Emergency Medicine

EMERGENCY MEDICINE
COMPETENCY-BASED CURRICULUM

OVERVIEW

The Emergency Medicine rotation involves caring for acutely ill patients with a broad range of clinical problems. This is best achieved by adopting a team approach consisting of the emergency room attending physician, general internist, and appropriate medical specialist or subspecialists, and others as indicated. Residents must learn to recognize acute and chronic critical illnesses, to develop differential diagnoses, to develop acute care plans, and to allocate limited resources appropiately to patients. Principles of emergency medicine, including triage, resuscitation and stabilization, pre-hospital care, and emergency procedures are presented in a variety of venues, including didactic sessions. Special attention is paid to the timing of educational experiences to assure that residents can fully benefit from clinical opportunities while assuming greater autonomy in patient care. Emergency physician's approach to patient care begins with the recognition of patterns in the patient's presentation that point to a specific diagnosis or diagnoses. Pattern recognition is both the hallmark and cornerstone of the clinical practice of Emergency Medicine, guiding the diagnostic tests and therapeutic interventions during the entire patient encounter.

DESCRIPTION OF THE ROTATION

This core rotation consists of one month spent in the Emergency Department (ED). The resident is closely supervised by the emergency medicine attending staff. Patient care responsibilities will be for patients triaged to the emergency room. Individual patient care is supervised by patients' individual attending emergency physicians. Teaching rounds are made under the direction of a member of the attending staff with specialty training in Emergency Medicine.

Residents will have first contact responsibility for the patients seen in the emergency room. This will include reviewing graphic sheets and events of the preceding evening, and being familiar with all new Emergency Department admissions, diagnostic information,and therapeutic interventions; residents must be prepared to comprehensively present their patients to their assigned emergency attending physician and together should decide wether the patient needs to be admitted. Residents also have a responsibility to provide didactic information appropriate to individual patients' problems to their attending physician as well as medical students. They are expected to have relevant medical literature when appropriate to use to supplement discussion of patient management.

Formal educational experiences will include the "Topics in emergency medicine" lecture series, and curriculum provided to residents by Emergency Department faculty.

GOALS

1. The resident will gain clinical experience as they participate in the evaluation and management of a wide variety of illnesses. Due to the nature of emergency medicine, a precise checklist is not possible. Nevertheless, the resident is likely to gain experience in the following clinical categories:

Chest pain
Acute coronary syndrome
Venous thromboembolism
COPD exacerbation
Congestive heart failure
Syncope
Pneumonia
Cerebrovascular disease
Abdominal pain
Gastroenteritis
Gastrointestinal bleeding
Urinary tract infection
Renal colic
Back Pain
Dysfunctional uterine bleeding
Threatened abortion
Extremity sprain/fracture
Soft tissue infections
Allergic reaction
Wound management
Burns
Sickle cell painful crisis
Headache
Cardiopulmonary arrest
Overdose and poisoning
Shock
Motor vehicle accidents

2. The resident will gain experience with the emergency medicine approach to patient care:

The use of nursing triage and triage categories
Establishing "instant rapport" with patients and their families
Acquiring clinical information in a previously unknown patient
Chief-complaint-directed physical examination
Establishing a differential diagnosis emphasizing "most lethal first"
Emphasizing the importance of admission versus discharge to patient morbidity and mortality
Managing multiple patients at once

3. The resident will learn to choose the appropriate diagnostic tests and gain experience in their interpretation and application. These will likely include:

Chest radiograph
Electrocardiogram
Obstructive series
CT head
CT chest
CT abdomen and pelvis
Ultrasound of right upper quadrant
Pelvic ultrasound
Arterial blood gas
Basic blood tests
Cardiac enzymes

4. The resident will learn how emergency physicians interact with physicians from a variety of medical specialties in arranging for continuity of care.

5. The resident should gain the knowledge to answer the many of the following questions related to each of common presenting complaints:

Acute Chest Pain

1. Describe risk factors, historical, examination and laboratory clues relating to the diagnosis of acute myocardial infarction.
2. Describe indications, contraindications and treatment protocols relating to both thrombolytic therapy and emergency cardiac catheterization in acute myocardial infarction.
3. List 3 potentially life-threatening complications to acute MI and their ED management.
4. Describe risk factors, historical, examination and laboratory clues relating to the diagnosis of pulmonary embolism.
5. Describe physical exam and EKG findings in acute pericarditis.

Acute Abdominal Pain

1. Describe 5 life-threatening causes of abdominal pain and the approach to diagnosis and management of each.
2. Describe physical findings in each area of the physical exam:HEENT, Chest, Abdomen, Extremities, Skin, etc., that are important to look for in defining causes of abdominal pain.
3. Compare and contrast abdominal pain in the young patient vs. the elderly patient
4. List 5 special problems in the evaluation of women with abdominal pain
5. List reasons for obtaining the following diagnostic studies for a patient with abdominal pain: abdominal plain films, KUB,sonogram, CT Scan, HIDA scan

Dyspnea/Wheezing

1. Discuss indications for radiologic evaluation of asthmatic patients
2. Describe the physical findings in patients presenting with congestive heart failure/failure/pulmonary edema.
3. Interpret arterial blood gases in terms of acute and/or chronic respiratory disease and be able to calculate and A-a-gradient
4. Outline a therapeutic approach to the patient who presents with an acute exacerbation of asthma
5. Outline a therapeutic approach to the patient who presents with acute pulmonary edema

GYN Problems

1. Describe the key elements important in obtaining a complete GYN history.
2. Perform an organized and complete GYN examination
3. Discuss criteria for admission of a patient with pelvic inflammatory disease.
4. Discuss risk factors, diagnosis and management of ectopic pregnancy
5. Describe the emergency department approach to a patient alleging sexual assault, including use of the Vitulo Rape Kit

Poisoning

1. Describe methods and reasons for gastric decontamination
2. List 8 causes of a high anion gap acidosis
3. Describe likely physical findings in a patient with an overdose of tricyclic antidepressants
4. Explain the indications for n-acetylcysteine treatment of acetaminophen overdose
5. Describe the general approach to a patient with an unknown drug overdose including the indications for and value of serum and urine Tox screens.

Psychiatric Problems

1. Describe indications, risks and complications to the use of physical and chemical restraints in acutely violent or dangerous patients
2. Discuss the medical evaluation of a patient presenting with depression, including the assessment of suicide risk
3. List the side effects of commonly used major tranquilizers and anti-depressant medications
4. Describe the major manifestations of three "street drugs" that may mimic psychotic syndromes.
5. Describe the presentation, differential diagnosis and treatment plan for a patient with presumed panic disorder.

Resuscitation

1. Discuss indications and methods for obtaining airway access in the cardiac arrest victim.
2. Demonstrate the appropriate techniques for closed chest cardiac massage and ambubag ventilation of the patient in cardiac arrest
3. Outline the ACLS protocols for the treatment of asystole,ventricular fibrillation, ventricular tachycardia (with and without a pulse), supraventricular tachycardia and pulseless electrical activity
4. Describe the three types of "heat illness" and the approach to resuscitation of each
5. Discuss the special considerations of resuscitation of the hypothermic patient

Altered Mental Status

1. Describe a complete mental status exam
2. Describe the Glasgow Coma Scale
3. List 3 metabolic causes of altered mental status and describe the likely findings in each
4. List 3 infectious causes of altered mental status and describe the likely findings in each
5. List 3 toxicologic causes of altered mental status and describe the likely findings in each

Minor Trauma/Musculoskeletal

1. Describe the examination and treatment options for patients presenting with low back pain
2. List the injuries likely to be sustained by a fall on the outstretched arm
3. Indicate the appropriate suture material and length of time sutures should be left in for simple lacerations to the scalp, face and extremities
4. Describe the appropriate management and follow-up care for patients with simple ankle sprains
5. Demonstrate for patients the appropriate use of crutches.

Headache

1. Describe the classic migraine
2. Define "cluster headache" and the typical Emergency Department presentation
3. List historical, physical exam and laboratory findings in patients with subarachnoid hemorrhage
4. Discuss the management of increased intracranial pressure
5. Outline the appropriate physical exam for a patient presenting to the Emergency Department with a chief complaint of headache

Dizziness

1. List historical information and physical examination cues that help differentiate between central and peripheral vertigo
2. Describe methods of assessment and significance of "orthostasis"
3. List drugs known to cause symptoms of dizziness
4. Describe five vascular causes of dizziness
5. Describe treatment approaches for peripheral causes of vertigo

Gastrointestinal hemorrhage

1. Discuss the appropriate history and physical exam of patients with a chief complaint of hematemesis
2. Describe rationale (if any) to the use of 1) nasogastric intubation 2) NG suction 3) gastric lavage 4) PPI in patients with suspected upper GI bleeding
3. List indications for emergency endoscopy for upper GI bleeding
4. Describe likely sources for lower GI bleeding depending on the age of the patient
5. Describe the indications for endoscopy, bleeding scan and angiography in evaluation of lower GI bleeding

6. PROCEDURES--Residents will learn, as appropriate to individual patients, the indications and contraindications and the performance of those medical procedures required by the American Board of Internal Medicine and Residency Review Committee (as detailed in the inpatient general medicine curriculum) and perform all procedures on patients under their care.

The resident will gain experience in performing certain procedures common to emergency medicine under direct supervision as patient presentation allows. These include:

IV access
Advanced Cardiac Life Support
Phlebotomy
Central line placement
NGT placement
ABGs
Thoracentesis
Abdominal paracentesis
Breast, pelvic, and rectal examinations
Foley catheter insertion
Lumbar puncture
Foley Catheter Placement
Fracture splinting and immobilization
Joint relocation
Suture techniques
Incision and drainage
Bandaging techniques
Wound management
Slit lamp use
Cervical spine immobilization
Intubation

PRINCIPAL TEACHING /LEARNING ACTIVITIES

-Resident Morning Report (RMR)—
Three mornings each week (Monday, Tuesday, & Thursday) from about 7:45- 8:45 AM all Interns, Junior Assistant Residents and Senior Assistant Residents on inpatient floor teams meet with assigned faculty to review patients admitted the previous day. Patients are presented briefly by the intern or resident who admitted them and discussed by the group, facilitated by the attending physician. The focus of the discussion is selected by the presenting resident and may reflect differential diagnosis, specific management issues, or other topics. Faculty will include general internists and subspecialists.

Each Friday from 8:00-9:00 AM the Senior residents will meet with assigned specialist attending physicians to review patients admitted the previous day. Selected patients are presented by the residents and further discussion including literature review and didactic teaching is guided by the attending physician.

-Sign-out Rounds (SR) -- Every evening, Monday through Friday, the the senior residents (Chief Resident, or his/her designate will be present during the first few months of the academic year), supervise sign-out rounds, which are attended by the out-going day team and incoming ADMITTING team. These may include topical discussions.

-Teaching Attending Rounds (AR) – Attending rounds format will vary depending on the preference of the attending. There should be discussion of the patients with concurrent teaching.. At the very least this should include bedside rounds on the new patients and others whom the resident/attending feel should be seen by the team. If possible beside rounds should be done on all patients.

-Management Rounds (MR) -- Each day the Attending physician responsible for care of patients on this service will meet with the residents at mutually agreeable and arranged times, to review specific aspects of patient management. It will be on these occasions that residents are supervised in details of recordkeeping, interaction with other healthcare team members, communication with consultants and family members, and all other aspects of patient management.

-Palliative Care and/or Ethics Rounds (PCR)— Once each month a voluntary faculty member with special interest and expertise in medical ethics and palliative care conducts palliative care rounds for all residents on inpatient teams. A particular patient or patients is/are selected for presentation. Discussion is directed and facilitated by the faculty member, emphasizing issues pertaining to death and dying, and relevant care and
communication skills necessary for residents to develop.

-Noon Conference (NC) -- Each weekday usually from 12 noon to 1 p.m. all residents attend a scheduled conference reviewing core topics in Internal Medicine.

-Journal Club (JC) -- Journal Club is held monthly. Following an annual presentation on the fundamentals of evidence-based medicine, individual residents are assigned a single article to critically review and present, facilitated by a faculty member, and followed by a group discussion.

-Grand Rounds (GR) -- Medical Grand Rounds are held each Wednesday from 8:00 -9:00 a.m. in the Medical Center Auditorium. Formats vary and include invited guests/visiting professor presentations, clinical-pathological conferences, morbidity and mortality conference, resident presentations, or other didactic, topical, or patient related topics.

-Ambulatory Care Conference -- (ACC) Each month faculty members meet with residents to review individual topics pertaining to ambulatory care medicine. This follows a three- year cyclic schedule of topics, so that our ambulatory care curriculum is presented in its entirety during the time of training for individual residents.

-Back to Basics (BTB)- Each month the residents choose a key topic in medicine to review in detail form pathophysiolgy to clinical manifestations and management. The topics are chosen be the residents and reviewed by the chief resident prior to discussion Topics generally follow a triennial cycle, covering all subspecialty areas within internal medicine during the time of training of individual residents.

- Turnover Rounds (TR)-- Turnover rounds occur at the end/beginning of each rotation and from 6:30- 7:30 a.m. daily. These facilitate transfers of patient care from one resident to another. (Sign in Rounds are a daily version of turnover rounds.)

-EBM conference (EBM)- Each month the ambulatory resident and intern are expected to investigate a clinical question that they do not have the answer for. Under the guidance of the faculty, they then formulate the question in a scientific format, search the literature for evidence, and develop an answer to the question. This is presented in a conference. Included in the presentation are the question, the search methods, the evidence found, and the conclusions derived.

-Patient Safety and Quality Improvement Conference (PSQI) – Formerly the Morbidity and Mortality Conference. We now have a monthly conference dedicated to identifying issues that affect patient safety. The issues maybe as varied as knowledge gaps in care for patients with unusual diseases to errors that occur in the course of care. There is a discussion about the residents' role in preventing such issues in the future. If warranted an action plan is made with follow up at subsequent meetings.

-Autopsy Rounds (AuR) When a death occurs on any of the teaching teams the family is offered the option of performing an autopsy. If an autopsy is performed, we hold a multidisciplinary presentation of the findings that includes medicine, pathology, radiology, surgery, and/or ob/gyn residents and faculty that were involved.

-MKSAP study pan (MKSAP)-This self directed study plan helps residents stay on track with their didactic reading and helps them evaluate their medical knowledge (strengths and areas of deficit). Residents can help develop individualized study plans to fill in any knowledge gaps and reinforce what they already know. This also helps residents develop skills and habits needed for lifelong learning.

-In-Training Examination (ITE) -- All of our residents must take this examination annually for their own assessment of progress and for edification. When examination results become available, the program director discusses these individually with residents and counsels residents about individualized study programs to facilitate their acquisition of knowledge.

EVALUATIONS
Assessment Methods (of Resident)

The evaluation methods that apply to these rotations include some or all of the following:

• Evaluation of resident competence by faculty attendings (AE)- Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.
• Mini CEXs may be used when warranted, particularly in the beginning of the academic year.
• Self-evaluation by In-service training examination scores
• MKSAP study plan (MKSAP)
• Participation and presentations at didactic conferences (DC)
• Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

PRINCIPLE EDUCATIONAL GOALS BY RELEVENT COMPETENCY

In the tables below, the principle educational goals for the Faculty Inpatient Service rotation are indicated for each of the six ACGME competencies. The second column of the table indicates the most relevant principle teaching/learning activity for each goal, using the legend below.

* Legend for Learning Activities (See preceding for descriptions)
ACC-Ambulatory Care Conference
AE-Attending Evaluations
AR- Emergency Medicine Attending Rounds
AuR- Autopsy Rounds
BTB-Back to Basics
DPC-Direct Patient Care
EBM-Evidence Based Medicine
GR- Grand Rounds
ITE-In-Training Exam
JC- Journal Club
MKSAP-Knowledge Self Study Plan
MR- Management Rounds
MS-Multisource Evals
NC- Noon Conference
PCR-Palliative Care/Ethics Rounds
PSQI-Patient Safety/Quality Improvement
RMR- Resident Morning Report
SR- Signout Rounds
TR-Turnover Rounds

1.) Patient Care

Goals and Objectives: PGY-1	Learning Activities*	Assessment
Master basic patient interviewing skills	DPC, AR, MR	AE, AR, TR, MR, MS
Master basic patient exam skills	DPC, AR, MR	AE, AR, TR, MR
Master basic psycho-social evaluation skills	DPC, AR, , MR, PCR	AE, AR, TR, MR
Define and prioritize patients' medical problems	DPC, AR, MR	AE, AR, TR, SR, MR,, RMR
Generate and prioritize differential diagnoses	DPC, AR, MR	AE, AR, TR, SR, MR, RMR
Develop rational, evidence-based management strategies	DPC, AR,PCR, JC, MR	AE, AR, TR, PR, MR, RMR

Goals and Objectives: : PGY-2 (in addition to above)	Learning Activities*	Assessment
Interview patients more skillfully	DPC, AR, MR	AE, AR, MR, SR, TR
Examine patients more skillfully	DPC, AR, MR	AE, AR, MR, SR, TR
Evaluate psycho-social issues more skillfully	DPC, AR, MR, PCR	AE, AR, MR, PCR, TR
Define and prioritize patients' medical problems	DPC, AR, MR, RMR	AE, AR, MR, RMR, TR
Generate and prioritize differential diagnoses	DPC, AR,RMR, MR	AE, AR, MR, RMR, TR
Develop rational, evidence-based management strategies	DPC, AR, RMR, PCR, JC, MR	AE, AR, JC, MR, RMR, TR
Manage a large volume of patients	DPC, AR, RMR , MR	AE, AR, MR, SR, TR
Develop and display leadership skills and responsibility	DPC, AR, RMR, PCR, JC, MR	AE, AR, MR, RMR, SR TR
Learn to be team leaders	DPC, AR,RMR, JC, MR	AE, AR, NC, , MR, SR, TR
Learn to be efficient teachers	DPC, AR, ,RMR, JC, MR	AE, AR, SR, MR, CMR, TR

Goals and Objectives: : PGY-3 (in addition to above)	Learning Activities*	Assessment
Efficiently and effectively direct the initial evaluation and continued management of patients requiring hospitalization including appropriate discharge planning.	DPC, AR, PR, MR	AE, AR, MR, SR, TR
Complete obtainment of certification in required Internal Medicine procedures. Supervises junior trainees in these procedures once certified to teach	DPC, AR, PR, MR	AE, AR, MR, SR, TR
Systematically obtains and reviews all prior/obtainable medical records pertinent to patient care.	DPC, AR, PR, MR	AE, AR, MR, SR, TR
Understands significance of all diagnostic test results affecting patient care.	DPC, AR, PR, MR	AE, AR, MR, SR, TR
Clinical judgment – makes informed decisions using risk/benefit analysis based on sound scientific evidence, patient performance after informed consent and consultation with consultants and more senior physicians (attending).	DPC, AR, PR, MR, JC	AE, AR, MR, SR, TR, JC
Begin to function as independent primary care givers	DPC, AR, PR, MR	AE, AR, MR, SR, TR

2.) Medical Knowledge

Goals and Objectives: : PGY-1	Learning Activities*	Assessment
Read and expand clinically applicable knowledge base of the basic and clinical sciences	DPC, AR, RMR, AuR, SR, NC, GR, BTB, MKSAP	AE, AR, TR, MKSAP, MR, SR
Access and critically evaluate medical information and scientific evidence relevant to patient care	DPC, AR, RMR, AuR, SR, NC, GR, BTB	AE, AR, TR, MKSAP, MR, SR

Goals and Objectives: : PGY-2 (in addition to above)	Learning Activities*	Assessment
Read and expand clinically applicable knowledge base of the internal medicine specialties	DPC, AR, RMR, AuR, SR, NC, GR, BTB, MKSAP	AE, AR, TR, MKSAP, MR, SR
Access and critically evaluate medical information and scientific evidence relevant to patient care	DPC, AR, RMR, JC, MKSAP	AE, AR, PR, JC, SR TR
Teach medical students and interns	DPC, AR, RMR, AuR, SR, NC, GR, BTB, MKSAP	AE, AR, TR, MKSAP, MR, SR
Read relevant articles and literature in journals	DPC, AR, RMR, AuR, SR, NC, GR, BTB, MKSAP	AE, AR, TR, MKSAP, MR, SR

Goals and Objectives: : PGY-3 (in addition to above)	Learning Activities*	Assessment
Develop medical knowledge about each patient illness so as to be able to make independent decisions based on scientific evidence and patient preference.	DPC, AR, RMR, AuR, SR, NC, GR, BTB, MKSAP	AE, AR, TR, MKSAP, MR, SR
Demonstrates knowledge by leading discussions on areas of pathophysiology concerning patient care including ongoing management of hospitalized patients.	DPC, AR, RMR, JC, MKSAP	AE, AR, PR, JC, SR TR
Demonstrates ability to access information from 3 different sources and to synthesize sources into an indepth understanding.	DPC, AR, RMR, AuR, SR, NC, GR, BTB, MKSAP	AE, AR, TR, MKSAP, MR, SR
Develop medical knowledge adequate to practice independently	DPC, AR, RMR, AuR, SR, NC, GR, BTB, MKSAP	AE, AR, TR, MKSAP, MR, SR

3.) Practice- Based Learning and Improvement

Goals and Objectives: : PGY-1	Learning Activities*	Assessment
Identify and acknowledge gaps in personal knowledge and skills	DPC, AR, PR, MR, MKSAP	AE, AR, MR, SR, TR, MKSAP
Develop and implement strategies for filling gaps in knowledge and skills	DPC, AR, PR, MR, MKSAP	AE, AR, MR, SR, TR, MKSAP
Accepts guidance from more experienced physicians and uses scientific evidence and practice outcomes for practice improvement.	DPC, AR, PR, MR	AE, AR, MR, SR, TR
Readily acknowledges practice omissions (errors) determined by self or supervisors and takes corrective measures.	DPC, AR, PR, MR, PSQI	AE, AR, MR, SR, TR, PQSI

Goals and Objectives: : PGY-2 (in addition to above)	Learning Activities*	Assessment
Develop plans for practice improvement from feedback.	DPC, AR, PR, MR, PSQI	AE, AR, MR, SR, TR, PQSI
Reduces level/rate of practice omissions from PGY-1 level (errors).	DPC, AR, PR, MR, PSQI	AE, AR, MR, SR, TR, PQSI
Improves efficiency of patient care (timelines) while maintaining quality and thoroughness.	DPC, AR, PR, MR, PSQI	AE, AR, MR, SR, TR, PQSI

Goals and Objectives: : PGY-3 (in addition to above)	Learning Activities*	Assessment
Continues to progressively reduce practice omissions/commissions from R-1, R-2 levels.	DPC, AR, PR, MR, PSQI	AE, AR, MR, SR, TR, PQSI
From medical knowledge and patient care experiences is able to question patient care practices not supported by scientific evidence/evidenced based care.	DPC, AR, PR, MR, PSQI, EBM	AE, AR, MR, SR, TR, PQSI
Develop PI skills to use in independent practice	DPC, AR, PR, MR, PSQI	AE, AR, MR, SR, TR, PQSI

4) Interpersonal Skills and Communication

Goals and Objectives: : PGY-1	Learning Activities*	Assessment
Communicate effectively with patients and families	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS
Communicate effectively with physician colleagues at all levels	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS
Communicate effectively with all non-physician members of the health care team to assure comprehensive and timely care of patients	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS
Present patient information clearly, in notes and during presentations	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS

Goals and Objectives: : PGY-2 (in addition to above)	Learning Activities*	Assessment
Successfully communicate with patients and families in a group meeting	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS
Supervise, lead, manage and teach more junior housestaff and medical students.	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS
Present patient information concisely and clearly, verbally and in writing at an advanced level	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS

Goals and Objectives: : PGY-3 (in addition to above)	Learning Activities*	Assessment
Successfully communicate with patients and families that may be considered difficult (angry, anxious, etc) advanced level	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS
Become fascicle at discussing difficult issues such as end of life care and delivering bad news	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS
Effectively teach students and junior trainees to improve their communication skills	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS

5) Professionalism

Goals and Objectives: : PGY-1	Learning Activities*	Assessment
Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues while maintaining confidentially.	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS
Always act in a moral, honest professional manner, and maintain appropriate relations with patients.	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS
Respect and defend each patient's autonomy and privacy and always act in the patients' best interest	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS

Goals and Objectives: : PGY-2 (in addition to above)	Learning Activities*	Assessment
Maintain a good record of attendance at conferences, completion of assignments, participation in clinical and didactic activities, prompt completion of dictations	DPC, AR, MR, PCR, MKSAP	AE, AR, RMR, SR, MS
Understand and apply principles of medical ethics toward patients, families, colleagues, and all members of the health care team	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS

Goals and Objectives: : PGY-3 (in addition to above)	Learning Activities*	Assessment
Understand the principles of moral and ethical behavior required of an independent practitioner	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS
Become familiar with actual or potential conflicts of interest; particularly those involving personal financial gain.	DPC, AR, MR, PCR	AE, AR, RMR, SR, MS

6) Systems-Based Practice

Goals and Objectives: : PGY-1	Learning Activities*	Assessment
Understand and utilize the multidisciplinary resources necessary to care optimally for patients	DPC, MR, AR, AuR	AE, AR, RMR, SR
Collaborate with other members of the health care team to assure comprehensive patient care	DPC, MR, TR, SR, AR	AE, AR, RMR, SR
Use evidence-based, cost-conscious strategies in the care of patients	DPC, AR, EBM , JC	AE, AR, RMR, SR, EBM, JC

Goals and Objectives: : PGY-2 (in addition to above)	Learning Activities*	Assessment
Apply evidence-based and cost-conscious strategies toward disease prevention, diagnosis and disease management.	DPC, MR, TR, SR, AR	AE, AR, RMR, SR
Develop understanding of the role of non-physician personnel in the care of patients	DPC, MR, TR, SR, AR	AE, AR, RMR, SR
Learn to efficient lead a team through management rounds	DPC, MR, TR, SR, AR	AE, AR, RMR, SR

Goals and Objectives: : PGY-3 (in addition to above)	Learning Activities*	Assessment
Develop lifelong strategies to optimize care for individual patients as an independent practitioner	DPC, MR, TR, SR, AR	AE, AR, RMR, SR

REFERENCE LIST

*All residents are expected to read about their patients in an appropriate general medicine text. Because it is frequently updated, extensively reference, and includes abstracts of reference articles, the program highly recommends UpToDate as primary information source.

• MD Consult
• Rosen's Emergency Medicine
• Clinical Procedures

1. Rosen and Barkin, et al, Emergency Medicine, Concepts and Clinical Practice (Three Volumes) Mosby
2. Tintinali, et al, Emergency Medicine, A Comprehensive Study Guide, McGraw-Hill
3. Goldfrank, et al, Toxicologic Emergencies, Appleton & Lange
4. Roberts and Hedges, Clinical Procedures in Emergency Medicine, WB Saunders
5. Hamilton, et al, Emergency Medicine, An Approach to Clinical Problem Solving, WB Saunders
6. Simon and Koenigsknecht, Emergency Orthopedics, The Extremities, Appleton & Lange
7. Advanced Cardiac Life Support Text, American Heart Association

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