Learning Objectives fort General Inpatient Medicine Ward Rotations

Transcription

1 Learning Objectives fort General Inpatient Medicine Ward Rotations Educational Purpose Inpatient training in general internal medicine is designed to enable house officers to achieve the knowledge, skills and attitudes of competent general internists. In the course of their inpatient rotations at HUP, PMC and the PVAMC, residents are expected to gain proficiency in the diagnosis and management inpatient medical issues. Learning occurs through hands on, supervised clinical experiences, amplified by bedside teaching. Teaching rounds and didactic conferences occur 5-6 days per week and are designed to reinforce the etiology, pathogenesis, clinical presentation and natural history of diseases treated by general internists; demonstrate appropriate skills in diagnosis, judgment and resourcefulness in therapy; receive instruction and feedback to master interviewing, communication and interpersonal skills that are necessary to elicit and record a thorough and accurate history, establish and maintain a therapeutic physician-patient relationship, and initiate or motivate the patient to implement optimal medical management; receive instruction and feedback to master physical exam skills; demonstrate the humanistic treatment and care of patients. The average PGY1, PGY2, PGY3 will spend 3, 1 and 1 months respectively on the general ward services at HUP, PMC and the VA. Patient Characteristics/Disease Mix: The combination of 3 clinical sites affords a unique opportunity to experience the breadth of medicine. HUP is both a community hospital as well as a tertiary and quaternary referral center. The patient population is drawn from surrounding West Philadelphia, a working class population with large number of unemployed and homeless people. The Clinical Care Associates (Penn s primary care network) and the subspecialty network provide a large referral base for both common presentations of uncommon disease as well as uncommon presentations of common diseases. In addition, HUP is a regional and national leader for many types of care from referrals nationwide. There are 9 acute medicine services at HUP: solid tumor, liquid tumor, congestive heart failure and 6 general medicine services run by hospitalists. PMC is predominantly a community-based hospital serving the West Philadelphia community. The patient population reflects the working class, indigent and homeless. The PVAMC is a large veteran s hospital that cares for patients with a large number of co-morbidities, psychosocial problems and HIV disease. Procedures: Directly Supervised Procedures (DSP) - Residents have the opportunity to learn procedures under the direct supervision of the ER Attending. Central venous lines, arterial lines, thoracentesis, paracentesis, lumbar punctures, intubations, arthorcentesis, cervical smears and cultures, microscopic analysis of the urine, sputum gram stains, paracentesis, and thoracentesis will be done in the presence of the attending or fellow until the resident has documented satisfactory competency in these procedures. Educational Goals by PGY level PGY 1 Patient Care: direct care for 6-10 patients including all order writing, test ordering, relevant procedures and documentation Participating in Rapid Response Calls and Codes Providing cross cover care for other team members over night and some weekends. Interview patients more skillfully Create and sustain doctor patient relationships that maximize the likelihood of the best outcomes for patients and the greatest personal satisfaction for physicians. Examine patients more skillfully

2 Define and prioritize patients' medical problems Generate rudimentary differential diagnoses and begin to prioritize them Medical Knowledge: Expand clinically applicable knowledge base of the basic and clinical sciences underlying the care of medical inpatients attending rotation based conferences and required departmental conferences, including intern report and Grand Rounds. Practice-Based Learning and Improvement: Identify and acknowledge gaps in personal knowledge and skills in the care of hospitalized patients Develop and implement strategies for filling gaps in knowledge and skills Interpersonal Skills and Communication: Communicate effectively with patients and families Communicate effectively with physician colleagues at all levels Communicate effectively with all non-physician members of the health care team to assure comprehensive and timely care of hospitalized patients Present patient information concisely and clearly, verbally and in writing Understand one's own personal reactions to difficult situations in order to understand potential barriers to communication. Professionalism: Behave professionally toward towards patients, families, colleagues, and all members of the health care team Systems-Based Practice: Understand and utilize the multidisciplinary resources necessary to care optimally for hospitalized patients. Collaborate with other members of the health care team to assure comprehensive patient care Use evidence-based, cost-conscious strategies in the care of hospitalized patients PGY 2: Patient Care: supervision for 2 interns and thus indirect care for patients generate complete differential diagnoses and prioritize them appropriately supervision of 1 third medical student each month, including modeling and teaching oral presentation and documentation skills as well as history taking and physical exam skills; develop rational, evidence-based management strategies respond to and supervise RRT and CODE calls. Medical Knowledge: access and critically evaluate current medical information and scientific evidence relevant to patient care providing major objectives for the educational content of resident teaching and attending rounds, including the liberal use of literature for the practice of evidence based medicine. attending rotation based conferences and required departmental conferences, including resident report and Grand Rounds.

3 Practice-Based Learning and Improvement: begin using electronic data bases, literature retrieval services and computer-based diagnostic reasoning programs. Interpersonal Skills and Communication: Know how to inform patients and obtain voluntary consent for the general plan of medical care and specific diagnostic and therapeutic interventions. functioning as an integral team member; including participation in interdisciplinary rounds. Systems-Based Practice: Collaborate with other members of the health care team to assure comprehensive patient care development of the organizational skills necessary to manage an inpatient team; PGY 3 In addition to those listed for the PGY 2 year, additional goals include: Patient Care: supervision of 1 fourth year medical student each month. Medical Knowledge: develop a comprehensive approach to learning based on ones own perceptions of gaps in fund of knowledge as well as the results of objective assessments, including the Intraining Exam and summative evaluations. Know the strengths of weaknesses of: randomized clinical trials, case control studies, cohort studies (retrospective, prospective) and meta analyses related to this patient population enhance teaching skills through the preparation of short talks for interns and students apart from attending rounds; Practice-Based Learning and Improvement: Demonstrate facility in using electronic data bases, literature retrieval services and computer -based diagnostic reasoning programs. Interpersonal Skills and Communication: enhance feedback and evaluation skills of supervised trainees. Professionalism: function as role models and mentors for younger trainees. Systems-Based Practice: Use evidence-based, cost-conscious strategies in the care of hospitalized patients Mastery of the organizational skills necessary to manage an inpatient team; Principal Teaching Methods/Learning Venues: Listed below are the principle educational goals for the Inpatient Floor rotations for all 3 sites. Each goal is listed as a function of the six ACGME competencies. The second column of the table indicates the most relevant principal teaching method/learning venue for each goal, using the legend below. Intern Pre Rounds (IPR) mark the arrival of the intern at the hospital between 7:00 AM and

4 8:00 AM in order to "preround" on their own patients before Resident Teaching Rounds. Resident Teaching Rounds (RTR) run from 8:00 AM until 9:15 on most services. These rounds consist of the residents reviewing at the bedside the old and new patients with their intern colleagues and medical students assigned to that team. This is a major educational forum and a time when residents are expected to review physical exam findings, discuss literature and practice evidence medicine. Multidisciplinary Care Rounds (MDCR) occur between 9:15-9:30 and include nursing, clinical resource managers and social workers. The goal is discharge planning. Morning report (MR) runs from 12-1 on Mon., Wed, Thurs. and Fri. This is our premier educational conference for second and third year residents that is run by the chief medical residents. It is case based, didactic and uses radiology and pathology as appropriate. Attending rounds (AR) run from 8:30-10:30 am daily. In addition 30 minutes of core didactic material time is also spent reviewing clinical details of patient management, teaching at the bedside and reviewing radiologic studies and pathology. There is a strong emphasis in separating the service/management issues from the more formally structured teaching. Residents are encouraged to define the goals and objectives of teaching rounds each month and use time outside of these rounds for review of clinical details related to the patients on their service. Intern Report (IR) runs from 1:15-2:15 on Mondays, Wednesdays, Thursdays and Fridays. The chief medical residents run Intern report. It is topic based early in the year to cover commonly encountered medical problems and case based thereafter. Medical Grand Rounds (GR) occurs each Tuesday at noon. It features national, regional and local experts in all aspects of Internal Medicine as well as many other disciplines. The content spans basic science and clinical medicine. Morbidity and Mortality-(MM) This is run by senior residents under the guidance of the Department s patient Safety Officer. This is multidisciplinary and participants from all aspects of the health care team are invited to participate. There is regular participation by nursing. Clinicopathologic Correlation Conference (CPC) Senior residents under the guidance of a faculty preceptor run these conferences. They represent difficult management issues and treatment decisions. Professors rounds (PR) occur monthly on 1 service at each hospital. It is typically run by the chief of service and is focused on bedside skills. Principal Educational Goals by Relevant Competency In the tables below, the principal educational goals of the floor rotation are highlighted for each of the six ACGME competencies. The second column of the table indicates the most relevant principal teaching/learning activity for each goal, using the legend below. * Legend for Learning Activities (See above for descriptions) AR - Attending Rounds DPC - Direct Patient Care RTR-Resident Teaching Rounds PR - Professor's Rounds GR - Grand Rounds MR - Morning Report IR - Intern Report IPR-Intern Pre-rounds MDCR-Multidisciplinary Care Rnds

5 1) Patient Care Interview patients more skillfully Create and sustain doctor patient relationships that maximize the likelihood of the best outcomes for patients and the greatest personal satisfaction for physicians. Examine patients more skillfully Define and prioritize patients' medical problems Generate and prioritize differential diagnoses Develop rational, evidence-based management strategies DPC, AR, PR, RTR DPC, RTR DPC, AR, PR, RTR IPR, MR, IR, MDCR IPR, MR, IR MR, IR 2) Medical Knowledge Expand clinically applicable knowledge base of the basic and clinical sciences underlying the care of medical inpatients Access and critically evaluate current medical information and scientific evidence relevant to patient care Know the strengths of weaknesses of: randomized clinical trials, case control studies, cohort studies (retrospective, prospective) and meta analyses DPC, AR, PR, MR, IR RTR, IPR, GR DPC, AR, MR, IR, RTR, GR AR, MR, GR 3) Practice-Based Learning and Improvement Identify and acknowledge gaps in personal knowledge and skills in the care of hospitalized patients Develop and implement strategies for filling gaps in knowledge and skills Demonstrate facility in using electronic data bases, literature retrieval services and computer-based diagnostic reasoning programs. DPC, AR, PR, MR, IR RTR, IPR, MDCR,GR MR, IR, RTR, MDCR DPC, RTR, AR, MR, IR 4) Interpersonal Skills and Communication

6 Communicate effectively with patients and families Communicate effectively with physician colleagues at all levels Communicate effectively with all non-physician members of the health care team to assure comprehensive and timely care of hospitalized patients Present patient information concisely and clearly, verbally and in writing Teach colleagues effectively Understand one's own personal reactions to difficult situations in order to understand potential barriers to communication. Know how to inform patients and obtain voluntary consent for the general plan of medical care and specific diagnostic and therapeutic interventions. IPR MR, IR, DPC, IPR, MDCR DPC, AR, PR, MR, IR, MMCPC, RTR MMCPC, MR DPC, RTR DPC, RTR, AR 5) Professionalism Behave professionally toward towards patients, families, colleagues, and all members of the health care team ALL 6) Systems-Based Practice Understand and utilize the multidisciplinary resources necessary to care optimally for hospitalized patients. Collaborate with other members of the health care team to assure comprehensive patient care Use evidence-based, cost-conscious strategies in the care of hospitalized patients DPC, MDCR, MC,GR DPC, MDCR,GR MR, IR Lines of Responsibility for and Supervision of Patient Care All core medical students on this rotation are supervised by PGY 1 residents. The PGY 1 is responsible for verifying patient information collected by and communicated from eh medical student. This includes a daily review of any chart documentation.

7 All subintern medical students are by PGY 2/3 residents. The PGY 2/3 is responsible for verifying patient information collected by and communicated from the medical student. This includes a daily review of any chart documentation. The PGY 1 resident on the team reports directly to their assigned PGY 2/3 resident. The PGY 2/3 resident has responsibility for all patients under the care of their assigned PGY 1 residents. This includes daily review of all aspects on patient care. The PGY 2/3 resident reports directly to the attending physician. The attending physician is responsible for supervising all members of the team in accordance with the institutional policy on Attending supervision. Recommended Educational Resources All residents are expected to read about their patients in an appropriate general medicine text. Because it is frequently updated, extensively referenced, and includes abstracts of referenced articles, the program highly recommends UpToDate as a primary resource. UpToDate is available at all 3 sites on the UPHS network. The reference shelf from the Biomedical library is also available online. Additional educational resources include the didactic conference curriculum, primary review of studies, as well as the review of microscopic and gross pathology. Evaluation Methods The evaluation methods that apply to these rotations include: Web enabled competency-based evaluation forms that are completed by faculty, peers and students when applicable. Procedure logs In-training examination scores ABIM summative exam results