Curriculum General Medicine

8/12/2019 Curriculum General Medicine

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Rotation Curriculum

Dept of Medicine Residency Program

Date Reviewed:_16 May 05____pproved RP!C_"0 #une 05 Reviewed 1$ #une "00%

Rotation: General Medicine Inpatient Services (MCG and VA)

!ducational Purpose:

&o provide supervised patient care and educational opportunities to develop t'e

following competencies of internal medicine: 'umanistic practice( professionalism(medical et'ics( lifelong learning( clinical met'od( continuity of care( medical interview(

p'ysical diagnosis( clinical p'armacology( nutrition( palliative care( and disc'arge

planning) &'e resident *y t'e end of t'e rotation s'ould 'ave improved and advanced 'is

level of competency in t'e principles of management of t'e most common medicalconditions necessitating 'ospitali+ation on general medical wards)

&eac'ing Met'ods:

1) ,edside instruction: ,edside teac'ing rounds on all su*-ects pertinent tospecific patient at 'and) Constitutes ma-ority of minimum .)5 'rs wee/ly

teac'ing rounds wit' attending p'ysician)") mall group discussion: &eam rounds or in team conference discussing

specific cases( general concepts appropriate to specific cases)

$) Personal feed*ac/: Daily as indicated to specific residents *y attending)ummary evaluation at mid and endrotation)

.) !valuation and review of write ups: ll write ups( progress notes( and

disc'arge summaries will *e reviewed *y attending( wit' written corrections

and comments to resident as indicated for improvement) ttendings aree2pected to complete one formal inpatient medical record review of eac'

resident during t'e rotation)5) Didactic lectures: Residents are e2pected to attend morning report( noonconferences( and Medicine 3rand Rounds w'ile on service) Residents are

e2pected to present case management discussions at morning report on

assigned dates( in accordance wit' case management format)6) ssigned readings: Residents are e2pected to 'ave wor/ing /nowledge

ac4uired *y reading t'e following at t'e times noted:

P31

irst rotation:

1) 7urst #8) &'oug'ts *out ,ecoming an 9ntern on a Medical ervice(

Resident and Staff Physician( 1;


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micro*ials( 3astrointestinal Diseases( ?iver Disease( Dia*etes Mellitus( and

>eurological Disorders)

$) Cecil Textbook of Medicine, ""ndedition( "00.

C'apter 1: pproac' to t'e Patient

C'apter ": ,ioet'ics in t'e Practice of MedicineC'apter $: Care of Dying Patients and &'eir amilies

C'apter 6: 9nterpretation of Data for Clinical Decisions

OR

Harrisons Principles of nternal Medicine, 16t'edition( "005

C'apter 1: &'e Practice of Medicine

C'apter ": DecisionMa/ing in Clinical Medicine

C'apter : Palliative and !ndof?ife Care

.) @roen/e @) &'e Case Presentation: tum*ling ,loc/s and tepping

tones)!" # Med 1;5A %:60560;)

econd rotation:

1) Washington Manual of Medical Therapeutics

C'apters on 7ypertension( llergy9mmunology( &reatment of9nfectious Diseases( 79B( and nemia

") Cecil Textbook of Medicine, ""ndedition( "00.

C'apter "6: Delirium and t'er Mental tatus Pro*lems in t'e lderPatient

C'apter "%: Principles of Drug &'erapy

C'apter ": PainC'apter $$: ntit'rom*otic &'erapy

C'apter 56: 7eart failure: Management and Prognosis

C'apter ;1: pproac' to t'e Patient wit' Respiratory DiseaseC'apter ": verview of Pneumonia

C'apter 1$0: pproac' to t'e Patient wit' 3astrointestinal Disease

C'apter ."$: pproac' to t'e Patient wit' >eurological Disease

OR

Harrisions Principles of nternal Medicine( 16t'edition( "005

C'apter "5%: cute Confusional tates and Coma

C'apter $: Principles of Clinical P'armacology C'apter 11: Pain: Pat'op'ysiology and Management

C'apter 10$: ntiplatelet( nticoagulant( and i*rinolytic &'erapy

C'apter "16: 7eart ailure and Cor Pulmonale C'apter "$$: pproac' to t'e patient wit' disease of t'e respiratory

ystem

C'apter "$: Pneumonia

C'apter "%1: pproac' to t'e patient wit' gastrointestinal disease


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C'apter $.6: pproac' to t'e patient wit' neurological disease

&'ird Rotation:

Cecil Textbook of Medicine, ""ndedition( "00.

C'apter ;5: C'ronic *structive ?ung DiseaseC'apter .: Pulmonary !m*olism

C'apter 110: pproac' to t'e Patient wit' Renal Disease

C'apter 10.: 'oc/ yndromes Related to epsisC'apter 1$$: 3astrointestinal 7emorr'age

C'apter 1.;: pproac' to t'e Patient wit' ?iver Disease

C'apter 156: Cirr'osis and its e4uelae

C'apter 1;: ?ung Cancer and ot'er Pulmonary >eoplasmsC'apter ".": Dia*etes Mellitus

OR

Harrisons Principles of nternal Medicine, 16t'edition( "005

C'apter ".": C'ronic *structive Pulmonary Disease C'apter "..: Pulmonary &'rom*oem*olism

C'apter .0: +otemia and rinary *normalities C'apter "5.: evere sepsis and septic s'oc/

C'apter $%: 3astrointestinal *leeding

C'apter ";": pproac' to t'e patient wit' liver disease C'apter ";;: lco'olic ?iver disease

C'apter ";: Cirr'osis and its complications

C'apter %5: >eoplasms of t'e lung

C'apter $"$: Dia*etes mellitus

ourt' Rotation

Cecil Textbook of Medicine, ""ndedition( "00.

C'apter ";.: &'e ystemic Basculitides

C'apter $0$: Pneumococcal Pneumonia C'apter $.1: &u*erculosis

C'apter .1.: >eurological Complications of 79B

C'apter .$$: l+'eimerEs Disease and t'er Diagnoses of Cognition

C'apter .$5: yncope C'apter .5;: >utritional and lco'olRelated >eurological Disorders

OR

Harrisons Principles of nternal Medicine, 16t'edition( "005 C'apter $06: &'e vasculitis syndromes

C'apter 11: Pneumococcal infections

C'apter 150: &u*erculosis C'apter 1%$: 79B disease( pages 10%;( 111511"0

C'apter $50: l+'eimerEs Disease and ot'er dementias

C'apter "0: yncope( aintness( Di++iness( and Bertigo

C'apter $%": lco'ol and lco'olism


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P3"

irst Rotation:

1) Cassell( !#) &'e >ature of uffering and t'e 3oals of Medicine($%#M 1;"A $06: 6$6.5

") mit' RC( 7oope R,) &'e PatientEs tory: 9ntegrating t'e Patient

and P'ysiciancentered pproac'es to 9nterviewing)!nn ntern Med11A115: .%0.%%)

$) merican ,oard of 9nternal Medicine) Clinical Competence in

9nternal Medicine)!nn ntern Med 1%A 0: .0".11)

.) !pstein RM( 7undert!M) Defining and ssessing ProfessionalCompetence) #M "00"A ";%: ""6"$5)

5) Creditor M) 7a+ards of 7ospitali+ation of t'e !lderly)!nn ntern

Med 1$A 11;: "1""$)

6) Morrison R( Meier D!) Palliative Care)$%#M "00.: $50:"5;""5;)

%) Bon @orff M( et al) Colla*orative Management of C'ronic 9llness)!nn ntern Med 1%A 1"%: 10%110")

;) >o'ria ( ?ewis !( tevenson ?8) Medical Management of

dvanced 7eart ailure)#!M! "00"A ";%:6";6.0)) Man ( Mclister ( nt'oniesen >R) in DD) Contemporary

Management of C'ronic *structive Pulmonary Disease: Clinical

pplications)#!M! "00$A "0: "$1$"$16)

econd Rotation:

1) drogue 7#( Madias >) 7yponatremia)$%#M "000A $.":1.$1.)") waroop B( C'ari &( Clain #!) evere cute Pancreatitis)#!M!

"00.A "1: ";65";6;)

$) 8outers !M) Management of evere CPD)&ancet "00.A $6.:;;$;.)

.) C'un ( Mc3ee R) ,edside Diagnosis of Coronary rtery

Disease: ystematic Review)!" # Med "00.: 11%: $$.$.$)

5) Mc3ee ( *ernet'y 8,( imel D?) 9s t'is Patient 7ypovolemicF#!M!1A ";1: 10""10")

6) ,allantyne #C( Mao #) piod &'erapy for C'ronic Pain)$%#M "00$A

$.:1.$15$)%) ?evine #( ,ranc' D8) Rauc' #R) &'e ntip'op'olipid yndrome)

$%#M "00"A $.6: %5"%6")

P3$

irst Rotation:

P9!R


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Dia*etic @etoacidosis

Congestive 7eart ailure

Basculitis Dementia

Delirum

DB& CPD

econd Rotation:

Renal ailure ystemic ?upus !ryt'ematosis

Mi2 of diseases:

Pulmonary Diseases: CPD( ast'ma( lung cancer( cystic fi*rosis(pneumot'ora2( restrictive and interstitial lung diseases( lung

a*scess( sarcoidosis)

3astrointestinal Disease: acute and c'ronic pancreatitis( upper and lower

gastrointestinal *leeding( cirr'osis( c'ronic and acute liver failure('epatitis( 3!RD( gastrointestinal malignancy( diverticulitis(

inflammatory *owel disease( diarr'ea( constipation( gastroparesis) Cardiac Disease: C7( syncope( arr'yt'mias( pericarditis( c'est pain

9nfectious Diseases: pneumonia( cellulitis( 79BG9D( pyelonep'ritis(

Meningitis( septic art'ritis >eurological: Delirium( dementia( sei+ure disorder( personality

disorders( depression( an2iety disorders( sc'i+op'renia( syndromes

of mental retardation( encep'alitis( encep'alopat'y


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&ypes of procedures: ?um*ar puncture( *ladder cat'eteri+ation( t'oracentesis(

paracentesis( -oint aspiration ( central venous cat'eter 3 tu*e( " monitoring( cognitive assessment

&ypes of services provided: cute inpatient care( palliative care( disc'arge planning

!ducational Resources to *e used:

1) Re4uired reading: s a*ove") ?i/ely opportunistic reading: Pu*Med( 'p to (ate( ot'er online resources as

appropriate)

$) Pat'ological material: *iopsies( smears( cytology( autopsy material)

Residents are encouraged to loo/ at all specimens personally).) t'er educational resources to *e used: Pre and Post testing as developed)

Definition of level of resident supervision *y faculty in all patientcare activities

ttending faculty p'ysicians are ultimately responsi*le for t'e outcome of allpatient care in *ot' t'e medical and legal sense) &'ey delegate t'is care in order to train

residents 'ow to care for patients t'emselves) upervision is graded to t'e level oftraining of t'e resident and education is individuali+ed to t'e needs and level of t'e

individual trainees on t'e ward team)

&'e P31 is responsi*le for up to 1" patients at one time) &'e P31 is t'eprimary caregiver to t'e patient as is identified as t'e HpatientEs doctor)I 7e develops t'e

diagnostic and t'erapeutic plan after discussion wit' t'e P3"G$ and attending( and is

responsi*le for t'e implementation of all diagnostic and t'erapeutic management( to

include procedure( retrieval and assessment of diagnostic tests and coordination ofmultidisciplinary( consultative( and disc'arge related resources)

&'e P3 "G$ is responsi*le for up to "6 patients at one time) 7e supervises t'e

P31 and su*intern and students in performance of duty( writes admission 'istory(p'ysical and initial plan of care( facilitates interpretation of diagnostic and t'erapeutic

outcome s and disc'arge planning) &'is resident is responsi*le for timely and complete

dictated summaries( *ut may delegate t'is duty to t'e P31( *ut not any medicalstudent) 7e mentors and teac'es su*ordinates and nursing and ot'er ancillary caregivers(

develops case reports and clinical researc' appropriate to case managed( and prepares

discussion of cases for management conference( mor*idityGmortality conference( s'ow

and tell( and ot'er departmental conferences) P3$ residents are e2pected to conductgreater 4uantity and 4uality of teac'ing( mentoring( and 4uality improvement activities

t'an P3" residents)

&'e attending is t'e final level of responsi*ility to t'e educational and servicemandates of t'e ward e2perience) &'e attending identifies t'e specific education needs of

eac' of t'e su*ordinate mem*ers of t'e ward team and facilitates t'eir ma2imum

competency *y supervising( evaluating( giving feed*ac/( and teac'ing appropriate toeac' team mem*er( w'ile assuring t'at e2cellent patient care is provided) )

?ines of Communication:


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Multiple lines of communication are necessary to ensure *ot' educational and

patient care o*-ectives)

PatientGamilyG>urse communication: &'e primary line of communication is fromt'e patient to 'is or 'er Hp'ysician(I t'e P31 or su*intern) &'is p'ysician s'ould *e

t'e first to see patients daily( *e t'e first to enter t'e room on wor/ rounds( and present

cases at t'e *edside at teac'ing rounds( unless t'e MM$ student is presenting) Ma-orre4uest and needs are to *e e2pressed *y t'e patient and nurses to t'e P31 and solved

at t'at level first) dditionally( significant counseling of t'e patient( suc' as results of

diagnostic test( planned t'erapy( H*ad news(I advance directives( etc)( is t'e duty of t'eP31 to initiate and complete) 9f communication pro*lems e2ist *etween t'e patient or

nurse and P31 or su*intern( t'e patient or nurse will ne2t pursue communication wit'

t'e P3"G$) 9f communication is unsuccessful 'ere( t'e attending will *e called) ny

failure of communication a*ove t'e level of t'e P31 will *e evaluated *y t'eattending( wit' appropriate feed*ac/)

rders are to *e written *y t'e P31 e2cept in only rare and emergent

circumstances *y ot'er on t'e team at t'e P3"G$ or attending level)

&'e attending is to *e called *y t'e P3"G$ on eac' admission wit'in . 'ours ofacceptance) &'e attending is to *e informed of t'e tentative diagnosis( management

issues( and prognosis in order to determine 'is need to personally evaluate t'e patientwit'in a timely manner) &'e attending will see all patients and write 'is note wit'in ".

'ours of admission)

or consultations( t'e primary line of communication s'ould *e *etween t'eattending and attending consultant) &'e attending p'ysician s'ould sign all consult

re4uests after discussing t'e reason for t'e consultation wit' t'e residents) &'e attending

may delegate calling in of consultation *y t'e resident if t'e typical procedure involves

first discussion at a resident or fellow level) Consultation recommendations are to *eimplemented only after discussion *y t'e attending and residents and discussion of

decisions *etween t'e P31 and patient)

!2pectations of Residents and ttendings as &eac'ers

1) Role of t'e P31: &'ey instruct students 'ow to write orders( do certain

procedures( arrange testing and consultations( and find and interpretla*oratory and study results) &'ey discuss on a daily *asis management

issues relating to -ointly managed patients) &'ey read( correct( and

countersign studentEs daily progress notes( and t'ey contri*ute to case

related teac'ing t'at occurs on wor/ rounds( attending rounds( and seminars)") Role of t'e P3"GP3$: Residents review t'e e2pectations of t'e student

on t'e ward service and set standards t'at are specific to t'e service and to

t'e residentEs teac'ing style) Residents are e2pected to engage case*asedteac'ing around cases 'andled *y students( specifically at times of decreased

patient management activity( suc' as at nig't( on call( and prior to sc'eduled

conferences) &'is entails ensuring ade4uate data collection


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gaining /nowledge of /ey principles of pat'op'ysiology and case

management pertinent to t'e rotation) Residents are also to provide

immediate and ongoing feed*ac/ to students on all aspects of t'eirperformance( as well as provide summative evaluation at mid and end of

rotation)

$) 8ard attending will teac' students during ward teac'ing rounds asappropriate to t'eir level( give feed*ac/ on /nowledge( participation in

patient care( and demonstrated 4ualities of professionalism( communication

s/ill( practice*ased learning( and systems*ased practice) &eac'ingattending will review and grade . patient writeups during t'e rotation( and

provide studentsonly *edside teac'ing for " 'ours wee/ly)

.) P31( "( and $ residents( along wit' t'e ward attending will participate in

a facilitated grading session at t'e end of eac' MM$ student rotation)

Met'od of evaluation of resident competence and 4uality of care

1) !2pected standards of competence and 4uality: Residents are e2pected to

demonstrate attitudes( s/ills( and *e'aviors consistent wit' t'e competencylevel appropriate for level of P3 training for t'e following

a) C3M! Competenciesi) Patient care: p'ysician patient interaction


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ii) &imely: Reducing waits and potentially 'armful delays for

*ot' t'ose w'o receive and w'o give care)

iii) !ffective: Providing services *ased on scientific /nowledgeto all w'o could *enefit and refraining from providing

services to t'ose not li/ely to *enefit


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/= Monitoring of 7C cost( ?( and outcome data for team and

individual mem*ers

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Curriculum General Medicine