New Application: Internal Medicine and Pediatrics
Review Committees for Internal Medicine and Pediatrics
ACGME
515 North State Street, Suite 2000, Chicago, Illinois 60654  312.755.5000  www.acgme.org
ADMINISTRATION OF THE COMBINED PROGRAM
1. Will there be a single program director with administrative responsibility for the combined program?
[Med-Peds Program Requirements (MPPR) II.D.] ........................................................ ☐ YES ☐ NO
2. Will the sponsoring institution provide adequate salary support for the program director for the
administrative activities of the program? [MPPR IV.A.]................................................. ☐ YES ☐ NO
3. Will the salary support prevent the program director from the need to generate income to support
the administrative activities of the program? [MPPR IV.A.1.] ........................................ ☐ YES ☐ NO
4. Will the program director have sufficient authority and resources to enact any required changes to
the program? [MPPR IV.C.].......................................................................................... ☐ YES ☐ NO
5. Will the program director have sufficient authority to determine the number of combined residents?
.................................................................................................................................... ☐ YES ☐ NO
6. Will the program directors for the core programs meet with the combined program director to
collaborate and coordinate the curriculum and rotations? [MPPR IV.F.] ....................... ☐ YES ☐ NO
7. How frequently will these meetings occur? [MPPR IV.G.] ................................................ [Frequency]
8. Will the meetings involve consultation with faculty and residents from both departments?
[MPPR IV.G.] ............................................................................................................... ☐ YES ☐ NO
If you answered “no” to any of the above, provide an explanation.
Click here to enter text.
9. Explain how the program will ensure adequate communication and collaboration between
departments. [MPPR IV.E.1.]
Limit response to 200 words
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EDUCATIONAL PROGRAM
1. Will there be a written curriculum for the combined program? [MPPR I.B.]................... ☐ YES ☐ NO
2. Will there be goals and objectives for all training experiences? [Common Program Requirements
(CPR) IV.A.2.] .............................................................................................................. ☐ YES ☐ NO
3. Will they be rotation and level specific? [CPR IV.A.2.] .................................................. ☐ YES ☐ NO
4. Will they be distributed to the residents and faculty? [CPR IV.A.2.] .............................. ☐ YES ☐ NO
5. Describe how residents will attend conferences in each of the specialties. Describe any joint
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conferences. [MPPR IV.H.1.]
Limit response to 75 words
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6. Explain how the curriculum will provide a cohesive planned educational experience and not simply
a series of rotations between the two specialties. [MPPR V.D.]
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7. Using a bulleted list below, identify any joint internal medicine-pediatric clinical experiences during
the course of the training program. [MPPR VI.]
Limit response to 150 words
 Click here to enter text.
8. Describe the mechanism that will be used to determine residents’ procedural competence. On the
day of the site visit provide the site visitor the mechanism used to assess procedural competence.
Procedures reports (from the ACGME’s case log system or another data collection system) should
not be appended to the PIF. [CPR V.A.1.b).(1)]
Limit response to 100 words
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9. Explain the process that will be used to remediate residents when deficiencies in procedural
competence are identified.
Limit response to 100 words
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©2015 Accreditation Council for Graduate Medical Education (ACGME)
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Patient Care - Continuity Experience
Provide the information below for all continuity sites that will be used in the program. Provide the name of the continuity clinic site, duration
and frequency of experience, number of residents assigned to each clinic, whether on-site faculty supervision will be available, and total
number of adult and pediatric patients seen. Add rows as necessary. Review the data for internal consistency.
1. Combined Continuity Clinics [MPPR V.G.3.]
Continuity
Clinic Sites
1.
2.
3.
Duration of
Experience
(weeks/year)
Frequency of
Experience
(# of 1/2
days/week)
Number of residents assigned to
this clinic
PGY-1
PGY-2
PGY-3
PGY-4
On-site
Faculty
Supervision
Total # of
Adult
Patients
Seen
Total # of
Peds
Patients
Seen
2. Medicine Continuity Clinics [MPPR V.G.4.a)-V.G.4.d)]
Continuity Clinic Sites
1.
2.
3.
Duration of
Experience
(weeks/year)
Frequency of
Experience
(# of 1/2
days/week)
Number of residents assigned to
this clinic
PGY-1
PGY-2
PGY-3
PGY-4
On-site
Faculty
Supervision
Total # of
Adult
Patients
Seen
On-site
Faculty
Supervision
Total # of
Peds
Patients
Seen
3. Pediatrics Continuity Clinics [MPPR V.G.4.a)-V.G.4.d)]
Continuity Clinic Sites
1.
2.
3.
Duration of
Experience
(weeks/year)
Frequency of
Experience
(# of 1/2
days/week)
Number of residents assigned to
this clinic
PGYPGYPGY1’s
2’s
3’s
PGY-4’s
4. How will the program ensure continuity of patient care for the combined residents? [MPPR V.G.5.]
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5. If residents are assigned to different continuity sites during the course of their training, explain how continuity will be maintained
throughout the four years of training. [MPPR V.G.1.]
Click here to enter text.
Medical Knowledge- Program Curriculum
Block Diagram - Following the instructions and format below, upload the block diagram to ADS:
1. Provide a rotation schedule that shows the rotations in chronological order for a typical medicine-pediatrics resident for each year of
training.
2. Use a distinct title for each rotation (e.g., Geriatric Medicine, General Medicine, General Pediatrics, and Neonatal Intensive Care). Do not
use local terminology (e.g., Blue I). The rotation name should clearly indicate the nature of the rotation. Define all required experiences.
3. For combined Med-Peds rotations, indicate whether this month counts towards IM or Peds time.
4. For the required pediatric subspecialty experiences, use “RS” for those subspecialties that come from List 1 in the program
requirements. Do not list as an elective. [Pediatric Program Requirement (PPR) IV.A.6.b).(3).(c)]
5. Indicate elective rotations with the term elective.
6. Indicate the duration of the rotations in weeks or months.
7. Indicate in bold type any experiences that differ from the training in the internal medicine or pediatrics residencies and experiences that
are unique to the medicine-pediatrics program.
Year 1
Rotation
Name
Duration of
Experience
Site
(Indicate
(i.e.,
weeks or
Hosp. 1) months)
Service
IM
Inpatient
(IP),
Number
Resident
Comb. Outpatient
% of
Freq. of
of Full Supervisory
Med(OP) or Ambulatory Avg. Duty Nights On- Days off
Role
Peds Peds
Both
Time
Hours/Week
call
Per Week
(Yes/No)
Year 2
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Updated 2/2015
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Rotation
Name
Site
(i.e.,
Hosp.
1)
Duration of
Experience
(Indicate
weeks or
months)
Site
(i.e.,
Hosp.
1)
Duration of
Experience
(Indicate
weeks or
months)
Site
(i.e.,
Hosp.
1)
Duration of
Experience
(Indicate
weeks or
months)
Service
IM
Inpatient
(IP),
Number
Resident
Comb. Outpatient
% of
Freq. of
of Full Supervisory
Med(OP) or Ambulatory Avg. Duty Nights On- Days off
Role
Peds Peds
Both
Time
Hours/Week
call
Per Week
(Yes/No)
Year 3
Rotation
Name
Service
IM
Inpatient
(IP),
Number
Resident
Comb. Outpatient
% of
Freq. of
of Full Supervisory
Med(OP) or Ambulatory Avg. Duty Nights On- Days off
Role
Peds Peds
Both
Time
Hours/Week
call
Per Week
(Yes/No)
Year 4
Rotation
Name
Service
IM
Inpatient
(IP),
Number
Resident
Comb. Outpatient
% of
Freq. of
of Full Supervisory
Med(OP) or Ambulatory Avg. Duty Nights On- Days off
Role
Peds Peds
Both
Time
Hours/Week
call
Per Week
(Yes/No)
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Updated 2/2015
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Rotation Schedule
1. Provide a narrative description of any experiences that differ from the training in the internal
medicine or pediatrics residencies and experiences that are unique to the medicine-pediatrics
program.
Click here to enter text.
2.
3.
4.
5.
Medicine
Pediatrics
#
#
#
#
Indicate the total number of months of direct
patient care responsibility
Indicate the total number of months spent in a
supervisory role
Indicate the total number of months spent on
Medicine night float
Indicate the total number of months spent on
Pediatrics night float
Year 1
Year 2
Year 3
Year 4
#
#
#
#
#
#
#
#
Pediatric Experiences
1. General Pediatric Inpatient Data
a) Provide all the information requested below for the most recent 12-month period. Information on
the participating sites should be reported only if residents rotate to these inpatient services to
complete their required five inpatient educational units (i.e., if five inpatient rotations are done at
the primary site but an additional month over and above the five months is done at the
community site, inpatient data for the latter need not be included). [PPR II.D)
Start date & end date for data collection:
Start: Click here to
Use the same 12-month period throughout
enter a date.
document
Patient Data
Total pediatric admissions for the year
Average Daily Census
Average length of stay
Site #1
#
#
#
Site #2
#
#
#
End: Click here to enter
a date.
Site #3
#
#
#
Site #4
#
#
#
b) Complete the following grid (replicate as necessary) to describe the experience at all
participating sites at which residents have required general pediatric inpatient rotations that
count towards the 5 required inpatient educational units. For example, Team #1 at Site #1,
Team #1 at Site #2, etc. Provide the number of daytime and nighttime patients for each
category for each team. [PPR II.D & IV.A.6.b).(2).(a).(i)]
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Updated 2/2015
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Inpatient Team Composition
Team # [ ] at Site # [ ]
(insert number for team and site)
Planned total # of residents actually on the
service acting as primary providers (include
residents from other specialties, such as
family medicine)
Categorical pediatrics
Combined med-peds
Other (specify)
Planned average number of patients for
each primary caretaker
Planned total number of residents providing
direct supervision or indirect supervision but
immediately available
Planned number of faculty providing direct
supervision or indirect supervision but
immediately available
Daytime
(do not include
residents post-call or
assigned to morning
clinic)
Nighttime
2. Resident Responsibilities for Supervision of Residents [PPR IV.A.4.]
Identify the experiences in which residents will act in a supervisory role. [PPR IV.A.4.b)]
Click here to enter text.
3. Life Support Skills [PPR IV.A.5.a).(2).(b)]
a) Will all residents be required to complete training and maintain certification in PALS?
............................................................................................................................... ☐ YES ☐ NO
b) Will all residents be required to complete training and maintain certification in NRP?
............................................................................................................................... ☐ YES ☐ NO
c) Will all residents be required to complete training in simulated placement of an intraosseous
line? ....................................................................................................................... ☐ YES ☐ NO
4. Intensive Care
a) Report the ICU educational units on the chart below: [MPPR VI.B.2.a).(1)-(2); PPR
IV.A.6.b).(2).(b)]
Block Rotations/Call
a) Required NICU educational units
b) Required PICU educational units
Year 1
#
#
Year 2
#
#
Year 3
#
#
Year 4
#
#
Total
#
#
b) Neonatal Intensive Care [PPR II.D.2)
Start date & end date for data collection:
Start: Click here to
Use the same 12-month period throughout
enter a date.
document
Internal Medicine - Pediatrics
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End: Click here to
enter a date.
Updated 2/2015
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Patient Data
NICU Level Designation (i.e. 2, 3A, 3C)
Annual NICU admissions
Total # of NICU beds
Avg. daily census/Avg. length of stay
Annual admissions < 1500 grams
Annual # of deaths in NICU
Site #1
#
#
#
#/#
#
#
Site #2
#
#
#
#/#
#
#
Site #3
#
#
#
#/#
#
#
Site #4
#
#
#
#/#
#
#
c) For each NICU team complete the following grid. Be sure the site designation is correct for each
team listed. If more than one site is used to meet the required NICU experience, replicate this
information. Provide the number of daytime and nighttime patients for each category. [PPR
II.D.2)
NICU Team Composition
Team # [ ] at Site # [ ]
(insert number for team and site)
Planned total # of residents actually on the
service acting as primary providers (include
residents in the combined program as well
as categorical residents and those in other
specialties)
Planned average # of patients per
resident (primary caretaker)
Planned number of Supervising
Residents, if applicable
Daytime
(do not include
residents post-call or
assigned to morning
clinic)
Nighttime
d) Pediatric Intensive Care [PPR II.D.2)
Start date & end date for data
collection: Use the same 12Start: Click here to enter a
month period throughout
date.
document
End: Click here to enter a
date.
Patient Data
Site #1
Site #2
Site #3
Site #4
Annual PICU admissions
#
#
#
#
Total # of PICU beds
#
#
#
#
Avg. daily census/Avg. length of
#/#
#/#
#/#
#/#
stay
Are post-operative cardiac
☐ YES ☐ NO ☐ YES ☐ NO ☐ YES ☐ NO ☐ YES ☐ NO
patients admitted to this unit?
Are other surgical patients
☐ YES ☐ NO ☐ YES ☐ NO ☐ YES ☐ NO ☐ YES ☐ NO
admitted to this unit?
Annual # of deaths in PICU
#
#
#
#
For each PICU team, complete the following grid. Be sure the site designation is correct. If more
than one site is used to meet the required months of PICU experience, replicate this
information. Provide the number of daytime and nighttime patients for each category. [PPR
II.D.2.]
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©2015 Accreditation Council for Graduate Medical Education (ACGME)
Updated 2/2015
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PICU Team Composition
Team # [ ] at Site # [ ]
(insert number for team and site)
Planned total # of residents actually on the
service acting as primary providers (include
residents in the combined program as well
as categorical residents and those in other
specialties)
Planned average # of patients per
resident
(primary caretaker)
Planned number of Supervising
Residents, if applicable
Daytime
(do not include post call
residents or residents
assigned to morning
clinic)
Nighttime
Emergency Medicine (EM)/Acute Illness (AI)
1. Complete the table below for the EM/AI experience during the four years of training. [MPPR
VI.B.2.c).(1); PPR IV.A.6.b).(4).(b)]
Total duration in educational units of EM experience
Duration of assignments to an Emergency Department (must be in an EMS
receiving setting)
Duration
Duration
2. Complete the chart below for emergency medicine experiences. Provide data for every site that is
used to meet the required educational units (e.g., if an outside ED is used to meet the requirement,
list this site and enter the requested data). Provide the site number, number of total visits per year,
percentage of patients under the age of 22, times staffed by residents, and average number of
patients per residents per shift. Add rows for additional sites if necessary. [PPR II.D.2)
Site #
Total visits per
year
If comb.
Adult/Ped, % of
patients under 22
Actual times staffed by
residents
(e.g., 0800-0500)
(not just # of hours)
Average number
of patients per
resident per shift
Individualized Curriculum
1. Will each resident have 2 educational units of an individualized curriculum determined by their
learning needs and career plans? [MPPR VI.B.2.d); PPR IV.A.6.b).(1)] ....................... ☐ YES ☐ NO
2. If yes, describe how subspecialty experiences will be chosen to support their learning needs and
career plans. [MPPR VI.B.2.d).(1); PPR IV.A.6.b).(1).(a)]
Limit response to 100 words
Click here to enter text.
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Updated 2/2015
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3. Describe (a) how the individualized curriculum will be implemented, (b) how a faculty mentor will
guide the development of the curriculum, (c) in what post graduate years these experiences will
occur, and (d) identify any of the experiences that will occur longitudinally. [MPPR VI.B.2.d).(1);
PPR IV.A.6.b).(1).(a)]
Limit response to 200 words
a) Click here to enter text.
b) Click here to enter text.
c) Click here to enter text.
d) Click here to enter text.
Internal Medicine Experiences
1. Geriatric Medicine
If there is not a separate geriatric medicine rotation, explain how residents will obtain clinical
experience in geriatrics. [Internal Medicine Program Requirements (IMPR) VI.A.8.]
Click here to enter text.
2. Adult Cardiology
Explain how residents will obtain significant exposure to cardiology. [IMPR VI.A.7.c)]
Click here to enter text.
EVALUATION
1. Will there be a regular meeting (that includes leadership from both medicine and pediatrics) to
discuss program goals and the effectiveness in achieving them? [MPPR IV.G.] .......... ☐ YES ☐ NO
2. How often will the above meeting occur? [MPPR IV.G.] .................................................. [ # ] per year
3. Will the minutes of these meetings documented? [MPPR IV.H.] .................................. ☐ YES ☐ NO
RESIDENT DUTY HOURS AND THE WORKING ENVIRONMENT
Duty Hours
Explain how the program will ensure that residents in the combined program meet the duty hour
requirements at the times of transition between specialties. [MPPR IV.I.]
Limit response to 100 words
Click here to enter text.
Night Float/Night Shift
If the program requires night experiences, describe how these are structured to provide educational
experiences. [IMPR I.A.2.m).(4); PPR VI.G.6.a)]
Limit response to 200 words
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Updated 2/2015
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Updated 2/2015
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