorders:
XI.B.5.a).(1) pleuropulmonary infections;
XI.B.5.a).(2) infections and other complications in patients with

HIV/AIDS;
XI.B.5.a).(3) cardiovascular infections;
XI.B.5.a).(4) central nervous system infections;
XI.B.5.a).(5) gastrointestinal and intra-abdominal infections;
XI.B.5.a).(6) skin and soft tissue infections;
XI.B.5.a).(7) bone and joint infections;
XI.B.5.a).(8) infections of prosthetic devices;
XI.B.5.a).(9) infections related to trauma;
XI.B.5.a).(10) sepsis syndromes;
XI.B.5.a).(11) nosocomial infections; and
XI.B.5.a).(12) urinary tract infections.
XI.B.6. Ambulatory Medicine Experience
XI.B.6.a) Ambulatory training must include longitudinal care (at least 12

months of direct supervision of each patient) of at least 20 patients
with HIV infection.
XI.B.6.b) Direct oversight of the longitudinal care of patients with HIV

infection by the fellows must be provided by an experienced HIV
physician.
XI.B.6.c) At a minimum, 25% of patients of either gender must be

represented in the fellow’s panel of patients. If this gender
distribution is not feasible due to the local epidemiology of HIV,
then alternative clinical experiences or didactic instruction must be
provided.
XI.C. Formal Instruction
XI.C.1. The training program must provide formal instruction for the fellows in the
cognitive aspects of the following:
XI.C.1.a) mechanisms of action and adverse reactions of antimicrobial

agents; antimicrobial and antiviral resistance; drug-drug
interactions between antimicrobial agents and other compounds;
the appropriate use and management of antimicrobial agents in a
variety of clinical settings, including the hospital, ambulatory
practice, non acute-care units, and the home;
XI.C.1.b) methods of determining antimicrobial activity of a drug; techniques

to determine concentration of antimicrobial agents in the blood
and other body fluids; interpretation of antibiotic levels in blood;
XI.C.1.c) appropriate procedures for specimen collection relevant to

infectious disease, including but not limited to bronchoscopy,
thoracentesis, arthrocentesis, lumbar puncture, and aspiration of
abscess cavities;
XI.C.1.d) principles of prophylaxis and immunoprophylaxis to enhance

resistance to infection;
XI.C.1.e) characteristics, use, and complications of antiretroviral agents,

mechanisms and clinical significance of viral resistance to
antiretroviral agents, and recognition and management of
opportunistic infections in patients with HIV/AIDS;
XI.C.1.f) methods for accessing databases of relevance to the care and

management of individuals with infectious diseases; and,
XI.C.1.g) the epidemiology, clinical course, manifestations, diagnosis,

treatment and prevention of mycobacterial infections and major
parasitic diseases.
XI.C.2. Conferences and Seminars
As part of the required conferences and seminars outlined in the Program

Requirements for Fellowship Education in the Subspecialties in Internal
Medicine, a minimum of 25 hours each year must be devoted to
discussion of HIV-related topics.
***
ACGME Approved: September 28, 2004 Effective July 1, 2005

Revised Common Program Requirements Effective: July 1, 2007
Editorial Revision: July 1, 2009
ABIM REQUIREMENTS:
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CERTIFICATION
JULY 2008
1
TABLE OF CONTENTS
Requirements for Certification in Internal Medicine
Requirements for Certification in Subspecialties
Certification Using the Research Pathway
Special Training Policies
Other Policies
INTRODUCTION
The American Board of Internal Medicine (referred to throughout this document as “ABIM”)
was established in 1936 and is a private, not-for-profit corporation. Board members are elected
by the Board of Directors and serve two-year terms.
ABIM receives no public funds and has no licensing authority or function. ABIM’s mission is to
enhance the quality of health care by certifying internists and subspecialists who demonstrate the
knowledge, skills, and attitudes essential for excellent patient care.
Certification by ABIM recognizes excellence in the discipline of internal medicine and its
subspecialties.
Certification is not a requirement to practice internal medicine, and ABIM does not confer
privileges to practice. ABIM does not intend either to interfere with or to restrict the professional
activities of a licensed physician based on certification status.
ABIM administers the certification process by: (1) establishing requirements for training and
self-evaluation; (2) assessing the professional credentials of candidates; (3) obtaining
substantiation by appropriate authorities of the clinical competence and professional standing of
candidates; and (4) developing and conducting examinations and other assessments.
All ABIM certificates issued in 1990 (1987 for critical care medicine and 1988 for geriatric
medicine) and thereafter are valid for 10 years. Dates of validity are noted on the certificates.
To remain valid, these certificates must be renewed through
ABIM’s Maintenance of Certification program. Certificates issued before these dates are valid
indefinitely, although ABIM strongly recommends such certificate holders recertify as well.
For information about the Maintenance of Certification program, visit ABIM’s website,
www.abim.org, or contact ABIM, 1-800-441-2246.
A candidate's eligibility for certification is determined by the policies and procedures described
in this document and on ABIM’s website, www.abim.org. This edition of Policies and Procedures supersedes
all previous publications. ABIM reserves the right to make changes in its fees, examinations, policies, and
procedures at any time without advance notice. Admission to ABIM’s examinations will be
determined under the policies in force at the time of application.
July 2008
107
REQUIRMENTS FOR CERTIFICATION IN INTERNAL MEDICINE
Predoctoral Medical Education

To receive a certificate in internal medicine, a physician must complete the requisite predoctoral
medical education, meet the graduate medical education training requirements, demonstrate
clinical competence in the care of patients, meet the licensure and procedural requirements, and
pass the Certification Examination in Internal Medicine.
Candidates who graduated from medical schools in the United States or Canada must have
attended a school that was accredited at the date of graduation by the Liaison Committee on
Medical Education (LCME), the Committee for Accreditation of Canadian Medical Schools, or
the American Osteopathic Association.
Graduates of international medical schools must have one of the following: (1) a standard
certificate from the Educational Commission for Foreign Medical Graduates without expired
examination dates; (2) comparable credentials from the Medical Council of Canada; or (3)
documentation of training for those candidates who entered graduate medical education training
in the United
States via the Fifth Pathway, as proposed by the American Medical Association.
Graduate Medical Education
To be admitted to the Certification Examination in Internal Medicine, physicians must have

satisfactorily completed 36 calendar months, including vacation time, of graduate medical
education accredited by the Accreditation Council for Graduate Medical Education (ACGME),
the Royal College of Physicians and Surgeons of Canada, or the Professional Corporation of
Physicians of Quebec by August 31 of the year of examination. Residency or research
experience occurring before completion of the requirements for the MD or DO degree cannot be
credited toward the requirements for certification.
The 36 months of residency training must include 12 months of accredited internal medicine
training at each of three levels: R-1, R-2, and R-3. No credit is granted for training repeated at
the same level or for administrative work as a chief medical resident.
In addition, training as a subspecialty fellow cannot be credited

toward fulfilling the internal medicine training requirements.
Content of Training
The 36 calendar months of full-time medical residency education:
(1) Must include at least 30 months of training in general internal medicine, subspecialty
internal medicine and emergency medicine. Up to four months of the 30 months may include
training in areas related to primary care, such as neurology, dermatology, office gynecology, or
office orthopedics.
(2) May include up to three months of other electives approved by the internal medicine program
director.
108
(3) Must include three months of leave for vacation time (or for parental or family leave or
illness, including pregnancy-related disabilities). Vacation or other leave cannot be forfeited to
reduce training time.
In addition, the following requirements for direct patient responsibility must be met:
(1) At least 24 months of the 36 months of residency education must occur in settings where the
resident personally provides, or supervises less experienced residents who provide, direct
care to patients in inpatient or ambulatory settings.
(2) At least six months of the direct patient responsibility on internal medicine rotations must occur
during the R-1 year.
Clinical Competence Requirements

ABIM requires documentation that candidates for certification in internal medicine are
competent in:
(1) patient care (medical interviewing, physical examination, and procedural skills)
(2) medical knowledge
(3) practice-based learning and improvement;
(4) interpersonal and communication skills;
(5) professionalism;
(6) systems-based practice.
Through its tracking process, ABIM requires program directors to complete clinical competence
evaluations each spring for internal medicine residents. A candidate may be excluded from an
ABIM examination if the required components of clinical competence are not satisfactorily
documented by the training program.
PROGRAM DIRECTOR RATINGS OF CLINICAL COMPETENCE

COMPONENTS and R-1 and R02 R-3 Fellows (any year)
RATINGS
Overall Clinical Competence

Satisfactory Full Credit Full Credit Full Credit
Marginal Full credit for one marginal Not Applicable Not applicable
year. Repeat one year if
both Ri & R2 ar e marginal
Unsatisfactory No credit, must repeat No credit-must repeat No credit – must repeat
Moral & Ethical Behavior
Satisfactory Full credit Full credit Full credit
Unsatisfactory Repeat year or, at Repeat a year, or at Repeat a year or at
ABIM’s discretion, a ABIM’S discretion, a ABIM’S discretion, a
period of observation period of observation period of observation
will be required will be required. will be required.
Evaluation of Individual Generall Competencies
Satisfactory Full credit Full credit Full credit
Unsatisfactory Full credit No credit, must Must repeat year of
repeat year during final year of
required training
As outlined in the table above, all residents must receive satisfactory ratings in overall clinical
competence and moral and ethical behavior in each year of training. In addition, residents must
receive satisfactory ratings in each of the components of clinical competence during the final
year of required training. It is the resident's responsibility to arrange for any additional training
needed to achieve a satisfactory rating in each component of clinical competence.
109
Procedures Required for Internal Medicine
Safety is the highest priority when performing any procedure on a patient. ABIM recognizes that
there is variability in the types and numbers of procedures performed by internists in practice.
Internists who perform any procedure must obtain the appropriate training to safely and
competently perform that procedure. It is also expected that the internist be thoroughly evaluated
and credentialed as competent in performing a procedure before he or she can perform it
unsupervised. For certification in internal medicine,
ABIM has identified a limited set of procedures in which it expects all candidates to be
competent with regard to their knowledge and understanding. This includes:
(1) demonstration of competence in medical knowledge relevant to procedures through their
ability to explain indications, contraindications, patient preparation methods sterile techniques,
pain management, proper techniques for handling specimens and fluids obtained, and test results;
(2) ability to recognize and manage complications
(3) ability to clearly all facets of the procedure necessary to obtain informed consent. For a subset of
procedures, ABIM requires all candidates to demonstrate competence and safe performance by
means of evaluations performed during residency training. The set of procedures and associated
competencies required for each are presented in the table on page 4.
PROCEDURES REQUIRED FOR INTERNAL MEDICINE
COMPETENCY
KNOW UNDERSTAND EXPLAIN
Indications; Contraindications; Specimen Handling Interpretation of Requirements and Perform Safely
Recognition and Management Results Knowledge to Obtain
of Complications; Pain and Competently
Informed Consent
Management; Sterile Techniques
Abdominal paracentesis X X X X
Advanced cardiac life X N/A N/A N/A X
support
Arterial line placement X N/A X X
Arthrocentesis X X X X
Central venous line X X N/A X
placement
Drawing venous blood X X X N/A X
Drawing arterial blood X X X X X
Incision and drainage of X X X X
an abscess X X X X
Lumbar puncture X X X X
Pap smear and X X X X
endocervical culture X X X X X
Placing a peripheral X N/A N/A N/A X
venous line
Pulmonary artery catheter N/A X X
placement
Thoracentesis X X X X
To help acquire both knowledge and performance competence, ABIM believes that residents
should be active participants in performing procedures. Active participation is defined as serving
as the primary operator or assisting another primary operator. ABIM encourages program
directors to provide each resident with sufficient opportunity to be observed as an active
participant in the performance of required procedures. In addition, ABIM strongly recommends
that procedural training be conducted initially through simulations. At the end of training, as part
of the
evaluation required for admission to the Certification Examination in Internal Medicine, program
directors must attest to each resident’s knowledge and competency to perform the procedures in
the table above. ABIM does not specify a minimum number of procedures to demonstrate
110
competency; however, to assure adequate knowledge and understanding of the common
procedures in internal medicine, each resident should be an active participant for
each procedure five or more times.
CREDIT IN LIEU OF STANDARD TRAINING FOR INTERNAL MEDICINE

CANDIDATES Training Completed Prior to Entering Internal Medicine Residency
ABIM may grant credit for some or all of the 12-month requirement at the R-1 level for training
taken prior to entering training in internal medicine. The program director of an accredited
internal medicine residency program must petition ABIM to grant credit in lieu of standard R-1
internal medicine training. Candidates who have already completed 12 months of accredited U.S.
or Canadian PGY-1 internal medicine training are not eligible to be petitioned for credit. Before
being proposed, the candidate should have been observed by the proposer for a minimum of
three months. No credit will be granted to substitute for 24 months of accredited R-2 and R-3
internal medicine training.
(1) Month-for-month credit may be granted for satisfactory completion of internal medicine
rotations taken during a U.S. or Canadian accredited non-internal medicine residency program if
all of the following criteria are met:
(a) the internal medicine training occurred under the direction of a program director of an
accredited internal medicine program;
(b) the training occurred in an institution accredited for training internal medicine residents; and
(c) the rotations were identical to the rotations of the residents enrolled in the accredited internal
medicine residency program.
(2) For trainees who have satisfactorily completed some U.S. o Canadian accredited training in
another specialty, ABIM may grant
(a) month-for-month credit for the internal medicine rotations that meet the criteria listed
under (1) above;
plus,
(b) a maximum of six months of credit for the training in family medicine or a pediatrics
program; or,
(c) a maximum of three months of credit for training in a non-internal medicine specialty
program.
(3) Up to 12 months of credit may be granted for at least three years of U.S. or Canadian
accredited training in another clinical specialty and certification by an ABMS member Board in
that specialty.*
(4) Up to 12 months of credit may be granted for at least three years of verified internal medicine
training abroad.*
* Requires a fee of $300. Guidelines for proposals are available at
www.abim.org/certification/policies/special.aspx.
Training Completed Abroad by Current Full-Time U.S. or Canadian Faculty*

Full-time internal medicine faculty members in an LCMEaccredited medical school or an
accredited Canadian medical school may qualify for admission to the Certification Examination
in Internal Medicine if they:
(1) are proposed by the chair or program director of an accredited internal medicine residency
program;
(2) have completed three or more years of verified internal medicine training abroad;
(3) hold an appointment at the level of Associate Professor or higher at the time of proposal; and
(4) have completed eight years, after formal training, as a clinician-educator or a clinical
investigator in internalmedicine with a full-time appointment on a medical school faculty.
* Requires a fee of $300. Guidelines for proposals are available at
111
www.abim.org/certification/policies/special.aspx.
Training in Combined Programs

ABIM recognizes internal medicine training combined with
training in the following programs:
• Dermatology
• Emergency Medicine
• Emergency Medicine/Critical Care Medicine
• Family Medicine
• Medical Genetics
• Neurology
• Nuclear Medicine
• Pediatrics*
• Physical Medicine and Rehabilitation
• Preventive Medicine
• Psychiatry
* Combined medicine/pediatrics training initiated July 1, 2007 or after must be undertaken in a
combined medicine/pediatrics program accredited by the ACGME.
Guidelines for the combined training programs and requirements for credit toward the ABIM
Certification Examination in Internal Medicine are available at
www.abim.org/certification/policies/imss/im.aspx.
REQUIREMENTS FOR CERTIFICATION IN SUBSPECIALTIES

GENERAL REQUIREMENTS
In addition to the primary certificate in internal medicine, ABIM
certifies physicians in the following subspecialties:
• Adolescent Medicine
• Cardiovascular Disease
• Clinical Cardiac Electrophysiology
• Critical Care Medicine
• Endocrinology, Diabetes, and Metabolism
• Geriatric Medicine
• Gastroenterology
• Hematology
• Hospice and Palliative Medicine
• Infectious Disease
• Interventional Cardiology
• Medical Oncology
• Nephrology
• Pulmonary Disease
• Rheumatology
• Sleep Medicine
• Sports Medicine
• Transplant Hepatology
To become certified in a subspecialty, physicians must have been reviously certified in internal
medicine by ABIM and must satisfactorily complete the requisite graduate medical education
fellowship training, demonstrate clinical competence in the care of patients, meet the licensure
and procedural requirements, and pass the secure examination for that discipline.
112
In order to be eligible for certification and renewal of a certificate in adolescent medicine,
hospice and palliative medicine, sleep medicine, and sports medicine, diplomates must maintain
a valid underlying certificate in either internal medicine or a subspecialty. Diplomates must
maintain a valid underlying certificate in cardiovascular disease to obtain certification and be
eligible for renewal of a certificate in clinical cardiac electrophysiology or interventional
cardiology. Diplomates must maintain a valid underlying certificate in gastroenterology to obtain
certification and be eligible for renewal of a certificate in transplant hepatology.
Fellowship training must be accredited by the Accreditation Council for Graduate Medical
Education (ACGME), the Royal College of Physicians and Surgeons of Canada, or the
Professional Corporation of Physicians of Quebec. No credit will be granted toward certification
in a subspecialty for training completed outside of an accredited U.S. or Canadian program.
Fellowship training taken before completing the requirements for the MD or DO degree, training
as a chief medical resident, practice experience, and attendance at postgraduate courses may
not be credited toward the training requirements for subspecialty certification.
To be admitted to an examination, candidates must have completed the required training in the
subspecialty, including vacation time, by October 31 of the year of examination. Candidates for
certification in the subspecialties must meet ABIM’s requirements for duration of training as
well as minimum duration of full-time clinical training. Clinical training requirements may
be met by aggregating full-time clinical training that occurs throughout the entire fellowship
training period; clinical training need not be completed in successive months. Time spent in
continuity outpatient clinic, during non-clinical training, is in addition to the requirement for full-
time clinical training. Educational rotations completed during training may not be
double-counted to satisfy both internal medicine and subspecialty training requirements.
Likewise, training which qualifies a diplomate for admission to one subspecialty examination
cannot be double-counted toward certification in another subspecialty, with the exception of the
formally approved pathways for dual certification.
Training Requirements for Subspecialties

The total months of training required, including specific clinical months, and requisite
procedures for each subspecialty are outlined by discipline in the table below.
Hospice and Palliative Medicine

No required procedures.
Infectious Disease
Microscopic evaluation of diagnostic specimens including preparation,staining, and
interpretation; management, maintenance, and removal of indwelling venous access catheters;
and administration of antimicrobial and biological products via all routes.
recommended.
Special Candidates for Subspecialties*

ABIM diplomates in internal medicine may be proposed for special consideration for admission
to a subspecialty examination by the program director of an accredited fellowship program if
they:
113
(1) have completed the full training required by ABIM in the subspecialty in another country and
have met all current applicable ABIM procedural requirements;
(2) are a full-time Associate Professor or higher in the specifies subspecialty division of the
Department of Medicine in an LCME-accredited medical school or an accredited Canadian
medical school;
(3) have served eight years, after formal training, as a clinician educator or clinical investigator
with a full-time appointment on a medical school faculty.
* Proposals require a fee of $300. Guidelines for proposals are
CERTIFICATION USING THE RESEARCH PATHWAY

The Research Pathway is intended for trainees planning academic careers as investigators in
basic or clinical science. The pathway integrates training in clinical medicine with a minimum of
three years of training in research methodology. Prospective planning of this pathway by trainees
and program directors is necessary. Program directors must document the clinical and research
training experience each year through ABIM’s tracking program. The chart on page 10 describes
the Research Pathway requirements. All trainees in the Research Pathway must satisfactorily
complete 24 months of accredited categorical internal medicine residency training. A minimum
of 20 months must involve direct patient responsibility.
The Research Pathway for certification in internal medicine and a subspecialty that requires 12
months of clinical training is a six-year program. For subspecialties such as cardiovascular
disease and gastroenterology, which require more than 12 months of clinical training, and for
dual certification in hematology/oncology, pulmonary disease/critical care medicine, and
rheumatology/allergy and immunology, the Research Pathway is a full seven-year program,
including 36 to 42 months of research, depending on the number of months of clinical training
completed
During the research period, 80 percent of time is devoted to research and 10 to 20 percent of time
to clinical work. The trainee must attend a minimum of one half-day per week in continuity
outpatient clinic. Time spent in continuity outpatient clinic during non-clinical training is in
addition to the requirement for full-time clinical training. ABIM defines research as scholarly
activities intended to develop new scientific knowledge. The research experience of trainees
should be mentored and reviewed. Unless the trainee has already achieved an advanced graduate
degree, training should include completion of work leading to one or its equivalent. The last year
of the Research Pathway may be taken in a full-time faculty position if the level of commitment to
mentored research is maintained at 80 percent.
During internal medicine research training, 20 percent of each year must be spent in clinical
experiences including a half-day per week in a continuity clinic. During subspecialty research
training, at least one half-day per week must be spent in an ambulatory clinic.
Ratings of satisfactory clinical performance must be maintained annually for each trainee in the
ABIM Research Pathway. For additional information, see
www.abim.org/certification/policies/research/requirements.aspx.
SPECIAL TRAINING POLICIES
Disclosure of Performance Information
Trainees planning to change programs must make requests to their current program and to ABIM
to send written evaluations of past performance to the new program. These requests must be
made in a timely manner to ensure that the new program director has the performance
evaluations for review before offering a position. A new program director may also request
performance evaluations from previous programs and from ABIM concerning trainees who
114
apply for a new position. ABIM will respond to requests from trainees and program directors by
providing any performance evaluations it has in its possession and the total credits accumulated
toward ABIM’s training requirements for certification. This information will include the
comments provided with the evaluation.
Due Process for Evaluations

The responsibility for the evaluation of a trainee's clinical competence and moral and ethical
behavior rests with the program, not with ABIM. ABIM is not in a position to re-examine the
facts and circumstances of an individual's performance. As required by the ACGME in its
Essentials of Accredited Residencies in Graduate Medical Education, the educational institution
must provide appropriate due process for its decisions regarding a trainee's performance.
Leave of Absence and Vacations

Trainees must take one month per year of training for vacation (or for parental or family leave, or
illness, including pregnancy-related disabilities). Training must be extended to make up any
absences exceeding one month per year of training. Vacation leave is essential and cannot be
forfeited or postponed in any year of training
Definition of Full-time Training

Full-time training is defined as daily assignments for periods of no less than one month to
supervised patient care, educational, or research activities designed to fulfill the goals of the
training program. Full-time training must include formative and summative evaluation of clinical
performance, with direct observation by faculty and senior trainees
Reduced-Schedule Training
Interrupted full-time training is acceptable, provided that no period of full-time training is shorter
than four weeks. In any 12-month period, at least six months should be spent in training. Patient
care responsibilities should be maintained in a continuity clinic during the non-training
component of the year at a minimum of one-half day per week. ABIM approval must be obtained
before initiating an interrupted training plan. Part-time training, whether or not continuous, is not
acceptable.
OTHER POLICIES
Board's Evaluations and Judgments

Candidates for certification and Maintenance of Certification agree that their professional
qualifications, including their moral and ethical standing in the medical profession and their
competence in clinical skills, will be evaluated by ABIM, and ABIM’s good faith judgment
concerning such matters will be final.
ABIM may make inquiry of persons named in candidates' applications and of other persons, such
as authorities of licensing bodies, hospitals, or other institutions as the ABIM may deem
appropriate with respect to such matters. Candidates agree that the ABIM may provide
information it has concerning them to others whom ABIM judges to have a legitimate need for it.
ABIM makes academic and scientific judgments in its evaluations of the results of its
examinations. Situations may occur, even through no fault of the candidates, that render
examination results unreliable in the judgment of ABIM. Candidates agree that if ABIM
determines that, in its judgment, the results of their examination are unreliable, ABIM may
require the candidates to retake an examination at its next administration or other time designated
by ABIM.
115
Board Eligibility
ABIM does not use, define, or recognize the term "Board Eligible."
Reporting Certification Status

ABIM will routinely report, through its website or by mail, whether candidates are certified
(including dates) or not certified. If a diplomate was previously certified, the dates of former
certification will be reported. If certification is revoked or suspended, ABIM will report that fact,
including the date of revocation or suspension.
On a candidate's written request to ABIM, the following information will also be provided in
writing: (1) that an application is currently in process; and/or (2) the year the candidate was last
admitted to examination.
Representation of Certification Status

Diplomates of ABIM must accurately state their certification status at all times. This includes
descriptions in curriculum vitae, advertisements, publications, directories, and letterheads.
Diplomates with expired time-limited certification or those whose certification is suspended or

revoked may not claim board certification by ABIM and must revise all descriptions of their
qualifications accordingly. When a physician misrepresents certification status, ABIM may
notify local credentialing bodies licensing bodies, law enforcement agencies, and others.
Errors and Disruptions in Examination Administration

Occasionally problems occur in the creation, administration, and scoring of examinations. For
example, power failures, hardware and software problems, human errors, or weather problems
may interfere with some part of the examination process. When such problems occur, ABIM will
provide the affected candidates with an opportunity for re-examination.
Re-examination shall be the candidate's sole remedy. ABIM shall not be liable for
inconvenience, expense, or other damage caused by any problems in the creation, administration,
or scoring of an examination, including the need for retesting or delays in score reporting. In no
circumstance will ABIM reduce its standards as a means of correcting a problem in examination
administration.
Confidentiality Policy
ABIM considers the certification or recertification status of its candidates and diplomates to be
public information.
ABIM provides a diplomate's certification status and personal identifying information, including
mailing address, e-mail address and social security number, to the Federation of State Medical
Boards (FSMB) and the American Board of Medical Specialties (ABMS) which publishes The
Official ABMS Directory of Board
Certified Medical Specialists. The FSMB and ABMS use personal identifying information,
including social security numbers, as a unique internal identifier and maintain the confidentiality
of this information. On request, ABIM provides a diplomate’s certification status and address to
the professional medical societies that provide educational resources relevant to the Maintenance
of Certification program.
116
ABIM provides residency and fellowship training directors with information about a trainee's
prior training and pass/fail status on certifying examinations. If a trainee has given permission,
ABIM will provide the program director with the trainee's score on his/her first attempt at the
certification examination for that area of training. ABIM uses examination performance, training
program evaluations, self-evaluations of knowledge and practice performance, and other
information for research purposes, including collaboration with other research investigators and
scientific publications. In such research, ABIM will not identify specific individuals, hospitals,
or practice associations. All practice performance data is HIPAA compliant.
ABIM reserves the right to disclose information it possesses about any individual whom it
judges has violated ABIM rules, engaged in misrepresentation or unprofessional behavior, or
shows signs of impairment.
Licensure
Candidates for certification and Maintenance of Certification must possess a valid, unrestricted,
and unchallenged medical license in the United States, its territories, or Canada. Candidates
practicing exclusively abroad and who do not hold a US or Canadian license, must hold a license
where they practice and provide documentation from the relevant licensing authority that their
license is in good standing and without conditions or restrictions. A candidate whose license has
been restricted, suspended, revoked, or surrendered in lieu of disciplinary action, in any
jurisdiction, cannot be certified recertified, or admitted to a certification examination.
Restrictions include but are not limited to conditions, contingencies, probation, and stipulated
agreements.
Disabled Candidates
ABIM recognizes that some candidates have physical limitations that make it impossible for
them to fulfill the requirement for proficiency in performing procedures. For such individuals,
the procedural skills requirement may be waived. Program directors should write to ABIM for an
exception before the individual enters training or when the disability becomes established.
ABIM is committed to offering suitable examination accommodations for all candidates,

including individuals with disabilities. When necessary, alternative arrangements under
conditions comparable to those provided for other candidates are offered to disabled individuals.
Candidates who need accommodation for a disability during an examination must provide a
written request to ABIM at the time of application for examination. ABIM will then inform the
candidate of the documentation that must be received by ABIM no later than the examination registration
deadline. Reapplication for special accommodation is not required for each examination
administration unless a new accommodation is requested. ABIM treats requests for
accommodations as confidential. For additional information about the process and
documentation requirements, please contact ABIM at accommodations@
abim.org, or refer to the ABIM website, www.abim.org.
Substance Abuse
If a candidate or a diplomate has a history of substance abuse, documentation of at least one year
of continuous sobriety from a reliable monitoring source must be submitted to ABIM for
admission to an examination or to receive a certificate. ABIM treats such information as
confidential.
Suspension and Revocation of Certificates

ABIM may, at its discretion, revoke or rescind certification if the diplomate was not qualified to
receive the certificate at the time it was issued, even if the certificate was issued as a result of a
117
mistake on the part of ABIM. It may also revoke the certificate if the diplomate fails to maintain
moral, ethical, or professional behavior satisfactory to ABIM, or engages in misconduct that
adversely affects professional competence or integrity. It may revoke or suspend the certificate
if: (1) the diplomate made any material misstatement of fact or omission of fact to ABIM in
connection with application or to any third party concerning the diplomate's certification status;
or (2) the diplomate's license to practice medicine has been revoked, suspended, restricted, or
surrendered in lieu of disciplinary action in any jurisdiction. Restrictions include but are not
limited to conditions, contingencies, probation, and stipulated agreements. A physician may
petition ABIM for recertification upon restoration of unrestricted licensure. If ABIM grants
the petition, and upon such conditions as ABIM may require, the physician must complete
ABIM’s Maintenance of Certification program. Upon successful completion of the Maintenance
of Certification program the physician will be granted a new timelimited certificate consistent
with the current policies of ABIM.
Irregular Behavior on Examinations

The ABIM’s examinations are copyrighted and administered in secure testing centers by test
administrators who are responsible for maintaining the integrity and security of the certification
process. Test administrators are required to report to ABIM any irregular or improper behavior
by a candidate, such as giving or obtaining information or aid, looking at the test material of
others, removing examination materials from the test center, taking notes, bringing electronic
devices (e.g., beepers, pagers, cell phones, etc.) into the examination, failing to comply with time
limits or instructions talking, or other disruptive behavior. In addition, as part of its effort to
assure exam integrity, ABIM utilizes data forensic systems that
118

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UCSF Fresno

Policy & Procedure

Revised July 20010

General Attending Physician Responsibilities

Fellow Responsibilities and Requirements

¾ The resident’s primary responsibility is to fulfill the education expectation of the

VACATION/CONFERENCE REQUEST FORM

NUMBER OF WEEK DAYS__________

SIGNATURE OF COVERING FELLOW________________________________

SIGNATURE OF PROGRAM DIRCTOR_______________________

POLICY: Impaired Residents / Fellows

The goals of this policy are:

In achieving these goals, several principles are involved:

3. At departmental request, a designated representative will be available to provide

Microbiology 7:30-11:30 7:30-11:30 7:30-11:30

ETC 3RD Thursday,

ROTATION Monday Tuesday Wednesday Thursday Friday

The fellows do a complete written survey of the program once a year.

Level of responsibility/ independence by proficiency level*

Average Average Frequency

Average Average Frequency

CONTINUITY CLINIC EXPERIENCE:

Other Ambulatory Experience:

Infections and other complications in patients with HIV/AIDS

Duration of rotation: [x] one month

General description of the rotation including educational purpose, rationale or value:

CRMC has an antimicrobial management program to ensure the appropriate utilization of

j. The fellow will take first call regarding antimicrobial approvals.

Educational Objectives: An expanded version of the competencies is listed under Core

Check all principle teaching methods used during this rotation:

Principal ancillary education materials used:

Methods used to evaluate the resident and the rotation:

Conferences or Attending/Patient Care Rounds: (Journal club, division rounds, etc.)

Name Location Day Time

Microbiology Rounds CRMC Lab Wed 1000-1100

General description of the rotation including educational purpose, rationale or value:

Educational Objectives: An expanded version of the competencies is listed under Core

Check all principle teaching methods used during this rotation:

Check the principal ancillary education materials used:

Methods used to evaluate the resident and the rotation:

Conferences or Attending/Patient Care Rounds: (Journal club, division rounds, etc.)

Name Location Day Time

Microbiology Rounds CRMC Lab Wed 1000-1100

Duration of rotation: [x] one month Average Number of Months

General description of the rotation including educational purpose, rationale or value:

Educational Objectives: An expanded version of the competencies is listed under Core

Check all principle teaching methods used during this rotation:

Check the principal ancillary education materials used:

Methods used to evaluate the resident and the rotation:

Conferences or Attending/Patient Care Rounds: (Journal club, division rounds, etc.)

Name Location Day Time

Microbiology Rounds CRMC Lab Wed 1000-1100

Duration of rotation: [x] one month Average Number of Months

General description of the rotation including educational purpose, rationale or value:

Educational Objectives: An expanded version of the competencies is listed under Core

Check all principle teaching methods used during this rotation:

Check the principal ancillary education materials used:

Methods used to evaluate the resident and the rotation:

Conferences or Attending/Patient Care Rounds: (Journal club, division rounds, etc.)

Name Location Day Time

Microbiology Rounds CRMC Lab Wed 1000-1100

Duration of rotation: [x] one month Average Number of Months