Preventive Medicine and Biometrics

PGY3 Year

The PGY3 year begins, typically on 1 July, on successful completion of the PGY2 year. Residents must spend a minimum of 48 weeks in practicum year rotations. Consequently, they are advised not to schedule more than two weeks of leave initially, to allow latitude for on-time graduation if convalescent leave or permissive TDY for house-hunting is needed during the training year.

The object of the PGY3 year is to complete the training of a preventive medicine officer by giving the resident a variety of opportunities to apply the 'book knowledge' of their PGY2 year and Journal Club to real-world preventive medicine practice situations. GPM residents, during their training, should aspire to meet the ultimate challenge of public health-making rational, evidenced-based decisions using sound data and science in the face of uncertainty, inadequate information, politics, economics, and other distracters.

The PGY3 year is structured as a series of rotations typically lasting as long as eight weeks each. Each rotation is built around previously discussed preventive medicine competencies and has a qualified and designated preceptor directly supervising the PGY3 resident. The resident is expected to fully participate in a "hands-on" mode during practicum rotations, and assume significant responsibilities. Usually the resident will complete a specific project or series of projects complementary to the needs of the practicum site and under the advisement of the preceptor. Such projects are intended to provide the PGY3 resident with the opportunity to actively apply core preventive medicine knowledge within a mentored setting. The resident and preceptor must balance the time invested in the project with other experiential and observational learning opportunities unique to the rotation. A rotation usually should not be overwhelmed by project demands.

Because of some unique strengths of the USUHS GPM residency (service-specific financial support for the residency, fully funded and salaried residents, and a prime location in the National Capital Area), a large number of practicum rotations are possible. The greatest dilemma for most residents in the PGY3 year is choosing among the many different rotation possibilities. Doing a variety of rotations is desirable because it allows the resident to experience a wide range of preventive medicine practice situations. While there may be a temptation to sacrifice the length of longer rotations for breadth and variety of shorter experiences, it should be noted that the resident will not gain nearly as much if a rotation is too short and (s)he does not have the chance to adequately orient to the organization and take on meaningful responsibilities. Prior to transition of the resident to the PGY3 year, a block rotation schedule and education plan for that phase of training is developed under the advisement of the program directors. The practicum year schedule may evolve over time and should be flexible. Each resident's PGY3 year is planned and adjusted as necessary to meet changing interests and needs, and to fulfill the ACGME requirements, including two months of DPC and two months in a Public Health Agency.

In addition to their rotations, practicum year residents are required to participate in residency business meetings, Journal Club and PMB noon seminars. They are expected to take a more active teaching and leadership role in these activities. They are expected to serve as mentors for the PGY2 residents, advising them on their courses and orienting them to the practicum year. Practicum year residents typically attend at least one national meeting and two to four special courses throughout the year. They are expected to present the results of their research or other projects at professional meetings and in peer-reviewed publications.

Core PGY3 Rotations

Currently, there are five or six "core" rotations, depending on the Service, designed to cover a wide spectrum of public health and preventive medicine practice ranging from front-line military and local civilian public health agencies to US Government agency policy-level experiences. Deviations from core rotations will be considered on an exception-to-residency-policy basis. The philosophy of the residency emphasizes a meaningful breadth of experience enabling graduates to succeed in a wide variety of settings, beginning at the local civilian level (county public health) and front-line military preventive medicine units (such as Navy Environmental and Preventive Medicine Units) extending to high-level policy making experiences(BUMED and AFMSA) and an understanding of clinical preventive services (AHRQ). If a resident already has significant experience in one of these areas, then a core rotation could be waived.

The ACGME RRC for Preventive Medicine currently requires each GPM resident to spend at least two months at a governmental public health agency during their practicum year. This requirement is interpreted by the NCC (USUHS) GPM Residency to mean that residents will rotate in the front-lines of civilian public health-a county health department. Thus, all residents must rotate through the Montgomery County Department of Health and Human Services or an equivalent county health department.

The required core rotations include:

  • A county public health department rotation, either Montgomery County, Anne Arundel County or Fairfax County Departments of Health and Human Services
  • A health services/clinical preventive services rotation at the Agency for Healthcare Research and Quality (AHRQ).
  • Direct Patient Care (DPC) rotations: 8 weeks minimum. Likely sites include
    • US Naval Academy (Brigade, Occ Med, Sports Med all possibilities)
    • US Air Force Academy
    • Andrews Flight Medicine Clinic
    • Pentagon Flight Medicine Clinic
    • Others have been and are continuing to be pursued
  • For Navy Residents
    • NEPMU: 6-8 weeks
    • BUMED and/or HQMC: 8 weeks
  • For Air Force Residents
    • AFMSA: 4-8 weeks
    • AFMOA: 2-4 Weeks
    • Trainee Health: 2-4 weeks @ Lackland, USAFA, USNA (may also count toward DPC)

There are a number of keys to a successful practicum rotation. One is a good learning environment with a strong and enthusiastic preceptor who actively mentors the resident and provides regular feedback. Another is a sound educational plan for the rotation based on achieving certain specified competencies. Thirdly, the PGY3 resident should be motivated, an aggressive learner, self-starting, and enthusiastic in taking advantage of rotation learning opportunities. Finally, the rotation site should have experience with training GPM residents. These required core rotations have proven repeatedly to meet these criteria.

PGY3 Elective Rotations

There are a wide range of additional rotations available. The remainder of the practicum year can be tailored to an individual resident's interests, needs, and experience level. With adequate notice, new rotations may be established as needed. Residents have great flexibility in electives and support from other military agencies such as the Global Emerging Infectious Surveillance and Response System (GEIS) which often allow them to travel for rotations if needed. Current elective opportunities include:

Public Health Policy Rotations

  • American College of Preventive Medicine, Washington, DC-this rotation is usually a competitive elective through the Pfizer Fellowship Program. It requires application and a recommendation letter from the Program Director. Information is posted on ACPM website.
  • Office for Disease Prevention and Health Promotion (ODPHP) - like the Pfizer Fellowship above, a competitive program awarded through the Association for Prevention Teaching and Research (APTR), requiring a short application and recommendation letter from the Program Director.

Primary Public Health Rotations

  • Armed Forces Health Surveillance Center (AFHSC), Washington, DC - often encouraged as a 1st choice elective
  • Navy and Marine Corps Public Health Center (NMCPHC), Norfolk, VA

Managerial Medicine Rotations

  • National Committee for Quality Assurance (NCQA), Washington, DC
  • Military Vaccine Agency (MILVAX), Falls Church, VA

Research Rotations

  • Naval Medical Research Center, Bethesda, MD
  • Military Overseas Research Activities
    • (Lima, Bangkok, Nairobi, Cairo, Jakarta)
  • DoD Health Research Center, San Diego, CA
  • USUHS Department of Preventive Medicine and Biometrics

Disaster Medicine

  • National Center for Disaster Medicine and Public Health (NCDMPH)

Other commonly used electives

National Center for Medical Intelligence (NCMI), Frederick, MD (Requires Top Secret security clearance. For those not possessing this level of security clearance, application must be initiated upon starting residency).

Vaccine Healthcare Center (VHC), WRAMC, Washington, DC

USU Center for Disaster and Humanitarian Assistance Medicine (CDHAM)

Other rotations within the DC metro area (and outside, funding permitting) are available or can be created based on the resident's interests and initiative in developing (nb: it typically takes several 6-12 months advance notice to gain administrative approvals within the NCC and the hosting agency to create a completely new rotation).

Practicum Year Didactic Component

During the practicum year, a variety of didactic training activities occur in addition to the rotations. Conferences, selected courses and other non-rotation requirements for the PGY3 year are described below:

Weekly Residency Business Meeting: The resident, while on rotations in the National Capital Area (that is, not on TAD/TDY orders or on leave), is required to return to USUHS on Wednesday afternoons and attend the weekly residency business meeting, immediately prior to the formal journal club. A variety of topics are covered, including updates and discussions of resident projects, ABPM examination preparation and review sessions, MMWR discussions, career planning, and discussion of residency policy issues. The time spent is intended to directly mentor residents for their careers within Public Health and General Preventive Medicine Residency, to teach, and to help them understand their new career field as well as to handle administrative issues germane to the residents.

Weekly Journal Club: Journal Club continues during the practicum year and each resident is expected to be highly involved with its planning and execution. This session follows the weekly Residency Business Meeting. The GPM Journal Club gives the resident an opportunity to hone critical appraisal skills, review relevant clinical preventive medicine literature, discuss current preventive medicine issues and give presentations. Although emphasis is on critical appraisal, some sessions will focus on specific public health-related "hot topics," "Journal Watch/Media Watch" sessions, or address gaps in the curriculum. Any practicum year resident out of the National Capital Area for more than four months of the year must document ongoing review of the current literature, including articles and other educational material distributed via e-mail for Journal Club sessions. All residents must also present a critical appraisal at Journal Club while in the local area on at least one (PGY2) or two (PGY3) occasion(s).

Due to the importance of information covered in Journal Club, the need for ongoing observation and evaluation by core program faculty, and budgetary limitations, away rotations are generally limited to no more than three months and usually less. In rare cases, with special approval of the program directors, away rotations may last up to six months. However, with the numerous opportunities for high quality practicum experiences within the National Capital Area no resident should plan for more than two to four months away.

Professional Conferences: During the practicum year, each resident is encouraged to attend at least one major professional conference, typically the American College of Preventive Medicine (ACPM) Annual Conference (www.acpm.org). If funding is available, PGY3 residents may also attend a DoD-connected prevention conference such as the Force Health Protection Conference or the Navy Public Health Conference. Funds permitting, other conferences may be considered on a case by case basis.

Additional Meetings which could be considered if funding is available and/or could be attended on PTDY status:

Other Courses: There are a wide variety of short courses and external seminars potentially available to residents. Required courses are labeled with "**" below. These requirements may occasionally be waived by the program director with extensive prior experience or equivalent training. Some of the courses include:

**Centers for Disease Control and Prevention (CDC) course, "Epidemiology and Prevention of Vaccine Preventable Diseases". This is an online course. Or Vaccine Healthcare Center Course

**USACHPPM Risk Communication Course- can be accomplished via PGY2 academic course or via arrangement with CHPPM course director(s)

**Medical Management of Chemical and Biological Casualties Course (MMCBC)

Medical Effects of Ionizing Radiation (MEIR) Standard Course (Highly encouraged, especially for Navy)

The Denver TB Course--the premier biannual four-day course held in at the National Jewish Medical and Research Center each October and April

Health Emergencies in Large Populations (HELP), Johns Hopkins University, Baltimore, MD--A three-week course sponsored by the International Committee of the Red Cross and hosted annually every July by the Department of International Health at the Johns Hopkins Bloomberg School of Public Health.

Global Medicine: an intensive two-week course sponsored by the USAF designed to train operational physicians to identify and plan for the infectious diseases and environmental conditions of medical and military significance worldwide. Quotas are managed through the USAF's School of Aerospace Medicine; please talk with Program Director for contact information and to discuss if interested
(Generally residents choose between Global Medicine or Military Tropical Medicine)

Military Tropical Medicine Course (generally post-residency for Navy residents; potentially also available to Air Force residents as a scheduled rotation or post-residency)

ACPM Board Review Course (post-residency)- (The residency has historically funded either the attendance fee or purchased the review books-funding permitting, graduating residents are usually able to choose one option.)

Resident Positions

There are positions of leadership available for PGY2 and PGY3 residents. They are the NCC GPM Chief Resident and the Graduate Medical Education Committee (GMEC) Resident Representative. During the PGY2 year, residents may be the MPH class representative and the Graduate Advisory Committee also has a resident representative for which residents may compete. During the PGY3 year, residents may be selected as Chief Resident, and the GMEC representative of the residency. The duties, responsibilities and selection process of each position are listed below.

GPM Chief Residents: The GPM Chief Residents work closely with the program directors in managing the activities of the residents. Responsibilities include:

  • 1. In each academic year for which there are at least four practicum year residents in training, the GPM Program Director will select at least one Chief Resident.
  • 2. Chief Residents must be PGY3 residents in good academic standing and are selected by the Program Director from among willing volunteers of the incoming practicum year residents. Residents will be notified of the opportunity at a pre-Journal Club business meeting and the business meeting notes disseminated by e-mail so that all eligible residents are aware and can respond. At least two weeks after the call for volunteers, the Program Director will select and announce the new chief resident(s). Selection will be made no later than the end of the Spring Quarter for the coming academic year beginning in July.
  • 3. Under Program Directors' supervision and approval, duties and responsibilities of the Chief Residents include but are not limited to:
    • a. Developing and implementing a schedule for Residency Journal Club and Business Meetings.
    • b. Developing and implementing a schedule for Board Review.
    • c. Functioning as liaison between Program Directors and residents to facilitate communication between faculty and residents.
      • i. Ensuring contact information is kept current for recall roster to facilitate accountability of residents to the residency director
      • ii. Forwarding concerns to the Program Directors in a confidential manner
        • d. Recording and disseminating minutes from weekly residency business meetings, ensuring that pertinent information is provided to all residents.
        • e. Performing review and revision of the Residency Handbook and website as needed, or at least on an annual basis.
        • f. Supporting residency director's efforts to market the residency, and participating in medical student residency program information programs.
        • g. Mentoring junior residents and medical students by:
          • i. Developing welcome packets
          • ii. Assigning sponsors
          • iii. Attending new resident orientation in July
          • iv. Coordinating resident teaching support for medical student courses in:
            • 1. Ethics
            • 2. Preventive Medicine
            • 3. Biostatistics and Epidemiology
        • h. Attending all required administrative meetings to include those of the Residency Advisory Committee.
        • i. Taking responsibility for use and appearance of the resident's room
        • j. Assuring all residents keep their duty hour logs up to date
      • 4. Chief resident duties will be equitably distributed between the two chief residents when two are selected. When a chief resident is on leave or TAD/TDY, duties will be assumed by the other chief resident or, in the case of both chiefs on leave or TAD/TDY, duties will be delegated to other PGY3 residents. All faculty, staff, and residents should receive email notification of this delegation and the time period of the delegation should be clearly specified.

      GMEC Resident Representative: The GMEC representative will represent both the Occupational Medicine and GPM residents at the monthly meeting of the GMEC. The meeting is typically held on the first Wednesday of the month at the USUHS Board of Regents conference room. This meeting is composed of two sub-meetings in which the GMEC representative is a voting member. The first meeting will include all the residency directors from the NCC as well as the resident representatives. The first meeting will discuss business related matters affecting the operations of the residency programs within the NCC. The second meeting is a case review of interns and residents with academic and/or personal issues. Specific details of the position can be found in the GMEC Handbook.

      Selection of the GMEC representative and an alternate are elected by the residents. All persons desiring to serve in this position should submit their intent to both the OEM and GPM program directors. The election is typically held during the PGY3 orientation when all residents are present. The elected residents will then be formally appointed by the GMEC via an appointment letter.

      Research and Scholarship during Residency

      A critical part of the residency experience is to foster an environment of inquiry and scholarship in which residents have structured research opportunities. The practice of preventive medicine requires solid grounding and experience in research because most preventive medicine practitioners must not only regularly interpret research findings but also design and conduct epidemiologically sound investigations on their own.

      In contrast to many purely clinical residencies, learning and applying research methods is an inherent and integral part of this residency. Residents learn many of the fundamental principles of research during the academic year in core courses such as epidemiology and biostatistics. The series of courses titled, "Introduction to the MPH Project and Practicum," "MPH Project and Practicum Design and Development," and "MPH Project and Practicum Implementation and Evaluation," are important because they provide a comprehensive overview of research principles and methods. These courses use the MPH/MTM&H independent project as a hands-on application for residents to develop a study hypothesis, design a study, review the literature, prepare for an ethical review (protection of human subjects), analyze data, and present results.

      The independent project, a critical part of the MPH and MTM&H, may be part of a faculty member's ongoing research or may be a project developed by the resident in conjunction with a faculty member. The project is closely mentored by faculty. The courses noted above along with the independent project provide a critical introduction and application of research in the residency. Other courses in the academic year, such as advanced epidemiology, can also provide significant additional experience in research methods.

      Members of the residency faculty are engaged in a wide variety of research projects and may also provide entree to organizations and agencies eager for assistance in the applied public health research central to the MPH/MTM&H independent project. Early in the academic year, residents are provided with information regarding ongoing research and given the opportunity to work with a wide variety of faculty members. This is a critical time for residents to identify and develop their independent project. More experienced and ambitious residents can develop their own projects under the mentorship of a faculty member. Residents also have the opportunity to participate in ongoing faculty research in independent study courses during the academic year.

      During the practicum year, a critical aspect of many rotations is the assignment of projects addressing specific questions or needs of the collaborating agency. These PGY3 rotation projects provide additional opportunities for residents to gain firsthand experience in applied research methods. There are a number of rotations in the practicum year where the resident can be assigned to a research institution such as the overseas infectious disease research laboratories. In addition, some residents continue to pursue their independent projects during the practicum year. Practicum rotations provide opportunities to further collect and refine data and develop presentation and publication skills. Some residents can elect to take an independent research elective rotation at USUHS.
       
      As mentioned earlier, residents are strongly encouraged to present their independent project or any other research efforts at professional meetings and to prepare a manuscript for publication. Residents are also required to present their Masters projects at the CAPT Richard Hooper Memorial Award oral presentation competition, the culminating experience of the academic year, and their Masters project or other substantive research project at Residency Advisory Committee meetings.

      Part of every resident's personal file will be a portfolio of research and projects carried out during the residency to document their scholarly activities.

      Tropical Medicine, Travel Medicine, and International Health Training During GPM Residency

      Military preventive medicine officers (PMOs) are often expected to be highly knowledgeable about tropical and travel medicine. Almost all PMOs must make recommendations to individuals and operational units concerning vaccines, malaria chemoprophylaxis, diarrhea prevention, and other common travel medicine issues. Providing preventive recommendations to deploying units often requires a broader, all threat, and more conservative approach compared to the highly customized and itinerary driven recommendations for individual travelers. PMOs often become involved in outbreak investigations in deployed units and knowledge of tropical diseases is essential given the global deployments of DoD. Some PMOs are assigned after residency to the infectious diseases research community where an understanding of tropical medicine is essential. PMOs may become involved in helping manage individual cases of malaria or other tropical diseases.

      PMOs also frequently become directly involved in international health matters through medical civic action projects, military-to-military cooperation programs, and disaster responses abroad. Residents should have a sound understanding of medicine in other cultures, development issues, and international public health organizations such as the World Health Organization (WHO) or the Pan-American Health Organization (PAHO), and other aspects of international health.

      USUHS and the GPM residency are unique in offering a wide range of tropical and travel medicine training opportunities. Very few medical schools and residencies have similar resources available. At one end of the spectrum, the GPM resident can take selected courses in travel and tropical medicine. (As noted above, some of these courses are required.) Those residents with more interest in tropical medicine can pursue the Tropical Public Health concentration for the MPH degree. The Tropical Public Health concentration requires courses in tropical medicine and international health, emphasizing preventive medicine and public health aspects in the international setting. Those wanting even more exposure to tropical medicine can elect to complete the Masters in Tropical Medicine and Hygiene (MTM&H) degree rather than the MPH after consultation with and approval by the residency Program Director. These students receive an even greater focus on these issues and must spend at least six weeks abroad during the practicum year.

      USUHS also offers an intensive twelve-week program in clinical tropical medicine and traveler's health in the spring quarter. Residents doing the tropical medicine public health track for their MPH or completing an MTM&H may take these courses. Residents who successfully complete the courses specified by the American Society of Tropical Medicine and Hygiene (ASTMH) and have the requisite overseas experience are eligible to take the ASTMH's Certification Examination in Clinical Tropical Medicine and Traveler's Health.