1 General Inpatient Medicine Curriculum Faculty Representatives: Robin Garrell, MD; Alison Leff, DO Resident Representative: Leigh Kennedy Revision Date: January 10, 2006 DESCRIPTION There are six inpatient teams. Each team consist of two PGY1 s, one PGY2 or PGY3 and one teaching attending. In addition there may be up to 3 medical students assigned to the team. All teams care for patients with both general medical and subspecialty problems. Patients of varying age ethnic background and economic status with a wide diversity of diseases are managed on the Inpatient Service. LEARNING VENUE All rotations take place at Pennsylvania Hospital. Teams are responsible for patients on general medical floors, telemetry monitored beds and in the Intermediate (Special) Care Unit. TEACHING METHODS Direct Patient Care: Each team is expected to provide thorough and comprehensive care to the patients assigned to their team in a timely and effective manner. All history and physicals, management decisions, and discharge plans are reviewed, supervised, and approved by the attending of record. Housestaff encounter patients admitted either directly from the outpatient setting, via the Emergency Room, or after transfer from the ICU or an outside hospital. Attending Rounds: Attending rounds take place a minimum of 3 sessions per week for at least 4.5 hours/week. They are either conducted at the bedside or more didactically in a conference room. All team members are required to be present. The students and interns present new and previously admitted patients to the attending for review of history and physical exam, lab data, a prioritized problem list and a diff dx for active problems. Residents are expected to help with the interpretation of abn lab data, to broaden the diff dx and guide the diagnostic work up and therapeutic management plan. The patients attending of record is available 24/7 either in person or via telephone for guidance.
2 Resident Morning Report: One hour conference run by the Chief Resident, mandatory for Inpatient Residents. It is held Monday-Thursday from 11am-noon. Each session is precepted by an attending physician. MR is a time for the floor residents to collaboratively discuss their most challenging cases, hone their oral presentation skills and learn diagnosis and management strategies from general internal medicine and subspecialty attendings. EKG and radiology studies are incorporated when available. Each session begins with the Question of the Day from the Chief Resident. Journal Club: One hour conference held once a week on Fridays from 11am-noon. This is a mandatory conference for all residents. Each week a resident presents an article from a major journal using the PowerPoint format. The study design and statistical methods are analyzed in detail. Facilitating each conference are Dr. Nick Scharff, MD, MPH and a subspecialty expert related to the topic of the article. Noon Conference: One hour conference held Monday, Wednesday, and Friday from noon-1pm. This is mandatory for all interns. This lecture series covers fundamental clinical and scientific topics pertinent to Internal Medicine and serves as the core curriculum. Topics are drawn largely from the major specialty disciplines. Grand Rounds: Each Tuesday from Noon-1pm. Traditional Grand Rounds format with a variety of speakers from the city, region, and nation. Morbidity and Mortality/Clinicopathological Conference: Thursdays from Noon-1pm. Each PGY3 resident is responsible for presenting one M&M and one CPC as part of their scholarly activity. Residents present important cases of diagnostic difficulty or morbidity, including health care quality or patient safety issues. Faculty members service as facilitators and subject experts. Board Review: The subject books of MKSAP series are covered in a 6 month schedule starting in January. A faculty facilitator discusses the questions and answers in depth, focusing on the distracters as well providing a critique of the correct answer. Procedural Skills Lectures/Quizzes: This is a series of procedure videotapes and quizzes offered by the ABIM which we show to the new interns in June and July. A faculty expert is present to comment on proper indications and technique. The quiz is then completed by each intern. In order to qualify to perform the procedure under supervision, the intern must receive a passing grade on each quiz. EDUCATIONAL CONTENT 1) Generate an appropriate differential diagnosis for the following common medical chief complaints: a) chest pain b) dyspnea c) headache
3 d) mental status changes e) acute abdominal pain f) new fever g) new rash h) lower extremity edema i) common GI complaints such as anorexia, constipation, diarrhea, nausea/emesis j) hematochezia/melena/hematemesis k) cough l) dizziness m) swollen joint n) weakness o) syncope 2) Identify and generate an appropriate treatment plan for the following common medical illnesses: a) DVT/PE b) DKA/HHNK c) CAP and Aspiration Pneumonia d) ARF e) Cellulitis/Osteomyelitis/Diabetic foot ulcers f) Asthma/COPD exacerbation g) UTI/Pylonephritis/Urosepsis h) Endocarditis i) Meningitis j) Acute coronary syndromes k) Pre-op evaluation l) Atrial Fibrillation and other arrthymias m) CHF n) Anemia o) Hypo/hypernatremia, kalemia and calcemia p) Decubitis ulcers, prevention and treatment q) Septic Arthritis r) Obstipation/partial SBO s) CVA t) Dementia u) Depression v) ETOH withdrawal w) Diverticulitis x) Pancreatitis y) Neutropenic fever z) Sickle cell crisis 3) Procedures: the following is a list of procedures either learned or reinforced on general medical rotations.
4 a) Arterial puncture b) Basic and advanced cardiac life support c) Lumbar Puncture d) Abdominal paracentesis e) Thoracentesis f) Arthrocentesis g) Nasogastric intubation 4) Intererpretive Skills: the following are skills which are reinforced or learned on general medicine rotation: a) Serum electrolytes and routine chemistry panel b) Urinalysis and microscopic examinations of urine c) Liver function tests d) Coagulations studies e) Arterial blood gases f) Chest x-ray interpretation g) Electrocardiogram h) Other radiologic studies (CT, MRI, abdominal flat plate) i) Peripheral smear j) Sputum Gram Stain k) Spirometry ROTATION SPECIFIC COMPETENCY OBJECTIVES BY TRAINING LEVEL 1) Patient Care a) History Taking: Housestaff at all levels of training will collect a thorough history by soliciting patient information and by consulting other sources of primary data in a logical and organized fashion. Interviewing will adapt to the time available, use appropriate nonverbal techniques, and demonstrate consideration for the patient. As the house officer progresses through each PGY level, he/she is expected to become more efficient, thorough, and proficient. b) Physical Exam: Housestaff at all levels will perform a comprehensive physical exam. As the house officer progresses through each PGY level, he/she is expected to become more skilled at recognizing abnormal finding and their significance. Eventually serving in a teaching role to confirm their presence for junior members of the team. c) Charting: House officers at all levels will record data in a legible, thorough, systematic manner. As the house officer progresses through each PGY level, he/she is expected to become more efficient and concise. d) Procedures: i) PGY1 and PGY2 residents will demonstrate knowledge of: Procedural indications, contraindications, necessary equipment, specimen handling,
5 patient after-care, and risk and discomfort minimization. They will participate in informed consent and assist patients with decision making. They will correctly identify the meaning of the test results. PGY1 residents will initially observe and then perform procedures prior to the completion of the first training year. ii) PGY3 residents in addition to mastering the above, will demonstrate extensive knowledge and facility in the performance of procedures while minimizing risk and discomfort to patients. They will assist their junior peers in skills acquisition. e) Medical Decision Making, Clinical Judgment, and Management Plans. All residents will demonstrate improving skills in assimilating information that they have gathered from the history and physical exam. i) PGY1 residents will be able to identify patients; problems and develop a prioritized differential diagnosis. They will understand their limitation of knowledge and seek the advice of more advanced clinicians when appropriate. PGY1 residents will begin to develop therapeutic plans that are evidence or consensus based. They will establish an orderly succession of testing based on their history and exam findings. Additionally, PGY1 s will understand the correct administration of drugs, and describe and anticipate drug-drug interactions. ii) PGY2 residents will continue to develop and enhance the above skills. In addition, they will regularly integrate medical facts and clinical data while weighing alternatives and keeping in mind patient preference. They will regularly incorporate consideration of risks and benefits when considering testing and therapies. They will present up-to-date scientific evidence to support their hypotheses. They will consistently monitor and follow-up patients appropriately. They will develop plans to avoid or delay known treatment complications and be able to identify when illness has reached a point where treatment no longer contributes to improved quality of life. iii) PGY3 residents will continue to develop and enhance the above skills. In addition, they will demonstrate appropriate reasoning in ambiguous situations, while continuing to seek clarity. They will continuously revise assessments in the face of new data. f) Patient Counseling i) PGY1 residents will be able to describe the rationale for a chosen therapy and will be able to describe medication side effects in lay terms. They will asses patient understanding and provide more information when necessary. PGY1 s will demonstrate the ability to be a patient advocate. ii) PGY2/PGY3 residents, in addition to the above, will be able to explain the pros and cons of completing therapeutic interventions or refusing those interventions. They will be expected to counsel patients regarding adverse habits and they will be able to counsel patients and families for enhanced compliance.
6 2) Medical Knowledge a) PGY1 residents will consistently apply current concepts in the basic sciences to clinical problem solving. They will use information from the literature and other sources including electronic databases to enhance their knowledge. PGY1 s will demonstrate satisfactory knowledge of common medical conditions, sufficient to manage urgent complaints with supervision. They must exhibit sufficient content knowledge of common inpatient medical problems to provide initial care with minimal supervision by completion of the PGY1 year. b) PGY2 residents will demonstrate a progression in knowledge and analytical thinking in order to develop well-formulated differential diagnoses for multiproblem patients. They will also demonstrate socio-behavioral knowledge as it is applicable to appropriate and effective patient care. c) PGY3 residents will continue to demonstrate a progression in knowledge and analytical thinking. They will also continue to develop appropriate habits to stay current with new knowledge. 3) Interpersonal and Communication Skills a) PGY1 residents will develop and refine their individual style when communicating with patients. They will strive to create ethically sound and respectful relationships with patients, the physician team, and supporting hospital personnel. They will create effective written communications through accurate, complete, and legible notes and patient signouts. They will exhibit listening skills appropriate to patient-centered interviewing and communication. House officers will continue to develop and refine their ability to recognize verbal and nonverbal cues from patients. Residents will respond to feedback in an appropriate manner and make necessary behavioral changes. b) PGY2 residents, in addition to the above, will also exhibit team leadership skills through effective communication as manager of a team. PGY2 residents are expected to assist junior peers, medical students, and other hospital personnel to form professional relationships with support staff. PGY2 s will be able to communicate with patients concerning end-of-life decisions. c) PGY3 residents should additionally be able to successfully negotiate nearly all difficult patient encounters with minimal direction. Third year residents should function as team leaders with decreasing reliance upon attending physicians. 4) Professionalism a) All residents will demonstrate integrity, accountability, respect, compassion, patient advocacy, and dedication to patient care that supersedes self-interest. Residents will demonstrate a commitment to excellence and continuous professional development. They will be punctual and prepared for teaching sessions. Residents will demonstrate commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, and informed consent. Residents are expected to show sensitivity and responsiveness to patients; culture, age, gender, and disabilities. 5) Practice-Based Learning and Improvement
7 a) PGY1 residents will use hospital and University library resources, including journals and systematic reviews to critically appraise medical literature and apply an evidence-based approach to patient care. They will model these behaviors to assist medical students in their own acquisition of knowledge through technology. PGY1 s will begin to use information technology to enhance patient education. b) PGY2 residents will in addition consistently seek out and analyze data on practice experience, identify areas for improvement in knowledge or patient care performance and make appropriate adjustments. They will regularly demonstrate knowledge of the impact of study design on validity or applicability to individual practice. They will develop a willingness and ability to learn from errors and use them to improve the health care system and their own practice. c) PGY3 residents will additionally model independent learning and development. 6) System-Based Practice a) PGY1 residents will be sensitive to health care costs while striving to provide quality care. They will begin to effectively coordinate care with other health care professionals as required for patient needs. They will recognize the importance and necessity of contact with the patient s primary care physician upon patient admission to the hospital. b) PGY2 residents, in addition to the above, will consistently understand and adopt available clinical practice guidelines and recognize the limitations of these guidelines. They will work with patient care managers, discharge coordinators, and social workers to coordinate and improve patient care and outcomes. c) PGY3 residents, in addition, will enlist social and other out-of-hospital resources to assist patients with therapeutic plans. PGY3 residents are expected to model cost-effective therapy. EDUCATIONAL MATERIALS/RESOURCES 1. Computer-based Resources a. On-line journals b. Systematic Review Databases c. Drug information and drug-drug interaction programs d. Electronic textbooks ( UPTODATE and MD CONSULT available on every patient floor) e. Radiology results on PACS available on every patient floor 2. Attending support via rounds or telephone 3. Hospital Medicine Curriculum-in development 4. MKSAP Procedure videotapes
8 EVALUATION METHODS: all formal evaluations from attendings and peers are available for review on-line as well as during the semi-annual meeting with the Program Director. 1. Attending evaluation for each inpatient rotation: The evaluation is competencybased and is available for review by the resident on-line, as well as during semiannual review by the Program Director 2. Peer evaluation for each inpatient rotation: The author of the evaluation is kept confidential, and these may only be reviewed once 5 total have been received in the online database 3. Mini-CEX forms 4. Clinical Skills Assessment Program: each categorical intern participates in 10 station OSCE which is videotapes and then reviewed individually with the Program Director 5. Procedures are also reviewed electronically by the supervising attending
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