Internal Medicine Residency Program

GOALS & OBJECTIVES

&

ORIENTATION MANUAL

Academic Year 2013

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Table of Contents

Overall Goals and Objectives......................................................... 03 Special Teaching Topics…………………………………………. 10 Outline of Core Rotations………………………………………... 14 Information about scheduling selectives / rotations……………… 15 Resident Safety Policy…………………………………………… 89 Intimidation and Harassment Policy….………………………….. 92 Evaluation and Feedback………………………………………… 93 About the Training Program and Residency Training Committees 96 Contact Information……………………………………………… 98 Websites/Societies/Conferences of Interest…………………….... 100 Medical Resources of Interest………………………….………… 101 Resident Wellness………………………………………………… 103 Guidelines for Relationships with Industry…………………..…... 104 Presentation Guidelines for Residents……………………………. 107

List of approved core rotations and selectives with goals and objectives

Allergy and Immunology................................................................ 17 Ambulatory Clinics Rotation.......................................................... 19 Anaesthesia..................................................................................... 21 Cardiology and Coronary Care Unit................................................ 23 Community Hospital Internal Medicine Experience....................… 26 Dermatology..................................................................................... 28 Acute General Internal Medicine Consults / ER Consults............... 30 Endocrinology.................................................................................. 32 Gastroenterology and Hepatology…................................................ 35 Medical Clinical Teaching Unit.................................................….. 38 General Internal Medicine Consultations......................................... 40 Geriatrics.......................................................................................... 42 Haematology-Oncology Clinical Teaching Unit and Consults........ 45 Immunodeficiency Rotation.............................................................. 49 Infectious Diseases............................................................................ 51 Intensive Care Unit............................................................................ 54 Medical Oncology............................................................................. 57 Nephrology......................................................................................... 59 Neurology........................................................................................... 61 Night Float…………………………………………………………. 63 Obstetrical Medicine......................................................................... 65 Palliative Care.................................................................................... 68 Radiology........................................................................................... 70 Respirology......................................................................................... 72 Rheumatology..................................................................................... 76 Scholarly Activity Rotation................................................................ 78 Transplantation Medicine................................................................... 82 Thrombosis Medicine......................................................................... 84 Tropical Medicine............................................................................... 87

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Overall Goals & Objectives Medical Expert The curriculum is structured to occur though regular teaching sessions, academic half-days, journal clubs, and in the patient-care context. The resident will be provided with adequate resources in this context, including electronic references and the Rational Clinical Exam Series (as published in JAMA). Simulation-based teaching on various procedures is offered throughout the curriculum. The academic half-day series is based on a 2-year curriculum as dictated by the Academic Curriculum Committee and guided on a regular basis by feedback regarding the topics/speakers. The schedule is available for review in one45 under “My Calendar.” Regular evaluation of a resident’s knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. An annual oral exam in OSCE format is also a means to evaluate this domain. Completion of the American College of Physicians In-Training Examination during the second and third years of residency is another means to evaluate this domain. As a result, the resident will be able to perform a complete and reliable history and physical examination, recognizing the normal from the abnormal. The resident will select appropriate investigations in a logical sequence, recognizing normal from abnormal results, and their significance. The resident will formulate a comprehensive problem list, synthesize an effective diagnostic and therapeutic plan, and establish appropriate follow-up. The resident will demonstrate effective consultation skills, presenting well-documented assessments and recommendations both verbally and in writing. The resident will be knowledgeable in both common and uncommon diseases, as further outlined in the each rotation’s rotation-specific objectives and the Royal College Objectives of Training for Internal Medicine (version 1.0, 2011). The resident will demonstrate technical expertise in performing the following procedures while knowing their indications and complications:

i. central venous catheter insertion ii. lumbar puncture iii. peripheral arterial catheter insertion iv. abdominal paracentesis v. endotracheal intubation vi. thoracentesis vii. knee joint aspiration viii. electrocardiographic interpretation

The resident will be familiar with the use of procedural ultrasound to aid in safely performing central venous catheter insertion, thoracentesis, and paracentesis. The resident’s knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced concepts and skills in this field as the resident’s clinical training progresses.

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Communicator The curriculum is structured to occur through regular teaching sessions and academic half-days (ethics/communication for R2/R3s), in the patient-care context through the recognition and application of the principles of verbal and written communication with patients, families, colleagues, and other health-care professionals, and in discussions and presentations with health-care professionals. Regular evaluation of a resident’s knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. Direct observation of difficult communication scenarios also occurs in the context of regular academic half-days devoted to improving communication skills. As a result, the resident will be able to establish a therapeutic relationship with patients and families based on trust and respect, recognizing the fundamental importance and benefits of this relationship. The resident will be able to obtain and synthesize a relevant history from patients and families, given specific challenges (for example, language or other communication barriers). The relevant history will include not only information about the disease, but also patient beliefs, concerns, and expectations about the illness. The resident will be able to listen effectively. The resident will be able to discuss appropriate information with patients, families, and the health-care team. Specifically, the resident will be able to communicate in a humane and understandable manner that fosters discussion and promotes patient understanding. The resident will recognize the importance of cooperation and communication among health-care providers, and recognize the importance of delivering consistent messages to patients. The resident’s knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced concepts in communication as the resident’s clinical training progresses.

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Collaborator The curriculum is structured to occur primarily through the patient-care context. It is in this context that the resident participates in the day-to-day care of in-and out-patients, as a collaborative member of the health-care team whose goal is the provision of optimal patient care, education, and research. There is an academic half-day for third-year residents on leadership and management skills, in which concepts of conflict-resolution and the assumption of the leadership role are further discussed. Finally, there is an annual Crisis Resource Management (CRM) session which is designed to teach team-work skills in the context of critical situations. Regular evaluation of a resident’s knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. The CRM session will also be a formative evaluation experience. As a result, the resident will be able to identify and describe the expertise and role of all of the members of an interdisciplinary team. The resident will develop a care plan for patients, based upon the collaboration among the different members of the health-care team. The resident will participate as a collaborative member of the health-care team, demonstrating the ability to accept, consider and respect the opinions of other team members, while contributing appropriate expertise to the team. The resident’s knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced attitudes and skills involved in being a collaborator as the resident’s clinical training progresses.

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Manager The curriculum is structured to occur primarily through the patient-care context. It is in this context that residents participate in the day-to-day care of in-and out-patients, as they make everyday practice decisions involving resources, co-workers, tasks, policies, and their personal lives. The ability to prioritize and effectively execute tasks is taught via the management of the resident’s multiple roles and responsibilities, including in-patient care, out-patient clinics, teaching, administrative, and personal responsibilities. There is an academic half-day on leadership and management skills, in which these and other themes will be discussed. Regular evaluation of a resident’s knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. As a result, the resident will be able to utilize resources effectively to balance patient care, learning needs, and outside activities. The resident will be aware of how to allocate health-care resources wisely. The resident will be aware of how to work efficiently in a health-care organization. The resident will utilize information technology to optimize patient care, life-long learning, and other activities. The resident will recognize the business and financial skills necessary for a successful medical practice. The resident’s knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced attitudes and skills involved in being a manager as the resident’s clinical training progresses.

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Health Advocate The curriculum is structured to occur primarily through the patient-care context and in an academic half-day on advocacy/ethics/communication (R2s/R3s). It is in these contexts that the resident participates in the day-to-day care of in- and out-patients, as an advocate for the individual patient and society as a whole. Regular evaluation of a resident’s knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. Formative feedback from the ethics/communication/advocacy sessions (R2s/R3s) will be provided based on directly observed interactions with standardized patients. As a result, the resident will be able to identify the important determinants of health affecting patients. More specifically, the resident will be able to educate patients about long-term healthy behaviour and preventive health-care. The resident will contribute effectively to improved health of patients and communities. The resident will recognize and respond to those issues where advocacy is appropriate. More specifically, the resident will appreciate the existence of global health advocacy initiatives for elimination of poverty and disease. The resident will apply the principles of quality assurance/improvement (see Quality Assurance/Improvement). The resident’s knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced attitudes and skills involved in being a health advocate as the resident’s clinical training progresses.

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Scholar The curriculum is structured to occur through regular journal clubs, academic half-days offered to second-year residents on teaching skills, structured epidemiology teaching, and through the completion of a scholarly project project. Participation in a minimum of a three-credit course taken as part of the McGill Summer Epidemiology Program is recommended for all residents. Residents are required to participate in a scholarly activity (see below), and will meet with their local Resident Research Coordinators to assist them in identifying any research interests. Academic half-days on how to teach allow for elaboration of a resident’s knowledge and skills in this area. The resident will have regular opportunities to present clinical cases and topic reviews at various clinical conferences. A mandatory scholarly activity is effective for all residents beginning training on or after July 1, 2011. This activity may consist of (i) a clinical vignette / case presentation / case report, (ii) a quality assurance / quality improvement (QA/QI) project, (iii) a medical education project, or (iv) a research project. Evidence of a scholarly activity is required and will be placed in each resident’s file. In order to meet this goal, each resident will be assigned 4 weeks of time towards a scholarly project (scholarly activity rotation) between PGY1-3. This may be taken as a 4 week rotation or separately in 1 or 2 week blocks of time. Regular evaluation of a resident’s knowledge, skills, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. The resident will receive regular feedback following presentations at clinical case conferences. Residents have the opportunity to present their work to their colleagues and to the hospital community at the annual “Resident Research Evening” and “Clinical Vignettes Evening.” Presentation of appropriate work at provincial, national, and international conferences is strongly encouraged and supported. As a result, the resident will be able to apply the principles of critical appraisal to sources of medical information, in the clinical, research, and educational contexts. The resident will be able to facilitate the learning of patients, students, residents, and other health-care professionals. The resident will contribute to the development of new knowledge. The resident will be able to develop and implement a personal continuing education strategy. The resident’s knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced concepts in clinical epidemiology, teaching, and research as the resident’s clinical training progresses.

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Professional The curriculum is structured to occur through teaching sessions, academic half-days offered to second-year residents on professionalism, through simulation-based teaching on advocacy, ethics and communication skills for R2s and R3s, and through the patient-care context. Further training in ethics sessions is provided as part of the academic curriculum, and a session on medico-legal issues is offered to residents in the context of an academic half-day devoted to this topic annually. Regular evaluation of a resident’s knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation, while formative feedback is provided as part of the simulation-centre sessions on this topic. As a result, the resident will be able to deliver quality care with integrity, honesty, and compassion. The resident will exhibit appropriate personal and interpersonal behaviours. The resident will practice medicine ethically, consistent with the obligations of a physician (see Ethics). The resident’s knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced attitudes and skills involved in being a professional as the resident’s clinical training progresses.

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Special Teaching Topics Ethics The curriculum is structured to occur through regular teaching sessions with clinical ethicists, in the patient-care context through the recognition and application of basic ethical principles throughout a resident’s clinical experience, and in the context of academic half-days. Regular evaluation of a resident’s knowledge, skills, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. As a result, the resident will have a knowledge of the common ethical issues that are commonly encountered in clinical practice, including:

i. Consent ii. Capacity iii. Substitute Decision-Making iv. Confidentiality v. Truth-Telling (esp. medical errors) vi. Conflicts of Interest (esp. physicians and pharmaceutical industry) vii. Boundary Issues (esp. gifts from patients, sexual relations with patients) viii. End-of-Life Decisions and Futility (esp. patient demands for treatment) ix. Resource Allocation x. Research Ethics xi. Professionalism xii. Medico-Legal Issues

The resident will be able to appreciate the ethical dimensions in medical decision-making. The resident will appreciate the professional, legal, and ethical codes to which physicians are bound. More specifically, the resident will recognize and know how to address unprofessional behaviours in clinical practice. The resident will be able to analyze the ethical and legal dimensions in a given clinical situation, to communicate with colleagues, families, and patients regarding these issues, and to recognize and deal with conflicts. The resident’s knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced concepts in clinical ethics as the resident’s clinical training progresses.

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Quality Assurance/Improvement The curriculum is structured to occur through regular teaching sessions with quality assurance experts, through regular morbidity and mortality rounds, through regular Residency Program Committee meetings, biannual meetings with the Chief Medical Residents to review the program, and journal clubs. A resident may also undertake a QA/QI project under the supervision of a local QA/QI leader, which is considered a scholarly activity (see Scholar). As a result, the resident will have a knowledge of the basic concepts of quality assurance/improvement, and their application in clinical medicine. The resident will be able to identify a problem in need of improvement, and to design a proposal for improvement. The resident’s knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced concepts in quality assurance/improvement as the resident’s clinical training progresses.

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Ambulatory Care The ambulatory care experience is structured to occur through regular general internal medicine clinics during the first two years of residency, through regular subspecialty clinics while on subspecialty rotations, and through a longitudinal clinic of the resident’s choice during the third year (general internal medicine or subspecialty). A rotation in ambulatory medicine is also recommended in the R2/R3 year, which is better described later in this manual. Regular teaching sessions devoted to outpatient medicine are also part of the resident’s ambulatory care experience. As a result, the resident will have a knowledge and skill in the management of outpatients with complex multi-system disease on both a short- and long-term basis (medical expert). The resident will be able to function in the role of consultant to family physicians and other subspecialists, when necessary (communicator, collaborator). The resident will learn the principles and practice of disease prevention and health promotion (advocate). The resident will learn to utilize cost-effective and evidence-based investigations and therapies in the outpatient setting (manager, scholar). The resident will develop an awareness of available community resources, and learn how to appropriately access these and utilize them (collaborator, manager). The resident will foster research appropriate to the optimal delivery of health-care in an ambulatory setting, and become familiar with available methodology (scholar). The resident’s knowledge, attitudes, and skills in this context will show appropriate evolution over the three years of training, with appropriate mastery of more advanced concepts in ambulatory care as the resident’s clinical training progresses.

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Community Hospital Internal Medicine Experience (CHIME) The curriculum is structured to occur primarily through the patient-care context in both rural rotations and other community rotations. The content of the rotation will vary by site, but will include a mix of in- and out- patient care, treadmill testing, peri-operative care, medical complications of pregnancy, and other procedures commonly performed by general internists in the community (ie. endoscopy, bronchoscopy, echocardiography, etc.). A list of Community Hospitals at which these rotations can be undertaken is available to all residents for their review on our website. The required rotations for each resident will vary according to the following guidelines:

(i) a CaRMS-stream resident who can safely function in a francophone health-care environment: 3 blocks of CHIME in rural locations as listed in the program website (in PGY2 or PGY3)

(ii) a CaRMS-stream resident who cannot function safely in a francophone environment: 2 blocks at St. Mary’s Hospital (1 month each in PGY2 and PGY3)

(iii) an out-sponsored trainee: 1 block at St. Mary’s Hospital (either in PGY2 or PGY3)

Note: residents described in (ii) and (iii) should expect to be assigned extra local rotations to compensate for the reduced CHIME rotations. These extra local rotations are left up to the discretion of each Site Director. Regular evaluation of a resident’s knowledge, skill, and attitudes during these rotations will follow the usual McGill Evaluation Scheme. As a result, the resident will gain a deeper understanding of the practice of medicine in a community setting. More specifically:

i. the resident will gain a deeper understanding of clinical decision-making when faced with limitations of technological resources,

ii. the resident will practice autonomy with independent decision-making in the context of limited access to sub-specialists,

iii. the resident will gain experience in the practice of internal medicine as a consultant, rather than in the primary care context.

The resident will be exposed to the practice of internal medicine in community contexts in order to consider a career as a specialist in a rural region. A selection of approved Community Hospitals are available through the resident’s local Teaching Office. Consideration will be given for sites that are not included in this document on a discretionary basis. Financial and other support is available for residents. It is recommended that this rotation be limited to residents in their second and third years.

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Selectives at McGill

Clinical selectives available to residents are listed in more detail in this manual. These are all approved rotations with pre-defined goals and objectives, also outlined in more detail here. Residents are required to choose their selectives from this list and inform their local Medical Teaching Office of their requested rotations. Please note that the Program encourages residents to take selectives across McGill’s teaching network to ensure a broad exposure to different patients and hospital systems. A resident is permitted to take a maximum of 2 selectives in the same field during their 3 years of training (R1-R3). This is to ensure that residents get a variety of exposure to a wide variety of domains, without focusing too much on one area.

Electives at McGill

During the course of their three years of training, a resident is permitted to take ONE rotation (called an elective) not included in this list (ie. sky service, radiation oncology, toxicology, aerospace medicine, etc.). Some elective options are listed in more detail on our website:

http://www.medicine.mcgill.ca/internalmed/home_welcome.htm

(scroll down to elective information)

Residents are required to contact their local Medical Teaching Office ahead of time to inform them of this elective choice and to obtain approval from their site director to ensure that it meets the requirements for pedagogy and appropriate supervision.

Please contact your local Medical Teaching Office to organize and schedule your rotations.

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Rotations outside of McGill’s teaching network

Residents are permitted to schedule a rotation outside of McGill only once they have completed 18 months of training in Internal Medicine (exception: if a candidate is applying to another school for their PGY4 subspecialty, then special permission may be obtained by asking for an exemption with their Site Director. In this manner, an out of province rotation may be booked in the first 6 months of your PGY2 year for career planning purposes).

McGill requires that the total number of rotations taken in non-accredited sites not exceed 3 months in a 5-year training program (this may be important for some residents in the future).

When applying for a rotation outside of McGill’s teaching hospital network, residents are required to comply with the following procedures (forms available on our website or at your local Medical Teaching Office): 1. CREPUQ Procedure for Quebec Inter-University Rotations 2. McGill - Additional information form Once you have done this, your Site Director will review the “McGill - Additional information form” and decide if the rotation meets appropriate pedagogical requirements. If the rotation’s pedagogical components are successfully approved, the administrative request for the rotation can then proceed under the CREPUQ system according to McGill's regulations and procedures.

For rotations requested outside of Quebec, further approval is required by the Collège des médecins after completion of their form, available on our website. As per the most recent FMRQ contract, rotations may be approved with pay even if they are available in Quebec. For more details, please refer to article 13.08 of the collective agreement.

Rotations in the USA are generally covered for medico-legal purposes. Any resident who wishes to do an rotation in the USA is also responsible for obtaining a J1 VISA. Please contact your local Medical Teaching Office and the Faculty of Postgraduate Medical Education well in advance for more information.

More information can be found on McGill’s PGME website about this.

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Rotation-Specific Objectives for Core Rotations and Selectives Allergy and Immunology The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in allergy and immunology. The resident is expected to:

Medical Expert Be able to elicit, present and document a history that is relevant and appropriate to the immune system. Be able to perform an accurate physical examination of the immune system, with emphasis on:

Lymph Nodes Skin Mucous membranes

Be able to provide a reasonable approach to the differential diagnosis, work-up and management of the following scenarios:

Angioedema Urticaria

Be able to provide the indications for and complications of immunomodulating therapy (including DMARDS, cyclophosphamide and corticosteroids), desensitization therapy, and use of the “EpiPen.” Be able to provide a rational approach to the prevention of opportunistic infections in patients with primary or acquired defects of the immune system. Be able to demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up and management of the following conditions:

Hypersensitivity reactions (including anaphylaxis) Vasomotor rhinitis Asthma Auto-immune vasculitides

Be able to interpret pulmonary function tests. Understand the indications for allergy testing. Communicator Be able to communicate effectively with patients and families with respect to their medical conditions. Be able to interact effectively with other healthcare professionals. Be able to accurately document the patient’s condition and progress with emphasis on the relevant issues.

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Collaborator Be able to identify and recognize the need to and benefit of consulting other physicians and healthcare professionals, specifically a general surgeon or a dermatologist when biopsy of lymph nodes or skin is being considered. Be able to contribute effectively to a multidisciplinary team and its activities. Manager Be able to use information technology to optimize patient care. Be able to use healthcare resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and family regarding avoidance of allergen exposure and smoking cessation. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents and other healthcare professionals. Be able to contribute to the development of new knowledge, through the participation in completion of a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues that arise in clinical practice. Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Ambulatory Clinics Rotation The objectives of this rotation emphasize the resident’s exposure to a broad variety of medical problems in the outpatient context. The Internal Medicine resident is expected to participate in weekly clinics in a number of different sub-specialties during a four-week block. The content areas of this rotation depend on the choice of clinics, which will vary with each Resident. The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in ambulatory clinics. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is relevant and appropriate to a broad variety of outpatient problems. Be able to perform an accurate physical examination that is relevant to the presenting problem. Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of a broad variety of complaints and problems commonly encountered in the outpatient context. Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of a broad variety of conditions that are commonly encountered in the outpatient context. Recognize the indications for hospital admission for work-up or therapy. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions, given the time limitations of an outpatient experience. Be able to interact effectively with other health-care professionals. Be able to document the patient’s condition accurately with emphasis on the relevant issues. Collaborator Be able to identify the need to and benefit of consulting other physicians and health-care professionals. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimize patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding factors that impact on their health. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition.

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Be able to teach medical students, residents, and other health-care professionals. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues as they arise in clinical practice. Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Anaesthesia The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in anaesthesia. The objectives for Internal Medicine residents during this rotation center around gaining further experience with procedures, with an emphasis on airway management, central intravenous catheter insertion, and arterial catheter insertion. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is relevant and appropriate to the anaesthetist. Be able to perform an accurate physical examination with emphasis on airway assessment. Gain experience with and an understanding of the different types of anaesthesia, including regional and general anaesthesia. Gain experience with and an understanding of the medications commonly used by anaesthetists, including paralytic and anesthetic agents, pressors, barbituates, and opioids. Gain experience with and an understanding of appropriate pain control in the peri-operative setting. Be able to perform central and peripheral venous catheter insertion (including a Swan-Gantz catheter), peripheral and central arterial catheter insertion, and airway management including endotracheal intubation. Be familiar with the role of procedural ultrasound in optimizing the safe performance of the above procedures. Demonstrate an understanding of the issues surrounding the transport of critically ill patients within the hospital. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. Specifically, be able to communicate with patients in the pre- and post-operative setting regarding the intra-operative events. Be able to interact effectively with other health-care professionals. Be able to document the patient’s condition and progress intra-operatively. Collaborator Be able to identify the need to and benefit of consulting other physicians and health-care professionals. Manager Be able to use information technology to optimize patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding factors that affect their peri-operative risk, including smoking cessation.

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Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues as they arise in clinical practice. Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Cardiology and Coronary Care Unit (CCU) The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in cardiology/CCU. It is expected that a resident’s knowledge, skills, and attitudes will evolve as they progress from a first-year resident to a third-year resident. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is relevant and appropriate to the cardiovascular system. Be able to perform an accurate physical examination of the cardiovascular system, with emphasis on:

JVP determination Heart sounds and murmurs: distinguishing normal from abnormal Pulmonary hypertension Peripheral vascular disease

Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of the following scenarios:

Chest pain (atypical and anginal) Dyspnea Syncope Palpitations, arrhythmias, and syncope, including heart block Systolic and diastolic murmurs Coronary artery disease (medical management, indications for stress testing and angiography) Role of thrombolysis – indications and contraindications Pericarditis/Tamponade Adult congenital heart disease (ASD, VSD, PDA, bicuspid aortic valve, coartation of the aorta)

Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of the following conditions:

Acute coronary syndromes and myocardial infarction (inferior, anterior, rhythm disturbances, post-infarct angina) Congestive heart failure Abnormal cardiac enzymes Valvular diseases (how diseases affect heart sounds and how these change with the natural history of disease; management: medical and surgical) Pulmonary hypertension Cardiomyopathies Aortic aneurysm and dissection

Demonstrate an understanding of the principles and practice of peri-operative cardiac risk assessment, including hypertension, coronary artery disease, arrhythmias, congestive heart failure, structural heart disease, and infective endocarditis prophylaxis. Demonstrate an understanding of the indications for referral for cardiac transplantation. Be able to perform and interpret ECGs. Be able to perform central venous catheter insertion, peripheral arterial catheter insertion, and endotracheal intubation.

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Be familiar with the role of procedural ultrasound in optimizing the safe performance of the above procedures. Understand the indications for and complications of EST, 24 hr. ECG monitoring, echocardiography (trans-thoracic and -esophageal), DIP-MIBI, dobutamine echocardiography, cardiac catheterization with or without angioplasty, and transcutaneous or transvenous pacing. Demonstrate an understanding of and be able to perform advanced cardiopulmonary resuscitation. Demonstrate an understanding of the indications for admission to and discharge from a monitored unit. Demonstrate an understanding of the issues surrounding the transport of critically ill patients within the hospital and to other centers. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. Specifically, be able to communicate with critically-ill patients, recognizing that these patients pose unique challenges that require unique solutions. Furthermore, be able to communicate with families of critically-ill patients in order to address their concerns while being realistic in terms of prognosis. Be able to interact effectively with other health-care professionals. Be able to document the patient’s condition and progress accurately with emphasis on the relevant issues. Collaborator Be able to identify the need to and benefit of consulting other physicians and health-care professionals, specifically cardiovascular surgeons when coronary artery bypass or other surgery is being contemplated. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimize patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding smoking cessation, exercise, nutrition, and other risk factors to optimize a patient’s cardiac risk. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition, specifically vardiovascular risk reduction. Be able to teach medical students, residents, and other health-care professionals. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project.

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Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues as they arise in clinical practice. Specifically, be able to understand and deal with the ethical issues that arise in the critically-ill patient including consent and capacity, level of intervention discussions and end-of-life decisions, substitute decision-makers, and advance directives. Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Community Hospital Internal Medicine Experience (CHIME) The Internal Medicine resident is expected to achieve competency in the areas described below during their rotations in Community Hospital Internal Medicine. It is expected that a resident’s knowledge, skills, and attitudes will evolve as they progress from a first-year resident to a third-year resident in this context. Ultimately, the resident is expected to function as an internal medicine consultant to family physicians. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is appropriate to a general internist functioning as a consultant. In particular, the resident will gain experience with independent decision-making in the context of limited access to sub-specialists. Be able to perform an accurate physical examination with emphasis on multi-system involvement. Be able to provide a reasonable approach to the pathophysiology, differential diagnosis, work-up, and management of the following scenarios and groups of conditions:

Peri-operative medical consultations (see General Internal Medicine Consultations) Pregnancy-related medical problems (see Obstetrical Medicine) Undifferentiated complaints Multi-system conditions

Be able to understand the indications for and complications of procedures commonly performed by internists in the community, including treadmill testing, endoscopy, and bronchoscopy. Be able to understand the indications for transfer to a tertiary-care center for further patient care or work-up. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. Be able to interact effectively with other health-care professionals, especially family physicians who will be managing the patients on a long-term basis. Be able to document the patient’s condition and progress accurately with emphasis on the relevant issues. Be able to understand the need for, benefits and limitations of telephone consultations for physicians in remote communities. Collaborator Be able to identify the need to and benefit of working with other physicians and health-care professionals, specifically with other family physicians who are providing primary care for patients. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimize patient care. Be able to use health-care resources cost-effectively in the context of limited access to technological resources. In particular, the resident should gain experience and understanding with the transfer of patients to other centers for diagnostic tests and consultations with other subspecialists.

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Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding the factors that impact on their health. Be able to contribute to and improve the health of the local community. Specifically, the resident is encouraged to consider a career in general internal medicine in the community setting. Scholar Be able to critically appraise sources of medical information in the context of limited access to sub-specialists. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals, especially family physicians who will be managing the patients as primary-care givers. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues as they arise in clinical practice. Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Dermatology The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in dermatology. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is relevant and appropriate to the dermatologic system. Be able to perform an accurate physical examination of the dermatologic system, with emphasis on:

Nail findings as manifestations of systemic disease (including clubbing) Skin findings as manifestations of systemic disease

Nutritional deficiencies Inflammatory bowel disease Coeliac disease Malignancy Connective tissue disease Endocrine and metabolic disease Systemic immunosuppression

Features of senile keratosis (differentiate from melanoma) Differentiate venous from arterial insufficiency Recognize cellulites and differentiate it from common mimickers

Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of the following scenarios:

Hyperpigmented lesions (differentiate from melanoma) Petechia, purpura (palpable and non-palpable), and echymoses Bullous skin disease Urticaria Maculopapular eruptions including drug reactions Pruritus

Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of common dermatologic conditions, including:

Eczema Stasis dermatitis Psoriasis Erythema nodosum Herpes zoster

Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of dermatologic emergencies, including:

Stevens-Johnson syndrome Toxic Epidermal Necrolysis DRESS Anaphylaxis Disseminated herpes simplex

Understand the indications for and complications of skin biopsy. Gain experience in performing skin biopsies.

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Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. Be able to interact effectively with other health-care professionals. Be able to document the patient’s condition accurately with emphasis on the relevant issues, using drawings or sketches as necessary and appropriate for further clarification. Collaborator Be able to identify the need to and benefit of consulting other physicians and health-care professionals. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimize patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding reducing sun exposure and the use of sunscreens. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues as they arise in clinical practice. Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Acute General Internal Medicine Consults / ER Consults The Internal Medicine resident is expected to achieve competency in the areas described below during their rotations in Internal Medicine Consults in the emergency room (dealing with acutely ill patients and relatively undifferentiated problems). It is expected that a resident’s knowledge, skills, and attitudes will evolve as they progress from a first-year resident to a third-year resident in the emergency room. Ultimately, the resident is expected to function as an internal medicine consultant to the emergency room and the goals and objectives of this rotation reflect this. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is focused and relevant to the clinical presentation of patients in the emergency room. Be able to perform an accurate physical examination that is focused and relevant to the clinical presentation. Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of a broad range of clinical presentations in acute and undifferentiated form. Specifically, be able to focus on the common or dangerous problems first, with reference to rare but interesting diagnoses only as appropriate. Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of a broad range of clinical conditions in acute and undifferentiated form. Understand the indications for and complications of and be able to perform central venous catheter insertion, lumbar puncture, arterial puncture and blood gas analysis, abdominal paracentesis, endotracheal intubation, thoracentesis, joint aspiration, electrocardiographic interpretation, and inspection and interpretation of urinary sediment. Be familiar with the role of procedural ultrasound in optimizing the safe performance of the above procedures. Demonstrate an understanding of the indications for admission to an internal medicine ward in a tertiary-care hospital. Demonstrate an understanding of the issues surrounding the transport of critically ill patients within the hospital and to other centers. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. Specifically, be able to communicate with acutely-ill patients. Furthermore, be able to communicate with families of acutely-ill patients in order to address their concerns. Be able to interact effectively with other health-care professionals. Specifically, be able to communicate the reasons for consultation with sub-specialists and the need for prompt responses to such requests in the emergency room context. Be able to document the patient’s condition and progress concisely and accurately while in the emergency room with emphasis on synthesizing the relevant issues and the plan of work-up and management in a concise fashion. Collaborator Be able to identify the need to and benefit of consulting other physicians and health-care professionals.

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Manager Be able to use information technology to optimize patient care. Be able to use health-care resources cost-effectively in the emergency room context. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding factors that impact on their health status. Be able to advocate on behalf of acutely ill patients in the ER to facilitate access to tests and other therapies. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues as they arise in clinical practice. Specifically, be able to understand and deal with the ethical issues that arise in the acutely-ill patient including:

Consent and capacity Substitute decision-makers Advance directives

Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Endocrinology The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in endocrinology. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is relevant and appropriate to the clinical presentation. Be able to perform an accurate physical examination, with emphasis on:

Thyroid gland Extrathyroidal signs of thyroid disease Diabetic feet Gynaecomastia Signs of dyslipidaemia

Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of the following scenarios:

Dyslipidaemias Thyroid nodule and goitre Pituitary nodule (including incidentaloma) Chronic corticosteroid therapy Incidental adrenal mass Hypercalcaemia and hypocalcemia Hypogonadism, male and female (including amenorrhoea and loss of libido) Hirsutism Galactorrhea and gynaecomastia Weight gain and loss Fatigue and malaise Obesity Amenorrhea and loss of libido

Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of the following conditions:

Diabetes mellitus 1 and 2: first visit, treatment, follow-up, complications, peri-operative and in-hospital management, management of diabetes in pregnancy Diabetic ketoacidosis and hyperosmolar non-ketotic states Hypoglycaemia Hyperthyroidism (including Graves’ disease and thyroid storm) Hypothyroidism (including myxoedema coma) Acromegaly Adrenal insufficiency (including Addisonian crisis and peri-operative management) Cushing’s syndrome (including Cushing’s disease) Pheochromocytoma Conn’s disease Osteoporosis Hyperparathyroidism and hypoparathyroidism Paget’s disease Panhypopituitarism Prolactinoma Porphyrias Diabetes insipidus

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Hyper- and hypo-gonadism Pancreatic endocrine tumors

Be able to interpret common endocrine laboratory results, including dynamic testing. Understand the indications for and complications of thyroid biopsy, static and dynamic testing of pituitary, thyroid, and adrenal function. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. Be able to interact effectively with other health-care professionals. Be able to document the patient’s clinical condition and plan accurately with emphasis on the relevant issues. Collaborator Be able to identify the need to and benefit of consulting other physicians and health-care professionals. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimize patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding the role of lifestyle modification in the control of diabetes mellitus and osteoporosis. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues as they arise in clinical practice.

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Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Gastroenterology and/or Hepatology The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in gastroenterology and/or hepatology. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is relevant and appropriate to the clinical presentation in gastroenterology. Be able to perform an accurate physical examination of the gastroenterological system, with emphasis on:

Peripheral signs of cirrhosis Differentiate kidney from spleen Ascites Extra-intestinal manifestations of IBD, including eye, skin, and articular findings Venous drainage of abdomen in normal and disease states Signs of malnutrition Full abdominal examination, including liver and spleen examination

Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of the following scenarios:

General Gastroenterology Hepatology Upper GI Bleed Lower GI Bleed Recurrent gastric and/or duodenal ulcer Oesophagitis Dyspepsia Nausea & vomiting Dysphagia Diarrhoea, acute and chronic Constipation, acute and chronic Abdominal pain, acute and chronic Malabsorption Weight loss Melena, haematochezia Pancreatitis Abnormal transaminases Abnormal cholestatic liver enzymes

Abnormal liver enzymes Spontaneous bacterial peritonitis Hepatic encephalopathy Jaundice Ascites Hepatitis Cirrhosis and its complications Esophageal varices Indications for referral for liver transplantation

Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of the following conditions:

Peptic ulcer disease, including helicobacter pylori Esophageal dysmotility, in particular achalasia Gastroparesis Crohn’s disease Ulcerative colitis PBC/Sclerosis cholangitis Viral hepatitis Non-alcoholic steatohepatitis Haemochromatosis Alcoholic liver disease Cirrhosis

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Ischaemic bowel Coeliac disease Whipple’s disease Neoplasia (oesophageal, gastric, intestinal, colonic, pancreatic, hepatoma)

Understand the indications for and complications of gastroscopy, colonoscopy, ERCP, liver biopsy, and paracentesis. Be able to perform a paracentesis and insertion of a nasogastric tube. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. Be able to interact effectively with other health-care professionals. Be able to document the patient’s clinical condition and plan accurately with emphasis on the relevant issues. Collaborator Be able to identify the need to and benefit of consulting other physicians and health-care professionals. Specifically, be able to initiate a referral for a pre-transplant assessment in cases of cirrhosis. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimize patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding the role of lifestyle modification in the control of peptic ulcer disease, gastoesophageal reflux disease, inflammatory bowel disease, cirrhosis, and coeliac disease. Be able to counsel and educate patients and families regarding the moderation of alcohol consumption. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice.

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Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues as they arise in clinical practice. Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Medical Clinical Teaching Units (CTUs) The Internal Medicine resident is expected to achieve competency in the areas described below during their rotations in the Medical Clinical Teaching Units. It is expected that a resident’s knowledge, skills, and attitudes will evolve as they progress from a first-year resident to a third-year resident. Specifically, a first-year resident will function as the primary physician of his/her patients under the supervision of the senior residents and attending physicians, and the primary goals reflect the acquisition of basic clinical skills. A second-year resident will function in a supervisory capacity over the medical students and first-year residents. An important goal is the acquisition of teaching and supervisory skills. A third-year resident will function as the team leader under the supervision of the attending physicians. An important goal is the further refinement of teaching skills and adopting more of a manager role in terms of the functioning of the team. With the above in mind, the resident is expected to: Medical Expert Be able to elicit, present, and document a history that is relevant and appropriate to the presenting complaints across the various domains in internal medicine. Be able to perform an accurate general physical examination and focused examination of the involved systems, with particular emphasis on:

Evidence-based physical examination skills (see JAMA Rational Clinical Exam series) Multi-system conditions

Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of a broad variety of clinical scenarios. Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of a broad variety of clinical conditions. Understand the indications for and complications of central venous catheter insertion, arterial blood gas, lumbar puncture, paracentesis, thoracentesis, and knee joint aspiration. Be able to perform central venous catheter insertion, arterial blood gas, lumbar puncture, paracentesis, thoracentesis, knee joint aspiration, EKG interpretation, and inspection and interpretation of urinary sediment. Be familiar with the role of procedural ultrasound in optimizing the safe performance of the above procedures. Be able to interpret EKG’s and arterial blood gas results. Demonstrate an understanding of the issues surrounding the transfer of unstable patients to a monitored unit. Demonstrate an understanding of the issues surrounding the appropriate and timely discharge of patients from the hospital. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. In particular, be able to communicate with patients from different ethnic backgrounds and language groups. Be able to interact effectively with other health-care professionals.

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Be able to document the patient’s admission and progress accurately while in hospital with emphasis on the relevant issues. Collaborator Be able to identify the need to and benefit of consulting other physicians and health-care professionals. In particular, be able to recognize one’s limits of knowledge and expertise. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimize patient care. Be able to participate in quality improvement initiatives on the CTUs (eg. M&M rounds). Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding the factors that impact on their health. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues as they arise in clinical practice. Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Internal Medicine Consults (or General Internal Medicine Consults) The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in General Internal Medicine Consultations, with an emphasis on providing consultative services to inpatients in the hospital admitted to non-medical units. This rotation is offered as a stand-alone service at the MUHC-MGH and JGH sites, and as a combined rotation with acute GIM consults / ER consults at the MUHC-RVH site. The resident is expected to: Medical Expert Be able to elicit, present and document a history that is relevant and appropriate to a broad variety of patients, including surgical, obstetrical, gynecological, and psychiatric patients. Be able to perform an accurate physical examination with emphasis on the appropriate systems. Be able to provide a reasonable approach to the differential diagnosis, work-up and management of the following scenarios and conditions in both the inpatient and outpatient settings (as appropriate):

Peri-operative management of the following conditions: Hypertension Coronary artery disease (Goldman and Detsky criteria) Arrhythmias Congestive heart failure Structural heart disease (valvular, cardiomyopathic) IE prophylaxis COPD/asthma Diabetes mellitus (oral hypoglaemics, insulin therapy) DVT prophylaxis and treatment Antiplatelet/anticoagulant management Adrenal insufficiency Renal insufficiency/planning for dialysis Minimizing peri-operative renal insults

Post-operative complaints of: Fever Confusion Dyspnea Cough Chest pain

Patients with multi-system conditions Patients with undifferentiated complaints and problems Obstetrical Medicine (see Obstetrical Medicine)

Understand the indications for and complications of central venous catheter insertion, arterial blood gas, lumbar puncture, paracentesis, thoracentesis, and knee joint aspiration. Be able to perform central venous catheter insertion, arterial blood gas, lumbar puncture, paracentesis, thoracentesis, knee joint aspiration, EKG interpretation, and inspection and interpretation of urinary sediment. Be familiar with the role of procedural ultrasound in optimizing the safe performance of the above procedures. Be able to interpret pulmonary function testing, EKG’s, and arterial blood gas results.

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Demonstrate an understanding of the issues surrounding the transfer of unstable patients to a monitored unit. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. Be able to interact effectively and respectfully with other healthcare professionals. Be able to document the patient’s progress either while in hospital or in the community accurately with emphasis on the relevant issues. Collaborator Be able to identify and recognize the need to and benefit of working closely with the consulting physician and health-care team in providing optimal health-care. Be able to function and contribute effectively in a multi-disciplinary team. Manager Be able to use information technology to optimize patient care. Be able to use both inpatient and outpatient health-care resources in a cost-effective manner. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding factors that might impact on their health, including cigarette smoking, alcohol consumption, and obesity. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents and other healthcare professionals. Be able to contribute to the development of new knowledge, through the participation in and completion of a research project (optional). Professional Be able to apply a knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues that arise in clinical practice. Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Geriatrics The Internal Medicine resident is expected to achieve competency in the areas described below during their rotations in geriatrics. The resident is expected to:

Medical Expert Be able to elicit, present and document a history that is relevant and appropriate to the elderly (including collateral information). Be able to perform an accurate physical examination, with emphasis on:

Postural vital signs Mental Status Exam (Cognition – Folstein MMSE) Gait and balance Functional assessment (basic and instrumental activities of daily living)

Be able to accurately screen non-medical evaluations such as social, environmental and home assessments, and quality of life, including assessments of pain. Be able to assess competency especially the ability to live alone and when to consider appropriate placement options. Be able to provide a reasonable approach to the differential diagnosis, work-up and management of the following scenarios:

Delirium Dementia Psychiatric Illness – specifically depression Urinary and Fecal Incontinence Constipation Osteoporosis Gait Instability Falls Alcoholism and other substance abuse Appropriate prescribing for the elderly (polypharmacy, iatrogenesis) Gradual change in functional status (failure to thrive) Impairment of vision and hearing Nutritional assessment (including indications for supplementation) Neglect/Abuse

Be able to demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up and management of the following conditions:

Anemia – specifically Vitamin B12 deficiency Stroke Parkinson’s Disease Dementia/Delirium Cancer in the Elderly Falls Awareness of atypical presentations of common diseases

Understand the indications for urodynamics. Be able to provide information on the demographics of the ageing population and at least one theory of ageing.

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Communicator Be able to communicate effectively with patients and their families with respect to their medical, psychiatric, and social conditions. Be able to effectively support patients and families receiving end of life care. Be able to interact effectively and respectfully with other healthcare professionals. Be able to document the patient’s progress either while in hospital or in the community accurately with emphasis on the relevant issues. Collaborator Be able to identify and recognize the need to and benefit of consulting other physicians and healthcare professionals, specifically social workers, liaison nurses, geriatric nurse specialists, pharmacists, dieticians, physical therapists, occupational therapists, recreation therapists, and pastoral services. Be able to function and contribute effectively in a multi-disciplinary team. Manager Be able to use information technology to optimize patient care. Be able to access and use both inpatient and outpatient health-care resources in a cost-effective manner for the elderly. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding posture, exercise, nutrition, smoking, alcohol and other drugs to optimize cognitive and functional status. Be an advocate (at the societal as well as individual levels) of appropriate, evidence-based care that is neither “ageist” nor inappropriately “aggressive.” Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents and other healthcare professionals. Be able to contribute to the development of new knowledge, through the participation in and completion of a research project. Professional Be able to apply a knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice.

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Be able to recognize and resolve ethical issues that arise in clinical practice. Specifically, be able to provide an ethical framework for the care of cognitively impaired elderly and to identify and work with surrogate decision-makers. Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Haematology Consults and Clinical Teaching Units

The Internal Medicine resident is expected to achieve competency in the areas described below during their rotations in haematology consults or haematology CTUs. The learning objectives encompass areas critical to the practice of internal medicine best taught in the setting of a specialized unit (CTU). Examples include transfusion medicine, holistic care of the patient with cancer, and common complications of chemotherapy. The resident will have an exposure to laboratory services and learn to integrate appropriate testing in the work-up of a variety of common problems including coagulopathies, anemias, and malignancy. The resident is expected to: Medical Expert Be able to elicit, present and document a history that is relevant and appropriate to the hematopoeitic system. Be able to perform an accurate physical examination of the hematopoeitic system, with emphasis on:

Splenomegaly Lymphadenopathy

Be able to provide a reasonable approach to the differential diagnosis, work-up and management of the following scenarios:

Anemia Thrombocytopenia Bicytopenia/pancytopenia Polycythaemia Eosinophilia Lymphadenopathy, localized and diffuse Splenomegaly Warfarin and other anticoagulant use in patient care: management and counseling Patients with bleeding diatheses and abnormal coagulation testing

Demonstrate the ability to recognize and manage common symptoms and complications of patients with cancer:

Emergency care: Tumor lysis syndrome Spinal cord compression Hypercalcemia Febrile neutropenia

Pain & symptom control (in conjunction with palliative care medicine) Secondary effects of commonly used chemotherapeutic agents

Nausea/vomiting Febrile neutropenia Cardiomyopathy Hemorrhagic cystitis

Demonstrate knowledge of the appropriate use of allogeneic blood products in patient care:

Indications for transfusion of allogeneic blood products pRBC’s Platelets Plasma Cryoprecipitate Coagulation concentrates Albumin

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Immunoglobulins Risks of transfusion of allogeneic blood products

Transfusion reactions Current risk of infectious complications

Alternatives to transfusion of allogeneic blood products Erythropoeitin/darbepoeitin Vitamin K Iron/vitamin replacement

The importance of informed consent in transfusion care Demonstrate an understanding of the pathophysiology, manifestations, investigation and management of a number of clinical conditions. Anemia Iron deficiency Vit B12/folate deficiency Hemoglobinopathies Hemolytic anemia Aplastic anemia Hypoproliferative anemia Thrombosis Venous Benign Disease Arterial Thrombophilia Bleeding disorders Congenital Hemophilia von Willebrand Factor deficiencies Platelet disorders Acquired Coagulation factors (eg. DIC, liver disease) Platelet disorders (eg. Sepsis, ITP, TTP-HUS) Malignant Disease Leukemia, acute and chronic Lymphoma Multiple Myeloma Myelodysplastic disorders Myeloproliferative disorder Breast cancer Gastrointestinal cancer Lung cancer Renal cell cancer Prostate cancer Transitional cell cancer Germ cell tumors Melanoma Thyroid cancer

Gain an understanding of the value of translational research in patient care by observing new and rapidly emerging treatment modalities in cancer care:

Immunotherapy in cancer The role of allogeneic and autologous stem cell transplant in cancer Humoral growth factors New agents (eg. imatinib)

Be able to interpret results of a complete blood count, basic coagulation studies, and manual blood smears.

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Understand the indications for and complications of a bone marrow biopsy/aspirate, and lymph node biopsy. Demonstrate an understanding of the issues surrounding the transfer of unstable patients to a monitored unit. Demonstrate an understanding of the indications for admission/discharge to hospital. Communicator Be able to communicate effectively with patients and families with respect to their medical conditions. Be able to interact effectively with other healthcare professionals. Be able to document the patient’s condition and progress accurately with emphasis on the relevant issues. Collaborator Be able to identify and recognize the need to and benefit of consulting other physicians and healthcare professionals, specifically a general surgeon or an invasive radiologist when a biopsy is required, or a pathologist for biopsy analysis. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimize patient care. Be able to use healthcare resources cost-effectively Be able to work efficiently and effectively Health Advocate Be able to educate and counsel patients and families regarding nutrition and alcoholism to optimize anemia risk, as well as behaviour which reduce infections when neutropenic. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents and other healthcare professionals. Be able to contribute to the development of new knowledge, through the participation in completion of a research project. Professional Be able to apply a knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues as they arise in clinical practice. In particular, be able to understand and deal with the ethical issues that arise in this patient population, including:

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Consent and capacity Level of intervention discussions and end-of-life decisions Substitute decision-makers Advance directives

Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Immunodeficiency Rotation The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in immunodeficiency. The emphasis of this rotation is to expose Internal Medicine residents to the outpatient care of patients infected with HIV in a multi-disciplinary environment. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is relevant and appropriate to the presenting problem in HIV-infected patients. Be able to perform an accurate physical examination that is relevant to the presenting problem. Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of the following scenarios in HIV-infected patients:

Fever (in patients with variable CD4 counts) Weight loss Respiratory: dyspnea, cough, hemoptysis GI: dysphagia, odynophagia, diarrhea, abdominal pain Hematology: anemia, thrombocytopenia, leukopenia Nephrology: acute and chronic renal failure Neurology: confusion, headache, cerebral masses

Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of the following conditions in HIV-infected patients:

Respiratory: pneumonia, including PCP pneumonia GI: oro-pharyngeal thrush, CMV/HSV esophagitis, CMV enteritis Hematology: HIV-associated monopenias Nephrology: HIV nephropathy Neurology: primary CNS lymphoma, CNS toxoplasmosis, meningitis (including cryptococcal infections) MAC infection TB, including pulmonary and extra-pulmonary Malignancies, including lymphoma, melanoma, and gynecological neoplasms Immunoreconstitution syndrome

Understand the indications for and complications of a broad variety of anti-retroviral treatments for HIV. Understand the treatments and prophylactic regimens for opportunistic infections. Be able to understand the management of patients at all stages of their disease, from new diagnosis to chronic infection to end-stage disease. Understand the indications for the measurement of viral load, viral genotyping, and CD4 count. Gain an understanding of the value of translational research in patient care by observing new and rapidly emerging treatment modalities in the care of patients with HIV. Be able to recognize the indications for hospital admission. Communicator Be able to communicate effectively and compassionately with patients and their families with respect to their medical conditions.

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Be able to interact effectively with other health-care professionals. Be able to document the patient’s clinical condition and plan accurately with emphasis on the relevant issues. Collaborator Be able to identify the need to and benefit of consulting other physicians and health-care professionals. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimize patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding factors that can decrease the risk of transmission of HIV and minimize their risk of opportunistic infections. Be able to educate patients and their families and friends regarding HIV and its treatment. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues as they arise in clinical practice. In particular, be able to recognize and deal with issues surrounding discrimination based on sero-positivity status, and advance directives and end-of-life issues in the context of patients with end-stage disease. Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Infectious Diseases The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in infectious diseases. The resident is expected to: Medical Expert Be able to elicit, present and document a history that is relevant and appropriate. Be able to perform an accurate physical examination, with emphasis on:

Peripheral signs of infective endocarditis Examination of the HIV infected patient (for both effects of disease and treatment) Clinical assessment of the febrile patient, in the inpatient and outpatient contexts

Be able to provide a reasonable approach to the differential diagnosis, work-up and management of the following clinical scenarios:

Pneumonia UTI / urosepsis Infective Endocarditis Meningitis - Encephalitis Cellulitis / other necrotizing soft-tissue infections Osteomyelitis / septic arthritis Intra-abdominal Infections Diarrhea (including in the returning traveler) Fever in the hospitalized patient (line sepsis, etc.) Skin lesions in the returning traveler Fever in the returning traveler Fever of unknown origin Fever in immunocompromised host (HIV, organ transplant, etc.) Febrile Neutropenia Sexually transmitted infections

Be able to demonstrate an understanding of infection control (universal precautions, airborne infections, and contract precautions). Be able demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of the following conditions:

Infective endocarditis (including prophylaxis, indications for surgery) Clostridium difficile colitis (including prevention and treatment strategies) Diabetic foot ulcers and infections, including the indications for debridement Tuberculosis (pulmonary and extra-pulmonary) Malaria HIV: New Diagnosis HIV: Prophylaxis and treatment of Opportunistic Infections HIV: Treatments of HIV and Immunoreconstitution syndromes

Be able to interpret PPDs. Understand the spectra, side effects, and dosage adjustments for hepatic and renal disease of currently available antibiotics.

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Be able to prescribe antimicrobial agents in an appropriate fashion based upon a thorough clinical assessment of the patient, taking into account the spectra of the antibiotics available. Be able to demonstrate an understanding of hospital infection control practices and apply these to the care of patients. Be able to demonstrate an understanding of the indications for admission to and discharge from hospital, in particular the indication for admission to an intensive care setting with the sepsis syndrome. Communicator Be able to communicate effectively with patients and families with respect to their medical conditions. Be able to interact effectively with other healthcare professionals. Be able to accurately document the patient’s condition and progress accurately with emphasis on the relevant issues. Collaborator Be able to identify and recognize the need to and benefit of consulting other physicians and healthcare professionals, specifically a general or plastic surgeon when debridement or biopsy is indicated. Be able to contribute effectively to inter-disciplinary team activities. Manager Be able to use information technology to optimize patient care. Be able to use healthcare resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding risk factors for disease transmission, and measures to reduce their spread, including hand washing. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents and other healthcare professionals. Be able to contribute to the development of new knowledge, through the participation in completion of a research project. Professional Be able to apply a knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues that arise in clinical practice.

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Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Intensive Care Unit The Internal Medicine resident is expected to achieve competency in the areas described below during their rotations in the intensive care unit. It is expected that a resident’s knowledge, skills, and attitudes will evolve as they progress from a first-year resident to a third-year resident in the intensive care unit. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is relevant and appropriate to the critically ill patient. In particular, be able to perfect the skill of history-taking from third parties and other sources when patients are unable to communicate given the severity of their medical conditions. Be able to perform an accurate physical examination of the critically ill patient, with emphasis on:

Assessing the comatose patient Assessing the patient in shock Assessing the patient in respiratory distress

Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of the following scenarios:

Shock/SIRS Hypo/hyperthermia Respiratory failure (hypercapnoeic, hypoxaemic) Elevated intra-cranial pressure Coma, including GCS Cardio-respiratory arrest

Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of the following conditions:

Allergy/Immunology: Anaphylaxis Dermatology: Stevens-Johnsons syndrome Endocrinology: Thyroid storm, myxedema coma, Addisonian crisis, DKA/HONK Gastroenterology: GI bleed (including variceal hemorrhage), pancreatitis, hepatic encephalopathy Hematology: coagulopathy and DIC, massive thrombosis and pulmonary embolism Hypertensive urgencies and crisis Infectious Diseases: sepsis, febrile neutropenia, infections in immunocompromised hosts Nephrology: acute renal failure and alterations in renal output Neurology: coma, Guillain-Barré syndrome, meningitis, acute cord compression Respirology: ARDS, COPD, status asthmaticus Other emergencies: Poisoning: ASA, methanol, TCA, acetaminophen, iron

Injuries: smoke inhalation and CO inhalation, electrocution Near drowning Hypo-and hyperthermia Cardio-respiratory arrest

Demonstrate an understanding of the indications for and complications of:

Inotropic and vasopressor support, demonstrating a knowledge of agents Mechanical cardiac support (including IABP, CVT consultation) Non-invasive ventilation, intubation, and extubation Renal-replacement therapy Enteral and parenteral nutritional support Blood product use in the critically ill

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Sedation/anxiolysis/analgesia/paralysis Understand the indications for and complications of central venous access, peripheral arterial access, endotracheal intubation, Swan-Ganz catheter, and temporary transvenous pacemaker. Understand the principles of and be able to manage mechanical ventilation, including a range of ventilatory modes and strategies. Be able to interpret arterial blood gas results and haemodynamic tracings. Be able to perform central venous catheter insertion, peripheral arterial catheter insertion, and airway management including bag and mask ventilation and endotracheal intubation. Be familiar with the role of procedural ultrasound in optimizing the safe performance of the above procedures. Demonstrate an understanding of the indications for admission to and discharge from a monitored unit. Demonstrate an understanding of the issues surrounding the transport of critically ill patients within the hospital and to other centers. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. Specifically, be able to communicate with critically-ill patients, recognizing that these patients pose unique challenges that require unique solutions. Furthermore, be able to communicate with families of critically-ill patients in order to address their concerns while being realistic in terms of prognosis. Be able to interact effectively with other health-care professionals of all sorts that are often involved in the care of the critically-ill patient. Be able to document the patient’s condition and progress accurately while in hospital with emphasis on the relevant issues, in the context of multi-system and complex patients in rapid evolution. Collaborator Be able to identify the need to and benefit of consulting other physicians and health-care professionals. Be able to contribute effectively to interdisciplinary team activities. Be able to participate in and lead an emergency team in a positive, organized, and effective manner, and to prioritize tasks in critical contexts. Manager Be able to use information technology to optimize patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively in the context of multiple demands on a resident’s time while managing critically-ill patients. Health Advocate Be able to educate and counsel patients and families regarding important factors affecting their health. Scholar

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Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues as they arise in clinical practice. Specifically, be able to understand and deal with the ethical issues that arise in the critically-ill patient including:

Consent and capacity Level of intervention discussions and end-of-life decisions Substitute decision-makers Advance directives

Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Medical Oncology The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in medical oncology. The emphasis of this rotation is to expose Internal Medicine residents to the outpatient care of patients with cancer. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is relevant and appropriate to the presenting problem in oncology. Be able to perform an accurate physical examination that is relevant to the presenting problem. Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of the following scenarios:

Febrile neutropenia Adenocarcinoma and neoplasia of unknown primary site Oncologic emergencies, including hypercalcemia, spinal cord compression, brain metastases, pleural effusions, and cancer pain syndromes.

Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of the following conditions:

Breast cancer Oesophageal, gastric, intestinal, colonic, pancreatic, hepatoma Lung cancer Ovarian cancer Endometrial Cervical Renal cell cancer Transitional cell cancer Prostate cancer Male germ cell tumours (seminomatous and NSGCT) Thyroid cancer Melanoma Paraneoplastic syndromes

Understand the indications and controversies surrounding screening for the following malignancies: breast, colorectal, lung, ovarian, and prostate. Understand the indications for and complications of various biopsy techniques in order to arrive at a tissue diagnosis. Understand the indications for CT, MRI, PET, bone and gallium scans, and other tests in patients being worked up or followed for malignancy. Be able to recognize the indications and side effect of a broad variety of chemotherapeutic regimens, with emphasis on nausea and myelosuppression. Be aware of the concepts of "adjuvant," "neo-adjuvant," and "curative" therapies. Be able to recognize and quantify the performance status of patients with cancer. Gain an understanding of the value of translational research in patient care by observing new and rapidly emerging treatment modalities in cancer care.

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Be able to recognize the indications for hospital admission. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. Be able to demonstrate sensitivity towards patient and family concerns in the context of oncological practice. Be able to interact effectively with other health-care professionals in a multi-disciplinary environment. Be able to document the patient’s clinical condition and plan accurately with emphasis on the relevant issues. Collaborator Be able to identify the need to and benefit of consulting other physicians and health-care professionals, including surgeons when resection is being considered. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimize patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding the role of lifestyle modification on the management of their cancer and its possible complications. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues as they arise in clinical practice. In particular, be able to recognize and deal with end-of-life issues in the context of patients with cancer. Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Nephrology The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in nephrology. The resident is expected to:

Medical Expert Be able to elicit, present and document a history that is relevant and appropriate to the renal system. Be able to perform an accurate physical examination with emphasis on:

Volume status, including JVP determination and peripheral edema Distinguish the kidney from the spleen on examination Signs of uremia: pleuropericarditis, asterixis, congestive heart failure, and Kussmaul’s breathing

Be able to provide a reasonable approach to the differential diagnosis, work-up and management of the following scenarios:

Hypo-hypernatremia Hypo-hyperkalemia Hypo-hypercalcemia Metabolic acidosis/alkalosis Acute renal failure Chronic renal failure (workup and complications) Nephrotic and nephritic syndrome Proteinuria Hematuria Hypertension Peripheral edema

Be able to demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up and management of the following conditions:

Acute tubular necrosis (including contrast nephropathy) Acute renal failure secondary to NSAID’s Allergic interstitial nephritis Renovascular hypertension Renal tubular acidosis Diabetic Nephropathy Hypertensive glomerulosclerosis Rhabdomyolysis

Be able to interpret urianalysis, urinary sediment microscopy, and urinary electrolytes. Understand the indications for and complications of renal ultrasonography, renal scan, and renal biopsy. Demonstrate an understanding of the indications and complications of different modes of renal replacement therapy. Demonstrate an understanding of the indications for renal transplantation. Demonstrate an understanding of the indications for admission to and discharge from hospital.

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Communicator Be able to communicate effectively with patients and families with respect to their medical conditions. Be able to interact effectively with other healthcare professionals. Be able to document the patient’s condition and progress accurately with emphasis on the relevant issues. Collaborator Be able to identify and recognize the need to and benefit of consulting other physicians and healthcare professionals, specifically surgeons when access for dialysis or transplantation is being contemplated. Be able to contribute effectively in a multi-disciplinary team. Manager Be able to use information technology to optimize patient care. Be able to use healthcare resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and families regarding smoking cessation, nutrition, exercise and other risk factors to optimize preservation of renal function and reduce cardiac risk. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents and other healthcare professionals. Be able to contribute to the development of new knowledge, through the participation in completion of a research project. Professional Be able to apply a knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues that arise in clinical practice. Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Neurology The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in neurology. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is relevant and appropriate to the clinical presentation. Be able to perform an accurate physical examination, with emphasis on:

Upper vs. Lower motor neuron findings Tremors Pupils (Adie’s, Argyll-Robertson, Marcus-Gunn) Examination of all cranial nerves, including palsies of all nerves with common causes Focused mental status examination Cerebellar examination Posterior column examination Compare/demonstrate radiculopathy and peripheral nerve disease (C5, C6, C7, L4, L5, S1 nerve roots and appropriate peripheral nerves) Interpret gait abnormalities Altered level of conssciousness (including Glasgow Coma Scale)

Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of the following scenarios:

Tremors Autonomic Insufficiency Polyneuropathy, mononeuritis multiplex, and peripheral neuropathy Seizure: first episode, recurrent, and status epilepticus Dementia, including normal pressure hydrocephalus Acute spinal cord compression Alcohol abuse and withdrawal Subarachnoid hemorrhage Acute neuromuscular weakness Brain tumours Stroke Altered mental status

Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of the following conditions:

Approach to stroke/transient ischemic attacks (and stroke syndromes): diagnosis, primary and secondary prevention, treatments Multiple Sclerosis: findings, diagnosis, treatment Parkinson’s Disease Myasthenia Gravis Guillain-Barre syndrome Amyotrophic Lateral Sclerosis Meningitis and encephalitis Acute spinal cord compression

Understand the indications for and complications of lumbar puncture, CT scan, MRI (both with and without contrast), EEG, and EMG.

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Be able to perform a lumbar puncture and interpret the results of cerebrospinal fluid analysis. Be aware of the criteria for and methods to determine brain death. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. Be able to interact effectively with other health-care professionals. Be able to document the patient’s condition and progress accurately with emphasis on relevant neurological issues. Collaborator Be able to identify the need to, and benefit of consulting other physicians and health-care professionals, including neurosurgeons if surgery is being contemplated. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimise patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and their families regarding the factors that impact on their health, in particular factors that impact on their risk of stroke. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals, especially family physicians who will be managing the patients as primary-care givers. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognise and resolve ethical issues as they arise in clinical practice. Be able to recognise and deal with unprofessional behaviours in clinical practice.

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Night Float Night float is a 1-2 week block of time during which residents function as relatively independent teams working only at night. These teams generally cover inpatients admitted in the Department of Medicine with acute medical problems requiring urgent assessment, cardiac arrests throughout the hospital, and are responsible for admitting patients to the medical clinical teaching units overnight. Generally, consults for admission to medicine in the ER are done by a separate team so this is not part of the responsibilities of the night float team. These teams generally consist of an R1 and either an R2 or R3. The Internal Medicine resident is expected to achieve competency in the areas described below during their rotations in night float. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is relevant and appropriate to the presenting complaints across the various domains in internal medicine, with an emphasis on urgent problems occurring on admitted patients in the hospital. Be able to perform an accurate general physical examination and focused examination of the involved systems, with particular emphasis on:

Evidence-based physical examination skills (see JAMA Rational Clinical Exam series) Multi-system conditions Medical complications of patients already admitted to the hospital

Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of a broad variety of clinical scenarios, eg. acute chest pain, dyspnea, fever, other vital signs abnormalities, dysuria, diarrhea in a hospitalized patient, GI bleeding, nausea and vomiting, hematemesis or melena / hematochezia in admitted patients. Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of a broad variety of clinical condition eg. ACS, CHF, pneumonia, sepsis, PUD, cellulitis, pyelonephritis, clostridum difficile diarrhea, DVT/PE in admitted patients. Understand the indications for and complications of central venous catheter insertion, arterial blood gas, lumbar puncture, paracentesis, thoracentesis, and knee joint aspiration. Be able to perform central venous catheter insertion, arterial blood gas, lumbar puncture, paracentesis, thoracentesis, knee joint aspiration, EKG interpretation, and inspection and interpretation of urinary sediment. Be familiar with the role of procedural ultrasound in optimizing the safe performance of the above procedures. Be able to interpret EKG’s and arterial blood gas results. Demonstrate an understanding of the issues surrounding the transfer of unstable patients to a monitored unit. Demonstrate an understanding of the issues surrounding the appropriate and timely discharge of patients from the hospital. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. In particular, be able to effectively communicate with patients and families in the context of limited previous contact.

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Be able to interact effectively with other health-care professionals – specifically, be able to recognize when to call your attending physician to inform them of overnight events. Be able to document the patient’s admission and progress accurately while in hospital with emphasis on the relevant issues overnight. Collaborator Be able to identify the need to and benefit of consulting other physicians and health-care professionals. In particular, be able to recognize one’s limits of knowledge and expertise, and to know when to call for help overnight. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimize patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively in the context of multiple competing demands. Specifically, to be able to identify which issues can wait until the next morning and when issues are urgent and should be addressed overnight. Health Advocate Be able to advocate for urgent tests needed for patients overnight, especially radiology tests, and requesting urgent consultations (ICU, CCU, etc.) in the same context. Scholar Be able to critically appraise sources of medical information. Be able to teach medical students, residents, and other health-care professionals. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognize and resolve ethical issues as they arise in clinical practice. Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Obstetrical Medicine

The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in obstetrical medicine.

The resident is expected to:

Medical Expert

Be able to elicit, present and document a history that is relevant and appropriate to the pregnant patient.

Be able to perform an accurate physical examination of the pregnant patient.

Be able to provide an approach to the differential diagnosis, work-up and management of the following scenarios in the pregnant patient:

Hypertension Valvular heart diseases Shortness of breath Palpitations Seizure Thrombocytopaenia Hyperglycemia Abnormal liver function tests Proteinuria

Be able to demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up and management of the following conditions in the pregnant patient:

Hypertensive disorders of pregnancy: chronic hypertension, gestational hypertension, pre-eclampsia-eclampsia Cardiac disorders: valvular heart disease (including endocarditis prophylaxis), cardiomyopathy of pregnancy Respiratory disorders: pneumonia, asthma Hyperemesis gravidarum Liver diseases of pregnancy, including cholestasis of pregnancy, HELLP, fatty liver of pregnancy, inflammatory bowel disease, viral and auto-immune hepatitis Renal disorders: acute and chronic renal failure, UTI Endocrine disorders: diabetes mellitus, gestational diabetes, thyroid diseases Venous thromboembolism Neurological disorders: migraines, seizures, MS Infectious disorders: HIV, TB Collage-vascular disorders: RA, SLE

Be able to understand the physiological changes that occur in pregnancy with respect to blood volume, hemodynamics, cardio-respiratory physiology, and renal physiology.

Be able to understand the impact of pregnancy and the post-partum period on chronic medical conditions.

Be able to understand drug prescribing in pregnancy and the post-partum period.

Know when to consult maternal-fetal experts and or medical sub-specialists.

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Understand the effects of radiographs, CT scans, nuclear imaging, and other imaging modalities on the pregnant patient.

Demonstrate an understanding of the indications for admission to and discharge from hospital.

Communicator

Be able to communicate effectively with patients and families with respect to issues relating to their pregnancy, health, and fetal well-being.

Be able to interact effectively with other healthcare professionals.

Be able to document the patient's condition and progress accurately with emphasis on the relevant issues.

Collaborator

Be able to identify and recognize the need to and benefit of consulting other physicians and healthcare professionals, specifically obstetricians, family doctors, maternal-fetal experts, high-risk obstetrical units, and geneticists.

Be able to contribute effectively in a multi-disciplinary team.

Manager

Be able to use information technology to optimize patient care.

Be able to use healthcare resources cost-effectively.

Be able to work efficiently and effectively.

Health Advocate

Be able to educate and counsel patients and families regarding factors that impact on their health including cigarette smoking, drug use, and alcohol.

Scholar

Be able to critically appraise sources of medical information.

Be able to educate patients and their families regarding their medical condition.

Be able to teach medical students, residents and other healthcare professionals.

Be able to contribute to the development of new knowledge, through the participation in completion of a research project.

Professional

Be able to apply a knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice.

Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice.

Be able to recognize and resolve ethical issues that arise in clinical practice.

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Be able to recognize and deal with unprofessional behaviours in clinical practice.

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Palliative Care The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in palliative care. The resident is expected to: Medical Expert Be able to elicit, present and document a history that is relevant and appropriate to the clinical presentations of palliative care patients. Recognize the physical, psychological, social, and functional consequences of end-stage diseases. Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of the following symptoms and conditions while demonstrating an understanding of their pathophysiology:

Pain, both acute and chronic, of various origins (bone, neuropathic, etc.) Constipation Edematous states, including lymphedema Nausea and vomiting Delirium Dyspnea Nutritional deficiencies (anorexia and cachexia)

Be able to recognize and manage terminal delirium. Understand the pharmacology of drugs used to manage symptoms associated with terminally ill patients. In particular, develop an expertise in the management of opioid medications for the treatment of pain. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. In particular, be able to communicate with patients from different ethnic backgrounds and language groups. Be able to interact effectively with other health-care professionals. Be able to document the patient’s condition and progress accurately with emphasis on relevant issues. Collaborator Be able to identify the need to, and benefit of consulting other physicians and health-care professionals, including radio-oncologists and medical oncologists. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimise patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and their families regarding the factors that impact on their health.

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Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals, especially family physicians who will be managing the patients as primary-care givers. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognise and resolve ethical issues as they arise in clinical practice, particularly:

Competency Surrogate decision-makers Goals of care and cardiopulmonary resuscitation Confidentiality Resource allocation

Be able to recognise and deal with unprofessional behaviours in clinical practice.

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Radiology The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in radiology. The resident is expected to: Medical Expert Understand the indications for, and be able to interpret chest X-rays and CT scan of thorax, with emphasis on:

Solitary lung nodule Pleural effusion Congestive heart failure Lobar collapse Interstitial vs. airspace disease Pulmonary fibrosis Pulmonary hypertension Hilar adenopathy

Understand the indications for, and be able to interpret abdominal X-rays and CT scan of the abdomen, with emphasis on:

Small/large bowel obstruction Bowel edema/inflammation (colitis, ileitis, etc.) Liver masses/cysts Renal masses/cysts

Understand the indications for, and be able to interpret CT scan of the head, with emphasis on:

Masses/cysts Hemorrhage Ischemic infarcts

Understand the indications for:

MRI Angiograms/interventional radiology procedures Bone/Gallium scans Other nuclear medicine scans Ultrasounds PET scans

Communicator Be able to interact effectively with other health-care professionals and discuss the results of various radiological tests. Collaborator Be able to identify the need to, and benefit of consulting other physicians and health-care professionals. Manager Be able to use information technology to optimise patient care. Be able to use health-care resources cost-effectively.

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Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and their families regarding the factors that impact on their health. Scholar Be able to critically appraise sources of medical information. Be able to teach medical students, residents, and other health-care professionals. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognise and resolve ethical issues as they arise in clinical practice. Be able to recognise and deal with unprofessional behaviours in clinical practice.

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Respirology The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in respirology. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is relevant and appropriate to the clinical presentation. Be able to perform an accurate physical examination, with emphasis on:

Clubbing Maneuvers for thoracic outlet obstruction Findings of chronic obstructive pulmonary disease Findings of respiratory distress Findings of pulmonary hypertension

Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of the following scenarios:

Wheeze Acute and chronic dyspnea Cough Cavitating lesions, including lung abcess Solitary pulmonary nodule Mediastinal mass Pulmonary fibrosis Hemoptysis Pleural effusion Superior Vena Cava syndrome Hilar adenopathy Interstitial lung disease

Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of the following conditions:

Pneumonia Empyema Asthma (including arterial blood gas analysis, criteria for ICU/intubation, status asthmaticus) Chronic obstructive pulmonary disease Pulmonary embolism Cystic fibrosis Primary lung neoplasms Pneumothorax Sarcoidosis Obstructive sleep apnea Occupational lung disease Lung cancer, including primary and metastatic

Understand the indications for, and be able to interpret chest X-rays and CT scan of thorax, with emphasis on:

Solitary lung nodule Pleural effusion Congestive heart failure Lobar collapse

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Interstitial vs airspace disease Pulmonary fibrosis Pulmonary hypertension Hilar adenopathy

Be able to perform an arterial blood gas and thoracentesis and interpret the results. Be familiar with the role of procedural ultrasound in optimizing the safe performance of a thoracentesis. Be able to perform bedside spirometry and interpret the results of pulmonary function testing. Understand the indications for, and complications of bronchoscopy, thoracoscopy, pleural and lung biopsies, chest tube placement, and thoracentesis. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. Be able to interact effectively with other health-care professionals. Be able to document the patient’s condition and progress accurately with emphasis on relevant pulmonary issues. Collaborator Be able to identify the need to, and benefit of consulting other physicians and health-care professionals, including thoracic surgeons if surgery is being contemplated. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimise patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and their families regarding the factors that impact on their health, particularly with respect to smoking cessation. Scholar Be able to critically appraise sources of medical information Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals, especially family physicians who will be managing the patients as primary-care givers. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project.

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Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognise and resolve ethical issues as they arise in clinical practice. Be able to recognise and deal with unprofessional behaviours in clinical practice.

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ROTATION IN RESPIRATORY MEDICINE at the

Montreal Chest Institute The rotation will be based at the Montreal Chest Institute, which is located on Avenue Saint-Urbain, just below Pine avenue. The rotation will consist of a broad variety of clinical exposures: very active and well-organized out-patient clinics, a 25-bed medical ward, a 7-bed ICU and a 10-bed day hospital. The rotation will consist of a 4 week block, divided in two periods of two weeks. The first block will be spent on the 25-bed respiratory ward, where the resident will be under the direct supervision of a respirologist. The resident will be expected to be the primary physician of 8-10 highly selected patients deemed appropriate for teaching purposes. Daily rounds, formal teaching sessions, medical thoracoscopy and two half-day of clinics will complement the ward activities. The second two-week block will be composed of more extensive out-patient exposure, organized according to the resident’s preferences and the various clinical programs offered at the MCI, namely:

- Smoking cessation - COPD rehabilitation - Cystic Fibrosis - Sleep medicine - Asthma - Tuberculosis - Home ventilation Program - CSST - Lung oncology clinic & Tumor board (Lung Oncology & Thoracic Surgery)

The resident will also be exposed to the Day Hospital program in order to gain experience in lung cancer staging and management as well as being able to gain experience in thoracentesis and chest tube insertion and management. Exposure to medical thoracoscopy and bronchoscopy will also be offered throughout the 4 week rotation. This rotation is open to all McGill Internal Medicine Residents. For more information, please contact Jennifer Landry by e-mail at jennifer.landry@mcgill.ca or speak to your local Medical Teaching Office about it.

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Rheumatology The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in rheumatology. The resident is expected to: Medical Expert Be able to elicit, present and document a history that is relevant and appropriate to the clinical presentations of various rheumatologic complaints and conditions. Be able to perform an accurate physical examination, with emphasis on:

Examination of the peripheral joints (foot and ankle, knee, hip, hand and wrist, elbow, shoulder) and axial skeleton (cervical, thoracic, and lumbosacral including sacroiliac joints) Extra-articular manifestations of rheumatoid arthritis, lupus, ankylosing spondylosis Examination for scleroderma Examination for low back pain

Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of the following scenarios:

Acute monoarthritis Acute polyarthritis Chronic polyarthritis Sacroileitis Low back pain (with emphasis on the danger signs prompting early evaluation) Vasculitis Complications of chronic corticosteroid use Interpretation of ESR, CRP, and autoantibodies Interpretation of bone mineral densitometry

Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of the following conditions:

Gout and pseudogout Septic arthritis Osteoarthritis Rheumatoid arthritis and Sjogren's syndrome Sero-negative arthopathies Systemic lupus erythematosis Ankylosing spondylitis Scleroderma Dermatomyositis/Polymyositis Raynaud’s phenomenon and disease Temporal arteritis and Polymyalgia Rheumatica Fibromyalgia Osteoporosis, particularly in the patient on corticosteroids Soft-tissue rheumatic pain, including tendonitis and bursitis

Be able to perform arthrocentesis of the knee and interpret the results of synovial fluid analysis. Understand the indications for and complications of anti-inflammatory, DMARDs, and immunosuppressive drugs in the treatment of rheumatologic conditions. Understand the indications for and complications of arthrocenteses for all joints, joint X-RAYS, joint scans, and bone-gallium scans.

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Be able to interpret joint fluid microscopy. Demonstrate an approach to interpreting bone and joint radiographs. Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. Be able to interact effectively with other health-care professionals. Be able to document the patient’s condition and progress accurately with emphasis on the rheumatological issues. Collaborator Be able to identify the need to, and benefit of consulting other physicians and health-care professionals, including orthopedic surgeons if surgery is being contemplated. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimise patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and their families regarding the factors that impact on their health, including the benefits of weight loss and exercise for prevention and management of osteoarthritis. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals, especially family physicians who will be managing the patients as primary-care givers. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognise and resolve ethical issues as they arise in clinical practice. Be able to recognise and deal with unprofessional behaviours in clinical practice.

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Scholarly Activity Rotation (SAR) A scholarly project is mandatory for all residents beginning their residency after July 1, 2011. This activity may consist of (i) a clinical vignette / case presentation / case report, (ii) a quality assurance / quality improvement (QA/QI) project, (iii) a medical education project, or (iv) a research project. Evidence of a scholarly activity is required and will be placed in each resident’s file. In order to meet this goal, each resident will be assigned 4 weeks of time towards a scholarly project (scholarly activity rotation) between PGY1-3. This may be taken as a 4 week rotation or separately in 1 or 2 week blocks of time. All SARs must have an identified attending supervisor and a completed evaluation form must be submitted for each block of time taken. Proof of completion of a scholarly project is required before the end of PGY3, and will be placed in each resident’s teaching portfolio.

(i) Clinical Vignette / Case Presentation / Case Report

A clinical vignette / case presentation / case report is a structured case presentation, with a literature review highlighting the unique aspects of the case in question (either diagnostics, therapeutics, or other aspects), as presented to a group of physicians in various contexts (hospital rounds, provincial or national conference) or as published in a peer-reviewed journal. There must be an identified faculty supervisor to guide the project and provide an evaluation (this faculty supervisor will also provide guidance and review slide sets/submissions for publication).

(ii) Quality Assurance / Quality Improvement Project

A quality assurance / quality improvement project is a structured project, with a defined goal of improving the quality of care at your local hospital, based on a problem and goal identified in your local hospital / service. The project includes identifying the area to improve on, structuring the intervention, implementing the change, and monitoring its impact. In a general sense, this follows the PDSA cycle of QI (Plan, Do, Study, Act). These interventions are designed to be implemented in real-life settings, and so an essential component of these projects is to test out the intervention and assess its impact. QA/QI projects, given their scope and nature, may be done in small groups of residents. There must be an identified faculty supervisor to guide the project and provide an evaluation.

(iii) Medical Education Project

A medical education project is a project looking at an educational question or intervention, preferably directed towards innovations in the Training Program itself (but these may involve other projects as well). For example, the Crisis Resource Management (CRM) sessions were developed and implemented directly as a result of a resident’s interest and motivation in medical education. There must be an identified faculty supervisor to guide the project and provide an evaluation.

(iv) Research Project

The general objective of a research rotation during core internal medicine training is to provide an introduction to the conduct of clinical or basic science research, in a field relevant to internal medicine. More specifically, the rotation should be an opportunity to learn about research from the investigator's standpoint. Hence the resident research experience should include all phases of a project, from design through data collection, analysis, interpretation, and reporting. Experience of a purely technical nature--work ordinarily performed by a research assistant or technician--is not suitable.

The scope of the project must reflect the limited time available. However, it is crucial that you be able to claim primary intellectual ownership of the work done. Hence it is preferable to complete a small project than to undertake one component of a larger one. To maximize the yield of "protected" research time, the planning stages should be completed before the research block-including study design, preparation of relevant data collection tools, and ethics committee approval (required for nearly all clinical studies, including chart reviews). This requires organization and input from both resident and supervisor. The research rotation itself should be devoted to data collection, analysis, and potentially preparation of results for presentation/publication.

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We encourage residents to be involved in at least one such research project during their first three years of residency training. Residents can generally take one extra rotation as a research rotation in their first 3 years of training in Internal Medicine (conditional upon satisfactory performance on clinical rotations and with Site Director permission). This research rotation is above and beyond the 1 month of already-assigned scholarly activity rotation. With this in mind, we will be organizing regular meetings with your local Resident Research Coordinators (JGH: Mark Blostein, MGH: Stella Daskalopolou, RVH: Kevin Schwartzman) throughout your residency to discuss these issues.

Please be advised that residents who undertake a research rotation must:

• submit a summary of the planned project, including a description of the resident's role, to the Teaching Office before the anticipated start date; this summary must be signed by both resident and supervisor,

• include a statement as to the target venue for presentation of the results: the name of the local, national, and/or international conference targeted, and/or the target peer-reviewed journal,

• upon completion of the rotation, have their supervisors complete an evaluation form with comments,

• submit a report of their research experience and of their results to their local Teaching Office, and

• be prepared to present their findings at the annual Resident Research event (evening or day event), held each spring.

Presentation, critical review, and dissemination of results are crucial elements of the research process. Hence presentation of results at a relevant conference is essential, and publication of a manuscript in a peer-reviewed journal is strongly encouraged. Financial support is available to offset travel and conference costs, potentially in conjunction with the research supervisor's funding. Residents must identify their institutional affiliation in any presentation or publication as "Resident, Internal Medicine Residency Training Program, Department of Medicine, McGill University, Montreal, Quebec, Canada." Hospital affiliations are NOT acceptable.

Your local Teaching Office must be notified of any presentations or publications that arise out of any research which you take part in before the end of your fourth year of residency. This is in order to track resident research and to comply with Royal College requirements. Please submit copies of abstracts and/or published articles to your local Teaching Office so that they can be placed in your file. Please review the references below:

Clinical Research During Internal Medicine Residency: A Practical Guide. The American Journal of Medicine, Volume 119, Issue 3, Pages 277-283 K. Hamann, T. Fancher, S. Saint, M. Henderson

Research Guide: A Primer for Residents, other health-care trainees, and practitioners. Bart J. Harvey, Eddy S. Lang, Jason R. Frank. Royal College of Physicians and Surgeons of Canada, 2011.

for tips of how to integrate research into your residency. Below are the goals and objectives of a research rotation in CanMEDS format: Medical Expert The resident will: Demonstrate expert knowledge of the pathogenesis, epidemiology, manifestations and management of the clinical condition(s) targeted by his/her research project.

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Develop a clear, comprehensive and relevant literature review. Formulate a clear, testable research question/hypothesis. Acquire proficiency in methods for collecting and analyzing data. Identify strengths and limitations of study design, methods, and results. Describe appropriate next steps based on his/her research findings. Communicator The resident will: Present his/her research protocol effectively in oral and written form. Present research findings effectively both orally and in written form (e.g. conference abstract, poster/slide talk, manuscript). When appropriate, participate in relevant communication with the research ethics committee, animal care committee, and/or human subjects (e.g. aid in development of consent forms). Collaborator The resident will: Work effectively with research supervisor(s). Work effectively with all members of the research team e.g. technicians, research assistants, statisticians, etc. Manager The resident will identify scientific, logistical, ethical, and financial advantages and disadvantages of various potential methods to address a particular research question. Health Advocate The resident will: Highlight the relevance of research findings to future improvements in health. Communicate results with subjects, patients, other health professionals, or other stakeholders as appropriate. Scholar The resident will: Synthesize relevant primary research evidence into an up-to-date literature review, placing his/her research question in suitable context. Critically evaluate related scientific literature. Demonstrate self-directed learning related to the substantive research question, and the methods used. Participate actively in relevant scientific seminars and presentations.

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Professional The resident will: Demonstrate exemplary professional, personal and interpersonal behaviour at all times. Develop and execute his/her project according to current standards for the ethical and humane conduct of research. Develop and demonstrate an understanding of the basic concepts of research ethics.

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Transplantation Medicine The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in transplantation medicine. The emphasis of this rotation will be to improve the resident’s basic knowledge about transplantation and immunosuppression and to gain exposure to the unusual problems faced by the transplant patient. The resident is expected to: Medical Expert Be able to elicit, present and document a history that is relevant and appropriate to the clinical presentations of various rheumatologic complaints and conditions. Be able to perform an accurate physical examination that is relevant to the presenting problem. Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of and demonstrate an understanding of the pathophysiology of the following scenarios and conditions in the transplant patient:

Rejection, acute and chronic Diabetes Hypertension Gout Renal dysfunction Dyslipidemia Osteoporosis Cancer Cardiovascular disease Immediate post-transplantation complications Infectious complications and prophylaxis

Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. Be able to interact effectively with other health-care professionals. Be able to document the patient’s condition and progress accurately with emphasis on relevant issues. Collaborator Be able to identify the need to, and benefit of consulting other physicians and health-care professionals. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimise patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and their families regarding the factors that impact on their health, with emphasis on the importance of concordance with medications.

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Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to recognise and resolve ethical issues as they arise in clinical practice. Be able to recognise and deal with unprofessional behaviours in clinical practice.

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Thrombosis Medicine

The JGH Thrombosis Program encompasses a broad range of clinical activities that relate to diagnosis, risk factors and treatment of venous and arterial thromboembolic disease, management of thrombophilia and issues pertaining to acute and long-term anticoagulation. Specific areas of clinical activity include the Thrombosis Clinic, Anticoagulation Clinic and In-patient Thrombosis Consultation Service. Attending staff include Drs. Mark Blostein, Andrew Hirsch, Susan Kahn (Director, Thrombosis Program) and Vicky Tagalakis, all of whom have expertise in Thrombosis Medicine.

We invite residents to sign up for a Thrombosis Elective at the JGH by contacting Dr. Kahn's assistant Maureen Morganstein at 514-340-8222 #7587, or via email: maureen.morganstein@epi.jgh.mcgill.ca.

The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in thrombosis medicine.

The resident is expected to:

Medical Expert

Demonstrate the requisite knowledge and skills to function as a thrombosis consultant in the inpatient and outpatient setting.

Performs clinical assessments that are accurate, concise and relevant.

Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of conditions as they relate to thrombosis and its treatment.

Understand the indications for, and be able to interpret commonly used diagnostic modalities in Thrombosis Medicine.

Be able to perform an accurate physical examination, with emphasis on:

• Findings of deep vein thrombosis (DVT) of the lower extremity and upper extremity • Findings of superficial vein thrombosis (SVT) • Findings of pulmonary embolism (PE) • Findings of PE with hemodynamic instability • Findings of phlegmasia cerulean dolens • Findings of post-thrombotic syndrome (PTS) of the lower extremity and upper extremity • Findings of chronic thromboembolic pulmonary hypertension (CTEPH) • Findings of heparin skin allergy • Findings of warfarin-induced skin necrosis

Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of the following scenarios:

• Suspected DVT of the lower extremity, upper extremity • Suspected SVT • Suspected PE • Suspected PTS • Suspected CTEPH • Suspected heparin-induced thrombocytopenia (HIT) • Suspected HIT with thrombosis (HITT) • Suspected unusual site DVT • Bleed on heparin (low molecular weight heparin; unfractionated heparin)

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• Bleed on vitamin K antagonists • Elevated INR without bleeding • Bleed on new oral anticoagulants, e.g. dabigatran, rivaroxaban

Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of the following conditions:

• DVT of the lower extremity and upper extremity • Anatomically extensive DVT • SVT • PE • Cancer-associated DVT, PE • Unprovoked DVT, PE • Pregnancy related DVT, PE • Unusual site DVT • PTS • CTEPH • Heparin-induced thrombocytopenia (HIT) • HIT with thrombosis (HITT) • Thrombophilia-inherited and acquired • Prevention of venous thromboembolism (VTE) in different patient risk groups (e.g. surgical,

medical, pregnant) • Bridging therapy for patients on chronic anticoagulation • Long-term management of warfarin, new oral anticoagulants • Bleed on heparin (low molecular weight heparin; unfractionated heparin) • Bleed on vitamin K antagonists • Elevated INR without bleeding • Bleed on new oral anticoagulants, eg. dabigatran, rivaroxaban

Understand the indications for, and be able to interpret:

• Chest X-rays, CTPA and VQ scans in patients with suspected PE and CTEPH • Venous ultrasounds, venograms and CT venograms in patients with suspected DVT • Venous ultrasounds in patients with suspected SVT • Coagulation testing for monitoring of heparin and vitamin K antagonists • D-dimer testing in the work-up and management of patients with VTE • Thrombophilia testing in the work-up and management of patients with VTE or arterial

thrombosis • Limited vs. extensive work-up for underlying cancer in a patient with unprovoked thrombosis • Platelet counts and HIT assays in the work-up and management of patients with HIT

Understand the indications for, and complications of thrombolytic approaches to the management of severe PE and DVT

Communicator

Be able to communicate effectively with patients and their families with respect to their thrombotic or bleeding conditions.

Be able to interact effectively with other health-care professionals.

Be able to document the patient's condition and progress accurately with emphasis on relevant thrombosis and/or anticoagulation issues.

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Collaborator

Be able to identify the need to, and benefit of consulting other physicians and health-care professionals, including radiologists and vascular surgeons.

Be able to contribute effectively to interdisciplinary team activities.

Manager

Be able to effectively and efficiently manage the consult service.

Prioritizes requests for consultation and follow-up.

Be able to use information technology to optimise patient care.

Be able to use health-care resources cost-effectively.

Health Advocate

Be able to educate and counsel patients and their families regarding the factors that impact on their health, particularly with respect to thrombosis prevention and safe anticoagulation care.

Recognizes and responds\ to those issues where advocacy is appropriate.

Scholar

Be able to critically appraise sources of medical information

Be able to educate patients and their families regarding their medical condition.

Be able to teach medical students, residents, and other health-care professionals, especially family physicians who will be managing the patients as primary-care givers.

Be able to contribute to the development of new knowledge, through the completion of or participation in a research project.

Professional

Be able to apply knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice.

Be able to apply knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice.

Be able to recognise and resolve ethical issues as they arise in clinical practice, including dealing with unprofessional behaviours in colleagues.

Meets deadlines and is punctual.

Evaluates personal abilities, knowledge, and skills and recognizes personal limitations.

Demonstrates integrity, honesty, compassion, and respect for diversity.

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Tropical Medicine

The Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in tropical medicine. The resident is expected to: Medical Expert Be able to elicit, present, and document a history that is relevant and appropriate to the clinical presentation. Be able to perform an accurate physical examination, with emphasis on:

Skin rashes, lesions, ulcers and their associations with tropical diseases Be able to provide a reasonable approach to the differential diagnosis, work-up, and management of the following scenarios:

Fever Diarrhea (acute and chronic, returning traveler) Dysentery Eosinophilia

Demonstrate an understanding of the pathophysiology, manifestations, diagnostic work-up, and management of the following conditions:

Intestinal helminths Intestinal protozoa Cestodes (hydatid, cystocercus, tapeworms) Trematodes (schistosoma, clonorchis, fasciola) Systemic protozoa (malaria, toxoplasma, leishmania, trypanosomes, pneumocystis) Systemic helminths (filaria) Bacterial infections (typhoid, leptospirosis, leprosy) Viral infections (arbovirus, viral hemorrhagic fevers) Rickettsia

Understand the indications for, be able to perform, and be able to interpret the results of the following clinical procedures:

Filarial skin snips Schistosoma rectal snips Leprosy skin slit smears

Understand the indications for and be able to interpret the results of the following laboratory procedures:

Microscopic identification of ova, cysts, trophozoites and worms found in urine or stool specimens Microscopic examination of blood for malaria (thick and thin smears) Microscopic examination of skin parasites Staining techniques (Giemsa, Quick, Hematoxylin, Kinyoun) Culture techniques Concentration techniques (formal ether, zinc sulfate, sucrose flotation)

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Communicator Be able to communicate effectively with patients and their families with respect to their medical conditions. In particular, be able to communicate with patients from different ethnic backgrounds and language groups, keeping in mind cultural contexts. Be able to interact effectively with other health-care professionals. Be able to document the patient’s condition and progress accurately with emphasis on relevant tropical medicine issues. Collaborator Be able to identify the need to, and benefit of consulting other physicians and health-care professionals. Be able to contribute effectively to interdisciplinary team activities. Manager Be able to use information technology to optimise patient care. Be able to use health-care resources cost-effectively. Be able to work efficiently and effectively. Health Advocate Be able to educate and counsel patients and their families regarding the factors that impact on their health, particularly with respect to transmission of disease and prevention of disease while travelling. Scholar Be able to critically appraise sources of medical information. Be able to educate patients and their families regarding their medical condition. Be able to teach medical students, residents, and other health-care professionals, especially family physicians who will be managing the patients as primary-care givers. Be able to contribute to the development of new knowledge, through the completion of or participation in a research project. Professional Be able to apply a knowledge of the professional and ethical codes and norms of behaviour that govern the behaviour of physicians in clinical practice. Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice, such as reporting certain diseases to public health authorities. Be able to recognise and resolve ethical issues as they arise in clinical practice. Be able to recognise and deal with unprofessional behaviours in clinical practice.

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Resident Safety Policy Preamble

The McGill Internal Medicine Residency Training Program, the McGill Postgraduate Medical Education (PGME) Office, and the McGill Health-Care Facilities recognize that residents have the right to a safe environment during their residency training. The responsibility for promoting a culture and environment of safety for residents rests with the Faculty of Medicine, regional health authorities, health-care establishments, clinical departments, and residents themselves. The concept of resident safety includes physical, emotional, and professional security. This policy provides a mechanism for residents to use when faced with a health and safety issue during the course of their training which cannot be resolved at the local level. On occasion residents/fellows may be confronted with a situation for which they are not sufficiently trained. It is expected that they, like other physicians, will deal with such situations as practicing professionals to the best of their ability. The word “resident” in the present document refers to all Residents and Fellows registered as students at McGill University in Postgraduate training programs.

Key Responsibilities:

For Residents • To provide information and communicate safety concerns to the program and to comply with safety policies.

For Residency Training Programs • To act promptly to address identified safety concerns and incidents and to be proactive in

providing a safe learning environment. • Individual residency programs must develop policies to deal with issues specific to their

discipline. These may include concerns related to physical safety, psychological safety and professional safety. Examples of such concerns include:

• Physical safety: Travel, working in isolated locations, electronic communication with patients, dealing with violent patients, body substance exposure, immunizations, call rooms, radiation exposure, pregnancy.

• Psychological safety: Intimidation and harassment, psychological illness, substance abuse, inequity in the workplace.

• Professional safety: Conflict in ethical/religious beliefs, adverse event/critical incident support, confidentiality of personal information, medico-legal coverage and threat of legal action.

I. PHYSICAL SAFETY

These policies apply only during residents’ activities that are related to the execution of residency duties:

• Residents should familiarize themselves with the location and services offered by the

Occupational Health and Safety Office of the health-care facility in which they are training. This includes familiarity with policies and procedures for infection control and protocols following exposure to contaminated fluids, needle stick injuries, and reportable infectious diseases.

• Residents who are infected by a blood borne pathogen must declare their condition to the

Associate Dean’s office and to the SERTIH (Service d’Évaluation des Risques de Transmission d’Infections Hématogènes), especially if they may be involved in exposure-prone procedures.

• Residents must observe routine practices and additional precautions when indicated.

• Residents must keep their immunizations up to date. Overseas travel immunizations and

advice should be sought well in advance when traveling abroad for rotations or meetings. Consult the Tropical Medicine Clinic at the MGH or other similar facility (fees may apply).

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• Call rooms and lounges provided for residents must be clean, smoke free, located in safe locations, and have adequate lighting, a phone, fire alarms, and smoke detectors. Any appliances supplied are to be in good working order. There must be adequate locks on doors.

• Residents working in areas of high and long term exposure to radiation must follow radiation

safety policies and minimize their exposure according to current guidelines.

• Radiation protective garments (aprons, gloves, neck shields) should be used by all residents using fluoroscopic techniques.

• Pregnant residents should be aware of specific risks to themselves and their fetus in the

training environment and request accommodations where indicated. • Residents should consult the Occupational Health and Safety Office of the health-care facility for

information.

• Residents should not work alone after hours in health- care or academic facilities without adequate support from Security Services.

• Residents are not expected to work alone at after-hours clinics.

• Residents are not expected to make unaccompanied home visits.

• Residents should only telephone patients using caller blocking and should use the health-care

facility phones and not their personal cellular phone or pda.

• Residents should not be expected to walk alone for any major or unsafe distances at night.

• Residents should not drive home after call if they have not had adequate rest.

• Residents should not assess violent or psychotic patients without the backup of security and an awareness of accessible exits and buzzers.

• The physical space requirements for management of violent patients must be provided

where appropriate.

• Special training should be provided to residents who are expected to encounter aggressive patients, for example Crisis Management courses are available in some health-care facilities – please contact your local residency office for information.

• Site orientations should include a review of local safety procedures.

• For long distance travel for clinical or other academic assignments, residents should ensure that

a colleague or the home residency program is aware of their itinerary. • Residents going on International Rotations should consult the Global Health web site on the

following link: http://www.mcgill.ca/globalhealth/internationalelectives/. http://www.mcgill.ca/globalhealth/internationalelectives/

• In general, the PGME Office will not approve rotations in regions for which the Canadian

government has issued a Travel Warning.

• Residents should not be on call the day before long distance travel for clinical or other academic assignments by car. When long distance travel is required in order to begin a new rotation, the resident should request that they not be on call on the last day of the preceding rotation. If this cannot be arranged then there should be a designated travel day on the first day of the new rotation before the start of any clinical activities.

• Residents are not to be expected to travel long distances during inclement weather for clinical or

other academic assignments. If such weather prevents travel, the resident is expected to contact the

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program office promptly. Assignment of an alternative activity is at the discretion of the Program Director.

II. PSYCHOLOGICAL SAFETY

• Learning environments must be free from intimidation, harassment, and discrimination.

• When a resident’s performance is affected or threatened by poor health or psychological

conditions, the resident should be placed on a leave of absence and receive appropriate support. These residents should not return to work until an appropriate assessor has declared them ready to assume all of their resident duties, including call.

• Residents must be aware of the mechanisms and resources in place to manage issues of

perceived lack of resident safety, intimidation, harassment and abuse.

III. PROFESSIONAL SAFETY • Some physicians may experience conflicts between their ethical or religious beliefs and the

training requirements and professional obligations of physicians. Resources should be made available to residents to deal with such conflicts via the PGME Office.

• Programs are bound by FMRQ contract allowances for religious and other statutory holidays.

• The PGME Office should promote a culture of safety in which residents are able to report and discuss adverse events, critical incidents, ‘near misses’, and patient safety concerns without fear of punishment.

• Residency program committee members must not divulge information regarding residents. It

is the responsibility of the residency Program Directors to make the decision and to disclose information regarding residents (e.g. personal information and evaluations) outside of the residency program committee and to do so only when there is reasonable cause. The resident file is confidential.

• With regard to resident files, programs must be aware of and comply with the Freedom of

Information and Privacy (FOIP) Act. Programs can obtain guidance about FOIP issues from the McGill Access and Privacy Coordinator. Contact information is found on the McGill Secretariat web site.

• Resident feedback and complaints must be handled in a manner that ensures resident

anonymity, unless the resident explicitly consents otherwise. However, in the case of a complaint that must be dealt with due to its severity or threat to other residents, staff or patients, a Program Director may be obliged to proceed, against the complainant’s wishes. In that case the Faculty of Medicine’s Residency Affairs Office or the main campus Harassment Office or the McGill Ombudsperson should be consulted immediately. Depending on the nature of the complaint, the Collège des médecins du Québec may need to be informed and involved. In general, the Program Director may serve as a resource and advocate for the resident in the complaints process.

• Residents are insured for professional liability by the Association québécoise d’établissements de

santé et de services sociaux (AQESSS) automatically when they have a valid training card.

• The Role of Residents during Medivac/Ambulance Transports: o In many programs, participation in patient transport is a valuable learning experience for

residents. There must be clear educational objectives underlying the resident’s participation in patient transport.

o Residents must have appropriate training with demonstrated competency in the circumstances relevant to the transport experience.

o Communication and supervision between the resident and his/her designated supervising physician must be available at all times.

o Resident well-being should be considered in all transports.

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Intimidation and Harassment Policy

Our Faculty strongly supports and acts upon the principles outlined in the following statement developed by the Association of American Medical Colleges for medical students.

The medical learning environment is expected to facilitate residents' acquisition of the professional and collegial attitudes necessary for effective, caring and compassionate health-care. The development and nurturing of these attitudes is enhanced and, indeed, based on the presence of mutual respect between teacher and learner. Characteristic of this respect is the expectation that all participants in the educational program assume their responsibilities in a manner that enriches the quality of the learning process.

While these goals are primary to a school's educational mission, it must be acknowledged that the social and behavioural diversity of students, faculty, residents and staff, combined with the intensity of the interactions between them, will, from time to time, lead to alleged, perceived or real incidents of inappropriate behaviour or mistreatment of individuals. Examples of mistreatment include: sexual harassment; discrimination or harassment based on race, religion, ethnicity, gender, sexual orientation, physical handicap or age; humiliation, psychological or physical punishment and the use of grading and other forms of assessment in a punitive manner. The occurrence, either intentional or unintentional, of such incidents, results in disruption of the spirit of learning and a breach in the integrity and trust between teacher and learner.

In order to assure that all students have an opportunity to learn and work in a supportive environment, it is vital that the Dean's office be aware of problems should they arise. Any concern can be brought forward by speaking with or writing to your Program and/or Site Director or the Associate Dean of Postgraduate Medical Education.

In the case of concerns related to sexual harassment, a formal university-based structure has been established. The Sexual Harassment Office can be contacted by calling (514) 398-4911.

In the case of concerns related to harassment, intimidation, discrimination, or abuse of power, McGill University has adopted a policy which covers every member of the university community, and this can be found by visiting this website:

http://www.medicine.mcgill.ca/postgrad/welcometopostgrad_standards.htm

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Evaluation and Feedback

Residents are continuously evaluated while they are rotating on clinical rotations. As such, you should be getting regular feedback on a daily basis on your performance - this is usually informal in nature. You should seek out more formal feedback from your supervisor around 2 weeks into each rotation - this is called mid-way feedback. It is especially important to ask for regular feedback if your supervisor has told you that you are below expectations (either borderline or unsatisfactory). In that case, you should ask for specific feedback regarding your performance and how to improve. You should then make specific efforts to improve your performance based on the feedback given to you.

At the end of each month, you will be given a final evaluation. Your supervisor will also complete evaluation form in one45 for your rotation. You may be shown your evaluation at the end of your rotation, if it is ready, or your final feedback may be verbal in nature. The evaluation form will be submitted in one45 for review by your Program and/or Site Director. You may visit one45 at any point to review your evaluations, once you have evaluated the rotation and faculty who have supervised you.

Rotation evaluations are reviewed anonymously by your Site Director to try to improve the Training Program, while Faculty evaluations are only released to Faculty 6 months after the end of each academic year, and only if there are more than 3 evaluations completed per Faculty member. This system ensures the feedback you input into one45 is anonymous.

Each rotation should only have 1 evaluation form completed for it. This is simple when a resident is supervised by one faculty member, and the supervisor submits one evaluation form in one45. If you have multiple supervisors in a given rotation, then some rotation evaluation systems are setup so that you may see all these individual evaluation forms as completed by each individual physician. This is not a problem if all of the evaluations are in agreement. Other rotations have contributor forms that are then collated by a head evaluator into a single, final evaluation. Regardless of which system is adopted for written evaluations, it is important that all evaluators agree on your final, overall assessment of your performance (the “overall” tick at the bottom of the evaluation). If there is disagreement among the evaluation forms received, these will be sent back for review to the evaluators so they may agree on the overall evaluation.

What to do if you get BORDERLINE or UNSATISFACTORY?

It is important to note that while you may rarely receive some borderline or unsatisfactory elements in your evaluation, the GLOBAL EVALUATION section should be at least SATISFACTORY. Anything below this means you did not meet the standards at McGill (ie. you did not pass).

(i) If you receive regular evaluations with borderline or unsatisfactory elements but with a GLOBAL EVALUATION of SATISFACTORY, then you will likely be called to meet with your Program and/or Site Director to review these and to come up with a plan to improve. The McGill Internal Medicine Promotions Committee follows the progress of any candidates who fall into this category, and may recommend specific action depending on the situation and according to the Promotions Guidelines (see below).

(ii) If you receive an evaluation with a GLOBAL EVALUATION of BORDERLINE or UNSATISFACTORY, then you should arrange a meeting with your Program and/or Site Director immediately. If your local Medical Teaching Office receives such an evaluation before you, they will contact you to arrange a meeting. At this time, reasons for the evaluation will be reviewed and a plan will be devised to help you improve your specific deficiencies. You will also meet with the Director of Evaluations and Promotions, who will try to identify areas to improve on and develop a plan to help you work on these areas.

According to the Promotions Guidelines, a resident may appeal such an evaluation, but we recommend that they speak to their supervisor first to see if they would be willing to change the evaluation based on your comments (your local Medical Teaching Office can help you with this, if you prefer). If the supervisor agrees to review the evaluation, then this should be forwarded to your local Medical Teaching Office and this evaluation becomes the official one. If the supervisor chooses not to change the evaluation, then you

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can decide to appeal the evaluation formally. You must inform your Program and/or Site Director in writing of your desire to appeal within 28 days of your receipt of the evaluation. The note does not need to be formal or complicated, you can simply jot down on a piece of paper that you choose to appeal (please date and sign your note).

As a reminder, the McGill Promotions Guidelines state that 4.1.c “During the academic year, a BORDERLINE evaluation in one rotation period with SATISFACTORY completion of all others may require a REPEAT rotation.” The final decision regarding whether you will be required to repeat the rotation will rest with the McGill Internal Medicine Promotions Committee, and will depend on the progress you show throughout the remainder of the academic year. Furthermore, 4.1.b states "During the academic year, an UNSATISFACTORY evaluation in one rotation period with SATISFACTORY completion of all others, requires the resident to complete a REPEAT rotaion of the same duration."

Furthermore, Article 4.2.a states that “A resident will be placed on PROBATION for any of the following reasons: i) UNSATISFACTORY or BORDERLINE in a REPEAT rotation period, ii) UNSATISFACTORY and/or BORDERLINE in two rotation periods in one academic year, iii) upon recommendation by the Program Promotions Committee (as per 4.3.h), iv) upon recommendation by the postgraduate Promotions Committee (as per 4.4.d).”

In all cases described above, you should seek advice on how to proceed from your local Medical Teaching Office.

6-month Reviews with your Site Director

Each resident will meet with their Program and/or Site Director every 6 months to review their overall progress and to give each resident a chance to review their evaluations in more detail. The Program and/or Site Director will review a summary that summarizes your overall progress over the previous 6 months. These meetings also serve to identify and address any particular strengths or problems that have been consistently identified in a number of evaluations. Your attendance at rounds and other teaching activities will be reviewed as well. Your procedure logs will also be reviewed in one45 so make sure these are completed before the meeting. Your Site Director will also go over your performance on the simulation curriculum, and also monitor your progress with regards to your mandatory scholarly project. Finally, these meetings are also an opportunity to review each resident's career goals and provide some career counselling. At the end of each academic year, this meeting also serves to promote each resident to the next level of residency training, as appropriate. At the end of your third year of training, a form will be completed that summarizes your three years of training.

Attendance at academic half-days and hospital rounds is monitored and logged throughout the academic year. A statement reflecting each resident's overall attendance at academic activities will be included in their 6-month reviews. A similar statement, reflecting each resident's overall attendance at academic activities throughout their training, will also be included in each resident's letter of reference for subspecialty applications written by each resident's Site Director (this letter is usually written early in each resident's R3 year).

Evaluations and Promotions Guidelines

The process above is governed by a set of guidelines set up by the Faculty of Postgraduate Medical Education. These are updated each year, and are available for your review via the PGME website. Please review these guidelines carefully.

The McGill Evaluation and Promotion in Postgraduate Training Programs Guidelines state:

... 3.12 In order to meet pedagogical requirements, a Resident should not miss more than 1/4 of a rotation due

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to illness, conference leave, vacation, etc. A rotation which includes less than 3/4 of the expected time commitment, may be considered INCOMPLETE.

3.13 An INCOMPLETE rotation should be completed, the duration of which is determined by the nature of the experience and the need for continuity: eg. a 2-week illness during an Emergency rotation could be made up by 2 weeks in the Emergency room, whereas a 2week illness during an ICU rotation might require a 4-week ICU rotation to be considered complete.

3.14 For any clinical interaction, it is the Faculty Supervisor who determines whether or not the contact with the resident was sufficient for meaningful evaluation.

... You must all be aware of these rules. Your Site and/or Program Director can help advocate for your "rights," but we are limited by the McGill rules in what we can do. You need to be aware of the implications of post-call days, clinic days, academic half-days, and all other absences (vacation, personal days, sick days, conference, and study weeks) on your rotations. If you foresee that you will be absent for more than 1/4 of a rotation, please discuss this with your supervisor immediately and bring it to the attention to your local Medical Teaching Office so that we can try to help out.

Summative vs. Formative Evaluation

The evaluation schemes described above are summative evaluations - they are meant to show how you are doing and count towards your promotion.

We also provide each resident with a number of formative evaluations of your progress - these are meant to guide your learning and do not count in the evaluation system. Examples of these include annual oral exams, the ACP-In Training exam for R2s and R3s, and simulation-based sessions on advocacy, communication, ethics crisis resource management, and procedures (airway, central lines, LP and knee arthrocentesis). While you will receive feedback and evaluation forms from these sessions, these are not counted towards your promotion in the Training Program, but will be placed in your file as part of your learning portfolios.

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About the Training Program & Residency Training Committees The McGill Internal Medicine Residency Training Program is a university-based training program. This means that its primary affiliation is with McGill University. The administrative structure governing the Training Program is as follows:

• Chair, McGill Department of Medicine • Associate Dean, Postgraduate Medical Education

• Program Director & Program Administrator

• McGill Residency Training Committee

• Site Directors & Site Administrators

• Director of Evaluations and Promotions

• Chief Medical Residents

• Site Residency Training Committees

• Site Medical Teaching Offices

• Residents

The Chair of McGill's Department of Medicine delegates the overall responsibility for running the Training Program to the Program Director. The Chair is a member of the McGill Residency Training Committee. The Chair also supports the Training Program financially in all respects, through the academic taxes that come out of the clinical earnings of all physicians working in the Departments of Medicine at the JGH, MUHC-MGH, and MUHC-RVH.

The Associate Dean of Postgraduate Medical Education oversees all of the Residency Training Programs across McGill. He is responsible for issues which affect all Training Programs, and is the Chair of the Faculty PostGraduate Education Committee (FPGEC), of which all Program Directors are members. The Associate Dean is responsible to the Dean of the Faculty of Medicine.

The Program Director is responsible for the overall Training Program across all sites and the program-wide curriculum and policies, including the goals and objectives of the training program. He delegates responsibility for running each site to a local Site Director. S/he is the Chair of the McGill Residency Training Committee, which oversees the training occurring at all sites. The Program Director is supported by the Program Administrator, who is in charge of program-wide activities. The McGill Residency Training Committee is composed of Site Directors, the Program Administrator, Chief Medical Residents from each site, Site Administrators, and the Chair of the McGill Department of Medicine. Other resident representatives may also be members. This Committee serves to oversee much of the program-wide curriculum and to deal with issues that affect the Training Program as a whole. This committee usually meets once monthly except during July and August.

The McGill Internal Medicine Promotions Committee is chaired by the Director of Evaluations and Promotions, and is composed of faculty representatives from the major teaching sites. This committee meets every 3-4 months to review the progress of residents in the Training Program, and identify those who may benefit from particular monitoring or interventions to improve their performance. This committee also formally promotes residents to the next level of residency towards the end of each academic year, based on performance criteria as outlined in McGill’s Promotions Guidelines (updated annually).

The Site Directors deal with local site issues as they relate to the Training Program, including scheduling, implementation of the site curriculum, and any other site issues including reviewing specific rotations, dealing with local challenges, local teaching, etc. The Site Directors are Chairs of their Site Residency Training Committees. The Site Residency Training Committees are composed of the local Chief Medical Residents, faculty representatives (often the CTU directors and service chiefs), and resident representatives. This committee deals with site-specific issues relating to the Training Program. These committees usually meet once monthly except during July and August.

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The Chief Medical Residents are R3s who have a number of administrative and teaching responsibilities. These are outlined in more detail in the CMR Roles and Responsibilities document (available on our website).

There are Site Medical Teaching Offices at each of the three hospitals where residents do much of their training: Jewish General Hospital, MUHC-Montreal General Hospital, and MUHC-Royal Victoria Hospital. Each local Medical Teaching Office has a Site Administrator, who is in charge of site-specific issues.

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Contact Information

McGill University Internal Medicine Residency Training Program - Central Teaching Office

Royal Victoria Hospital, Room M10.02 687 Pine Avenue West,

Montreal, Quebec H3A1A1

Program Director: Thomas Maniatis, MD, CM, MSc (Bioethics), FACP, FRCPC e-mail: thomas.maniatis@mcgill.ca

tel.: (514) 843-1506 fax: (514) 843-1725

Program Administrator: Maureen Dowd e-mail: maureen.dowd@muhc.mcgill.ca

tel.: (514) 843-1506 fax: (514) 843-1725

Site Teaching Offices

MUHC – Royal Victoria Hospital Medical Teaching Office Royal Victoria Hospital, M6.02 687 Pine Ave. West, Montreal, Quebec H3A1A1

Site Director: Josée Verdon, MD, MSc, FRCPC e-mail: josee.verdon@mcgill.ca tel.: (514) 934-1934 ext. 35931 fax: (514) 843-1547

Site Administrator: Carol Seguin e-mail: carol.seguin@muhc.mcgill.ca tel.: (514) 934-1934 ext. 35921 fax: (514) 843-1547

Chief Medical Resident Room M3.04 tel.: (514) 934-1934 ext. 34523 e-mail: cmr.rvh@gmail.com

MUHC-Montreal General Hospital Medical Teaching Office Montreal General Hospital, Suite D6.237 1650 Cedar Avenue, Montreal, Quebec H3G1A4

Site Director: Patrizia Zanelli, MD, FRCPC e-mail: patrizia.zanelli@mcgill.ca tel.: (514) 934-1934 ext.43064 fax: (514) 937-0803

Site Administrator: Marie Harkin Talbot e-mail: marie.harkintalbot@muhc.mcgill.ca tel.: (514) 934-1934 ext. 43064 fax: (514) 937-0803

Chief Medical Resident Room D6.178 tel.: (514) 934-1934 ext. 43068 e-mail:cmr.mgh@gmail.com

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Jewish General Hospital Medical Teaching Office Jewish General Hospital, Room G-050 3755 Côte-Sainte-Catherine, Montreal, Quebec H3T1E2

Site Director: Ruxandra Bunea, MD, FRCPC e-mail: ruxandra.bunea@mcgill.ca tel.: (514) 340-8222 ext. 4974 fax: (514) 340-7905

Site Administrator: Angie Sacratini e-mail: asacrati@mtd.jgh.mcgill.ca tel.: (514) 340-8222 ext. 4974 fax: (514) 340-9705

Chief Medical Resident Room G-055 tel.: (514) 340-8222 ext. 4825 e-mail: cmr.jgh@gmail.com

Websites of interest

Internal Medicine Residency Training Program website

www.medicine.mcgill.ca/internalmed

McGill’s Faculty of Postgraduate Medical Education website

http://www.medicine.mcgill.ca/postgrad/

CaRMS website

www.carms.ca/

one45 website for McGill

https://mymres.mcgill.ca

McGill’s Summer Epidemiology Session website

http://www.mcgill.ca/epi-biostat-occh/summer/

McGill’s Department of Medicine website

http://www.medicine.mcgill.ca/deptmedicine/

Professional societies and conferences of interest

Canadian Society of Internal Medicine (CSIM) (annual conference with clinical vignettes and research presentations by residents,

clinically focused on internal medicine topics for Canadians)

http://www.csimonline.com

Association of Specialists in Internal Medicine of Quebec (ASMIQ) (francophone conference, often cover special topics: thrombosis, diabetes, obstetrical medicine via

GÉMOQ)

http://www.asmiq.qc.ca

American College of Physicians (ACP) (annual conference in the USA, focus is on primary-care and hospitalist adult practice)

http://www.acponline.org

Royal College of Physicians and Surgeons of Canada

(annual conference is on residency education)

http://www.royalcollege.ca/

Reminder of conference reimbursement policy: 1000$ is available per resident to attend a conference(s); an additional 1000$ is available for residents presenting (oral/poster) at a conference.

Receipts/proof of presentation are required for all reimbursements: residents must submit receipts to their local Medical Teaching Office for reimbursement within 1 month of the conference dates.

(the above policy applies to residents starting after July 1, 2012. Residents beginning the program before this date are eligible for a total of 1500$ per resident to attend a

conference.)

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Useful Medical Resources

Some of the more relevant resources for Internal Medicine Residents are listed below (please note that you may need to access many of these resources through the McGill Life Sciences Library portal rather than using the links below):

Clinical Evidence: www.clinicalevidence.org/ ACP Journal Club / EBM Journal: www.acpjc.org/ Cochrane Library: www.cochrane.org PubMed: www.pubmed.gov/ Ovid: www.ovid.com/ UptoDate: www.uptodate.com/ MDConsult: www.mdconsult.com/ STAT!Ref: www.statref.com/ PIER (available through STAT!Ref)

Guideline Clearing House: www.guideline.gov/ JAMA Users’ Guides: www.usersguides.org/ Rational Clinical Exam Series on the web: http://www.medicine.mcgill.ca/internalmed/ >>Resources>>JAMA RCE or www.sgim.org/clinexam-rce.cfm Procedure-related videos and PDFs from the NEJM: http://www.medicine.mcgill.ca/internalmed/ >>Resources>>NEJM Tutorial Videos or http://www.nejm.org/multimedia/videos-in-clinical-medicine?cm=marcomtr EvidenceUpdates: A review of recent publications, rated by quality and relevance. Email alerts available according to one’s interests. More info. and to sign up, please visit: http://plus.mcmaster.ca/EvidenceUpdates/ Some suggested journals to review on a regular basis (you can ask to receive their electronic table of contents at the websites below)

JAMA (www.jama.com) The Lancet (www.thelancet.com) The New England Journal of Medicine (http://content.nejm.org) The Annals of Internal Medicine (www.annals.org)

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The ACP Journal Club (www.acpjc.org) CMAJ (www.cmaj.ca) The British Medical Journal (www.bmj.com)

Health Canada’s MedEffect e-Notice You may wish to subscribe to Health Canada’s electronic adverse events service (called MedEffect e-Notice) by visiting: www.hc-sc.gc.ca/dhp-mps/medeff/subscribe-abonnement/index_e.html and entering your email address in the indicated section. Health Canada will send you regular safety updates regarding medications/devices in Canada.

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Resident Wellness The Quebec Physicians Health Program (QPHP) is a valuable tool to help residents to manage stress and provides resources for physicians specifically adapted to their needs. The following information is from their website (http://www.pamq.org/): “The Quebec Physicians’ Health Program – QPHP – is a non-profit organization incorporated in 1990. Our ability to heal depends on our ability to remain healthy For Physicians Residents Students Physicians helping physicians It is crucial to recognize in ourselves or in a colleague signs of • burnout • inability to adapt • mental illness • emotional problems • substance abuse It stems from the will and determination of doctors to provide to their colleagues throughout the province reliable, expert and discreet help should they need it and to carry out prevention and awareness campaigns. Two major values are at the very core of our Health Program: confidentiality and discretion. Quebec Physicians’ Health Program 1 René-Lévesque Blvd. East, Suite 200 Montréal (Québec) H2X 3Z5 Phone: (514) 397•0888 – 1 800 387•4166 Fax: (514) 397•0654. (Alternate #: Tel: 514 397-0888 or 1 800 387-4166) E-mail: info@pamq.org”

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Faculty of Medicine

Guidelines for Avoiding Conflicts of Interest in Relations Between Faculty Members and Industry

Preamble These guidelines apply to the interactions between McGill’s Faculty of Medicine, its Faculty, trainees (students, residents), and staff and its Industry partners. “Industry” is used to refer to pharmaceutical, biotech, and device industries collectively. It is important to note that interactions between McGill University’s Faculty of Medicine and Industry can be positive; these relationships can serve to further the missions of McGill’s Faculty of Medicine in the provision of excellent patient care, training future generations of physicians, and performing cutting edge research. In the context of these partnerships, these relationships must be above reproach and any potential or real conflicts of interest must be recognized and managed appropriately. With this in mind, the Faculty of Medicine has developed the following guidelines for consideration by its leaders and membership. Given the Faculty of Medicine’s commitment to the highest ethical and legal standards, it is of critical importance to avoid conflicts of interest – whether perceived or real. A conflict of interest is defined as a set of conditions in which one’s judgment concerning a primary interest may be unduly influenced by a secondary interest. McGill’s Faculty of Medicine recognizes that conflicts of interest do arise. It is not acceptable for motivations of personal gain or professional advancement to influence patient care decisions. These guidelines are meant to provide guidance and direction to members of McGill’s Faculty of Medicine when faced with conflicts of interest in their relations with Industry. The Faculty of Medicine recognizes its commitment to raising awareness of conflicts of interest among its Faculty, trainees, and staff. In light of this, the Faculty of Medicine is committed to providing educational sessions among trainees and Faculty regarding the ethical and professional issues that arise in the context of Physician-Industry interactions. These guidelines apply equally to students, residents, and Faculty (S/R/F), both on and off University grounds (on-site and off-site). These guidelines do not deal with the relationship between McGill’s Faculty of Medicine and Industry in the context of research.

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Faculty of Medicine

Relations between Members of the Faculty of Medicine & Industry Guidelines for Students, Residents, and Faculty

Industry funding for undergraduate, graduate, & postgraduate medical education Industry involvement with undergraduate, graduate, & postgraduate medical education Continuing Health Professional Education (CHPE) Non-accredited, Industry-sponsored conferences Gifts to individuals Professional travel

• Any Industry funding for undergraduate, graduate, or postgraduate (U/G/P) medical education or scholarships must be in the form of an educational grant to the University or Hospital Department, and not directed to individuals. The allocation of these funds must be done without Industry involvement, and must be based on pedagogical objectives as determined by the University. • The control over the content, speaker, and educational materials for teaching rounds given as part of U/G/P medical education must remain solely with the appropriate University-appointed Director or Course Coordinator. • S/R/F who are involved in teaching in the Faculty must declare their conflicts of interest both in writing on any materials submitted and verbally at the time of the lecture. This declaration must be sufficiently detailed for the trainees to be able to make a reasoned judgment about the possibility of bias. Full-time and part-time employees of Industry who have Faculty appointments and therefore a teaching role have the potential for a particularly strong conflict of interest. The course Director or Unit Chair must review the notes, presentations, and declaration of conflict of interest statements from such individuals beforehand to ensure compliance with this policy. • The relationship between CHPE providers and Industry must conform to the following norms and guidelines: McGill Continuing Health Professional Education (CHPE) office and/or the Code of Ethics of Parties Involved in CME (Conseil Québécois de Développement Professionel Continu des Médecins). • In particular, the content and speakers for all educational activities must be determined by the program planners. Industry must not be members of the planning committee. • Disclosure of all relevant conflicts of interest of CHPE planners must be made to the planning committee. • Other national accreditation standards may also be applicable (Royal College of Physicians and Surgeons of Canada, College of Family Physicians of Canada, SCCPD Position Paper on the Role of Industry-Based CME/CPD approved by Boards of Directors of AFMC Nov. 2010). • S/R/F should not attend or present at non-accredited conferences organized or supported by Industry. There may be special circumstances in which such conferences provide for unique educational opportunities, particularly as this applies to novel medical devices. In these situations, participation in such conferences serves to enhance patient safety and may be acceptable. • S/R/F must not solicit nor accept gifts from Industry. Industry support for food and hospitality at non-accredited events, both on-site and off-site, is considered a gift. • S/R/F must not accept payment from Industry for simply attending an activity or conference. • S/R/F must not accept travel funds from Industry for simply attending a conference. This does not preclude reimbursement of expenses in the context of contractual or other legitimate services.

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Faculty of Medicine

Site access by Industry representatives Ghostwriting & speaker’s bureaus Pharmaceutical samples Trainees and research Consulting and other contractual relationships outside of research Purchasing

• Access by Industry reps. to individual physicians must be restricted to non-patient care areas, must take place by appointment only, and according to applicable regulations. • Industry reps. must not be present during any patient care interaction without prior consent from the patient. • S/R should not interact with representatives of Industry, unless there is a clear pedagogic objective that cannot be met in another manner (ie. learning how to use a novel device). Any interactions between S/R and Industry must only take place with the presence of a Faculty member, and only when these are necessary for the education of the S/R. • S/R/F must always take full responsibility for any presentations made in their name, whether verbal or written. S/R/F must not allow their names to be used for anything that is ghostwritten (ghostwriting is understood to occur when a paid professional writer, whether medically trained or otherwise, writes something credited to someone else). • Individual physicians should not accept pharmaceutical samples. Alternative systems for accepting and distributing samples should be developed that are hospital-appropriate. • S/R should not solicit nor accept funds for research from Industry. Funding for research by S/R should generally be provided via the residents’ supervisor, research-funding agency, hospital, or university. • Faculty considering entering into consulting or other contractual relationships with Industry must first present the details of the proposed relationship with the Faculty member’s Dean, Chair, or senior administrator. Payment of Faculty in this context must be commensurate with the tasks assigned. Previously existing arrangements that are still in effect should be disclosed and reviewed in light of this policy. • Faculty members involved in purchasing decisions for hospital formularies or for equipment/devices/supplies must disclose any relevant conflicts of interest to the relevant hospital administrator, and recuse themselves from direct involvement in purchasing decisions relevant to their conflicting interests. This does not preclude an individual from participating in the analysis of a product if they offer particular expertise in the relevant area, so long as their conflict has been disclosed and they do not participate directly in the purchasing decision.

2011.9.29

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Presentation Guidelines for Residents Keep in focus the primary message that you wish your audience to retain and prepare your presentation around this focus point. Don’t forget to consider who your audience will be, and to keep this in mind while preparing your talk. You should also ask yourself just how interactive you would like your talk to be. When preparing for your talk, consider using different sources as appropriate: review articles and resources like UpToDate, primary scientific articles, articles from the lay press, and historical works. When presenting at rounds with case-based presentations, (i) begin with the case presentation and be clear when/how you want to encourage interaction (be prepared with pauses, questions), (ii) then lead into the topic with specific questions that the case brought up, (iii) then present the discussion based on the questions (trying to answer each question with a review of the literature, guidelines, primary articles), and (iv) then bring it back to the case at the end of the presentation (how did the patient do, what happened, etc.). PREPARATION Slides • For text slides: - use the “6 x 6 rule": no more than 6 lines and 6 words per line - do not write everything you say - “bullet” headings should be used to keep attention focused - to emphasize a particular point, highlight a line of text • Tables, graphs, and figures: - can be made easily with graphics programs - should be kept simple to show one or two points - tables and figures directly copied from publications are sometimes inappropriate for projection, and may need to be reworked. Don’t forget to provide references, when applicable. - there must not be patient names or identifiers on slides and you cannot have an image that clearly identifies a patient unless you have written permission to use the image for teaching. • Standardized slides for a specific lecture give an overall impression of organization and are easy to follow. The Training Program has developed standard “McGill” backgrounds for slides, available for download at: http://www.medicine.mcgill.ca/internalmed/resources/resources_links.htm • When placing the slides in order: - Intersperse text slides with descriptive slides (graphs, diagrams for clarity and interest). - If you wish to discuss a slide twice, make two copies to avoid going backwards. - If you must apologize for a slide, don’t use it. ALLOTED TIME • In general, for an allotted time of 60 minutes, plan on speaking for 45 minutes, reserving 15 minutes for discussion and questions. This will vary depending on the interactivity of the session. In general, you should plan for a minimum of a minute of talk time per slide. You should think about this ahead of time, and decide how interactive you would like the session to be. For more interactive sessions, you may need to cut down your “talk” to 30-40 minutes, leaving 20-30 minutes for discussion and questions. JUST BEFORE THE PRESENTATION • Go to the room/hall where you will be presenting early and check how all the technical controls work. • Load your presentation on the computer, and make sure it works.

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THE PRESENTATION Introduction • Identify yourself, and your topic. • Make a disclosure statement of any 3rd party influence that might affect the content of your talk. • State your learning objectives and give the outline of your presentation. Body of the talk • Slides: about 1 per minute with a target of 40 or less for a talk lasting 40 minutes. • Knowledge transfer tends to vary inversely with the number and the density of the slides. • It is nice to spark interest by presenting a case that will be addressed in the discussion period. • Please use your own material. Provide full references, where appropriate. Be aware of copyright limitations!! Conclusion or Summary • It is nice to end with a short summary of your presentation. • Emphasize the key learning points (take-home messages). • Make sure to have answered any questions you may have asked to stimulate interest and revisit any cases you may have presented to frame your discussion before finishing your talk. Questions and Discussion • The duration may vary from 15-30 minutes for a 60-minute time slot. • This can include cases alluded to at the beginning of the presentation. • It is important to repeat any questions so that they are clear to all. Helpful Hints • Think of ways to engage the audience - make them think or interact during the presentation. • The attention span of an individual is about 30 minutes and a successful speaker often makes three major points to take away from a presentation. The delivery • Speak to audience not to the screen (ie. avoid turning around to look at the screen and showing your back to the audience). • Scan the audience rather than fixing on one person: this will give you an idea of how well you are communicating and will help hold their attention. • Do not read slides verbatim. Speak “around” the summary on the slide. • Consciously slow down your rate of presentation: most people speak too quickly, seldom too slowly. • If you are presented with less time than you had anticipated, do not try to compress all of the presentation into less time (by speaking faster). Instead, please choose less relevant items to remove from the presentation in the interest of limited time. The pointer or the computer screen pointer • Should be used to emphasize a point. • Don’t scan the screen or switch the pointing device on and off. • A randomly moving pointer is extremely distracting. • Lighting in the room should be as bright as possible. • Be prepared to carry on with your lecture even if there are technological failures. • Do not teach too much in one session. • Start on time and end on time. HANDOUTS • These can be a copy of your slides (usually 6 to a page) or include a general outline of your lecture so the learners can see where you are going. • Give a framework with ample space or gaps in between sections for learners to add their own notes. Do not write down everything you say. • Full references are appreciated.

Adapted from the McGill CME Guildelines for speakers