CompetencyBased Curriculum
OVERVIEW
This assignment blends several overlapping educational experiences. First,
it offers interns and Junior/Senior Assistant Residents opportunities
care for inpatients with a variety of medical illnesses during the night.
This allows for greater autonomy in making critical patient care decisions.
A second valuable aspect of this assignment includes the chance to independently
assess, triage, and admit patients in the emergency department and to
mimic the roles of attending physicians (including coordinating care choosing
consultants, and communicating with attending physicians at night). And
third, the residents care for patients as part of a team (developing effective
communication skills, improving sign outs, reducing error during transfer
of care). Finally, residents will carry out and learn the principles of
general medical consultation when required.
Residents function under the direct supervision of the admitting physician
caring for the patient. Additional supervision comes from the faculty
and chief resident.
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.
-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.
- 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.)
-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.
DESCRIPTION OF THE ROTATION
Two Interns and one Junior/Senior Assistant Resident are assigned to this
service each month. Residents will care for patients and admit new patients
from the emergency room. The team will be responsible for the care of
all in-hospital general medicine patients on the teaching services. In
addition they will evaluate and appropriately triage any patients they
are consulted on by the emergency department. They will have no responsibility
for patients in the critical care units.
The resident should take face-to-face verbal and written sign-outs from
the out-going team. The incoming tem must become intimately familiar with
all patients, especially those whose clinical status is unstable. All
patients who need evaluation will be seen and appropriate notes, decisions,
and dispositions effected. Residents will have the opportunity to discuss
patient issues with attendings over the phone as necessary or whenever
they feel that discussion would improve patient care.
Resident will also have the opportunity to discuss any questions or issues
with faculty and the chief resident at morning report. The team will also
be responsible for presenting all overnight events on the inpatient units
as well as all patients admitted overnight. The team is expected to have
completed a didactic search to answer any clinically relevant patient
care questions that came up during the night. Residents have a responsibility
to provide this didactic information appropriate to the incoming teams.
They are expected to have relevant medical literature when appropriate
to use to supplement discussion of patient management.
GOALS AND OBJECTIVES
The principle objective for this month is to complement other resident
experiences enabling residents to learn how to function independently
in assessing and caring for sick emergency room and hospitalized patients.
As noted, this involves emergency room triage, routine admissions, medical
consultations, and acute emergent problems.
Residents will gain familiarity, above and beyond other general medical
experiences, with diagnosis, differential diagnosis, pathophysiology,
management, and preventative aspects of patient care. In addition, they
will develop leadership, self study and educational, and QI project development
skills. They will also learn the value of developing and maintaining a
portfolio.
Specific objectives:
- Master medical management of surgical, obstetrics/gynecologic, psychiatric,
orthopedic and podiatric and other non-medical patients.
- Manage acute medical emergencies.
- Manage general medical patients and problems encountered in hospitalized
patients (as and detailed in the critical care, cardiac care, and inpatient
general medicine curricula).
- Learn the skills of receiving and giving appropriate sign-out when transferring
care of a patient form one team to another.
- Learn to evaluate the transfer process and develop initiatives to improve
hand-off and reduce errors.
- Master evidence-based, cost effective, contemporary management of medical
patients and problems.
- Develop leadership and team-building skills.
- Master procedures that an internist is required to perform on in-hospital patients.
- Develop self-guided study skills.
- Develop and maintain a portfolio of experiences, educational activities,
and scholarly endeavors, accomplishments.
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)
MS-Multisource evaluations
ACC-Ambulatory Care Conference
AE-Attending Evaluations
AR- 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
NC- Noon Conference
DPC-Direct Patient Care
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, RMR, SR |
AE, SR, RMR, |
Master basic patient exam skills |
DPC, RMR, SR |
AE, SR, RMR, |
Master basic psycho-social evaluation skills |
DPC, RMR, SR |
AE, SR, RMR, |
Define and prioritize patients' medical problems |
DPC, R MR, SR |
AE, TR, SR, RMR |
Generate and prioritize differential diagnoses |
DPC, RMR, SR |
AE, TR, SR, RMR |
Develop rational, evidence-based management strategies |
DPC, RMR, SR |
AE, TR, PR, RMR |
Goals and Objectives: : PGY-2 (in addition to above) |
Learning Activities* |
Assessment |
Interview patients more skillfully |
DPC, RMR, SR |
AE, SR, R MR, |
Examine patients more skillfully |
DPC, RMR, SR |
AE, SR, RMR, |
Evaluate psycho-social issues more skillfully |
DPC, RMR, SR |
AE, SR, RMR, |
Define and prioritize patients' medical problems |
DPC, R MR, SR |
AE, TR, SR, RMR |
Generate and prioritize differential diagnoses |
DPC, RMR, SR |
AE, SR, R MR, |
Develop rational, evidence-based management strategies |
DPC, RMR, SR |
AE, SR, RMR, |
Manage a large volume of patients |
DPC, RMR, SR |
AE, SR, RMR, |
Develop and display leadership skills and responsibility |
DPC, R MR, SR |
AE, TR, SR, RMR |
Learn to be team leaders |
DPC, RMR, SR |
AE, TR, SR, RMR |
Learn to be efficient teachers |
DPC, RMR, SR |
AE, TR, PR, RMR |
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, RMR, SR, MKSAP |
AE, SR, RMR, , MKSAP |
Access and critically evaluate medical information and scientific evidence
relevant to patient care |
DPC, RMR, SR, MKSAP |
AE, SR, RMR, , MKSAP |
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, RMR, SR, MKSAP |
AE, SR, R MR, , MKSAP |
Access and critically evaluate medical information and
scientific evidence relevant to patient care
|
DPC, RMR, SR, MKSAP |
AE, SR, RMR, , MKSAP |
Teach medical students and interns |
DPC, RMR, SR, MKSAP |
AE, SR, RMR,, MKSAP |
Read relevant articles and literature in journals |
DPC, R MR, SR, MKSAP |
AE, TR, SR, RMR, MKSAP |
3.) Practice- Based Learning and Improvement
Goals and Objectives: : PGY-1 |
Learning Activities* |
Assessment |
Identify and acknowledge gaps in personal knowledge and skills |
DPC, RMR, SR. PSQI |
AE, SR, R MR, PSQI |
Develop and implement strategies for filling gaps in knowledge and skills |
DPC, RMR, SR, PSQI |
AE, SR, RMR, PSQI |
Accepts guidance from more experienced physicians and uses scientific evidence
and practice outcomes for practice improvement. |
DPC, RMR, SR, PSQI |
AE, SR, RMR, PSQI |
Readily acknowledges practice omissions (errors) determined by self or
supervisors and takes corrective measures. |
DPC, R MR, SR, PSQI |
AE, TR, SR, RMR, PSQI |
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 |
4) Interpersonal Skills and Communication
Goals and Objectives: : PGY-1 |
Learning Activities* |
Assessment |
Communicate effectively with patients and families |
DPC, RMR, SR |
AE, SR, R MR, |
Communicate effectively with physician colleagues at all levels |
DPC, RMR, SR |
AE, SR, RMR, |
Communicate effectively with all non-physician members of the health care
team to assure comprehensive and timely care of patients |
DPC, RMR, SR |
AE, SR, RMR, |
Present patient information clearly, in notes and during presentations |
DPC, R MR, SR |
AE, TR, SR, RMR |
Goals and Objectives: : PGY-2 (in addition to above) |
Learning Activities* |
Assessment |
Successfully communicate with patients and families in a group meeting |
DPC, RMR, SR |
AE, SR, R MR, |
Supervise, lead, manage and teach more junior housestaff and medical students. |
DPC, RMR, SR |
AE, SR, RMR, |
Present patient information concisely and clearly, verbally and in writing
at an advanced level |
DPC, RMR, SR |
AE, SR, RMR, |
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, RMR, SR |
AE, SR, R MR, |
Always act in a moral, honest professional manner, and maintain appropriate
relations with patients. |
DPC, RMR, SR |
AE, SR, RMR, |
Respect and defend each patient's autonomy and privacy and always act
in the patients' best interest |
DPC, RMR, SR |
AE, SR, RMR, |
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, RMR, SR |
AE, SR, R MR, |
Understand and apply principles of medical ethics toward patients, families,
colleagues, and all members of the health care team |
DPC, RMR, SR |
AE, SR, RMR, |
6) Systems-Based Practice
Goals and Objectives: : PGY-1 |
Learning Activities* |
Assessment |
Understand and utilize the multidisciplinary resources necessary to care
ptimally for patients |
DPC, RMR, SR |
AE, SR, R MR, |
Collaborate with other members of the health care team to assure comprehensive
patient care |
DPC, RMR, SR |
AE, SR, RMR, |
Use evidence-based, cost-conscious strategies in the care of patients |
DPC, RMR, SR |
AE, SR, RMR, |
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.
REFERENCE LIST
*All residents are expected to read about their patients in an appropriate
general medicine text. In addition, a vast variety of print and on-line
reference material is available though the library (24-hour access for
all residents) and the on-line portal. Because it is frequently updated,
extensively referenced, and includes abstracts of reference articles,
the program highly recommends UpToDate as an adjunctive information source.
MDConsult is also a valuable resource and residents should become familiar
with use as a rapid search engine for clinical information
REFERENCES FOR THE NIGHT ADMITTING TEAM ROTATION
1. Adams J, Murray R. The general approach to the difficult patient. Emergency
Medicine Clinics of North America 1998; 16:689-99.
2. O'Keefe KP, Sanson TG. Elderly patients with altered mental status.
Emergency Medicine Clinics of North America 1998; 4:701-15.
3. Jouriles NJ. Atypical chest pain. Emergency Medicine Clinics of North
America 1998; 16:717-40.
4. Fuller GF. Falls in the elderly. American Family Physician 2000; 7:2159-68.
5. Managing falls in older people. Drug and Therapeutic Bulletin 2000; 38:68-72.
6. Mahoney J. Immobility and falls. Clinics in Geriatric Medicine 1998;
14:699-726.
7. DS Cheung, M Kharasch Evaluation of the patient with closed head trauma:
An evidence based approach. Emergency Medicine Clinics of North America
1999; 17:9-23.
8. Cunningham R, Mikhail M. Management of patients with syncope and cardiac
arrhythmias in an emergency department observation unit. Emergency Medicine
Clinics of North America 2001; 19:105-21.
9. Meyer MD, Handler J. Evaluation of the patient with syncope: An evidence
based approach. Emergency Medicine Clinics of North America 1999; 17:189-201.
10. Bradford JC, Kyriakedes CG. Evaluation of the patient with seizures:
An evidence based approach. Emergency Medicine Clinics of North America
1999; 17:203-20. Night
11. Smith BJ: Treatment of status epilepticus. Neurology Clinics 1999;
19;347-69.
12. Michelson E, Hollrah S: Evaluation of the patient with shortness of
breath: An evidence based approach. Emergency Medicine Clinics of North
America 1999; 17:221- 37.
13. Pianka JD, Affronti J: Management principles of gastrointestinal bleeding.
Primary Care: Clinics in Office Practice 1999; 28:239-61.
14. Peter DJ, Dougherty JM: Evaluation of the patient with gastrointestinal
bleeding: An evidence based approach. Emergency Medicine Clinics of North
America 1999; 17:239- 61.