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A. General Information1. Organization and Structure
a. The Department of Medicine at the University of North Carolina at Chapel Hill provides an integrated, progressive experience for residents in their 36- month training period. The goal of our curriculum is to prepare residents to be well- trained general internists. We believe this type of training not only prepares our residents for careers in General Internal Medicine but also provides the necessary foundations for further training as a subspecialist.
The curriculum in the Department of Medicine changes greatly from the PGY 1 year to the PGY 3 year. The PGY 1 year consist of 9 months of inpatient rotations and 3 months of ambulatory medicine. During the second and third years, residents spend an increasing amount of time in the outpatient setting, so that by the time a resident is in the PGY 3 year, a majority of rotations occur in ambulatory medicine. The curriculum will be specifically described for each of the 3 year of training.
The PGY 1 Year
Each PGY 1 resident must develop competence in the following categories:
Patient CareMedical KnowledgePractice Base Learning and ImprovementInterpersonal and Communication SkillsProfessionalismSystem Based Practice
In the context of monthly rotations, competency is defined for each of the categories. Patient Care- medical interviews, physical examinations, review of data, procedural skills, diagnostic and therapeutic decision making
Medical Knowledge- basic and clinical science, evidence- based medicine, literature searching
Practice Based Learning and Improvement- evaluation of own performance, incorporation of feedback, use of technology for patient care and self improvement
Interpersonal and Communication Skills- establishment of relationships with patients and families, education and counseling of patients, team skills with colleaguesProfessionalism- demonstration of respect, compassion, integrity, and honesty, commitment to self assessment, acknowledges errors, considers needs of patients and colleagues
System Based Practice- ability to utilize resources, use a systematic approach to reduce errors and improve patient care
These competencies are reviewed with all residents and the faculty and serve as the foundation for monthly evaluation. The evaluation tool includes a description of each of the core competencies and a scale of evaluation for each from 1-9. A copy of the evaluation took is included in Section ___. -------------------
The PGY 1 curriculum consists of a series of monthly rotations linked with a number of Departmental teaching conferences.
The monthly inpatient rotations for each PGY 1 resident are as follows:
Cardiology/MICU- 2 monthsInpatient General Medicine Ward- 2monthsInpatient Subspecialty Wards- 5months
On all inpatient rotations the role of the PGY 1 resident is to serve as the primary physician for all of his/her patients. In this role the PGY1 resident:
1. Performs a history and physical examination on each new patient
2. Enters all orders3. Communicates with the patient and ward team regarding
daily progress4. Enters a history and physical and daily progress notes into
the patient record5. Develops a diagnostic and therapeutic plan for each patient6. Enters a discharge summary in to the patient record
Cardiology -consists of 32 beds covered by four teams. Each team is made up of one upper level resident and one PGY 1 resident. One faculty member and one subspecialty fellow are assigned to each team to assist in patient management and to conduct teaching rounds. Didactic teaching rounds and bedside teaching occur daily. Also, there is a weekly core curriculum lecture series that is case- based.
A copy of the Cardiology Curriculum is included in Section 2. Common diagnoses of patients admitted to the cardiology service included myocardial infarction, arrhythmias, and chronic heart failure. Residents follow patients in the CCU (12 beds) and the general floor (20 beds). Residents on service place central lines including Swan Ganz catheters and perform arterial blood gases and thoracenteses.
ICU- Consist of 19 beds in a MICU. There are 4 teams, each team consisting of one upper level resident and one PGY 1 resident. One faculty member serves as the attending in the MICU. There is also a Critical Care Fellow. Teaching rounds include didactic presentations (30 min/day, 6 days/week), bedside teaching(2hours/day, 7days/week), and x-ray teaching (30 minutes/day,6days/week). There is a designated curriculum (Section 2). Patients admitted commonly have the following diagnoses: GI bleeding, septic shock, drug overdose, s/p cardiopulmonary arrest, DIC, COPD exacerbation, cystic fibrosis exacerbation, rejection s/p lung transplant, and acute renal failure. Residents perform all procedures.
Inpatient General Internal Medicine - consists of 2 general medicine services. For each service, there is one attending, one upper level resident, and two PGY 1 residents. Teaching rounds occur for one hour, five times per week covering a number of topics described in the Inpatient General Medicine curriculum (see Section 2). Patients admitted have a variety of problems including: community acquired pneumonia, COPD exacerbation, diabetic complications, and lupus complications. Residents perform all procedures.
Also, residents rotate at Wake Hospital, a community hospital in Raleigh, NC. There are four teams consisting of one attending, one upper level resident, and one PGY 1 resident. Teaching rounds occur for one hour five times per week covering topics in General Internal Medicine. Residents perform all procedures.
Inpatient Subspecialty Wards- Service #bedsMedicine A-Geriatrics 20Medicine B- Nephrology 20Medicine E- Hematology/Oncology 40Medicine G- Pulmonary 20Medicine K- Infectious Disease 20
For each service there is one attending, one upper level resident, and two PGY 1 residents. Each of these services has daily work rounds and attending rounds. Each service has designated reaching time occurring at a minimum of five hours per week. During teaching time a series of topics pertinent to each service are reviewed. A copy of each curriculum is included in Section 2. Residents perform all procedures on these services.
The PGY 1 Curriculum also includes the following rotations:
Emergency Medicine- 1 month
Same Day Clininc-1 month
Continuity Care/Ambulatory Elective- 1 month
Emergency Room – faculty from the Department of Emergency Medicine supervise PGY 1 residents. PGY 1 residents have a generic experience seeing medical, surgical, and obstetrics/gynecology patients. There are four hours of didactic teaching per week, which cover a wide variety of topics. Examples of monthly topics are included in Section 3.
Same Day Clinic- This is a walk in clinic for the established IM patients and also serves as an Urgent Care clinic. Faculty in the Division of General Internal Medicine supervise PGY 1 residents. A variety of outpatient problems are encountered. Didactic teaching takes place daily for 30 minutes. Subjects covered in the curriculum are included in Section 3.
Continuity Care/Ambulatory Elective- PGY 1 residents spend one month in the General Medicine clinics working with Faculty from the Division of General Medicine. Some of the modules include enhanced care in anticoagulation, diabetes, pain management, and travel medicine. Each resident also undertakes a CQI project. PGY 1 residents may also rotate on a subspecialty service of the Department of Medicine. Consultations are done on inpatients and outpatients and patients are also seen in subspecialty clinics. Division faculty provide supervision. Curricula for each rotation are included in Section 3.
Teaching Conferences
PGY1 residents attend a series of Departmental Conferences. The daily work schedule is set up to allow PGY 1 residents to attend the conferences (Table 1).
Table 1
UNC Department of Medicine- Schedule of Daily Activities
Time Monday Tuesday Wednesday Thursday Friday0700 Pre Rounds Pre Rounds Pre rounds Pre Rounds Pre Rounds
073001000
Work Rounds
Work Rounds
Work Rounds
Work Rounds
Work Rounds
1000 Residents Report
Residents Report
Residents Report
Residents Report
Residents Report
1100 Attending Rounds
Attending Rounds
Attending Rounds
Attending Rounds
Attending Rounds
1200 Core Curriculum
Core Curriculum
Intern Conference
Grand Rounds/
Morbidity and
Mortality Conference
EBM Conference
Residents are expected to attend all conferences. The conferences are as follows:
Monday- Resident Core Curriculum Conference 1 hour
Tuesday- Resident Core Curriculum Conference 1 hour
Wednesday- Interns Conference 1 hour
Thursday- Grand Rounds 1 hour
Friday – EBM Conference 1 hour
The content of some of these conferences is briefly described. Lecture topics are included in Section 4.
Monday and Tuesday- Residents Conference- Faculty in the Department of Medicine presents a series of lectures covering focused topics.
Wednesday- Interns Conference- A lecture series o f Emergency Medicine Topics mixed with case based group discussion.
Thursday- Grand Rounds
Thursday- Mortality and Morbidity- The morbidity and mortality conference centers on a subject relating to patient care in the department. The Vice Chair of the department conducts this lecture.
Friday- Evidence Based Medicine Conference- An evidence based medicine discussion of selected literature by both faculty and residents.
The PGY 2 Year
Each PGY 2 resident must demonstrate competence in the following:
Patient CareMedical KnowledgePractice Based Learning and ImprovementInterpersonal and Communication SkillsProfessionalismSystem Based Practice
Competency is defined as outlined above for PGY 1 residents and is used for monthly evaluations of PGY 2 residents
The PGY 2 year is composed of a series of monthly rotations coupled with Departmental teaching conferences.
The monthly inpatient rotations for a PGY 2 resident are as follows:
1. MICU- 1month2. Cardiology- 2months3. UNC inpatient Medicine Ward- 2-3 months4. Wake Med- 1 month5. Night Float- 2-3 2 week blocks
On inpatient rotations the role of the PGY 2 resident is to be in charge of the ward team. In this role the PGY 2 resident:
1. Performs a history and physical examination on each new patient2. Reviews the treatment plan for each new patient with the PGY 1
resident3. Reviews the performance of MS 3 students 4. Conducts daily work rounds5. Supervises all procedures
On night float the PGY 2 resident reports at 7pm and until 7 am. They are responsible for the primary evaluation and management of all non intensive care patients admitted to the Department of Medicine. At 7am the care of those patients goes to the incoming team on call. The Attending Physician of the service provides supervision.
Cardiology/ICU/Inpatient General Medicine Wards/Inpatient Subspecialty Wards -
These have been previously described under the PGY 1 resident. The role of the PGY 2 resident on these services is supervisory. The PGY 2 resident evaluates all patients on service and the PGY 2 resident is integral in constructing a plan of care, which is carried out by the PGY 1 resident. Another major responsibility is teaching. The PGY 2 resident teaches and supervises medical students on these services.
The PGY 2 curriculum also includes the following rotations:
Ambulatory General Internal Medicine- 2-3 monthsSubspecialty Consultation- 2-3 months
Ambulatory General Internal Medicine – PGY 2 residents can choose from several month blocks focusing on outpatient skills of the generalist. Some of the choices are:
Wake Hospital Ambulatory RotationSiler City- PGY 2 residents spend the month in a community setting
supervised by general internists.
Subspecialty Consultation- PGY 2 residents can choose among any subspecialty in the Department of Medicine. Consultations are done on inpatients. Patients are also seen in subspecialty clinics. Division faculty provides supervision. Curricula for each rotation are included in Section 3.
Teaching Conferences
Like PGY 1 residents, PGY 2 residents attend a series of conferences, which are integrated with the daily work schedule. Some have been described previously including Monday Resident Core Curriculum, Tuesday Core Curriculum, Thursday Grand Rounds and Friday Evidence Based Medicine. In addition, PGY 2 residents attend Morning report. This is case- based with residents presenting unknown patients to their peers. The presenting resident completes his /her presentation with a review of a particular subject. This review like all presentations is posted on the internet so that residents may review these at their leisure. These conferences are coordinated by the Chief Residents. The curriculum is set by the chief residents; a list of topics discussed is included in Section 4.
The PGY 3 Year
ACGME Competencies
Each PGY 3 resident must develop competency in the following:
Patient CareMedical KnowledgePractice Based Learning and ImprovementInterpersonal and Communication SkillsProfessionalismSystems Based Practice
Competency is defined as outlined above for the PGY 1 and PGY 2 residents and is used in monthly evaluation.
In many ways the PGY 3 year is similar to the PGY 2 year in that the residents function as described previously under the PGY 2 year, include teaching conferences. The rotations however, are different and are as follows:
1. Wake Med- 1 month2. UNC Internal Medicine Wards- 1-2 months3. Same Day Clinic- 1 month4. Ambulatory General Internal Medicine- 2-3 months5. Subspecialty Consultations 2-3 months6. Special electives – 1 month7. MICU or Cardiology- 1-month8. Night Float- 2-3 2 week blocks
Inpatient General Internal Medicine Wards/ Inpatient Subspecialty Ward- The role of the PGY 3 resident is identical to that described previously for the PGY 2 resident.
Same Day Clinic- The role of the PGY 3 resident is identical to that of the PGY 1 resident
Ambulatory General Internal Medicine- PGY 3 residents can choose from several month blocks including those described for PGY 2 residents. There are additional choices as follows:
General Medicine Consults/Hospitalist Service- PGY 3 residents see patients on other services, providing General Medicine Consultations. Also a small number of inpatients are cared for. Supervision is provided by faculty from the Division of General Internal Medicine Hospitalist group.
Geriatric Medicine- PGY 3 residents are exposed to management of this population. Faculty trained in Geriatrics provide supervision
Subspecialty Consultations- The role of the PGY 3 resident is the same as described for the PGY 2 resident on those rotations.
Special Electives- These rotations are designed to enhance individual training. Residents pick a faculty mentor to conduct clinical or basic research. Rotations at other institutions or international rotations can also be done.
SECTION 2
INPATIENT CURRICULUM
Cardiology
Intensive Care Unit
General Medicine
Geriatrics
Nephrology
Hematology/Oncology
Pulmonary
Infectious Diseases
Endocrinology
Section 2
Inpatient Curriculum
General
Each inpatient service has designated teaching time, previously described in Section 1. It is the responsibility of the division faculty when on service to review a series of topics during the monthly rotation. The division faculty generates these topics with input from residents as well as data supplied to each division from preceding In-Training Examination. A dominant theme for these conferences is to review material a general internist must know about each discipline. The curricular goal for each resident is to have a working knowledge of these subjects.
Cardiology Inpatient Curriculum
Objective 1. Takes a history
Demonstrates knowledge necessary to obtain an orderly history on patients suspected of having cardiovascular diseases and recognizes the importance of
A. Dyspnea ( resting, exertional, nocturnal, positional)B. Chest pain ( specifically, what constitutes “typical” angina)C. EdemaD. Palpitations/arrhythmiasE. Exercise toleranceF. History of hypertension and treatment G. History of rheumatic feverH. History of congenital heart diseaseI. History of cardiac murmurs or valvular diseaseJ. Cardiovascular risk factors, including family historyK. Presyncope and syncopeL. Claudication
Objective 2. Performs a physical examination
Demonstrates knowledge necessary for performing an orderly, systematic and adequate physical examination of patients with cardiovascular problems and recognizes the importance of
A. Arterial System &Jugular Venous Pulse1. Reports and demonstrates the correct method of measuring arterial
blood pressure2. Is familiar with difficulties in measuring arterial blood pressure
accurately:a. Variation between extremities, position, and level of
extremityb. The auscultatory gap c. Proper cuff size
3. Is familiar with normal and common abnormal findings found by inspection or palpation of the venous and arterial pulses, including the following:
a. a,c,v waves; visual estimation of central venous pressure;hepatojugular reflux
b. effect of inspiration on neck veinsc. pulsus alternans, pulsus bisferiens, pulsus paradoxusd. aortic regurgitation and stenosis
B. Examination of the Heart 1. Discusses normal and common abnormal findings found by
inspection and palpation of anterior chest including the following:a. Right and left ventricular heaves: palpable A –wavesb. Thrills
2. Understands the events of the cardiac cycle and the genesis of: a. S1,S2,S3,S4, summation of gallop, splitting of S2 ( normal
&reversed), and opening snapb. Mitral valve clicksc. Semilunar valve ejection soundsd. Artificial valve sounds ( normal& abnormal)e. Innocent murmurs, including flow murmurs, venous humsf. Murmurs of valvular stenosis and regurgitationg. Maneuvers that alter murmurs, i.e. Valsalva, squatting,
inspiration, expiration h. Pericardial rubs
Objective 3. Orders or performs diagnostic studies and interprets laboratory data in a reasonable and cost effective manner.
A. Electrocardiography ( EKG)1. General knowledge of the range of normal variation in P, QRS, ST, T
wave2. Understanding of EKG diagnosis of LVH, left atrial enlargement,
acute ischemia and patterns of myocardial infarction3. Basic understanding of the diagnostic utility of the EKG in the
diagnosis of arrhythmias B. Chest X-Ray
1. General knowledge of normal chest x-ray findings 2. Apvreciation of abnormalities- seen in:
a. Heart failureb. Valvular diseasec. Hypertensive diseased. Ischemic heart diseasee. Common congenital abnormalities seen in adulthood
C. Non-Invasive Testing1. Basic appreciation of the indications for:
a. Echocardiographic assessment ( transthoracic and transesophageal) including 2D and Dopler echocardiography
b. Ambulatory EKG ( Holter) monitor
c. Exercise testing with and without perfusion scintigraphy. Including an understanding of the meaning of sensitivity and specificity with regards to the latter test in the diagnosis if coronary disease
d. Tomographic imaging techniques, including MRI and CT
D. Invasive Testing1. Basic knowledge of methodology involved in performing coronary
angiography, left ventricular hemodynamic assessment and electrophysiologic testing; Understands the indications and risks of invasive diagnostic procedures
Objective 4. Understands the pathophysiology, natural history, clinical presentation, diagnostic work up and management of common cardiac disorders.
A. Heart Failure1. Altered myocardial hemodynamics as well as abnormal neuroendocrine
responses2. Precipitating causes of worsened heart failure3. Mechanisms and importance of diastolic dysfunction 4. Therapy including relative values and limits of diuretics, digoxin,
vasodilators, beta blockers, inotropes, fluid restriction, and other pharmacologic and non-pharmacologic therapies
B. Coronary Artery Disease 1. Risk factors for coronary artery disease and their modification2. Differential diagnosis of chest pain3. Chronic and acute ischemic syndromes ( unstable angina and acute MI)
with emphasis on proper history taking4. Noninvasive and invasive testing in patients with suspected coronary
artery disease5. Complications n acute post myocardial infarction syndromes such as
arrhythmias, sudden death, mechanical lesions, pericarditis and cardiac rupture
6. Indications for coronary angiography7. Role of interventional procedures ( e.g. PTCA) and cardiac surgery in
treatment of coronary artery disease.
C. Arrhythmias1. Bradyarrhythmias including various forms of conduction
disturbances and AV block, with emphasis on the indications for pacing
2. Tachyarrhythmias, including an emphasis on the EKG diagnosis of wide complex tachycardia’s
a. Atrial 1. Atrial tachycardia / AV nodal reentrant tachycardia2. Atrial fibrillation 3. Atrial flutter
b. Ventricular1. Premature ventricular contractions ( PVC’s)2. Ventricular tachycardia3. Torsades de pointes4. Ventricular fibrillation
c. Pre-excitation syndromes ( e.g. Wolff- Parkinson- White)3. Understands the importance of the use of cather ablation
techniques in treatment of supraventricular arrhythmias, including atrial fibrillation
D. Cardiomypathy1. Differential diagnosis and laboratory assessment2. Treatment including indications for cardiac
transplantation and mechanical cardiac support3. Follow Up of the post transplant patient
E. Valvular Heart Disease1. Acute rheumatic fever, including diagnostic criteria2. Aortic stenosis/regurgitation3. Mitral stenosis/ regurgitation4. Tricuspid stenosis/ regurgitation5. Pulmonary stenosis/regurgitation6. Mitral valve prolapse
F. Pericarditis 1. Acute: etiologies, symptoms and diagnosis2. Chronic: including large pericardial effusion, cardiac
tamponade and the indications for pericardiocentesis3. Diagnosis and management of constrictive pericarditis
G. Cardiac Tumors1. Cardiac involvement in metastatic cancer2. Myxoma
H. Congenital Heart Disease1. Diagnosis, history and physical of the adult with
congenital heart disease espically for the diagnosis of :
a. Atrial septal defectb.Ventricular septal defectc.Aortic stenosisd.Pulmonic stenosis
e.Coarctation of the aorta
2. Basic understanding of the adult with partially corrected congenital heart disease and post op complications of the more common repair procedures such as:
a. Transposition of the great vesselsb. Tetralogy of Fallotc. Ebstein’s anomaly
I. Pulmonary Heart Disease1. Cor pulmonale2. Pulmonary embolism3. Primary pulmonary hypertension
J. Cardiac involvement in systemic illnesses1. Diabetes mellitus2. Thyroid disease3. Obesity4. Thiamine deficiency5. Pheochromocytoma6. Rheumatic disorders including scleroderma, SLE, temporal
arteritis, polyarteritis nodosa and rheumatoid arthritis
K. Peripheral Vascular Disease1. Arteriosclerosis obliterans ( ASO)2. Aneurysms
a. Abdominal aortic b. Thoracic aortic ( including aortic dissection)c. Peripheral vascular
L. Miscellaneous Cardiac Conditions1. Trauma to the heart and great vessels2. Infectious disease
a. Viral myocarditisb. Infectious endocarditis
3. Asses preoperative risk for non cardiac surgery
Objective 5. Develops treatment plan for common cardiac problems
A. For each major disease of the cardiovascular system indentifies the appropriate therapeutic approach
B. Understands the indications for and can perform the following:1. Cardiopulmonary resuscitation and advanced life
support2. Emergency cardioversion3. Carotid massage4. Central venous pressure catheter insertion5. Recognizes the possible need, and request
medical consultation, for the performance of the following therapeutic procedures:
a. Transvenous pacemaker b.Pericardiocentesis
c. Swan-Ganz catheter insertion d. Elective cardioversion
C. For each of the treatments and drug types listed below identifies indications, dose, mechanism of action, main effects, side effects, adverse reactions, interactions, cost, efficacy, and appropriate follow-up:
1. Digitalis and other inotropic agents2. Antiarrhythmic drugs3. Diuretics4. Calcium channel entry blockers5. Beta blockers6. Angiotensin-converting enzyme inhibitors 7. Vasodilators8. Anticoagulants & thrombolytic therapy9. Antihypertensive agents10. Lipid lowering agents11. Rheumatic fever prophylaxis12. Endocarditis prophylaxis 13. Nitrates14. Angiotensin receptor blockers15. Aldosterone antagonists16. Inotropes
D. Informed, aware, and able to participate in and teach to patients, students, medical personnel and colleagues regarding:
1. Preventive cardiology and patient education2. Psychological aspects of cardiac disease3. Behavioral therapy including stress management, risk factor reducation, etc. 4. Proper nutrition, especially regarding lipid management and obesity5. Medical “cost/benefit” including different national systems and medical
care rationing 6. Preventive cardiology7. The clinical trial and meta analysis
Intensive Care Unit Inpatient Curriculum
Resuscitation BCLS and ACLSShock: Causes, assessments, and treatmentEarly goal directed therapy for septic shock
PulmonaryRespiratory failure: Hypoxemic and hypercapnicIntubation criteria, oral/nasal/tracheostomy complicationsMechanical ventilator modes, monitors and complicationsWeaning criteria and techniques, daily spontaneous breathing trialsARDS: Causes, physiology, therapy and complicationsAsthma and COPDPulmonary embolismPulmonary hemorrhage
CardiologyShock: Differential diagnosis and initial treatment Acute MI: Diagnosis, treatment and complicationsArrhythmiasPericarditis, Tamponade, and Constrictive pericarditisCHF and Pulmonary edemaPulmonary artery catheter: indications, placement, and interpretationInotropic drugs
NephrologyAcute renal failure: causes and treatmentRenal replacement therapy: continuous and intermittentElectrolyte abnormalities: Na+,K+, C1- Acid based disturbances and compensationsMetabolic acidosis: increased and normal anion gapUrine electrolytes
MetabolismNutrition: assessment, requirements, enteral feeding, TPNDiabetic ketoacidosis and non-ketotic hyperosmolar comaAdrenal crisis and steroid therapy
Gastrointestinal
Upper GI hemorrhageLower GI hemorrhageLiver disease: alcoholic, viral, otherPancreatitisThe acute abdomen: causes and assessment
PoisonsInitial assessment and treatment optionsAcetaminophenAnti depressantsSalicylatesAlcohols
InfectionsPneumoniasAspiration pneumonitisCentral line related bloodstream infections:prevention and managementTuberculosisImmunocompromised patients and opportunistic infections
HematologyAnemia and transfusionsThrombocytopenia, coagulopathy DICHemolysisSickle cell disease
Administration and/EthicsAdmission and discharge criteriaIllness severity scores and prognosesAdvance directivesUse/limitation of life sustaining treatmentsPractice and system based improvements: protocols and data monitoring
General Medicine Inpatient Curriculum
Likelihood Ratios; testing
Community Acquired Pneumonia
Pulmonary Emboli
Chest Pain Evaluation; CAD
Diabetic ketoacidosis, complications
Meningitis
Venous Stasis Ulcers
Peripheral Vascular Disease
W/U of Diarrhea
COPD, acute exacerbation
Depression, mood disorders
Stroke, endarterectomy
Hypertension Emergencies
Common Biliary tract diseases, cholecystitis, cholangitis
Dementia
Delirium
Diverticulitis
Avitaminoses
Peripheral Neuropathy
Cellulitis
Pulmonary Nodule
Anemia of chronic disease, liver disease
Pancreatitis
Poisonings- ethylene glycol, arsenic
Geriatrics Inpatient Curriculum
Current requirements from the Residency Review Committee for Internal Medicine, as outlined by the Accreditation Council for Graduate Medical Education, specify that “Residents must have formal instruction and assigned clinical experience in geriatric medicine. The curriculum and clinical experience should be directed by an ABMS- certified geriatrician. These experiences may occur at one or more specifically designated geriatric inpatient units, geriatric consultation services, long-term facilities, geriatric ambulatory clinics,, and/ or in home care settings.”
The Department of Medicine at the University of North Carolina at Chapel Hill currently has a separate Division of Geriatric Medicine with faculty and fellows in graduate medical training who are dedicated to the education of medical students and residents.
Currently residents receive training in the care of geriatric patients in both inpatient and outpatient settings.
Inpatient Geriatric Curriculum:
UNC currently has a Geriatric Inpatient Service that is always staffed by one of the faculty from the Division of Geriatric Medicine. Internal Medicine residents who rotate on this service work closely with the Geriatrics Faculty Attending in the care of older adults with acute medical illnesses.
Based upon the guidelines as outlined by the AGS Education Committee in 2004, resident trainees on this rotations will meet the following goals in attitudes, knowledge and skills required for the appropriate care of older patients.
1. Attitudes: This training program encourages respect for older people and their autonomy. The rotation on the inpatient service promotes compassionate, high quality care. Residents gain an appreciation for the heterogeneity in older people in respect to functional status, health, values and personal preferences. The resident learns the skills needed to negotiate the goals of care with the patients and family. Our inpatient service offers a truly multidisciplinary experience and the resident learns the importance of this approach to caring for older patients. The residents on our service work closely with a Geriatric Nurse Practitioner, Recreational Therapist, Physical Therapy service, social worker and specialized nurses interested in the care of older adults. The resident on this service truly gains an appreciation for the fact that the maintenance of function and quality of life may be more the goal than cure.
2. Knowledge: Internal Medicine residents who complete a rotation in the inpatient service will know:
a. Age related changesb. Pharmacokinetics and the importance of polypharmacy
c. Appropriate history and physical examd. Decision making capacity, competence, autonomy, ethical
considerationse. Role of exercise and rehabilitation f. Comprehensive geriatric assessmentg. Recognition of malnutritionh. Preoperative evaluation and postoperative care in older patientsi. End of life, palliative treatments including management of pain,
dyspnea, and other symptomsj. Evaluation and management of:
1. Cognitive impairment/dementia2. Depression3. Incontinence4. Gait and balance disorder, falls5. Immobility6. Pressure ulcers7. Polypharmacy8. Sensory impairment9. Pain10. Delirium
k. Difference in incidence, natural history, presentation, management and outcomes of medical problems when they occur in elderly patients
3. Skills: the resident will be able to:a. Perform assessments of basic and Instrumental activities of daily
living ( ADL and IADL), cognitive function, and gait and mobilityb. Work within an interdisciplinary team to develop a plan of carec. Facilitate medical decision making with older patients,
incorporating medical assessments and patient values and preferences
d. Diagnose and manage acute and chronic multiple illnesses in older patients
e. Conduct discussions regarding goals of care and end of life care
Nephrology Inpatient Curriculum
A. Teaching materials1. Reading material : selected articles and
publications from journals and nephrology data base
B. Topics to be discussed during Rounds:1. Hemodialysis and peritoneal dialysis:
techniques2. Hemodialysis and peritoneal dialysis:
dialysis prescription3. Evaluation of kidney structure and function
i. Urinalysisii. Measurement of GFR
iii. Evaluation of proteinuriaiv. Measurement of urinary
electrolytesv. Renal imaging techniques
4. Chronic Kidney disease5. Acute Kidney injury6. Metabolic acidosis7. Metabolic alkalosis8. Disorders of water metabolism
( hyponatremia and hypernatremia)9. Disorders of potassium and magnesium
metabolism10. Disorders of calcium, phosphorus and bone
metabolism11. Overview of evaluation and treatment of
hypertension12. Glomerular syndromes
i. Nephritic syndromeii. Nephrotic syndrome
13. Diabetic nephropathy14. Principles of kidney transplantation
Hematology/Oncology Inpatient Curriculum
Goals: This rotation should acquaint you with the general principles of diagnosing and treating Hematologic and Oncologic diseases. The inpatient services are divided into one that focuses on patients with malignant hematologic disease such as leukemias (E1) and lymphomas and the other (E2) on the rest of oncology. While there is some overlap in the services, we suggest that you focus your reading on the service you were assigned to. Every effort will be made for you to do the other service at least once during your residency. A case based teaching program to supplement your reading that combines patients from both services is done from 11:00-12:00 on Mondays, Tuesdays, Wednesdays, and Fridays.
1. Acute Leukemiaa. ALLb. AML
a. Genetics of AMLc. Clinical Presentation of Acute Leukemia
a. Laboratory Diagnosisb. Bone Marrow Examination
d. Gerneral Therapy for Acute Leukemia’sa. Therapy for ALLb. Therapy for AML
Tallman MS, Nabhan G; Acute promyelocytic leukemia. Blood 2002;99;759-67
2. Sickle Cell Disorders3. Febrile Neutropenia and infected catheters
Mermel LA et al: Guidelines for the management of intravascular catheter related infections. Clin Infect Dis 32:1249,2001
4. Thrombotic Disordersa. Major risk factorsb. Laboratory testing in thrombotic disordersc. Management of a thrombotic defectd. Treatment and prevention of thrombosis
5. Breast Cancera. Risk factors for breast cancer and risk reduction strategiesb. W/U of a suspicious breast massc. Primary therapy for a newly diagnosed breast cancerd. Systemic therapy for breast cancere. Quality of life in breast cancer survivors
Fisher B et al: Twenty year follow up of a randomized trail comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation of the treatment of invasive breast cancer. N Engl J Med 347: 1233, 2002
Wong ZW, Ellis MJ: First- line endocrine treatment of breast cancer: Aromatase inhibitor or antiestrogen? Br J Cancer 90:20, 2004
Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15 year survival: an overview of the randomized trials. Lancet 2005; 365, 1687
Ravdin PM et al: Computer program to assist in making decision about adjuvant therapy for women with early breast cancer. J Clin Oncol 2001;19:980 m
6. Colorectal Cancera. Risk factors for colorectal cancerb. Clinical features of colorectal cancerc. Staging of colorectal tumorsd. Management of resectable colorectal tumorse. Post resection surveillance in colorectal cancerf. Management of patients with metastatic colorectal cancer
Baron J et al: A randomized trial of aspirin to prevent Colorectal adenomas. N Engl J Med 348:391, 2003
Walsh JME, Terdiman JP: Colorectal cancer screening: JAMA 289:1288, 2003
7. Lung Cancera. Clinical presentation of lung cancerb. Diagnosis and treatment of lung cancerc. Non Small Cell Lung cancerd. Small cell lung cancer
American College of Chest Physican: Diagnosis and management of lung cancer: ACCP evidence based guidelines. Chest, 123: 1S, 2003
8. Cancer of Unknown Primary Sitea. Adenocarcinoma of Unknown primary siteb. Squamous cell carcinoma of unknown primary sirec. Poorly differentiated carcinoma of unknown primary site
Hainsworth JD, Greco FA: Management of patients with cancer of an unknown primary site. Oncology 14:563,2000
9. Lymphadenopathy, lymphoma and Multiple Myeloma
Diehl V et al: Hodgkin’s lymphoma – Diagnosis and treatment. Lancet Oncol 5;19, 2004
Barlogie B et al: Treatment of multiple myeloma. Blood 103:20, 2004
10. Prostate Cancera. The screening controversyb. Treatment of prostate cancerc. The Gleason Scored. Comparison of treatment modalitiese. Sequelae of treatment in prostate cancerf. Management of recurrent prostate caner
Nelson WG et al: Prostate cancer. N Engl J Med 349:366, 2003
11. Testicular CancerBosl GJ. Et al: testicular germ-cell cancer. N Engl J Med 337:242,1997
12. Oncologic Emergenciesa. Metabolic Emergences ( Hypocalcaemia, Hyperuricemia, and Hypoatremia)b. Hematologic Emergency: DVTc. Mechanical Emergencies ( Spinal Cord Compression, SVC, Pericardial
Effusion and Tamponade)
Strewler GJ: The parathrid hormone-related protein. Endocrine Metab Clin. North Amer 29:629,2000
Yim BT et al: Rasburicase for the treatment and prevention of hyperuricemia. Ann Pharmacotherapy 37: 1047, 2003
13. Chemotherapy, biotherapy, and hematopoietic colony stimulat ing factors:
American Society of Clinical Oncology: Update of recommendations for use of hematopoietic colony stimulating factors: Evidence based clinical practice guidelines. J Clin Oncol 2000:3558-85
14. Antimetics
Wisner, W. Practical management of chemotherapy – induced nausea and vomiting oncology 2005;5 : 637-45
15. Pain Management
Levy MH: Pharmacologic treatment on cancer pain. N Engl J Med 335:1124, 1996
Pulmonary Inpatient Curriculum
1. Pulmonary Physiologya. Gas exchangeb. Mechanicsc. Measures of function
i. Arterial blood gasesii. Lung volumes and DLCO
iii. Imaging techniques2. Obstructive Pulmonary ( Airway) Disease
a. Chronic Bronchitisb. Emphysema
i. Centrilbularii. Panacinar
c. Cystic Fibrosisd. Bronchiolitis
i. Bronchiolitis obliteransii. BOOP
iii. Bronchiolitis obliterans associated with lung transplantation
e. Bronchiectasis3. Asthma
a. Epidemiology and definitionb. Classification
i. “Intrinsic or nonallergic”ii. “Extrinsic or allergic”
c. Pathogenesisd. Clinical manifestations and diagnosise. Therapy
4. Respiratory Infectionsa. Community acquired pneumoniasb. Infections in the immuncomprimised host
i. . AIDSii. Other causes of immunosuppression
c. Tuberculosis and nontuberculous mycobacteriad. Anaerobic lung infections and aspiratione. Empyema
5. Interstitial Lung Diseasea. Idiopathic pulmonary fibrosisb. Drug inducedc. Connective tissue diseased. Sarcoidosise. Esoinophillic granuloma
6. Lung Neoplasmaa. Carcinomasb. Mesotheliomasc. Benign tumorsd. Staging evaluatione. Resectability
7. Lung transplantationa. Indicationsb. Common diseases transplantedc. Single versus double lung transplantsd. Survivale. Complications
8. Pulmonary Vascular Siseasea. Pulmonary thromboembolib. Pulmonary hypertensionc. Pulmonary vasculititsd. Alveolar hemorrhage/hemoptysis
9. Miscellaneousa. Pleural disease
i. Effusionsii. Pneumothorax
b. Occupational Lung diseasec. Sleep disordersd. Lymphangioleiomyomatosis
Resident Activities while on the Pulmonary Inpatient Rotation
1. Each resident will be expected to prepare a minimum of three 20-30 minute, informal lectures to be given to the rest of the team throughout the month.
2. Houseofficers are expected to attend Chest X-Ray rounds Monday, Wednesday, and Fridays at 2:30
3. The medical houseofficers are encouraged to attend the pulmonary lectures and conferences ( conference schedule enclosed).
Med G Syllabus Journal Articles
A. ASPIRATION PNEUMONIA
Aspiration Pneumonia. Lung Abscess, and Emphysema
B. ASTHMA
Review Article- Asthma
The Assessment and Management of Adults with Status Asthmaticus
C. COMMUNITY ACQUIRED PNEUMONIA
American Thoracic Society clinical guidelines for the initial management of adults with community acquired pneumonia
Current concepts- community acquired pneumonia
ATS guidelines for the initial management of adults with community acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobrial therapy
D. COPDManagement of Chronic Obstructive Pulmonary DiseaseCurrent Concepts management of chronic obstructive pulmonary disease
E. Cystic FibrosisReview article -drug therapy management of pulmonary disease in patients with cystic fibrosis
F. HemoptysisMassive hemoptysis: assessment and management
G. Hospital Acquired Pneumonia
Hospital acquired pneumonia in adults: diagnosis , assessment of severity, initial antimicrobial therapy, and preventive strategies
H. Lung MalignanciesPulmonary manifestations of extrathoric management lesionsStaging systems of lung cancer
I. Mycobacterial DiseaseClarithromycin regimens for pulmonary Mycobacterium avium ComplexControl of Tuberculosis in the United StatesTreatment of Tuberculosis and Tuberculosis infection in adults and children
J. Pneumocystis Carinii PneumoniaMayo clinic proceedings- Pneumcystis carinii Pneumaonia in patients without acquired immunodeficiency syndrome: Associated Illness and Prior Corticosteroid therapyPneumocystis Carinii Pneumonia in patients with the acquired immunodeficiency syndrome
K. Pulmonary vascular diseaseInvasive and noninvasive diagnosis of pulmonary embolism-preliminary results of the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-ped)Clinical features of pulmonary embolism – doubts and certaintiesValue of the Ventilation/Perfusion Scan in Acute Pulmonary Embolism –Results of the Prospective Investigation of Pulmonary Embolism Diagnosis ( PIOPED)
Anticoagulation in the prevention and treatment of Pulmonary EmbolismVenous Thromboembolism
L. SarcoidConferences and reviews-enigmas in Sarcoidosis
M. Sleep ApneaCurrent Concepts Obstructive sleep apneaTreatment of obstructive sleep apnea – a review
N. MiscellaneousMayo- rare pulmonary neoplasmsMechanisms of disease- hvpercapniaReview article- mechanisms of disease-pathophysiology of dyspneaDyspnea: mechanisms, assessment, and management: a consensus statementReview article- Primary Pulmonary Hypertension
Infectious Disease Inpatient Curriculum
Antibiotics I ( antibacterials)
Antibiotics II ( antivirals and antifungals)
HIV I
HIV II
Sepsis
Endocarditis
Skin and Soft Tissue Infection (Including osteomyelitits)
Diarrhea
Urinary Tract Infection
FUO
New and unusual infections, including Lyme disease and RMSF
Endocrine Inpatient Curriculum
Residents will work on a daily basis with the endocrinology team to include an attending (Dr. O’Connell and/or Dr. DeCherney), an endocrine fellow, an endocrine nurse practitioner and possibly a diabetes educator during their rotation. Other attendings with special interest will be invited to rounds periodically when interesting cases are seen( i.e. Dr. Sharpless for interesting pituitary cases, Dr. Rubin for interesting bone cases, etc.)
The resident will participate in the care of a wide variety of endocrine disorders seen in the hospital. Inpatient diabetes management will be a major focus.
The residents will see patients one half day per week ( Tuesday mornings) in the endocrine outpatient clinic ( High gate Specialty Center) under the supervision of an attending.
The residents will learn from their interactions with the team members, managing complex endocrine patients and from teaching while at the bedside. The endocrine curriculum will be provided and topics selected for teaching on a daily/weekly basis reflecting the patient material encountered. We will coordinate these teaching activities with the General Medicine Inpatient and Outpatient curriculum. Additionally, the residents will have the oppturnity to attend the Endocrine Division’s weekly conferences held Thursday afternoons from 3-5:30 in 2020 Bondurant. These sessions include a 3-4 pm didactic lecture given on an array of topics by attendings from multiple departments ( nuc med, pathology, ophthalmology, Endocrine, ect.) From 4-5 is journal club or a research presentation and from 5-5:30 is a case presentation by one of the fellows.
The goal of the inpatient endocrine service is to improve care of admitted patients with endocrine disease. It is the hope of the Endocrine Division that the medicine residents will find this rotation an enjoyable and educational experience and that after the rotation, they will be better prepared to manage endocrine patients in both the inpatient and outpatient settings.
Section 3
Ambulatory Curriculum
Emergency Room
Same Day Clinic
Cardiology
Endocrinology
Hematology/Oncology
Pulmonary Disease
Digestive Disease
Infectious Disease
Rheumatology
Nephrology
Adolescent Medicine
Geriatric Medicine
PGY -1 Continuity Elective
PGY- 2/3 Continuity Elective
Enhanced Care Elective
Section 3Ambulatory Curriculum
General
Each rotation has designated teaching times. The responsibility for teaching is given to the respective department or a division in the Department of Medicine. The topics are generated by the faculty with input from the Department of Medicine. These curricula are designed for consultation as well as direct patient care.
Emergency Medicine Curriculum
UNC Department of Emergency Medicine
The Emergency Department (ED) attendings work 8 hour shifts, 7a-3:00p, 1p-9p, 10 a-6p, 3p-11p, 6p-2a, and 11p-7a. Two attendings are on duty, with the exception of the time period from 2a to 10a when one attending is on duty.
The ED has 3 main areas. The Acute Care area has 24 beds including 2 cardiac rooms and 3 trauma rooms. Team C is an adjacent area with 8 beds. Team C is open 9a to midnight daily. Pediatric Acute Care is a separate unit staffed by Pediatric attending and residents. Pediatric Acute Care is open from 9a-2a daily. After those hours, pediatric patients (age 15 and below) are treated in the main ED. During your rotation, you will be assigned shifts in both the Acute Care area of the ED and the Minor Trauma area.
Guidelines for House officers
Introduction and General Principles
Welcome to the Department of Emergency Medicine! During this rotation, you will learn skills that are essential to your medical education. You will be supervised by faculty members who are Board Certified or Board Eligible in Emergency Medicine. Our faculty have practiced in a variety of institutions and settings, and thus, your experience here will be enhanced by exposure to different styles of practice.
Emergency Medicine differs in many respects from the inpatient and clinic settings. During this rotation, you will see a broad spectrum of illnesses ranging from the most trivial complaints to life-threatening diseases. It is important to remember that all patients come to the ED for a reason. Many present to the ED early in the course of their illness, therefore a serious disease may initially present to you as an apparently benign compliant. Many may present with complaints that could be handled elsewhere. It is our role to ensure our patients receive our best efforts to guide them through the increasing complex healthcare system as well as to diagnose and treat acute care conditions. Remember the Emergency Department is an important portal of entry into the hospital and provides a strong impression of the institution to patients, their families, and referring physicians from other medical centers.
House Officer Requirements for Successful Completion of Emergency Medicine Rotation
1. Completion of the Online Orientation ModuleEach house officer must complete the online orientation course and exam before starting their Emergency Medicine rotation. The orientation module is available online at www.med.unc.edu/wrkunits/2depts/emergmed.
2. Assigned shifts in the Emergency DepartmentBe prompt for your assigned shifts. If you are ill or must miss an assigned shift, you need to contact:
a. Your Chief Resident. Chief Residents from each rotating department will be responsible for providing replacement coverage for their individual department residents who are unable to fill an assigned shift.
b. The ED attending physician working at the time your shift begins( 966-4721)
In order to successfully complete the ED rotation as required by your residency, you must complete all assigned shifts. Illnesses are only excused if verified by your personal physician (not a resident physician) or your residency director.
3. Resident ConferencesIn order for the Department of Emergency Medicine, Medicine, Surgery, Family Medicine and OB/GYN to meet the requirements of the Residency Review Committee, weekly attendance at our Emergency Medicine Conferences is MANDATORY. These conferences are held on Wednesday mornings from 7a to noon. The schedule of topics is available monthly. Emergency Medicine interns/residents are required to attend conferences 5 hours per week. Off service interns/residents are required attend 3 hours per week. During your rotation, you will likely be scheduled in the ED on one or more Wednesday mornings. On these mornings you should attend sign out rounds and check in with the ED attending prior to departing for conference. When you are not scheduled to work in the ED, you should attend at least part of the Wednesday morning conference. Attendance will be taken at these conferences and reported to individual residency directors at the end of each rotation along with your final evaluation.
If you have questions or concerns, please feel free to contact:Kevin Biese, MD
Assistant Professor Education Director
966-6440
Important Items to Keep in Mind:
1. Although you will be quiet busy at times, make sure you speak to any family members or visitors who may be in the waiting room after you have finished your evaluation. It is important to let them know how well the patient is doing and give them an estimate of the anticipated length of stay. Always overestimate the length of stay. Things may take longer than you think.
2. Laboratory studies and X-Rays are ordered only if they impact on acute treatment, immediate decision making, or are essential for the provision of follow up care. The Emergency Department is not the place to begin an extensive workup of non-critical problems.
3. Every patient should be given instructions for follow up care and referred to a follow up physician, no matter how trivial the problem may seem. ( see documentation and charting guidelines)
4. You should be able to arrive at a reasonable clinical diagnosis on most patients. If you lack a definitive diagnosis, you must have formulated a clear differential diagnosis and have ruled out all possible life treating conditions before the patient can be discharged safely.
5. Information concerning patients seen or discussed in the ED is confidential. It should not be discussed anywhere else, other than medical conference setting. This means you must not discuss patient information in the hallways, nor elevators, nor in downtown restaurants, etc. You are a professional and must conduct yourself as such.
6. All patients who are seen in the Emergency Department are the ultimate responsibility of the attending emergency physician. Consequently, THE EMERGENCY DEPARTMENT ATTENDING MUST SEE EVERY PATIENT AND SIGN EVERY CHART PRIOR TO THE PATIENTS DISCHARGE, ADMISSION OR TRANSFER.
7. Some patients have such serious illness at the time of presentation that they may decompensate in a very short period of time. Because of this, there are certain circumstances when it is vital for you to notify the attending physician of the patient’s condition IMMEDIATELY AND POSSIBLY BEFORE YOU HAVE FINISHED YOUR INTIAL EVALUATION. (You will find a list of these circumstances attached in this handout.) If you think a particular patient is unstable, alert the attending on duty.
8. T System: All ED patients are tracked on a computer system called T System. When you arrive in the ED, you will be instructed how to use this system to sign up as the provider for the patients you are evaluating. In order to access this system, you must have a valid UNC Hospital code and password.
9. As patients enter the Emergency Department, they are triaged by the nursing staff. The triage designations are :
ESI-1 ESI-2 ESI-3 ESI-4 ESI-5
Stability of vital functions
Unstable Stable Stable Stable Stable
Life-threat or organ-threat
Obvious Reasonably likely
Unlikely (possible)
No No
Severe pain or severe distress
Immediately Sometimes Seldom No No
Expected resource intensity
Maximum: staff at bedside continuously; mobilization of outside resources
High: multiple, often complex diagnostic studies; frequent consultation; continuous (remote) monitoring
Medium: multiple diagnostic studies; or brief observation; or complex procedure
Low: one simple diagnostic study; or simple procedure
Low: exam only
Med/staff response
Immediate team effort Minutes Up to 1 hr Could be delayed
Could be delayed
Expected time to disposition
1.5 hr 4 hr 6 hr 2 hr 1 hr
Examples Cardiac arrest, intubated/hypotensive trauma patient, acute (<3 hr) MI or stroke
Most chest pain, stable trauma (MOI concerning), elderly pneumonia patient, altered mental status, behavioral disturbance
Most abdominal pain, dehydration, esophageal food impaction, hip fracture
Closed extremity trauma, simple lac, simple cystitis, typical migraine
Sore throat, minor burn, recheck
In general, patients should be seen in the order in which they arrive in the ED, however patients triaged as “1” or “2” should be evaluated before those designated “3-4-5”. If you are unsure which patient you should evaluate next, ask the attending or a senior resident to direct you.
SCHEDULE
Housestaff will be assigned to one section of the department and will report ONLY to the attending staffing that section.
RESPONSIBILITIES
Role of the Emergency Department Attending
The ED attending is primarily responsible for patient flow and consultation. The ED attending will be responsible for the supervision of all medical students and house officers. Housestaff cannot sign student orders. Role of the PGY-III ResidentThe PGY-III Emergency Medicine Resident has three main responsibilities in the ED:
1. Directly evaluate patients as the primary physician, with particular attention to critically ill or injured patients.
2. Ensure that patient flow in the ED is maintained.3. Supervise one or more PGY-I residents who are working in the ED.4. Perform or supervise procedures required for patient care.5. At times, these residents may take a turn at being “in charge” of the ED under the
supervision of the attending..
Role of the PGY-I and PGY-II Residents and Medical Students
The PGY-I resident and medical student are primarily responsible for patient evaluation and management. Remember that you are here to learn and that specific questions are expected. It is better to ask and ask early!
PATIENT CARE AND CASE PRESENTATION
It will be the responsibility of the EM PGY-III resident, all PGY-I residents, and medical students to pick up new patients as they are added to the board by the triage nurse. Patients are to be seen according to their time of entry into the ED unless another patient with a potentially life-threatening complaint has not yet been evaluated. Patients with life-threatening complaints are designated by a triage classification of “1” (in red) and should be seen promptly. If you are not certain whether a particular patient is to be seen, ask the attending physician or triage nurse.
The residents will see and evaluate the majority of patients. This initial evaluation is to consist of a history and physical examination, which may be “directed” if the patient has an obviously isolated problem (such as a minor extremity injury). All other patients should have a complete history and physical examination including social and family history, medications and allergies. This evaluation should take no longer than 5 to 10 minutes to complete.
ANY PATIENT WITH A CONDITION WHICH MAY DETERIORATE PRECIPITOUSLY MUST BE CALLED TO THE ATTENTION OF THE ED ATTENDING IMMEDIATELY, EVEN IF THE INITIAL EVALUATION IS NOT COMPLETED. A list of such conditions is listed in this handout.
After formulating a differential diagnosis and treatment plan, but before writing orders, the intern is to present the patient to the ED attending. At that time, an evaluation and treatment plan can be formulated and orders written. No verbal orders are acceptable.
After all ancillary studies have been completed; the house officer is to present the case to the ED attending again, this time noting the results of laboratory values, X-rays, etc. At this time a disposition will be made and the patient will be either be discharged, admitted or transferred to a different institution.
TYPES OF PATIENTS SEEN
Adult patients with a wide variety of complaints are seen in the Acute Care area of the ED. In addition to evaluating and treating patients with general medical and surgical problems, you will gain experience with patients whose complaints include the following:
Psychiatric - Our responsibility is medical clearance; be especially careful with elderly patients or those with confounding medical problems; some psychiatric patients will be seen directly by the Psychiatric consultants.
OB-Gyn - Women at 20 weeks or greater gestation are transferred directly to Labor and Delivery. The exceptions to this are if they have any type of trauma or a complaint totally unrelated to pregnancy. All women between ages10-60 should be assumed to be pregnant until proven otherwise by a negative urine or serum pregnancy test.
Trauma - Major trauma patients, as determined by criteria, are seen by the Trauma team, EM Attending and Senior Emergency Medicine Residents. Patients with lesser trauma are evaluated and treated by the general ED staff.
Pediatrics (ages 15 and below) - These patients are seen directly by a Pediatric resident, either in Pediatric Acute Care (9a-11p) or in the Acute Care ED at other times.
ANCILLARY SERVICES
Laboratory Studies
1. Laboratory studies are ordered in writing on the order sheet.
2. Laboratory reports results can be obtained on the computer. Be sure to check the computer frequently for results so the patient can receive disposition in a timely manner
3. All laboratory studies must be documented on the chart, including those that are pending at the time of disposition.
Radiologic Studies
1. If a patient needs an X-ray or other imaging study, write the order on the order sheet and give the order sheet to the clerk. You need to write a reason for the X-ray study, i.e. chest pain or SOB. The X-ray orders are entered into the computer by the nursing staff.
2. Look at the patient’s X-rays even though the radiologist’s interpretation is available. Remember that you have the advantage of knowing the patient’s clinical presentation and thus may notice something the radiologist might have misses.
3. If you have any questions regarding the interpretation of a particular radiograph, you may consult the radiology attending or resident by dialing 68850.
4. All radiologic studies must be documented on the chart!
MEALS
Housestaff are encouraged to briefly leave the ED for nutrition breaks as patient flow permits, but only after notifying the attending that they are leaving.
DOCUMENTATION STANDARDS
It is your responsibility to see that these standards are met on every chart. Charts will be returned to you for completion if documentation standards are not met.
DISCHARGE INSTRUCTIONS AND FOLLOW-UP
All patients are to receive a discharge instruction sheet prior to leaving the Emergency Department. There are specific items that must be included on the discharge form.
PATIENTS LEAVING THE EMERGENCY DEPARTMENT AGAINST MEDICAL ADVICE (AMA)
All patients who threaten to leave the Emergency Department against medical advice (AMA) must be seen by the ED attending immediately. The patient is required to sign an AMA form on the back of the chart and must be properly informed of the risks of departing AMA.
SECURITY AND PARKING
Escorts to the parking decks are available 24 hours a day. USE THEM!! Use the Point to Point Service (962-7867) or have hospital security accompany you! You cannot park in the ED patient parking lot.
DRESS CODE AND IDENTIFICATION
Name badges must be worn at all times. Housestaff are expected to look and act like professionals at all times. Scrub suits are acceptable for wear in the Emergency Department provided they are clean and in good condition. Jeans, shorts, sweats and T-shirts are not permitted.
WHEN YOUR SHIFT ENDS
You must turn your patients over to an intern or resident on duty in the ED. If your patient is nearing completion of their evaluation – please fill out the chart completely including the discharge form if appropriate. If the evaluation is in progress, please have a clear plan to pass on to the next doctor.
Medical Conditions RequiringImmediate Attending Physician Notification
The following is a list of conditions that require immediate notification of the Emergency Department attending physician, regardless of your level of training. This list does not cover all possible situations, and you should feel free to notify the attending immediately if you have a patient you feel may deteriorate precipitously or if you are uncomfortable given your present level of training.
1. Any patient who presents with or develops acute cardiopulmonary arrest.
2. Any patient with a complete or partially obstructed airway.
3. Any patient who presents with or develops a significant cardiac arrhythmia, whether stable or not.
4. Any patient with acute onset Alteration of Mental Status (AOMS). This includes any patient presenting with this as the chief complaint or any patient whose mental status deteriorates while in the ED.
5. Any patient with significant hypotension or hypertension. For these purposes, significant hypotension will be defined as blood pressure of less than 100 mmHg systolic and significant hypertension will be defined as a blood pressure of greater than or equal to 180 mmHg systolic or hypertension associated with acute alteration of mental status.
6. Any patient with severe respiratory distress. For these purposes, significant respiratory distress will be defined as a respiratory rate greater than 30 breaths/minute, any patient with a pulse oximeter reading of less than or equal to 90 mmHg, any patient with an acute elevation of pCO2 greater than or equal to 60 mm Hg, any patient with a complaint of shortness of breath accompanied by diaphoresis, use of accessory muscles of respiration, cyanosis, alteration of mental status, bradycardia, or any other signs consistent with imminent respiratory failure.
7. Any patient with significant tachycardia or bradycardia. For these purposes, significant tachycardia is defined as a heart rate greater than or equal to 150 beats/minute and significant bradycardia is defined as a heart rate less than or equal to 60 beats/minute.
8. Any patient with a significant cardiac arrhythmia.
9. Any patient with either clinical or EKG evidence of acute myocardial infarction.
10. Any patient with a fever greater than 105 degrees Fahrenheit, any patient with significant alteration of mental status associated with a fever, or any patient with a fever and a potentially immunocompromised state (e.g. HIV disease, cancer patients, transplant patients, etc.)
11. Any patient with significant hypothermia. For these purposes, significant hypothermia is defined as a rectal temperature less than or equal to 95 degrees Fahrenheit.
12. Any patient with severe abdominal pain or abdominal pain associated with peritoneal signs.
13. Any female with abdominal pain and a positive pregnancy test.
14. Any patient with significant upper or lower GI bleeding (whether hypotensive or not).
15. Any patient who develops seizure activity while in the Emergency Department.
16. Any patient with significant abnormality of any laboratory value (e.g. hypo/hypernatremia, hypo/hyperkalemia, symptomatic hypercalcemia, hematocrit less than 28, etc.).
17. Any patient with a history of significant trauma.
18. Any patient with a pregnancy and sign/symptoms of a precipitous delivery.
19. Any patient with an overdose of prescription or over-the-counter medications.
20. Any patient or visitor who gives evidence of becoming significantly agitated, violent, or suicidal.
21. Any patient with a blood sugar of less than 70 mg/dL.
22. Any patient with a snake bite.
23. Any patient with significant bleeding, or bleeding associated with hemophilia (blood dyscrasias).
24. Any patient with a significant allergic reaction.
25. ANY PATIENT WHO YOU FEEL IS BEYOND YOUR PRESENT CAPABILITIES AS A RESIDENT, OR WHO YOU THINK MAY DETERIORATE SUDDENLY.
Documentation Standards
The following information is required on all charts for all Emergency Department patients for legal and billing purposes. Please review this in conjunction with the copy of the chart included in this packet.
1. The Emergency Department uses the T System for charting. Please complete the T System training module before starting your first shift.
2. For all patient charts, documentation should reach a “level 5” by the standards of the T System Documentation System. Please confirm this before signing your chart.
3. It is important to write a short summary of your assessment and plan in each chart..
Based on the differential problem list that you have established, it should be obvious by reviewing the chart how you distinguished among the possibilities and came to your final diagnosis. Some examples: GI cocktail given, patient with complete relief; Phenergan 25mg IV given, nausea relieved and patient tolerating PO well.
If you make a clinical diagnosis without any work-up, you need to explain that. For example: 20 year old white female with reproducible chest wall pain, no risk factors for CAD and no associated symptoms, likelihood of cardiopulmonary disease as the underlying etiology is very low. We will treat her with NSAID’s. Patient knows to return if symptoms change or worsen.
4. You need to list the medications the patient is taking and any drug allergies the patient has.
5. If the patient is in the Emergency Room for a significant length of time waiting for disposition or a bed, you need to make note that you reevaluated the patient during this time. For example: 2:45 pm Patient now afebrile and tolerating oral fluids well. Many conditions such as respiratory distress, chest pain and abdominal pain require frequent reevaluation, and you need to document it.
6. If you call a consultant to see the patient, record the time and who you talked with. For example: 6 pm Discussed case with Dr. Smith (General Surgery) who will evaluate patient. “Curbside” consultations are not official. If there is really a question, the patient must be seen by the consultant.
7. Record a procedure note for all procedures done on the patient including laceration repairs, lumbar punctures, central lines, etc
.8. Please select a disposition and diagnosis (often more than 1diagnosis) for each patient.
DISCHARGE INSTRUCTIONS
The T system has standard discharge instructions for many different diagnoses as well as medications Every discharged patient should receive 1 or more of these instruction sets.
All patients should receive Follow-Up. Follow-up options include but are not limited to:
1. Follow-up with their own doctor (MUST BE NAMED) for a specific period of time. If the patient is unable to identify an MD, a referral should be given.
2. UNC Clinic Appointment: Options for obtaining this are:
* You can call and get an appointment for the patient (Mon-Fri 8a-5p)
* Fill out a clinic referral sheet available in the ED; these are faxed to a central office where appointments are made,
* You can give the patient the phone number for a specific clinic (listed in the T system discharge instructions) BUT, keep in mind, it may be several months before a patient can get an appointment.
Welcome!From the Nurses in the Emergency Department
The following handout details survival skills for your emergency department rotation. We hope that it may be helpful to you.
The ED is divided into several sections:
1. Triage2. Acute Area3. Team C4. Pediatric Acute Care
The nursing staff is assigned by “team.” One or two nurses are assigned to the triage area. These nurses are responsible for screening all patients and prioritizing their care. The Acute Area is divided into Team A and Team B. Two or more nurses are assigned to cover each of these teams.
There are three trauma bays, including a pediatric resuscitation bay. There are two cardiac resuscitation rooms. The Acute Area is divided into the A and B teams which are each responsible for ½ the acute area of the department. Team C is a separate area that usually evaluates ESI score 4 and 5 patients (see above).
A charge nurse is assigned to coordinate the care of the ED patients. At various times, the charge nurse will also have a patient care assignment. Two nurses are assigned to the trauma team. If there is a trauma in progress and the nurse assigned to a certain area becomes unavailable, refer all questions to the charge nurse.
Remember, if you are busy, so is the nursing staff!This is a team-oriented department. Help us and each other!
General Information
It is mandatory that you wear your name tag!
Familiarize yourself with the clean and dirty utility rooms on your first day. You will find this invaluable. Most of the equipment you need is located in these areas. Equipment is secured in the PYXIS.
Tidy up after yourself after completing an exam or procedure. There are trash cans located at each patient care bedside. (This includes the lounge!)
The ED staff is a life form in itself. The nursing assistants, clerks, nurses, and social worker can be great resources for the inside scoop on usual routines, community resources, etc.
Clerks can help you with phone calls and paging. Clerks answer the phones, even if you have paged someone. Listen to the intercom for your name or the person you have paged. The key staff in the ED has assigned intercom cell phones.
Nursing Assistants can perform the following:
1. simple wound preps2. crutch set-up3. lab transport4. patient transport (excluding monitored patients)5. room set-up6. assist with procedures
Remove all needles and sharps from trays and dispose of them in the sharps box!
If a laceration needs sutures, anesthetize the wound prior to wound prep. The department’s infection rate has been consistently 0% because the NA’s do an excellent job.
RN’s
1. Unless the patient is acutely ill, please allow the RN to triage the patient prior to beginning your exam or Gathering information
. 2. ED nurses will assess the acuity of patients and institute treatment and diagnostic
procedures prior to you seeing the patient. For example: monitoring, IV access. Orders still need to be written for the patient.
Educational Conferences
Emergency Medicine conferences are held Wednesday from 7:00 am to noon. All PGY1 residents assigned to the Emergency Department each month will be expected to attend.
Scheduling in the Emergency Department
PGY-1 Medicine Interns will work 12 hour shifts beginning at 7 am, 10 am, or 7pm. These times will rotate throughout the month.
Same-Day Clinic CURRICULUM
Low Back Pain
Monoarticular Arthritis
Approach to Arthritis
Musculoskeletal Syndromes of the Neck and Arm
Depression
Initial Diagnosis and Management of Hypertension
Initial Diagnosis and Management of Type II Diabetes
Bronchitis
Rhinitis/Sinusitis
Headache
Pharyngitis/Mononucleosis
PID
Chest Pain
STD’s
This curriculum is taught each day from 8:00-8:30am by the faculty member who is attending for the 8-12 shift. The format is case based with significant participation by the residents assigned to the Same Day Clinic.
CARDIOLOGY AMBULATORY CURRICULUM
Consultations including preoperative evaluations will be handled by internal medicine residents, cardiology fellows and faculty. When the residents is not involved with patient work-ups, he or she can see patients in faculty clinics, participate in exercise stress testing, read EKG’s from teaching files and/or ACC patients. The following subjects will be reviewed on the month rotation
1. Evaluation of arrythmias in the post-operative patient2. Pre-operative risk assessment for the patient with known cardiac disease3. Evaluation and management of malignant hypertension4. Use of thrombolytic therapy5. Evaluation and management of shock in the post-operative patient6. Endocarditis prophylaxis7. Evaluation and management of lipid abnormalities8. Evaluation and management of peripheral vascular insufficiency9. Recognize common EKG abnormalities10. Recognize common echocardiographic abnormalities11. Evaluation and management of patients with left ventricular dysfunction
Endocrinology and Metabolism Curriculum
Dear Residents and Students,
The Endocrine Division is delighted that you will be taking our Endocrinology and Metabolism Elective. Our clinic is located in Durham near Southpoint Mall off of Hwy 54 (Highgate Specialty Center, 5316 Highgate Dr, Suite 125, Durham NC, 27713. 919-484-1015). The majority of your time will be spent in the clinic working with various attendings and seeing a variety of Endocrine patients. On rare occasions, when too many residents/students are assigned to Endocrinology, you may be asked to spend a few days with the inpatient team.
Clinic Operations
Highgate Specialty Center opens at 7:30am and closes by 5:30pm. Please arrive by 8:30 each morning and look for Dr. O’Connell who will help coordinate the attending with whom you will work (usually Dr. O’Connell the first day and any day that other attendings are not available). We will try to have you work with almost every attending during your two weeks so you can see a wide variety of patients and styles. Dr. O’Connell is never at Highgate on Thursdays so if your first day is Thursday, simply come and introduce yourself to another attending that is present that day. Dr. Ontjes is usually there on Thursdays and is always amenable to working with residents and students.
The clinic is closed most Thursday afternoons to allow everyone to attend Thursday afternoon Endocrine Conferences. Conferences
Thursday afternoon Endocrine conferences as described below are from 3 pm to 5:30 pm. You are expected to attend these while on your Endocrine rotation. They are located in the GCRC conference room, 3rd floor bedtower.
3pm: Fellows conference: a faculty member will give a didactic lecture to the fellows/residents
4pm: Endocrine Journal Club:5pm: 30 minute case presentation and discussion by one of the fellows
EvaluationsPlease give your evaluation form (students) to the Elective Director, who will then
distribute it to the fellows and faculty in the division. Evaluations (students and residents) are compiled by the Elective Director after input from other members of the division.
We appreciate your attention to these matters and hope that you find your rotation with us to be educational and enjoyable. Please bring any concerns to our immediate attention. Sincerely, Tom O’Connell, MD (pager 216-6359)Resident Elective DirectorEndocrinology and Metabolism [email protected]
Hematology/Oncology Curriculum
Overview:
This is a 1month block of time designed to expose medical residents to some of the breadth of outpatient oncology or hematology patients. We suggest that the resident choose either the Oncology block or the Hematology Block and not make a combined block of the various clinics. This will enable the resident to get a good spectrum of one part of this broad field. The resident will see patients along with the attending physician and will be responsible for obtaining histories and examinations, dictate or type consult notes and progress notes, follow up on calls and tests. In many cases there will be a reading list to master. This can be discussed with the attending for each clinic. Residents are also encouraged to participate in the Division conferences and when possible, present at the Case of the month program. Participation at Case of the month should occur if this is offered during the resident’s rotation (The division can let the resident know ahead of time.).
Outpatient Rotation Oncology
Monday Tuesday Wednesday Thursday Friday
7:30 am Head and Neck Conference
GI Clinic with Dr. O’Neil and Dr. Bernard
Breast Cancer Clinic with Dr Carey**
Thoracic Oncology GU Clinic
Check
12:30 Monday Lectures Divison lectures.*
Multidisciplinary Thoracic Oncology conference.
Breast Conference 10:30 to 12
1:15 GU tumor board.
Breast Cancer Clinic with Dr Carey
Thoracic Oncology Breast Oncology GU clinic
** If Dr Carey’s clinic does not take place go to head and neck clinic. Head and Neck Conference on Friday is optional but encouraged if you have seen these patients.
***Beginning in 1/2008, Fellows’ Conference is switching to Tuesdays.
Outpatient Rotation Hematology
Monday Tuesday Wednesday Thursday Friday
7:30 am Fellows’ Conference
7:30 am Fellows’ Conference) **
7:30 am Fellows’ Conference.
Hemophilia Clinic with Dr Key and Ma
Sickle Cell Clinic Heme Malignancy Clinic with Drs VanDeventer and Voorhees
Parker conference at 11am
Heme clinic, Dr Ma
12:30 Monday Division Lectures *
1PM Heme conference
Coagulation Clinic with Dr Moll
Sickle Cell Clinic
Heme clinic, Dr Ma
Check with the Division re the Conference on Mondays for titles and place **Beginning in 1/2008, Fellows’ Conference is switching to Tuesdays. Check with Dr Ma. She may be moving her clinic to Thursdays. When that happens the
clinic will be off site and you will not need to go to Parker Conferences.
PULMONARY DISEASES AMBULATORY CURRICULUM
In overview, the medical resident’s activities will mirror the responsibilities of the Pulmonary consult Fellow, i.e., evaluation of inpatient and outpatient referrals and interpretation of standard pulmonary function tests. The resident will interact closely with the Pulmonary consult Fellow and Attending.
The overall educational goals will be accomplished through several formats:
1. Daily inpatient consults on all non—ICU pulmonary referrals (we average 1.5 consults per day).
2. Interpretation of pulmonary function tests and review of tests with the Attending physician. We perform about 600 individual pulmonary function tests per month. Specific attention will be focused on interpretation of blood gases and spirometric parameters. Understanding the indication for lung volume and DLCO tests will be a goal for the resident’s experience.
3. Work—up of a new pulmonary outpatient referral and follow—up of selected patients in each Wednesday’s day—long clinic. In conjunction with the consult fellow and clinic attending, this will involve selecting and interpreting appropriate pulmonary function tests.
4. Evaluation of sleep clinic outpatient referrals on Friday mornings and review of sleep apnea studies in conjunction with a senior Fellow and the Attending. The goal will be to better define for the resident indications for obstructive sleep apnea studies.
5. Evaluation of outpatient “walk—in” referrals or outpatient consults who need to be “added on” and seen on days other than Wednesday. We see 2—4 new patients per week by this route.
6. Presentation and discussion of cases at the weekly medicine— radiology—chest surgery—oncology conference (1 hour).
7. Three didactic conferences (1 hour each) per week related to critical care medicine, clinical topics, and review of research papers. These presentations draw on faculty and fellows from Pulmonary, Infectious Disease, Radiology, Critical Care Surgery, Anesthesiology, & etc.
8. The weekly pulmonary division clinical—pathologic “work” conference (2 hours) that involves presentation of difficult, complex, and/or interesting cases. Pathophysiologic concepts are emphasized.
9. Although the consult service performs a number of procedures, we will not emphasize the technical aspects of those studies except for aspects of the thoracentesis and/or pleural biopsy. The opportunity to observe decision—making about bronchoscopic procedures, and to visualize endobronchial anatomy during bronchoscopy, will contribute to the resident’s appreciation for the role of this procedure in the evaluation of pulmonary disease.
In summary, the medical resident will enjoy an integrated experience of inpatient and
outpatient evaluations, learn the indications and interpretation of pulmonary functions tests, have exposure to patients referred for sleep—apnea studies (and perhaps learn some indications for these referrals), better appreciate the role of fiberoptic bronchoscopy in evaluation of pulmonary disease, and expand their pulmonary physiologic concepts. Overall, this resident rotation complements the resident’s ICU and inpatient exposure to pulmonary diseases. It provides an experience that will be useful for most internal medicine physicians because pulmonary disease is a common cause for clinic visits to the internists.
DIGESTIVE DISEASES AMBULATORY CURRICULUM
On the Digestive Diseases Consultation Service, residents have the opportunity to see patients with gastroenterology as well as hepatology disorders. The following subjects will be reviewed on the month rotation.
1. Evaluation and treatment of diarrhea
2. Evaluation and treatment of jaundice
3. Inflammatory bowel diseases
4. Hepatitis - viral and non-viral
5. Diagnosis and management of peptic ulcer disease
6. Nutritional support - enteral and intravenous
7. Colonoscopy - indication and screening
8. Diagnosis and management of pancreatitis
9. Diagnosis of esophageal motility disorders
10. Evaluation and treatment of abdominal pain
11. Diagnosis and management of cirrhosis
12. Liver transplantation - indicators and outcomes
13. Diagnosis and management of GI bleeding
14. Appropriate use of radiologic studies of the gastrointestinal system
15. Evaluation and management of gallstones/gallbladder diseases
INFECTIOUS DISEASE AMBULATORY CURRICULUM
Role:
Residents play an important role on the consult service and in the clinic, where they help to manage outpatients with AIDS, chronic fatigue syndrome, and a variety of different infections including endocarditis and osteomyelitis. Residents are supervised by an attending physician.
Teaching Conferences:
Teaching conferences include a Wednesday clinical case conference at 8:30 a.m. and a Friday 8:30 a.m.conference which is didactic and/or research oriented.
Topics:
Topics covered through these conferences can be organized according to an organ system approach in Infectious Disease. These include 1) central nervous system infections, including meningitis and encephalitis; 2) infections of the eyes, ears, nose and throat; 3) infections of the upper and lower respiratory tracts; 4) infections of the cardiovascular system including endocarditis; 5) infections of the intestinal tract including infectious diarrhea and intra-abdominal catastrophe; 6) infections of the urinary tract, including sexually transmitted diseases; 7) systemic infections, including HIV; 8) infectious disease syndromes, including chronic fatigue syndrome. General lectures also include a) antibiotics, b) host defenses, c) microbial pathogenesis. Pathogenesis includes discussion of worms, protozoans, fungi, viruses and bacteria.
Resident’s Responsibilitiesfor Consults and Ward Service
Rounds will begin at 1:30 PM in the Clinical Microbiology lab with discussion of sterile fluid infection, review of new micro data and “unknown” case presentations from Microbiology faculty.
Consultations & Rounds: Residents are responsible for full evaluations of patients seen in consultation. Residents are responsible for following in-patients daily, presenting patients during rounds, discussing differential diagnoses with the attending, and writing appropriate notes in the medical record. The on-call schedule and sequence of assignments will be discussed by the Attending or the Fellow at the beginning of the rotation.
Conferences
The following conferences are held weekly by either the Division of Infectious Diseases or the Department of Medicine. All listed conferences are required.
Day/Conference Time Place
Wednesday:Case Presentation 8:30am Orthopedic Conference Room
Thursday:Dept. of Medicine Grand Rounds 12:00pm Clinic Auditorium
Friday:ID Didactic/Research Conference 8:30am Clinic B Conference Room
RHEUMATOLOGY AMBULATORY CURRICULUM
Welcome to the Division of Rheumatology and Immunology. Although rheumatologic and autoimmune disease are, in the aggregate, extremely common, physicians who miss this special opportunity for a rotation on a rheumatology service may never acquire the knowledge and skills required for caring for patients with these disorders. For this reason, emphasis during your rotation will be on learning “nuts and bolts” rheumatology:
a. signs and symptoms of the different arthritidesb. performance of a musculoskeletal history and examc. construction of common differential diagnosesd. choice and interpretation of laboratory tests and x-rayse. arthrocentesis and soft-tissue injection techniquesf. choice of therapy for commonly encountered conditions.
In addition, you will learn the basic elements of the pathogenesis and disease expression in rheumatologic disease.These educational objectives will be accomplished by seeing patients, clinical discussions with faculty and fellows, literature searches and reviews, various lectures and conferences, and Bob Berger’s “tool-kit.”
Rheumatology is largely an out-patient specialty, and the major block of your time will be spent in the Musculoskeletal Module in the ACC. This module houses rheumatology examining and consult rooms, facilities for physical therapy, occupational therapy, patient education, a library, and a special bone and joint x-ray suite. You will also see in-patient consults at UNCH. Scheduling of consult rounds, on-call responsibilities, your time in clinic, etc., will vary from month-to-month. Schedules and responsibilities will be discussed with you by the Attending and/or Fellow at the beginning of your rotation.
There are only four rules: 1) Be in clinic on time. Medicine residents and students should report to clinic at 9:00am. 2) If you are not called to see an urgent consult, be in the clinic. 3) Formal consult rounds will not be held until 3:30pm in order to minimize conflicts with your ambulatory care experience in the clinic. 4) Turn in the evaluation sheet and list of patients seen to me at the end of your rotation.
Resident’s Responsibilities for Clinics and Consults
Report to the musculoskeletal module, 1st floor, Ambulatory Care Center at 9:00 am. Meet for Consult Rounds at the film assembly desk (“cage “) in Radiology at the times designated by the Attending or Fellow.
Clinic Responsibilities:
Residents will perform complete evaluations of new patients and return patients, as assigned by the Attending. The nursing staff may also direct residents to do initial work-ups on patients. Residents will be responsible for presenting patients to the Attending, developing a therapeutic plan, discussing differential diagnoses with the attending, and completing a write-up for the medical record.
Consultations & Rounds:
Residents are responsible for full evaluations of patients seen in consultation. Residents are responsible for following in-patients daily, presenting patients during rounds, discussing differential diagnoses with the attending, and writing appropriate notes in the medical record. The on-call schedule and sequence of assignments will be discussed by the Attending or the Fellow at the beginning of the rotation.
Schedule
The following schedule is subject to some change. Please check with your attending on the first day of the rotation to confirm the following schedule.
Monday Tuesday -Friday
8:30-3:30Clinic
8:30-12Clinic
10:00-11:00 Rheumatology Grand Rounds
1:00-3:00Clinic
12:00-1:00Immunology Journal Club
3:30-5:00Clinic or Consult Rounds
2:00-3:00Research In progress
3:30-5:00 Clinic or Consult Rounds
Please note that this schedule only includes required events. Optional conferences, etc. are listed separately.
• NOTE: Consult rounds are held 2-3 days per week. Days of week may vary in different months. Formal consult rounds will not be held earlier than 3:30. Scheduling of consult rounds far the month will be defined by the Attending at Fellow at the beginning of each rotation.
Conferences
The following conferences are held weekly by either the Division of Rheumatology and Immunology or the Department of Medicine. Please note that several are required for medical students and others are optional. For more in formation regarding speakers and titles, contact the Rheumatology Division Office in 3330 Thurston Building, (919) 966-4191.
Day/Conference Time Place Required/Optional
Monday
Immunology Journal Club 10:00am 3280 Thurston Optional
Rheumatology Grand Rounds 12:00noon 3280 Thurston Required
Research-I n-Progress 2:00pm 3280 Thurston Optional
Wednesday
Lecture: Program On Aging 12:00 Noon Clinic Auditorium Optional
Thursday
Dept. of Medicine Grand Rounds 12:00 pm Clinic Auditorium Required
FridayAmbulatory Care Conference 12:00 Noon Clinic Auditorium Optional
Nephrology Ambulatory Curriculum
Nephrology Consultation Service Resident Curriculum
Role of Resident
Evaluation and discussion of patients with kidney disease, hypertension, and disorders of fluid, and electrolyte and acid-base balance disorders in the consultative setting under the supervision of Nephrology faculty.
Consults
Residents will see both hospitalized and ambulatory patients in consultation on a daily basis, unless assigned to their continuity clinic. Patients with a wide range of renal diagnoses will be seen and discussed with the Nephrology Attending and fellow. Residents are expected to communicate consultative recommendations with the referring physicians, and to provide ongoing follow up while on the rotation.
Curriculum
Topics to be discussed during rounds as well as during formal didactic sessions will include the following:
Evaluation of kidney structure and functiono Urinalysiso Measurement of GFRo Evaluation of proteinuriao Measurement of urinary electrolyteso Renal imaging techniques
Chronic kidney disease Acute kidney injury General principles of dialysis
o Hemodialysiso Peritoneal dialysiso Continuous renal replacement therapies
Critical care nephrology Metabolic acidosis Metabolic alkalosis Disorders of water metabolism (hyponatremia and hypernatremia) Disorders of potassium and magnesium metabolism Disorders of calcium, phosphorus and bone metabolism Overview of evaluation and treatment of hypertension Glomerular syndromes
o nephritic syndromeo nephrotic syndrome
Diabetic nephropathy Principles of kidney transplantation
ClinicsParticipation in several Nephrology Subspecialty Clinics is available to residents interested in
seeing patients with specific diagnoses and is optional. Residents will see patients under the direction of one of the Nephrology Attendings.
Monday PM Hypertension Clinic Tuesday AM and PM Transplant Clinic Thursday AM and PM Vasculitis Clinic
Renal Conferences
Residents are encouraged to attend the following Divisional Educational Conferences during the rotation:
Conference Time Topic Leader/Organizer
Hypertension 2nd and 4th Review of literature related to Drs. RomuloJournal Club Mondays hypertension Colindres and Steven
4-5 pm Grossman
Transplant 1st and 3rd Review of literature related to Dr. Randy DetwilerJournal Club Mondays kidney transplantation 4-5 PM Fellows Tuesday Review of topics in Drs. Romuloconference 4-5 pm clinical nephrology and Colindres and Renal Physiology Gerald HladikNephrology Wednesday Review of nephrology Nephrology DivisionJournal Club 8:30-9:30 am literature; study of issues
related to design and analysisof clinical studies
Nephrology Wednesday Clinical nephrology Nephrology DivisionConference 4-5 pm
ADOLESCENT MEDICINE AMBULATORY CURRICULUM
1) Knowledge of the epidemiology of adolescent health issues• Describe the major causes of adolescent morbidity and mortality.• Describe the ways that these issues are addressed in routine adolescent care.• Understand that the rationale for guidelines for preventive adolescent health care is based
on the major causes of adolescent morbidity and mortality.• Describe guidelines for routine health screening, including laboratory tests.
2) Skill in communicating with adolescents• Recognize that adolescents should be interviewed privately as a routine part of physician
visits.• Describe how the issues of consent and confidentiality are managed with minor adolescents.• Perform a thorough history, including an adolescent risk assessment.
3) Understanding of normal adolescent development• Describe normal psychosocial and cognitive development.• Recognize that the timing of psychosocial and cognitive development is independent of
pubertal development.• Accurate assessment of Tanner staging.• Describe the range of normal variation in timing of pubertal changes.• Recognize and manage common concerns of puberty (e.g. Am I normal? Gynecomastia in
males, Acne, etc.).
4) Sexuality• Perform a complete sexual history in a sensitive and age-appropriate manner.• Demonstrate appropriate anticipatory guidance and risk-reduction counseling.• Perform a complete pelvic exam including collection of cervical cytology and tests for STDs.• Perform a male genital examination including tests for STDs.• Teach self-breast examination and self-testicular examination.• Provide contraception.• Instruct and demonstrate how to use condoms.
5) Common acute and chronic medical problems of adolescence• Recognize, evaluate, and manage common medical problems of adolescence (e.g. acne,
dysmenorrhea, STDs, pregnancy diagnosis, scoliosis, Osgood- Schlatter disease, headaches, etc.).
• Describe a strategy for evaluation and management of chronic somatic symptoms, including recognition that mental health problems may present as somatic symptoms.
• Understand the influence of puberty and adolescent development on chronic illness.• Describe the issues regarding the transition of adolescent patients with chronic illness to
adult care.6) Identification and management of mental health problems
• Recognize abnormal psychosocial development.• Recognize that significant psychiatric disease can present in adolescence.• Perform an assessment for depression and suicide, and describe appropriate
management of patients with varying risk of suicide.
• Understand that mental health issues are often associated with multiple risk-taking behaviors.
• Describe strategies to persuade adolescents and parents of the need forpsychological evaluation and treatment.
7) Substance use
• Perform an assessment of substance use, including tobacco, alcohol, illicitdrugs, and steroids.
• Describe risk factors for substance abuse.• Describe physical symptoms or signs associated with substance use.• Describe management plans for adolescents with varying risk of substance
abuse.• Understand that mental health problems may be associated with substance abuse.
8) Nutrition eating disorders
• Perform a nutrition history.• Demonstrate ability to accurately assess growth using height, weight, and BMI.• Describe counseling regarding healthy foods and eating patterns.• Describe management for mild to moderate obesity.• Recognize symptoms and signs of eating disorders, and describe strategy for
appropriate evaluation and management.
9) Sports Medicine
• Perform a pre- participation sports examination.• Describe the indications for limiting/requiring protective devices for sports
activities.• Describe the initial management of common sports injuries.• Understand the importance of screening for abnormal eating patterns and steroid use
GERIATRIC MEDICINE CURRICULUM
Outpatient Geriatric Curriculum:
Residents will work at all times with a Faculty member from the Division of Geriatric Medicine and will rotate through the following sites of care:
1. Long Term Care Communities: Residents will work with faculty and Geriatric Fellows and will see and evaluate patients who are in the outpatient clinic setting as well as the health center/skilled nursing care area in these communities. They will see patients who are older and completely independent who are followed for continuing care at the clinics on site, as well as patients with dementia and other functional limitations who reside in the nursing care area.
2. Hospice: Residents will evaluate patients with the hospice team by doing home visitations. Residents will also meet regularly with the hospice team and director to discuss patient management issues.
3. Geriatric Evaluation Clinic: Residents will work with faculty and Geriatric Fellows in the Evaluation Clinic by seeing and evaluating older patients with complicated issues who have been referred for complete geriatric assessments. Residents will work with an interdisciplinary team to develop a plan of care for patients.
4. Senior Center: Residents will work with one of our Faculty members and a trained Physical Therapist to conduct screenings and assessments of older adults.
5. Residents will also spend time with the Geriatric Psychiatry inpatient unit, Rehabilitation clinic, and memory disorders clinic. Residents may also chose to have additional time with faculty who work with incontinence, urogynecology, dementia, movement disorders, sleep disorders, or other specific interests.
6. Residents with interests in subspecialty training may chose to do additional work with faculty in congestive heart failure, nephrology, intensive care, or other areas of interest.
7. Residents will meet weekly with the division and the fellows for educational conferences.
Based upon:
2004 The American Geriatrics Society: Curriculum Guidelines for Geriatrics Training in Internal Medicine Residency Programs. The AGS Education Committee. Updated Jan 2004.
PGY -1 Continuity Elective
Enhanced Intern Outpatient Education Rotation and Ambulatory Medicine Tract
Learners: Interns interested in careers in outpatient internal medicine. The emphasis will be acquiring outpatient skills in a diverse primary care setting. The acquired skills and experience will be generalizable to other outpatient internal medicine specialties.
Objectives:
1. Fulfill the traditional core residency competencies of patient care, medical knowledge, professionalism, and interpersonal skills and communication in the outpatient setting. The resident will acquire intensive disease and condition specific outpatient training in the following domains:
a. Diabetes mellitusb. Anticoagulationc. Chronic pain and comorbid psychiatric conditionsd. Acute care medicine through the Same Day Clinice. Continuity clinicsf. Travel medicine through existing Internal Medicine Travel Clinicg. Women’s healthh. (Possibly dermatology. Dean Morrell open to this but department has had faculty
shortage.)2. Acquire first-hand experience with new competencies of practice-based learning and systems-
based practice within Internal Medicine Clinic Enhanced Care Programa. Learn quality improvement methodologyb. Learn the importance of patient tracking through patient registries/databasesc. Work in multidisciplinary teams consisting of physicians, clinical pharmacists, nurse
practitioners, physicians assistants, dieticians, nurses, care assistants, lab personnel3. Provide intensive continuity with a panel of patients early in residency
Curriculum:
Existing curriculum for residents on Continuity Elective with selective adaptations.
Infrastructure and Template:
1. Capitalize on existing UNC Internal Medicine and Enhanced Care Programs that already provide an educational environment for medical students, residents in continuity clinic, residents on continuity elective, and pharmacy students and residents.
2. Rotation would last one month
Sample Schedule
Mon Tues Wed Thurs Fri
Am CC Pain DM Conferences, QI Project, Reading WH
Noon Ambulatory
Conference
Grand Rounds
Pm Coag Precept/Mentor SDC CC SDC
Legend: DM=Diabetes program; Pain=Chronic pain management; Coag=Anticoagulation management; SDC=Continuity Clinic; TC=Travel Clinic; CC=Continuity Clinic; Preceptor/Mentor=One-on-one preceptorship and mentorship in attending clinic
WH=Women’s health
Features:
1. Two continuity clinics per week.2. Dedicated continuing education time on Thursday3. Balanced outpatient experience consisting of acute, continuity, women’s health, travel clinic,
and disease specific care.4. Preceptorship with mentoring and role-modeling by experienced internal medicine faculty
PGY -2/3 Continuity Elective
Resident Continuity Elective
Rationale
Chronic disease has replaced acute disease as the principle consumer of health care resources; more than 75% of resources are expended on chronic illness care. Most chronic disease management occurs in ambulatory settings. Internal medicine residencies, however, have historically trained physicians in managing acute medical problems and have not provided structured, continuous training in ambulatory and chronic illness care. Chronic illness care poses a different set of challenges than acute illness care where patients are symptomatic and understand the imperative for intensive, structured medical care. Chronic illness often produces no symptoms, and prevention is the focus of management. Both providers and patients need to be aware that the absence or stability of symptoms does not preclude intensive patient care that is informed by data from clinical trials. This challenge requires a new set of skills that traditionally have not been imparted in internal medicine residencies.
Objectives
1. To improve resident training in ambulatory medicine through exposure to chronic disease management programs in the ambulatory care setting.
2. To develop skills that will prepare residents to provide high quality chronic illness care, regardless of which specialty of internal medicine they pursue. Residents will gain knowledge and expertise in the following areas: Knowledge base for effectively managing chronic illness. Systems for tracking patient outcomes that improve the quality of care. These systems rely
on ancillary medical professionals, electronic medical records, databases and information technology.
Continuous quality improvement. This elective addresses a core competency emphasized by the ABIM for Improving Performance in Practice. The UNC model has been presented at national meetings and is being adopted at other institutions, though it has not yet directly been applied to resident education at our institution.
Collaboration with mid-level providers such as clinical pharmacists, physician assistants and nurse practitioners involved in chronic disease management
Structure
1. Combine Urgent Care months with structured ambulatory care time over a two month period. Total Urgent Care time will remain neutral at one month. By coupling acute and chronic medical care, this elective does not seek to de-emphasize the importance of acute care; rather, it will prepare residents for the realities of independent practice where both acute and chronic issues are addressed continuously.
2. The elective will be offered to residents at all levels of training. It will be an alternative to other electives and provide an additional outpatient option.
3. The resident will rotate through the existing disease management modules: anti-coagulation, chronic pain, diabetes mellitus.
4. The resident will manage patients independently using approved protocols. The resident will receive guidance from attending physicians and clinical pharmacists experienced with systematic disease management.
5. The resident will spend one half day a week seeing patients independently with an attending physician (team leader) who will provide direct teaching related to ambulatory internal
medicine on a one-on-one basis. (Recall that the usual precepting and continuity clinic experience diffuses an attending’s attention over up to four residents at a time.) The resident and attending physician will be templated for 12 to 14 patients in this half day. Billing will therefore not need to adhere to the Primary Care Exception.
6. The resident will spend one half day per week in her or his own continuity clinic. The resident will have the option to schedule her or his patients for close follow up during other half days at the ACC when clinically indicated. This will provide an experience of close continuity that is currently lacking in resident continuity clinics.
Sample Elective Template
Monday Tuesday Wednesday Thursday Friday
Am DSM: Anticoag CC UCC Grand Rounds/Conferences
UCC
Pm CC with team leader
DSM: DM UCC DSM: Pain UCC
LegendDSM= Disease state managementAnticoag= Anticoagulation managementDM= Diabetes mellitus managementPain=Chronic pain management
Logistics
1. The new elective will have a capacity for 12 residents in the first year.2. This will mean that two residents will be accommodated simultaneously.
Team Leaders for Disease Management Precepting
1. Michael Pignone, MD, MPH2. Darren DeWalt, MD, MPH3. Paul Chelminski, MD, MPH4. Second full time ACC clinician
Enhanced Care Elective Rotation UNC General Internal Medicine Clinic
Ambulatory Care PreceptorshipAmbulatory Care Center, UNC Hospitals
Primary PreceptorPaul Chelminski, MD, MPHAssistant Professor of MedicinePager: (919) 216-6163Office: (919) 966-0471Email: [email protected]
Disease Management Preceptors
Betsy Bryant Shilliday, Pharm.D., CDE, CPPClinical Pharmacist PractitionerAssistant Professor of MedicineAssistant Clinical Professor of PharmacyPager: (919) 216-5723Office: (919) 843-0391Email: [email protected]
Robb Malone, Pharm.D., CDE, CPPClinical Pharmacist PractitionerAssistant Professor of MedicineAssistant Clinical Professor of PharmacyPager: (919) 216-5736Office: (919) 843-0391Email: [email protected]
Timothy Ives, Pharm.D., MPH, CDE, CPPClinical Pharmacist Practitioner Associate Professor of Pharmacy and MedicinePager: (919) 216-0193Office: (919) 843-0391Email: [email protected]
Goal
The Enhanced Care elective incorporates various components of outpatient medicine including disease management clinics, continuity clinic, urgent care clinic, and one-on-one preceptorship with an attending physician. This elective will provide the opportunity for the learner to build upon information acquired in his/her didactic education and to apply the knowledge and skills in direct patient care activities in the primary care setting and specialty outpatient clinics. This experience will be gained primarily under the Preceptorships of Drs. Betsy Bryant Shilliday, Robb Malone, Tim Ives, and Paul Chelminski.
Practice Site Description
The Enhanced Care team is an interdisciplinary team that provides disease state management services to patients who have established care with a primary care physician in the UNC General Internal Medicine (GIM) clinic. The patient population consists of adults, ages 18 and older with a variety of medical conditions. Patients can be referred to any of three existing programs: 1) Anticoagulation 2) Diabetes and/or 3) Chronic Pain. Clinical experiences afforded to the learner include, but are not limited to: anticoagulation, hypertension, hyperlipidemia, diabetes mellitus, depression, arthritis, congestive heart failure, cardiovascular risk reduction, chronic pain and osteoporosis. The clinic is located on the 3 rd
floor of the Ambulatory Care Center (ACC) on Mason Farm Road, Chapel Hill, North Carolina.
Hours & Clinic Descriptions
Hours of the rotation are typically Monday through Friday 8am to 5pm. However, afternoon hours may vary depending on patient workload and issues that arise during clinic hours.
Clinic Template
Monday Tuesday Wednesday Thursday Friday
Am UCC DSM: Anticoag DSM: Pain Grand Rounds/Div.Meeting
DSM Meeting
UCC
Pm UCC Preceptorship with attending
DSM: DM CC UCC
UCC: Urgent Care Clinic; DSM: Disease Management; CC: Continuity Clinic
The Urgent Care Clinic will be Mondays and Fridays 8am to 5pm. This clinic will familiarize the learner with a variety of acute medical issues. The evaluation of this component of the rotation will occur through the normal evaluation process through supervising attending physicians and not separated out to this rotation.
The Continuity Clinic will be on Thursday afternoons and will allow the resident learner to increase clinic time for this 2 month block of time. The afternoon clinic slots will begin at 1:30pm. The evaluation of this component will be under the normal evaluation process of supervising attending physicians and not separated out to this rotation.
The one-on-one physician preceptorship will allow the resident learner to work in tandem with an attending physician in his or her outpatient clinic to improve outpatient management skills.
The Anticoagulation Clinic consists of a Clinical Pharmacist Practitioner, Physician Assistant, Nurse Practitioner, and Registered Nurse who see patients for warfarin initiation/education, INR monitoring, warfarin dosage adjustment and enoxaparin (Lovenox®) bridging. Patients are scheduled for 15-minute appointments as often as necessary but return to clinic at least once every four weeks while on warfarin therapy.
The Diabetes Clinic is a multidisciplinary clinic, consisting of Clinical Pharmacist Practitioners, Nurse Practitioner, Registered Dietician and Research Assistants, designed to medically manage and educate patients with uncontrolled diabetes. Patients are followed until their A1c reaches goal < 7%. Though emphasis is placed on diabetes management, clinical care encompasses cardiovascular risk reduction, hypertension, hyperlipidemia, congestive heart failure, depression and arthritis.
The Chronic Pain Clinic consists of a Clinical Pharmacist Practitioner, Nurse Practitioner, and Research Assistant specializing in disease management of chronic pain syndromes and associated psychiatric disorders (depression and anxiety). Patients are assessed using screening tools such as the Brief Pain Inventory (BPI) and Center for Evaluation Studies of Depression (CES-D), and use of physical assessment at every visit. Learners will be exposed to the prescribing and use of chronic controlled substances and adjunct analgesics. They will also become proficient in the outpatient monitoring of this patient population, including the potential for medication diversion.
Global Program Objectives
1. To improve resident training in ambulatory medicine through exposure to chronic disease management programs in the UNC Internal Medicine Clinic.
2. To develop skills that will prepare residents to provide high quality chronic illness care, regardless of which specialty of internal medicine they pursue. Residents will gain knowledge and expertise in the following areas: Knowledge base for effectively managing chronic illness. Systems for tracking patient outcomes. These systems rely on ancillary medical
professionals, electronic medical records, databases and information technology. Continuous quality improvement and systems-based practice which is a core competency
required by the ABIM for Improving Performance in Practice. The resident will have opportunities to performing chart audits of their clinic patients with diabetes. After completion of the self-audit the resident will be able to consider how their performance can improve with their individual practice or with the system as a whole.
Collaboration with mid-level providers such as clinical pharmacists, physician assistants and nurse practitioners involved in chronic disease management
Specific Program Objectives
General:
1. Develop a better understanding of the roles and functions of disease management programs.2. Assess potential barriers to care including literacy, psychosocial issues, finances, transportation,
etc. and assist patients with those obstacles.3. Focus clinic visit time on the specific chronic disease versus the patient’s acute problems or
entire problem list.4. Adopt a better understanding of the UNC pharmacy benefit program and disease management
contracts.
Anticoagulation:
1. The learner should familiarize himself/herself with CHEST guidelines. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004 Sept; 126(3) supp.
2. Understand how to better manage warfarin therapy and bridging with low molecular weight heparin, while taking into account patient specific bleeding and thromboembolic risk factors.
3. Determine an appropriate INR goal for specific patient indications based on CHEST guidelines, learn how to properly adjust warfarin dose to target the goal INR and how to dose low molecular weight heparin for various bridging procedures.
4. Assess signs/symptoms of bleeding/bruising.5. Review current medication list, update in medical record and address any drug-drug
interactions, including over-the-counter (OTC) medications such as aspirin and NSAIDs.6. Educate patient on vitamin K content of diet and importance of consistency while on warfarin
therapy.7. Educate patient on role of warfarin therapy in relation to their indication for therapy, discussing
duration of therapy.8. Educate patient on proper use of OTC items such as pain relievers, herbals, vitamins,
supplements, etc.9. Adjust weekly warfarin dose to target goal INR for patient’s indication using nomograms and
patient history.
10. Assess past medical history (PMH) for factors which put the patient at an increased risk for thromboembolic events.
11. Assess PMH for factors which may increase the patient’s risk for bleeding complications from warfarin therapy.
Diabetes:
1. The learner should familiarize himself/herself with ADA Guidelines 2005, JNC VII, and NCEP guidelines.
2. Obtain a focused CV and DM history and ROS.3. Perform foot exams.4. Assess vaccination status.5. Assess tobacco use, determine stage of change, and recommend appropriate intervention.6. Make appropriate referrals to ophthalmology and/or nutrition.7. Assess current DM, HTN, and lipid therapy for appropriateness. Determine goal blood pressure
and lipids based on patient’s co-morbid conditions and recommend additional therapy with evidence-based reason, if needed and according to protocols.
8. Assess current level of diabetes control, develop a medication regimen and monitoring plan and properly adjust and/or add medications to obtain glycemic goals.
Pain:
1. Assess the type and level of pain, develop a medication regimen and monitoring plan to manage any combination of pain (e.g., nociceptive, neuropathic, inflammation)
2. Assess and manage co-morbid conditions associated with pain (e.g., depression, anxiety, sleep disorders, hypertension).
3. Learn how to more effectively control the prescribing of controlled substances in patients with chronic pain to protect oneself, the patient and the community from potential drug abuse and diversion (e.g., use of urine toxicology screening).
Responsibilities and Activities
Take an active role in patient care. Collect pertinent information from each patient’s medical record in preparation for clinic visits. Familiarize oneself with disease management protocols for each program. Formulate a comprehensive, evidence-based, patient-centered therapeutic plan for each
patient. Work collaboratively with preceptors during clinic visits. Educate and collaborate with patients and their families/caregivers at their respective literacy
level to ensure a patient-centered model of care. Document patient care activities for each visit as directed by preceptor Provide timely patient follow-up via telephone when necessary. Attend grand rounds Thursday mornings at 7:30am, when applicable in the 4th Floor Old Clinic
Auditorium. Attend General Medicine Division meeting every Thursday morning at 8:30am in the 5 th Floor
Conference Room of Old Clinic Building. Attend Disease Management meeting every Thursday morning at 9:30am in room 3004
(Hematology/Oncology Conference Room), 3rd Floor Old Clinic Building.
Present at least one journal club of current literature related to pertinent chronic disease topics, with one being presented at General Medicine Division meeting at designated time.
Actively participate in ongoing disease management projects and Continuous Quality Improvement (CQI) initiatives pertinent to the disease management programs.
Required Readings
All required readings can be found in hard copy format as well as full text on a CD kept in the Learner’s Notebook.
Disease Management:
1. Ofman J, Badamgarav E, Henning J et al. Does Disease Management Improve Clinical and Economic Outcomes in Patients with Chronic Diseases? A Systematic Review. Am J Med. 2004;117:182-192.
2. Bodenheimer, T.; Wagner, E. H., and Grumbach, K. Improving primary care for patients with chronic illness. JAMA. 2002 Oct 9; 288(14):1775-9.
Anticoagulation:
1. The Pharmacology and Management of the Vitamin K Antagonists: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:204S-233S.
2. Harrison L, Johnston M, Massicotte P et al. Comparison of 5 mg and 10 mg Loading Doses in Initiation of Warfarin Therapy. Annals of Internal Medicine. 1997;126:133-136.
3. Kovacs M, Rodger M, Anderson D et al. Comparison of 10 mg and 5 mg Warfarin Initiation Nomograms Together with Low-Molecular-Weight Heparin for Outpatient Treatment of Acute Venous Thromboembolism. Ann Intern Med. 2003;138:714-719.
4. Ridker P, Goldhaber S, Danielson E et al. Long-Term, Low-Intensity Warfarin Therapy for the Prevention of Recurrent Venous Thromboembolism. NEJM. 2003;348:1425-1434.
5. Kearon C, Ginsberg J, Kovacs M et al. Comparison of Low-Intensity Warfarin Therapy with Conventional-Intensity Warfarin Therapy for Long-Term Prevention of Recurrent Venous Thromboembolism. NEJM. 2003;349:631-639.
Supplemental Readings:
6. Antithrombotic Therapy for Venous Thromboembolic Disease: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:401S-428S.
7. Antithrombotic Therapy in Atrial Fibrillation: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:429S-456S.
8. Antithrombotic Therapy in Valvular Heart Disease--Native and Prosthetic: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:457S-482S.
Diabetes:
1. Krentz A, Bailey C. Oral Antidiabetic Agents: Current Role in Type 2 Diabetes Mellitus. Drugs. 2005;65(3):385-411.
2. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomized placebo-controlled trial. Lancet. 2003;361:2005-2016.
3. Gaede P, et al. Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised study. Lancet. 1999;353: 617-622.
4. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and reisk of complications in patients with type 2 dieabetes (UKPDS 33). Lancet. 1998;352:837-853.
5. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet. 1998;352:854-865.
Supplemental Readings:
6. Rothman R, Malone R, Bryant B et al. A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes. American Journal of Medicine. 2005;118:276-284.
7. Rothman R, DeWalt D, Malone R et al. Influence of Patient Literacy on the Effectiveness of a Primary Care-Based Diabetes Disease Management Program. JAMA. 2004;292:1711-1716.
8. Rothman R, Malone R, Bryant B et al. The Spoken Knowledge in Low Literacy in Diabetes Scale: A Diabetes Knowledge Scale for Vulnerable Patients. Diabetes Educator. 2005;31(2)215-224.
9. Rothman R, et al. Pharmacist-led, primary care-based disease management improves hemoglobin A1c in high-risk patients with diabetes. Am J Med Qual. 2003 Mar-Apr;18(2):51-8.
10. Clark PM, Gray AM, Briggs A, et al. Cost-utility analyses of intensive blood glucose and tight blood pressure control in type 2 diabetes (UKPDS 72). Diabetologia. 2005;48:868-877.
Pain:
1. Holdcroft A, Power I. Management of Pain: Recent Developments. BMJ. 2003;326:635-639.2. Ballantyne J, Mao J. Opioid Therapy for Chronic Pain. NEJM. 2003;349:1943- 1953.3. Strasser F, Driver L, Burton A. Update on Adjuvant Medications for Chronic Nonmalignant Pain. Pain Practice. 2003;3(4):282-297. 4. Hammett-Stabler C, Pesce A, Cannon D. Urine Drug Screening in the Medical Setting. Clinica Chimica Acta. 2002;315:125-135. 5. Goldenberg D, Burckhardt C, Crofford L. Management of Fibromyalgia Syndrome. JAMA. 2004;292:2388-2395.
Supplemental Readings:11. Chelminski, P. R.; Ives, T. J.; Felix, K. M.; Prakken, S. D.; Miller, T. M.; Perhac, J. S.; Malone, R. M.; Bryant, M. E.; DeWalt, D. A., and Pignone, M. P. A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity. BMC Health Serv Res. 2005 Jan 13; 5(1):3. 12. Gardner-Nix J. Principles of opioid use in chronic noncancer pain. CMAJ. 2003;169(1):38-43. 8. Moulin, D. E.; lezzi, A.; Amireh, R.; Sharpe, W. K.; Boyd, D., and Merskey, H.
Randomised trial of oral morphine for chronic non-cancer pain. Lancet. 1996; 347(8995):143-7.
Assessment and Feedback Self Assessment: A verbal self-assessment will be completed by all preceptors at the end of the
fourth week of the rotation. A written self-assessment will be completed the last week of the rotation and reviewed/discussed with the learner upon completion of the rotation. You are welcome at any time to request an informal evaluation of your progress.
Preceptor Assessment: A written assessment of the disease management elective should be completed at the end of the rotation. Formative verbal assessment is appreciated throughout the month.
SECTION 4
TEACHING CURRICULUM
Interns’ Conference
Ambulatory Care Conference
Internal Medicine Core Curriculum Conference
Board Review
Occupational and Environmental Diseases
Bioethics and the Legal Principles of Medicine
Physician Impairment
Laboratory Medicine
Medical Informatics
Violence
Gender-Specific Health Care
Palliation Care & Pain Management
Section 4
Teaching Curriculum
General
The Department of Medicine has daily teaching conferences that supplement teaching done on individual rotations. As previously mentioned in Section 1, these conferences are held at times that do not conflict with the activities of the respective services. The formats of these conferences have also been described in Section 1.
Content is planned so that each resident is exposed to the breath of information necessary to become a well-trained general internist. Specific curricula are also incorporated into these conferences. These curricula are described in this section
INTERNS’ CONFERENCE
All PGY-1 residents are excused from clinical duties each Wednesday from noon to 1:00 pm. At the beginning of the academic year, each conference is led by a member of the faculty who discusses a topic pertinent to PGY-1 management of patients. Topics included are listed below. Following this series of conferences, the format for this conference changes to case-based teaching of 1-2 topics per session. This format continues throughout the year.
Topics for Conferences
EMERGENCIES NEPHROLOGYAnaphylaxis / PEHematology/Oncology Emergencies
SVC SyndromeTumor LysisHypercalcemiaCord Compression
Pneumothorax / Aortic Dissection
CARDIOLOGYHypertensionAtrial FibrillationMyocardial InfarctionCongestive Heart FailureEKG Interpretation
NEUROLOGYSeizuresCVAAltered Mental Status
PULMONARYChronic Obstructive Pulmonary DiseaseLung CancerAsthmaPneumonia
INFECTIOUS DISEASESHuman Immunodeficiency VirusTuberculosisMeningitis
Acute Renal FailureChronic Renal Failure
ENDOCRINOLOGYThyroid DiseaseAdrenal Disease
DIGESTIVE DISEASESPUDPancreatitisLiver Failure / ETOH Liver DiseaseHepatitisDiarrhea
HEMATOLOGY/ONCOLOGYAnemiaBreast CancerProstate CancerColon Cancer
RHEUMATOLOGYRheumatoid Arthritis/OsteoarthritisLupusSarcoidosis
INTRODUCTION TO EVIDENCE BASED MEDICINE
AMBULATORY CARE CONFERENCE
This conference occurs each Friday from noon to 1 pm and is attended by PGY-1, -2, and -3 residents. Each conference is led by a PGY-2 or PGY-3 resident. The resident researches a topic, presents a key article, and critically appraises the article and the literature. The focus of this conference is evidence-based medicine.
Topics for Conference
HEENTSinusitis/Rhinitis/Otitis/LaryngitisHearing LossPharyngitisBlinding Eye Diseases
RespiratoryCough/BronchitisPulmonary NoduleOutpatient Management of Asthma
CardiovascularEvaluation and Treatment of HypertensionTesting strategies for Suspected Coronary Artery DiseasePeripheral Vascular Disease (arterial)Chronic Venous DisordersCarotid Bruits and TIA’s
GIIrritable Bowel SyndromeDiverticular DiseaseDyspepsiaConstipationDiarrheaAvitaminoses
EndocrineOutpatient Management of Type I DMOutpatient Management of Type II DMOsteoporosisGoiter and Thyroid NodulesHyper- and Hypothyroidism
MusculoskeletalLow Back PainCommon Foot Problems in Primary CareEvaluation of Musculoskeletal Complaints-1- Neck and UE-2- Hip and LEGout/CPPD
Gynecologic/GenitourinaryPrescribing Oral ContraceptivesMenopause/Hormone Replacement TherapySTD’s/Vaginitis/ Safe Sex CounselingPelvic Inflammatory DiseaseSexual DysfunctionBPH/ProstatitisUTI/Asymptomatic BacteriuriaNephrolithiasisDysfunctional Uterine BleedingHematuria/ProteinuriaIncontinence
NeurologicDizzinessSyncopeHeadachePeripheral Neuropathy
PsychiatricAnxiety/Panic DisorderManagement of Chronic Benzodiazepine UseNarcotic Addiction/Narcotic-seeking BehaviorRecognition of Abuse in the outpatient setting (Domestic violence/Incest/Rape)Depression in Primary CareInsomniaRecognition of Personality Disorders in the Outpatient Screening
DermatologyOutpatient Dermatology
Screening/PreventionSmoking: Counseling and CessationTuberculosis Screening and ProphylaxisImmunizations and Post-Exposure ProphylaxisGeneral Principles of Screening and Preventive CareCholesterol ScreeningBreast Cancer ScreeningCervical Cancer ScreeningTraveler’s MedicineColorectal Cancer ScreeningProphylaxis for Procedures
MiscellaneousOutpatient Management of HIV infectionPreoperative Medical Evaluation in the clinic setting
INTERNAL MEDICINE CORE CURRICULUM CONFERENCE
This conference occurs each Monday from noon to 1 pm. A series of topics is selected, each one reviewed by a faculty member of the Department of Medicine. The subjects are chosen based upon resident performance on the ACP sponsored In-Training Examination. All residents attend this conference. The following subjects are reviewed in this conference.
CARDIOLOGY DIGESTIVE DISEASE INFECTIOUS DISEASES
MI diagnosisMI ManagementArrhythmiasDiagnostic TestingEKG & Physical ExamCHF ManagementChest pain evaluationHTN etiologyHTN ManagementEndocarditis diagnosisEndocarditis ManagementCAD interventions
ICUAortic AneurysmShockRespiratory FailureARDSPulmonary EmbolismPneumoniasIonotropic MedsDKAOverdoses
NEPHROLOGYAcidosisAlkalosisElectrolyte AbnormalitiesHematuria/ProteinuriaLupus/VasculitisTransplantsUrinalysisDialysis / ARF
RHEUMATOLOGYCrystal Disease Inflammatory arthritis Autoimmune disease
NutritionUpper GI bleedLower GI bleedLiver FailurePancreatitisDiarrheaCholecystitis/CholangitisDiverticulitisInflammatory Bowel DiseasePeptic Ulcer DiseaseCirrhosis
HEMATOLOGYSickle cell diseaseDICCoagulopathiesHemolysisAnemiaThrombocytopeniaAnticoagulation
GENERAL MEDICINEVenous stasis ulcersDepressionStrokeBack painDementiaNeuropathyScreeningOccupational Health & ExposureOccupational Health - Toxins
ETHICS DNR Apache Score/ PrognosisLegal Principles
MeningitisHIV 1 - Opportunistic InfectionsHIV 2 - Anti retroviral therapyHepatitisAntibiotics IAntibiotics IIFever of unknown originSepsisUrinary Tract InfectionsRare infections
PULMONARYAsthmaPulmonary noduleTuberculosisInterstitial lung diseasePleural effusionsPulmonary Function Tests
ONCOLOGYLung Cancer Leukemia Hem/Onc emergenciesLymphomaBreast cancerColon cancerProstate cancerMycloprahjeratwe disordersMultiple myelomaBone marrow transplantation
Inflammatory arthritisAutoimmune disease
INTERNAL MEDICINE BOARD REVIEW
At the conclusion of each academic year, a review of Internal Medicine is given to prepare PGY-3 residents for the certification examination in Internal Medicine. The core of this review is a series of lectures given by faculty members. All PGY-3 residents are excused from clinical duties to attend.
The goal of each lecture is to give a broad overview of the subjects. Each lecture has an accompanying handout. These are collected so that each participant receives a syllabus for the course.
OCCUPATIONAL AND ENVIRONMENTAL DISEASES
Internists must always consider that certain symptoms and disease processes are related to exposures in the occupational setting or particular environmental settings. At the completion of training, residents should have a working knowledge and sufficient patient experience to satisfy the following goals:
Incorporate into a history, occupational and environmental exposures.
Identify physical and laboratory findings suggestive of occupational/environmental exposure - alopecia, wheezing, hearing loss, chest x-ray abnormalities of silicosis, asbestosis, CO poisoning, lead exposure.
Understand appropriate reporting to monitoring agencies
Know the procedure and how to assess disability
Know how to counsel patients about exposure risks
The information necessary to meet these goals is the subject of several teaching conferences. It is also part of the Curriculum of the Pulmonary service as well as Allergy Clinic, and part of Rheumatology rotation.
BIOETHICS AND THE LEGAL PRINCIPLES OF MEDICINE
On a day-to-day basis, residents face ethical issues. Residents must gain expertise in the following subjects and be familiar with their societal and legal boundaries.
Understand living wills and power of attorney and incorporate this into a history
Be able to define criteria for withdrawal of support
Be able to counsel a patient when the patient refuses treatment or is ambivalent about treatment.
Understand the legal aspects of confidentiality
Understand what constitutes malpractice and steps to prevent litigation.
Develop expertise with the dying patient and family.
Understand the role of hospice and be familiar with referral criteria
Be familiar with surrogate decision-making and permission for treatment.
Understand the legal aspects of “Do not resuscitate” orders.
Understand the legal aspects of confidentiality of medical records.
These subjects are reviewed in several teaching conferences in the Department of Medicine. Some of these issues are part of the curriculum in the ICU and the general medicine inpatient service, and the Hematology/Oncology service. In addition several Grand Rounds per year are devoted to these subjects.
PHYSICIAN IMPAIRMENT
A significant number of physicians are impaired by alcohol, chemical dependency, and/or psychiatric dysfunction. The recognition of such physicians, how they can be referred for help, and their outcome should be appreciated by residents. Specifically, the following aspects of physician impairment should be part of the knowledge base in internal medicine.
What constitutes physician impairment and how to identify it.
What is appropriate treatment for impaired physicians.
Recognition of the disease of addiction.
The utility of a contract for an impaired physician.
This subject and its components are discussed at a mandatory hospital orientation for all new residents. In addition, several Departmental conferences each year are given on this subject.
LABORATORY MEDICINE
As part of a diagnostic evaluation, internists often order and subsequently interpret a variety of laboratory tests. Internists should demonstrate competency in these areas for the tests listed. This information is reviewed in the subspecialty and general medicine curricula.
Allergy and Immunology - levels of complement, C1 esterase, eosinophil count
Cardiology - cardiac enzymes, nuclear heart scan
Dermatology - Tzanck smear, microscopic exam for scabies
Endocrinology - bone mineral densitometry, serum glucose, gylcosylated hemoglobin, serum gonadotropins, serum lipids, serum prolactin, thyroid function tests, thyroid scanning, urine metanephrines, serum calcium, serum phosphate
Gastroenterology - assays for H. pylori, serum tests for liver diseases, colonoscopy, stool for O&P, ercp, fecal electrolytes and osmolality, gall bladder scan, serum gastrin, viral hepatitis serology, liver biopsy, stool fat, endoscopy
Hematology - bone marrow aspirate and biopsy, cytogenetics, clotting assays, iron studies, lymph node biopsy, electrophoresis, B12 levels, flow cytometry
Infectious Disease - CD4 counts, csf analysis, ELISA, PCR, serology for common infections, syphilis serology
Nephrology - 24-hour urine electrolytes, fractional excretion of sodium, creatinine clearance, renal biopsy, serology for glomerulornephritis, renal angiography
Neurology - anticonvulsant drug levels, carotid Dopplers, imaging of CNS, sleep study
Oncology - cytology, estrogen/progesterone receptors, serologic tumor markers
Pulmonary - bronchoscopy, pleural fluid analysis, and lung scans
Rheumatology - antinuclear antibodies, ESR, complement levels, rheumatoid factor, synovial analysis for crystals.
MEDICAL INFORMATICS
The extent of medical information, both educational as well as related to patient care, is vast. Organization of this information is critical for an internist to function effectively. To this end, an internist must have certain knowledge of computer systems. The following curricular goals should be achieved.
Be able to use basic word processing
Be able to use CD-ROM’s and the Internet for education and literature searching
Be able to use the electronic medical record
Know essential aspects of information storage.
To emphasize these goals, each resident attends a course to develop skills in using the clinical workstations at the UNC Hospitals. Furthermore, there are instructional conferences on CD-ROM for educational use.
Violence
An internist must be able to recognize signs and symptoms of abuse as well as know how to manage or refer patients who are victims of abuse. The following objectives will be addressed in didactic sessions.
1. The signs and symptoms of domestic abuse
2. The signs and symptoms of sexual abuse
3. The signs and symptoms of elder abuse
4. Hospital & community resources to deal with these problems
5. The legal issues involved in abuse
These subjects are discussed at the departmental level at Grand Rounds, by experts in abuse. These experts work under the Beacon Program at the UNC Hospitals, which includes faculty members from the Department of Medicine, the Department of Social Services, & the Legal Department.
Gender-Specific Health Care
Women’s Health
The general internist will be called upon to perform health maintenance, recognize and treat common disorders, and refer appropriately for complex diseases of women.
In preparation for these functions, the following objectives should be met in the residency:
1. Be able to perform bimanual pelvis examination, including preparing pap smears
2. Be able to perform a breast examination and instruct patients in self-examination
3. Know health maintenance guidelines for these examination
4. Be able to prescribe common contraceptives
5. Understand the evaluation of galactorrhea
6. Be able to diagnose and treat common STD’s-syphillis, gonorrhea, herpes
7. Be familiar with rape protocol
8. Understand the presenting signs of sexual abuse
9. Be familiar with the evaluation of pelvic pain
10. Know the physical signs of cystocele, rectocele, uterine prolapse
11. Be familiar with the presenting signs of pregnancy
12. Be able to prescribe and understand the risks and benefits of hormone replacement
Physical examination skills for these objectives will be met in the continuity clinic, urgent care, general medical rotations, as well as the Emergency Room. Didactics on these subjects are covered in these different rotations as well as in Department conferences including Grand Rounds, ACC conferences, update conferences, and resident’s report.
Men’s Health
The general internist also will be involved in health maintenance, referral, diagnosing and treating disorders specific to men. The following objectives should be met:
1. Be able to perform a genital examination, including examination of the prostate.
2. Know the health maintenance guidelines for the genital examination, including PSA screening
3. Recognize presenting symptoms of prostate cancer
4. Be able to diagnose and treat prostatitis
5. Be able to diagnose and treat common STD’s-syphillis, gonorrhea, and herpes
6. Be familiar with the evaluation of impotence
7. Be able to recognize and diagnose common hernias
8. Be able to recognize and treat epididymitis
9. Be familiar with the evaluation of a testicular mass
10. Understand the pathophysiology of gynecomastia
The appropriate skills and didatics will be covered in the same manner as described for women’s health issues.
Palliative Care and Pain Management
A number of diseases that the general internist faces have no effective treatment. For these diseases once a diagnosis is made, the internist may have to focus all efforts on palliation and terminal care. The following objectives should be met to prepare residents for these patient care situations:
1. Develop an understanding of palliation care as perceived by the patient & family
2. Learn the role of the health care team in the delivery of palliation care
3. Learn the role of hospice in the care of terminally ill patients
4. Learn the principles of symptoms management including pain, nausea, vomiting, & dyspnea
5. Understand about the financial aspects of palliation care, particularly in the home
These subjects will be covered in a series of lectures by expert faculty. Dr. Stephen Bernard, Division of Hematology/Oncology, will give several of these. He has specific training & conducts an elective course in the School of Medicine in palliation care. Members of the Department of Anesthesiology who serve on the pain consultation service will also participate. Regarding specific experience, the Geriatrics rotation includes time at a hospice.
Section 5
Evaluations
EVALUATION
Resident performance must be evaluated on every rotation. The categories of evaluation as defined by the Residency Review Committee (RRC) for Internal Medicine are as follows:
1. Patient Care2. Medical Knowledge3. Practice-Based Learning and Improvement4. Interpersonal and Communication Skills5. Professionalism6. Systems-based Learning
The resident evaluation form asks faculty to evaluate residents in each of the competencies. A copy is enclosed. The competencies have been reviewed with the Attendings in departmental conferences.
Separate evaluation forms have been developed for Continuity Clinic and Same-day clinic. The form will be filled out by the clinic preceptor after each clinic session for residents and the data will be aggregated twice a year by the director of the clinic. Copies of the forms are included.
Faculty in the Division of General Medicine and Geriatrics evaluate residents using the Mini-CEX. These evaluations are done in both the inpatient and outpatient setting. The Program Director reviews these in the semiannual evaluation.
All residents are evaluated semi- annually by the Program Director. At the end of each year a global evaluation is submitted to the American Board of Internal Medicine. It is reviewed with the resident and a copy is provided for each resident.
Residents are asked to evaluate the faculty on each rotation and to evaluate the curriculum annually. Faculty are also asked to evaluate the curriculum Copies of these forms are provided.
Procedure Competency
The American Board of Internal Medicine requires that residents perform safely and competently the following procedures:
1. ACLS2. Drawing venous blood3. Drawing arterial blood4. Pap smear and endocervical culture5. Placing a peripheral venous line
For other procedures the Board requires that residents know the indications, contraindications, management of complications, and interpretation of results. Performing these procedures is not required for Board certification. These include:
1. Paracentesis2. Arterial line placement3. Arthrocentesis4. Central venous line placement5. Incision and drainage of an abscess6. Lumbar puncture7. Nasogastric intubation8. Pulmonary artery catheter placement9. Thoracentesis
The Department of Medicine has responded to this initiative by developing a comprehensive procedure curriculum. This is given to all PGY 1 residents. First, residents are required to watch videos and read selected articles about the procedures. The next step is a half-day workshop in our simulation lab where residents practice central venous line placement, peripheral venous line placement, and lumbar puncture. Clinical instructors are present for each procedure. A post –workshop test is given to each resident.
All residents are given a procedure log to use throughout the residency to record all procedures done. The information includes any complications and the supervisor for the procedure. The log becomes part of the resident’s permanent folder.
Attending Evaluation of Resident
Interpersonal and Communication Skills (Question 1 of 10 - Mandatory)
Does not establish even minimally effective therapeutic relationships with patients and families; does not demonstrate ability to build relationships through listening, narrative or nonverbal skills; does not provide education or counseling to patients, families, or colleagues.
Establishes a highly effective therapeutic relationship with patients and families; demonstrates excellent relationship building through listening, narrative and nonverbal skills; excellent education and counseling of patients, families, and colleagues; always "interpersonally" engaged.
No Interaction
Unsatisfactory Satisfactory Superior
0 1 2 3 4 5 6 7 8 9
Medical Knowledge (Question 2 of 10 - Mandatory)
Limited knowledge of basic and clinical sciences; minimal interest in learning; does not understand complex relations, mechanisms of disease.
Exceptional knowledge of basic and clinical sciences; highly resourceful development of knowledge; comprehensive understanding of complex relationships, mechanisms of disease.
No Interaction
Unsatisfactory Satisfactory Superior
0 1 2 3 4 5 6 7 8 9
Patient Care (Question 3 of 10 - Mandatory)
Incomplete, inaccurate medical interviews, physical examinations, and review of other data; incompetent performance of essential procedures; fails to analyze clinical data and consider patient preferences when making medical decisions.
Superb, accurate, comprehensive medical interviews, physical examinations, review of other data, and procedural skills; always makes diagnostic and therapeutic decisions based on available evidence, sound judgment, and patient preferences.
No Interaction
Unsatisfactory Satisfactory Superior
0 1 2 3 4 5 6 7 8 9
Practice-Based Learning and Improvement (Question 4 of 10 - Mandatory)
Fails to perform self-evaluation; lacks insight, initiative; resists or ignores feedback; fails to use information technology to enhance patient care or pursue self-improvement.
Constantly evaluates own performance, incorporates feedback into improvement activities; effectively uses technology to manage information for patient care and self-improvement. Delete
No Interaction
Unsatisfactory Satisfactory Superior
0 1 2 3 4 5 6 7 8 9
Professionalism (Question 5 of 10 - Mandatory)
Lacks respect, compassion, integrity, honesty; disregards need for self-assessment; fails to acknowledge errors; does not consider needs of patients, families, colleagues; does not display responsible behavior.
Always demonstrates respect, compassion, integrity, honesty; teaches/role models responsible behavior; total commitment to self-assessment; willingly acknowledges errors; always considers needs of patients, families, colleagues.
No Interaction
Unsatisfactory Satisfactory Superior
0 1 2 3 4 5 6 7 8 9
System-Based Practices (Question 6 of 10 - Mandatory)
Unable to access/mobilize outside resources; actively resists efforts to improve systems of care; does not
Effectively accesses/utilizes outside resources; effectively uses systematic approaches to reduce
use systematic approaches to reduce error and improve patient care.
errors and improve patient care; enthusiastically assists in developing systems' improvement.
No Interaction
Unsatisfactory Satisfactory Superior
0 1 2 3 4 5 6 7 8 9
Overall/Summary (Question 7 of 10 - Mandatory)
Resident's overall clinical competence in rotation. Resident's overall clinical competence in rotation.
No Interaction
Unsatisfactory Satisfactory Superior
0 1 2 3 4 5 6 7 8 9
Comments (Question 8 of 10)
Formal evaluation ends here. Please rate and comment on the E*Value evaluation system below.
System Ease of Use (Question 9 of 10, Confidential)
E*Value was easy to use.
NA Strongly Disagree
Disagree Neutral/Undecided Agree Strongly Agree
0 1 2 3 4 5
E*Value Comments: (Question 10 of 10)
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Curriculum Evaluation
PGY 1 ___ PGY 2 ___ PGY 3 ___ (Please designate your year.)
Strongly Agree Agree Neutral Disagree Strongly Disagree
Scale: 1 2 3 4 5
1. Grand Rounds topics were clinically relevant and contributed to my knowledge base. _____
2. M&M’s presented a wide array of diseased processes and contributed to my knowledge base._____
3. Noon Conferences were clinically relevant and contributed to my knowledge base. _____
4. Teaching conferences placed an appropriate emphasis on Evidence-Based Medicine _____
5. Teaching conferences placed too much emphasis on Evidence-Based medicine. _____
6. The In-Training Examination adequately assessed my fund of information. _____
7. Residents Report presentation’s contributed to my knowledge base. _____
8. The case-based format of Residents Report was an effective learning environment. _____
9. The housestaff website was an effective tool for literature searching. _____
10. My schedule allowed me adequate time to read. _____
Please feel free to add individual comments:
Curriculum Evaluation
Instructor/Assistant Prof ___ Associate/Full Professor ___ Division ___________
Strongly Agree Agree Neutral Disagree Strongly Disagree
Scale: 1 2 3 4 5
1.Grand Rounds topics were clinically relevant and contributed to my knowledge base. _____
2.Morbidity/Mortality conferences were clinically relevant and contributed to my knowledge base. _____
3.Textbooks are a main source of reference to prepare resident lectures _____
4.Journal articles are a main source of reference to prepare resident lectures _____
5.Electronic references are a main source to prepare resident lectures _____
6.When I am attending, I hold teaching rounds at least 3 times a week _____
7.When I am attending, I do bedside teaching at least 3 times a week _____
8.The current call schedule for residents facilitates teaching _____
9.The electronic record facilitates teaching _____
10.The Department values my teaching efforts ______
Please feel free to add individual comments:
Clinic Resident Evaluation
Resident (Residents' Clinic)
Performance Elements 1Below Average
2Expected
3Outstanding
Prepares for preclinic conference and arrives on time
Shows empathy toward patients
Attends to preventive care
Works efficiently
Demonstrates medical knowledge and competence in practiceHas a positive attitude and a willingness to help othersPresents succinctly in a problem focused formatDocuments care appropriately using clinic note and WebCIS functions
Additional Comments
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