Internal Medicine GMF In-Patient Rotation Curriculum 2017-18

Internal Medicine GMF In-patient rotation Curriculum 2017-18

GOALS: The Internal Medicine in-patient rotation is structured to provide residents with the opportunity:  To demonstrate appropriate progression in fundamental knowledge base of internal medicine and the essential principles in the approach to internal medicine inpatients,  To demonstrate the basic techniques of physical examination,  To demonstrate the necessary skills in performing clinical procedures,  To demonstrate the ability to communicate clearly with patients, their families and other members of the health care team.  To perform a comprehensive preoperative evaluation and optimal postoperative follow up of patients for non-cardiac surgery using a systematic approach based on clinical practice guidelines and other pertinent current literature.  To demonstrate performance to provide care to inpatients for common medical conditions  To diagnose and provide care to patients with chronic, medically complex, and undifferentiated conditions.

Roles of Team Members:  Educational coordinator;  Core and Key faculty: Dr. Saadia Memon Dr. Amar Chadaga Dr. Armand Krikorian Dr. Mitali Roy Dr. Lee Tai Dr. Parimal Sura Dr. Amisha Shah Dr. Kevin Loughry Dr. Bela Nand Dr. Melanie Gordon Dr, Natasha Shah Dr. Tajwaar Khan Dr. Priya Sharma Dr. Zubair Ilyas Dr. Firas Aubeid

Faculty Attending:  Attending will make rounds with his/her on-call team every day. The interns or medical students present new admissions to the attending, who will discuss patient history, clinical findings, and results of laboratory tests. .  At the bedside, the attending will interview and examine the patient to verify or modify any abnormal findings reported by the residents.

Manager resident:  The resident is responsible for leading the floor medicine team on a day-to-day basis.  The resident will also be responsible for direct supervision of the interns and medical students.  The resident is expected to conduct work rounds, which are separate from those of the attending.

Interns:  The team interns will be responsible for admitting all patients for the team and performing and documenting a complete history and physical exam.  The interns will be responsible for day-to-day management of the team patients.  They will be responsible for documenting and reporting to the manager or team attending about patients' status, recording daily progress notes, discharging the patients from the team, and ensuring effective transition to post-hospital outpatient follow-up.  The interns dictate discharge summaries of their patients. DACR: Daily acting chief resident This resident is responsible for taking ED calls, running medical emergency responses, and providing coverage during weekends.  Providing medicine consult services to non-medical services, e.g., Psych, Rehab, OB-Gyne, etc.  Providing supplemental teaching sessions for the GMF team or selected individuals

Venues, sites and methods  Bedside teaching  Small and large group discussions  Team pm table rounds  Didactics  Self-directed and assigned readings  Project teams/groups

Structure of Ward Rotation: The 4 ward teams will alternate call. There is a long/short call system,

ROTATION-SPECIFIC CORE COMPETENCY EXPECTATIONS It is not expected that a resident will demonstrate achievements of competencies to the level of “unsupervised practice” in the early phases of training. A trajectory of progression is expected and monitored for throughout the training period. Successive rotations on GMF rotations should demonstrate progression to goal of ready for entrustment for unsupervised practice.

Patient Care

 Obtain a comprehensive hypothesis-driven history, including secondary sources, subtleties, and information not always disclosed voluntarily and recognize common abnormal physical findings.

 Construct a master problem list, a working diagnosis, and a group of differential diagnoses

 Demonstrate familiarity with and application of the concept of pre-test and post-test probabilities of disease.

 Demonstrate how to improve patient/physician relationships in a professional way.

 Residents should demonstrate compassion, but be humble and honest, not only with their patients, but also with their co-workers.

 Residents should show progression to develop leadership in teaching and supervising interns and medical students.

 Actively demonstrate participation in all phases of patient care, especially transitions of care.  Residents should demonstrate self-directed motivation to read on related topics, to share new learning with their colleagues and to keep their fund of knowledge up-to-date

 Demonstrate appropriate progression of confidence, autonomy, and reducing need for direct supervision in clinical situations on trajectory to unsupervised, entrusted practice.

 Demonstrate ability to use the electronic and other resources for literature searches, analysis and discussions.

Medical Knowledge

The achievement of having a knowledge basis of independently managing patients with common acute and chronic medical problems across multiple care settings is not expected during a single rotation or even an academic year. But demonstrable progress is expected with successive rotations and experience. Extending this achievement, then, to demonstration of depth of knowledge to independently taking care of complex, uncommon, and undifferentiated clinical situations is the goal of successful completion of training.

The following is a brief statement of the scope of achievable medical knowledge competency.

1. Human Growth, Development, and Aging: adolescent medicine, aging and introduction to geriatric medicine, management of common problems in the elderly.

2. Preventive Medicine: principles of preventive medicine, immunization, alcohol and substances abuse.

3. Principle of Diagnosis and Management: clinical approach to the patient, clinical decision-making, interpretation of laboratory data.

4. Cardiovascular Diseases: Congestive heart failure, cardiac arrhythmias, hypertension, coronary heart disease, interpretation of EKG, interpretation of echocardiogram, nuclear medicine imaging, indication for cardiac catheterization.

5. Respiratory Diseases: Respiratory failure, COPD, asthma, pulmonary embolism, pleural effusion, interpretation of pulmonary function tests.

6. Renal Diseases: disorders of electrolytes and acid-base, acute renal failure, chronic renal failure, glomerular diseases, tubule-interstitial diseases, vascular disorders.

7. Gastrointestinal Diseases: gastrointestinal bleeding, small bowel obstruction, large bowel obstruction, ischemic bowel diseases, pancreatitis, and diarrhea.

8. Diseases of the Liver and Hepatobiliary Tract: Viral hepatitis, cirrhosis and portal hypertension, and hepatic failure. 9. Hematologic Diseases: Anemia’s, interpretation of the peripheral blood smear, transfusion of blood and blood products, neutropenia, disorders of the platelets, disorders of blood coagulation.

10. Oncology: Acute leukemias, oncologic emergencies, lymphomas.

11. Metabolic Diseases: Hyperlipoproteinemias, gout.

12. Nutritional Diseases: Principles of nutritional support, parenteral nutrition.

13. Endocrine Diseases: Diabetes mellitus, diabetic keto-acidosis, adrenal disorders, thyroid diseases, osteoporosis.

14. Musculoskeletal and Connective Tissue Diseases: Arthritis, SLE, vasculitis syndromes.

15. Infectious Diseases: Septic shock, principles of antimicrobial therapy, pneumonias, UTI, soft tissue infections, osteomyelitis, infective endocarditis, bacterial meningitis, enteric infections, tuberculosis, fungal infections, HIV infection, treatment of AIDS and related disorders.

16. Neurology: The neurologic examination, neuro- radiologic imaging, cerebrovascular accident, dementias, sleep disorders, seizures, basics of CT/MRI imaging.

Practice Based Learning Improvement

Objectives

 The resident demonstrates the use of feedback and self-evaluation in order to improve performance.

 The resident demonstrates reading pertinent required material and articles provided to enhance learning.

 The resident demonstrates the use the medical literature search tools in the library to find appropriate articles related to interesting cases.

 The resident demonstrates review and self-reflection of past performance to improve performance

Interpersonal and Communication Skills

Objectives

 The resident demonstrates ability to communicate effectively and appropriately with all members of health care team  The resident demonstrates ability to present a case to the attending staff in an organized and thorough manner.

 The resident demonstrates ability to establish rapport with a patient and effectively communicate to promote the patient’s welfare.

 The resident demonstrates effective education and counseling for patients.

 The resident demonstrates ability to effectively and timely document with organized legible notes.

 The resident demonstrates effective, appropriate communication of any patient problems to the attending staff in a timely fashion.

Professionalism.

Objectives

 The resident demonstrates ethical behavior, and the humanistic qualities of respect, compassion, integrity and honesty.

 The resident demonstrates a willingness to acknowledge errors and determine how to avoid future similar mistakes.

 The resident demonstrates responsibility and reliability at all times.

 The resident always considers the needs of patients, families, colleagues, and support staff.

 The resident t maintains a professional appearance at all times.

 The resident demonstrates respect for patient autonomy and modifies plan to account for patient’s unique characteristics and needs.

Systems Based Learning

Objectives

 The resident demonstrates improvement in the utilization of and communication with many health services and professionals such as nurses, dieticians, respiratory therapists, physical therapists, social workers, and other medical consults.

 The resident demonstrates knowledge and practice of high value care without detriment to effective and safe care.  The resident has participated in determining root cause of error.

 The resident demonstrates promotion of patient safety and process and quality improvement.

Educational Materials

Mandatory Reading

 Appropriate sections in Harrison’s Principles of Internal Medicine

 Appropriate sections in Cecil’s Textbook of Medicine

 Residents should focus reading in particular to sections that directly relate to the problems of their patients.

 MKSAP booklets.

Medical Literature

 The resident should demonstrate reading current medical literature pertaining to current patient problems. Examples of appropriate current medical literature are the New England Journal of Medicine, Annals of Internal Medicine, Archives of Internal Medicine and Up-to-date

Evaluative methods

 The resident’s evaluation and assessments of competencies and skills are multifactorial. The methods include direct observation, questions and responses, bedside and didactic based responses, review of records and order writing, soundness, evidence based, and critical analytical thinking, and observations and feedback on behavior and interpersonal relations and communicative skills.

Resident Evaluation

 The attending will closely supervise and monitor the ward team activities and the performance of residents.

 The attending is expected to give constructive suggestions and/or criticisms as soon as the attending identifies any significant deficiencies.

 The attending will provide residents with a mid-rotation evaluation to comment on their performance.  The attending will fill out the standard evaluation on New Innovations for evaluations as delineated above to grade the resident in each of the six competencies.

Feedback

 Residents are encouraged to discuss with the faculty advisor, attending physician, assistant program director or program director their learning experiences, difficulties or conflicts.

 Attendings are encouraged to use the “early concern” and “praise” throughout the rotation. A formal evaluation and verbal discussion with the resident is to be done at the end of the rotation.

REFERRENCES

 Society of Hospital Medicine

 Journal of Hospital Medicine

 AAIM

 ABIM

 ACGME

EXPECTATIONS FOR ACHIEVEMENTS OF SPECIFIC REPORTABLE MILESTONES DURING THE GMF ROTATION

GOAL: Manage care of patients with acute common diseases across multiple care settings.

MILESTONES FOR PGY-1

PC-1 Acquire relevant and accurate history from patient in an efficiently customized, prioritized, and hypothesis driven fashion.

PC-1 Performs accurate physical examinations that are targeted to patient’s complaints.

PC-2 Consistently develops appropriate care plan PROF-1 Honest and forthright in clinical interaction and documentation. Consistently respectful in all interactions with patient and health care team.

MILESTONES FOR PGY-2/3

PC-1 Gathers and synthesizes essential and accurate information to define each patient’s clinical problem(s).

PC-1 Obtains relevant historical subtleties that inform and prioritize differential diagnoses and diagnostic plans, including sensitive, complicated and detailed information that may not often be volunteered by the patient.

PC-2 Appropriately modifies care plans based on patient’s clinical course, additional date, and patient preferences.

MK-1 Possesses the scientific, socioeconomic and behavioral knowledge to provide care for common medical conditions.

Mk-1 Independently manages patients across inpatient settings who has a broad spectrum of clinical disorders, including undifferentiated syndromes.

GOAL: Manages transitions of care

SBP-4 Appropriately utilizes available resources to coordinate care and ensures safe and effective patient care within and across delivery systems

PROF-4 Demonstrates accountability for the care of the patient.

ICS-2 Engages in collaborative communication with appropriate members of the team

SBP-1 Understands the roles and responsibilities of and effectively partners with all members of the team.

MILESTONES FOR PGY2/3

SBP-4 Proactively communicates with past and future care givers to ensure continuity of care. PROF-1 Demonstrates empathy, compassion, and respect to patient, and caregivers in all situations.

SBP-3 Consistently works to address patient specific barriers to cost-effective care

SBP-2 Advocate for safe patient care and optimal patient care systems.

GOAL; Lead and work within inter-professional health care teams

ICS-2 Engages in collaborative communication with appropriate members of the team

SBP-1 Understands the roles and responsibilities of all members of the inter-professional team.

PBLI-3 Solicits feedback from supervisors

SBP-1 Engages in team meetings and collaborative decision making.

MILESTONES FOR PGY-2/3

SBP-1 Efficiently coordinates activities of other team members to optimize care

PROF-1 Is available and responsive to needs and concerns of members of the inter- professional team to ensure safe and effective care.

ICS-2 Consistently and actively engages in collaborative communication with all member of the team

PROF-1 Positively acknowledges input of members of the inter-professional team.

GOAL: Enhance patient safety

PC-1 Seeks and obtains verified, accurate, and prioritized data from secondary sources.

PC-2 Recognizes situations requiring urgent or emergent care and seeks additional guidance as appropriate.

PROF-4 Demonstrates integrity, honest and accountability to patients and the profession.

SBP-2 Reflects upon and learns from critical incidents that may lead to medical error. MILESTONES FOR PGY-2/3

PC-1 Recognize disease presentations that deviate from common patterns and require complex decision-making.

MK-1 Possess scientific, socioeconomic and behavioral knowledge required to care for complex, uncommon, and ambiguous medical conditions

PROF-4 Demonstrate integrity, honesty, and accountability to patients and the profession.

SBP-2 Teach others regarding importance of recognizing and mitigating medical error.