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Rotation Curriculum Dept of Medicine Residency Program Date Reviewed:_16 May 05____ pproved RP!

C_"0 #une 05 Reviewed 1$ #une "00% Rotation: General Medicine Inpatient Services (MCG and VA) !ducational Purpose: &o provide supervised patient care and educational opportunities to develop t'e following competencies of internal medicine: 'umanistic practice( professionalism( medical et'ics( lifelong learning( clinical met'od( continuity of care( medical interview( p'ysical diagnosis( clinical p'armacology( nutrition( palliative care( and disc'arge planning) &'e resident *y t'e end of t'e rotation s'ould 'ave improved and advanced 'is level of competency in t'e principles of management of t'e most common medical conditions necessitating 'ospitali+ation on general medical wards) &eac'ing Met'ods: 1) ,edside instruction: ,edside teac'ing rounds on all su*-ects pertinent to specific patient at 'and) Constitutes ma-ority of minimum .)5 'rs wee/ly teac'ing rounds wit' attending p'ysician) ") 0mall group discussion: &eam rounds or in team conference discussing specific cases( general concepts appropriate to specific cases) $) Personal feed*ac/: Daily as indicated to specific residents *y attending) 0ummary evaluation at mid1 and end1rotation) .) !valuation and review of write ups: ll write ups( progress notes( and disc'arge summaries will *e reviewed *y attending( wit' written corrections and comments to resident as indicated for improvement) ttendings are e2pected to complete one formal inpatient medical record review of eac' resident during t'e rotation) 5) Didactic lectures: Residents are e2pected to attend morning report( noon conferences( and Medicine 3rand Rounds w'ile on service) Residents are e2pected to present case management discussions at morning report on assigned dates( in accordance wit' case management format) 6) ssigned readings: Residents are e2pected to 'ave wor/ing /nowledge ac4uired *y reading t'e following at t'e times noted: P3511 6irst rotation: 1) 7urst #8) &'oug'ts *out ,ecoming an 9ntern on a Medical 0ervice( Resident and Staff Physician( 1::; < ugust=: 6:1%$) ") Washington Manual of Medical Therapeutics C'apters on Patient Care in 9nternal Medicine( >utritional &'erapy( 6luid and !lectrolyte Management( 7eart 6ailure( Pulmonary Diseases( nti1

micro*ials( 3astrointestinal Diseases( ?iver Disease( Dia*etes Mellitus( and >eurological Disorders) $) Cecil Textbook of Medicine, ""nd edition( "00. C'apter 1: pproac' to t'e Patient C'apter ": ,ioet'ics in t'e Practice of Medicine C'apter $: Care of Dying Patients and &'eir 6amilies C'apter 6: 9nterpretation of Data for Clinical Decisions OR Harrisons Principles of nternal Medicine, 16t' edition( "005 C'apter 1: &'e Practice of Medicine C'apter ": Decision1Ma/ing in Clinical Medicine C'apter :: Palliative and !nd1of1?ife Care .) @roen/e @) &'e Case Presentation: 0tum*ling ,loc/s and 0tepping 0tones) !" # Med 1:;5A %::605160;) 0econd rotation: 1) Washington Manual of Medical Therapeutics C'apters on 7ypertension( llergy19mmunology( &reatment of 9nfectious Diseases( 79B( and nemia ") Cecil Textbook of Medicine, ""nd edition( "00. C'apter "6: Delirium and Ct'er Mental 0tatus Pro*lems in t'e Clder Patient C'apter "%: Principles of Drug &'erapy C'apter ":: Pain C'apter $$: ntit'rom*otic &'erapy C'apter 56: 7eart failure: Management and Prognosis C'apter ;1: pproac' to t'e Patient wit' Respiratory Disease C'apter :": Cverview of Pneumonia C'apter 1$0: pproac' to t'e Patient wit' 3astrointestinal Disease C'apter ."$: pproac' to t'e Patient wit' >eurological Disease OR Harrisions Principles of nternal Medicine( 16t' edition( "005 C'apter "5%: cute Confusional 0tates and Coma C'apter $: Principles of Clinical P'armacology C'apter 11: Pain: Pat'op'ysiology and Management C'apter 10$: ntiplatelet( nticoagulant( and 6i*rinolytic &'erapy C'apter "16: 7eart 6ailure and Cor Pulmonale C'apter "$$: pproac' to t'e patient wit' disease of t'e respiratory 0ystem C'apter "$:: Pneumonia C'apter "%1: pproac' to t'e patient wit' gastrointestinal disease

C'apter $.6: pproac' to t'e patient wit' neurological disease &'ird Rotation: Cecil Textbook of Medicine, ""nd edition( "00. C'apter ;5: C'ronic C*structive ?ung Disease C'apter :.: Pulmonary !m*olism C'apter 110: pproac' to t'e Patient wit' Renal Disease C'apter 10.: 0'oc/ 0yndromes Related to 0epsis C'apter 1$$: 3astrointestinal 7emorr'age C'apter 1.;: pproac' to t'e Patient wit' ?iver Disease C'apter 156: Cirr'osis and its 0e4uelae C'apter 1:;: ?ung Cancer and ot'er Pulmonary >eoplasms C'apter ".": Dia*etes Mellitus OR Harrisons Principles of nternal Medicine, 16t' edition( "005 C'apter ".": C'ronic C*structive Pulmonary Disease C'apter "..: Pulmonary &'rom*oem*olism C'apter .0: +otemia and Drinary *normalities C'apter "5.: 0evere sepsis and septic s'oc/ C'apter $%: 3astrointestinal *leeding C'apter ";": pproac' to t'e patient wit' liver disease C'apter ";;: lco'olic ?iver disease C'apter ";:: Cirr'osis and its complications C'apter %5: >eoplasms of t'e lung C'apter $"$: Dia*etes mellitus 6ourt' Rotation Cecil Textbook of Medicine, ""nd edition( "00. C'apter ";.: &'e 0ystemic Basculitides C'apter $0$: Pneumococcal Pneumonia C'apter $.1: &u*erculosis C'apter .1.: >eurological Complications of 79B C'apter .$$: l+'eimerEs Disease and Ct'er Diagnoses of Cognition C'apter .$5: 0yncope C'apter .5;: >utritional and lco'ol1Related >eurological Disorders OR Harrisons Principles of nternal Medicine, 16t' edition( "005 C'apter $06: &'e vasculitis syndromes C'apter 11:: Pneumococcal infections C'apter 150: &u*erculosis C'apter 1%$: 79B disease( pages 10:%1:;( 1115111"0 C'apter $50: l+'eimerEs Disease and ot'er dementias C'apter "0: 0yncope( 6aintness( Di++iness( and Bertigo C'apter $%": lco'ol and lco'olism

P351" 6irst Rotation: 1) Cassell( !#) &'e >ature of 0uffering and t'e 3oals of Medicine( $%#M 1:;"A $06: 6$:16.5 ") 0mit' RC( 7oope R,) &'e PatientEs 0tory: 9ntegrating t'e Patient1 and P'ysician1centered pproac'es to 9nterviewing) !nn ntern Med 1::1A 115: .%01.%%) $) merican ,oard of 9nternal Medicine) Clinical Competence in 9nternal Medicine) !nn ntern Med 1:%:A :0: .0"1.11) .) !pstein RM( 7undert!M) Defining and ssessing Professional Competence) # M "00"A ";%: ""61"$5) 5) Creditor M) 7a+ards of 7ospitali+ation of t'e !lderly) !nn ntern Med 1::$A 11;: "1:1""$) 6) Morrison R0( Meier D!) Palliative Care) $%#M "00.: $50:"5;"1 "5;:) %) Bon @orff M( et al) Colla*orative Management of C'ronic 9llness) !nn ntern Med 1::%A 1"%: 10:%1110") ;) >o'ria ( ?ewis !( 0tevenson ?8) Medical Management of dvanced 7eart 6ailure) #!M! "00"A ";%:6";16.0) :) Man 06( Mc lister 6 ( nt'oniesen >R) 0in DD) Contemporary Management of C'ronic C*structive Pulmonary Disease: Clinical pplications) #!M! "00$A ":0: "$1$1"$16) 0econd Rotation: 1) drogue 7#( Madias >) 7yponatremia) $%#M "000A $.":1.:$11.::) ") 0waroop B0( C'ari 0&( Clain #!) 0evere cute Pancreatitis) #!M! "00.A ":1: ";651";6;) $) 8outers !6M) Management of 0evere CCPD) &ancet "00.A $6.: ;;$1;:.) .) C'un ( Mc3ee 0R) ,edside Diagnosis of Coronary rtery Disease: 0ystematic Review) !" # Med "00.: 11%: $$.1$.$) 5) Mc3ee 0( *ernet'y 8,( 0imel D?) 9s t'is Patient 7ypovolemicF #!M! 1:::A ";1: 10""110":) 6) ,allantyne #C( Mao #) Cpiod &'erapy for C'ronic Pain) $%#M "00$A $.::1:.$11:5$) %) ?evine #0( ,ranc' D8) Rauc' #R) &'e ntip'op'olipid 0yndrome) $%#M "00"A $.6: %5"1%6") P351$ 6irst Rotation: P9!R <www)acponline)org= Dia*etes Mellitus 99

Dia*etic @etoacidosis Congestive 7eart 6ailure Basculitis Dementia Delirum DB& CCPD 0econd Rotation: Renal 6ailure 0ystemic ?upus !ryt'ematosis Mi2 of diseases: Pulmonary Diseases: CCPD( ast'ma( lung cancer( cystic fi*rosis( pneumot'ora2( restrictive and interstitial lung diseases( lung a*scess( sarcoidosis) 3astrointestinal Disease: acute and c'ronic pancreatitis( upper and lower gastrointestinal *leeding( cirr'osis( c'ronic and acute liver failure( 'epatitis( 3!RD( gastrointestinal malignancy( diverticulitis( inflammatory *owel disease( diarr'ea( constipation( gastroparesis) Cardiac Disease: C76( syncope( arr'yt'mias( pericarditis( c'est pain 9nfectious Diseases: pneumonia( cellulitis( 79BG 9D0( pyelonep'ritis( Meningitis( septic art'ritis >eurological: Delirium( dementia( sei+ure disorder( personality disorders( depression( an2iety disorders( sc'i+op'renia( syndromes of mental retardation( encep'alitis( encep'alopat'y <post1ano2ic=( persistent vegetative state) Meta*olic Disorders: 7ypertension( dia*etes and dia*etic complications( t'yroid( adrenal( pituitary( ovarian( testicular disorders( electrolyte distur*ances) Renal: acute and c'ronic renal disorders Collagen vascular diseases Patient c'aracteristics: Most patients will *e very seriously ill( wit' near end1stage disease( poor prognosis( and multiple interacting pat'ologies) &'ey will also 'ave severe psyc'ological( social( economic and spiritual comple2ities resulting from and contri*uting to t'eir disease) Most patients and t'eir families will *e suffering) &'ey will comprise adults from age 1% upwards( from predominantly poor to middle1class socio1 economic *ac/ground( of all races and *ot' genders) Predominant religious preference and cultural *ac/ground will *e sout'ern ,lac/ evangelical C'ristian) 6amily and social support will range from e2tensive to a*sent) Patients will include t'ose transferred from state correctional and domiciliary facilities( as well as nursing 'omes( intensive care units( and re'a*ilitation facilities( emergency rooms( clinics( and outside 'ospitals) &ypes of clinical encounters: 9n patient evaluation( management and disc'arge planning)

&ypes of procedures: ?um*ar puncture( *ladder cat'eteri+ation( t'oracentesis( paracentesis( -oint aspiration ( central venous cat'eter <femoral=( arterial *lood gas( pea/ flow measurement( PPD s/in testing( >3 tu*e( C" monitoring( cognitive assessment &ypes of services provided: cute inpatient care( palliative care( disc'arge planning

!ducational Resources to *e used: 1) Re4uired reading: s a*ove ") ?i/ely opportunistic reading: Pu*Med( 'p to (ate( ot'er on1line resources as appropriate) $) Pat'ological material: *iopsies( smears( cytology( autopsy material) Residents are encouraged to loo/ at all specimens personally) .) Ct'er educational resources to *e used: Pre and Post testing as developed) Definition of level of resident supervision *y faculty in all patient1care activities ttending faculty p'ysicians are ultimately responsi*le for t'e outcome of all patient care in *ot' t'e medical and legal sense) &'ey delegate t'is care in order to train residents 'ow to care for patients t'emselves) 0upervision is graded to t'e level of training of t'e resident and education is individuali+ed to t'e needs and level of t'e individual trainees on t'e ward team) &'e P3511 is responsi*le for up to 1" patients at one time) &'e P3511 is t'e primary caregiver to t'e patient as is identified as t'e HpatientEs doctor)I 7e develops t'e diagnostic and t'erapeutic plan after discussion wit' t'e P351"G$ and attending( and is responsi*le for t'e implementation of all diagnostic and t'erapeutic management( to include procedure( retrieval and assessment of diagnostic tests and coordination of multidisciplinary( consultative( and disc'arge related resources) &'e P35 "G$ is responsi*le for up to "6 patients at one time) 7e supervises t'e P3511 and su*intern and students in performance of duty( writes admission 'istory( p'ysical and initial plan of care( facilitates interpretation of diagnostic and t'erapeutic outcome s and disc'arge planning) &'is resident is responsi*le for timely and complete dictated summaries( *ut may delegate t'is duty to t'e P3511( *ut not any medical student) 7e mentors and teac'es su*ordinates and nursing and ot'er ancillary care1givers( develops case reports and clinical researc' appropriate to case managed( and prepares discussion of cases for management conference( mor*idityGmortality conference( s'ow and tell( and ot'er departmental conferences) P351$ residents are e2pected to conduct greater 4uantity and 4uality of teac'ing( mentoring( and 4uality improvement activities t'an P351" residents) &'e attending is t'e final level of responsi*ility to t'e educational and service mandates of t'e ward e2perience) &'e attending identifies t'e specific education needs of eac' of t'e su*ordinate mem*ers of t'e ward team and facilitates t'eir ma2imum competency *y supervising( evaluating( giving feed*ac/( and teac'ing appropriate to eac' team mem*er( w'ile assuring t'at e2cellent patient care is provided) ) ?ines of Communication:

Multiple lines of communication are necessary to ensure *ot' educational and patient care o*-ectives) PatientG6amilyG>urse communication: &'e primary line of communication is from t'e patient to 'is or 'er Hp'ysician(I t'e P3511 or su*intern) &'is p'ysician s'ould *e t'e first to see patients daily( *e t'e first to enter t'e room on wor/ rounds( and present cases at t'e *edside at teac'ing rounds( unless t'e M0M1$ student is presenting) Ma-or re4uest and needs are to *e e2pressed *y t'e patient and nurses to t'e P3511 and solved at t'at level first) dditionally( significant counseling of t'e patient( suc' as results of diagnostic test( planned t'erapy( H*ad news(I advance directives( etc)( is t'e duty of t'e P3511 to initiate and complete) 9f communication pro*lems e2ist *etween t'e patient or nurse and P3511 or su*intern( t'e patient or nurse will ne2t pursue communication wit' t'e P351"G$) 9f communication is unsuccessful 'ere( t'e attending will *e called) ny failure of communication a*ove t'e level of t'e P3511 will *e evaluated *y t'e attending( wit' appropriate feed*ac/) Crders are to *e written *y t'e P3511 e2cept in only rare and emergent circumstances *y ot'er on t'e team at t'e P35"G$ or attending level) &'e attending is to *e called *y t'e P35"G$ on eac' admission wit'in . 'ours of acceptance) &'e attending is to *e informed of t'e tentative diagnosis( management issues( and prognosis in order to determine 'is need to personally evaluate t'e patient wit'in a timely manner) &'e attending will see all patients and write 'is note wit'in ". 'ours of admission) 6or consultations( t'e primary line of communication s'ould *e *etween t'e attending and attending consultant) &'e attending p'ysician s'ould sign all consult re4uests after discussing t'e reason for t'e consultation wit' t'e residents) &'e attending may delegate calling in of consultation *y t'e resident if t'e typical procedure involves first discussion at a resident or fellow level) Consultation recommendations are to *e implemented only after discussion *y t'e attending and residents and discussion of decisions *etween t'e P3511 and patient) !2pectations of Residents and ttendings as &eac'ers 1) Role of t'e P3511: &'ey instruct students 'ow to write orders( do certain procedures( arrange testing and consultations( and find and interpret la*oratory and study results) &'ey discuss on a daily *asis management issues relating to -ointly managed patients) &'ey read( correct( and countersign studentEs daily progress notes( and t'ey contri*ute to case1 related teac'ing t'at occurs on wor/ rounds( attending rounds( and seminars) ") Role of t'e P351"GP351$: Residents review t'e e2pectations of t'e student on t'e ward service and set standards t'at are specific to t'e service and to t'e residentEs teac'ing style) Residents are e2pected to engage case1*ased teac'ing around cases 'andled *y students( specifically at times of decreased patient management activity( suc' as at nig't( on call( and prior to sc'eduled conferences) &'is entails ensuring ade4uate data collection <appropriate 'istory( p'ysical and la* results= *y t'e student( reviewing t'e studentEs understanding of eac' pro*lem and management plan( reviewing eac' student write1upA practice and coac' t'e student in moc/1presentation of t'e case *efore t'e student presents to t'e attending( and assist t'e student in

gaining /nowledge of /ey principles of pat'op'ysiology and case1 management pertinent to t'e rotation) Residents are also to provide immediate and on1going feed*ac/ to students on all aspects of t'eir performance( as well as provide summative evaluation at mid and end of rotation) $) 8ard attending will teac' students during ward teac'ing rounds as appropriate to t'eir level( give feed*ac/ on /nowledge( participation in patient care( and demonstrated 4ualities of professionalism( communication s/ill( practice1*ased learning( and systems1*ased practice) &eac'ing attending will review and grade . patient write1ups during t'e rotation( and provide students1only *edside teac'ing for " 'ours wee/ly) .) P3511( "( and $ residents( along wit' t'e ward attending will participate in a facilitated grading session at t'e end of eac' M0M1$ student rotation) Met'od of evaluation of resident competence and 4uality of care 1) !2pected standards of competence and 4uality: Residents are e2pected to demonstrate attitudes( s/ills( and *e'aviors consistent wit' t'e competency level appropriate for level of P35 training for t'e following a) C3M! Competencies i) Patient care: p'ysician patient interaction <p'ysical and written= t'at is compassionate( appropriate and effective for t'e treatment of 'ealt' pro*lems and promotion of 'ealt'( *ased on standards of evidence in t'e medical literature) ii) Medical /nowledge: understanding and facility a*out esta*lis'ed and evolving *iomedical( clinical and cognate sciences <e)g) epidemiological and social1*e'avioral= and t'e application of t'is /nowledge to patient care) iii) Practice1*ased learning and improvement t'at involves investigation and evaluation of t'eir own patient care( appraisal and assimilation of scientific evidence and improvement in patient care) iv) 9nterpersonal and communication s/ills: t'at result in effective information e2c'ange and teaming wit' patients( t'eir families and ot'er 'ealt' professionals v) Professionalism( as manifested t'roug' a commitment to carrying out professional responsi*ilities( ad'erence to et'ical principles and sensitivity to a diverse patient population) vi) 0ystem1*ased practice( as manifested *y actions t'at demonstrate an awareness of and responsiveness to t'e large conte2t and system of 'ealt' care and t'e a*ility to effectively call on system resources to provide care t'at is of optimal value) *) 9nstitute of Medicine Juality ims i) 0afety: voiding in-uries to patient from t'e care t'at is intended to 'elp t'em)

ii) &imely: Reducing waits and potentially 'armful delays for *ot' t'ose w'o receive and w'o give care) iii) !ffective: Providing services *ased on scientific /nowledge to all w'o could *enefit and refraining from providing services to t'ose not li/ely to *enefit <avoiding underuse and overuse( respectively= iv) !fficient: voiding waste( including waste of e4uipment( supplies( ideas and energy v) !4uita*le: Providing care t'at does not vary in 4uality *ecause of personal c'aracteristics suc' s gender( et'nicity( geograp'ic location and socio1economic status) vi) Patient centered: Providing care t'at is respectful of and responsive to individual patient preferences( needs and values and ensuring t'at patient values guides all clinical decisions) ") Met'ods of measurement a= Ct'er direct o*servation *y more senior residents and attending on wor/ and teac'ing rounds( management of individual patients( o*servation of procedures <Patient care( 9CM Juality ims= *= !ac' intern and resident will 'ave one admission note evaluated and formally graded using t'e H*lue s'eetI inpatient evaluation form( wit' feed*ac/ given resident on areas needing improvement <Patient care( communication=) c= !ac' intern and resident will 'ave one disc'arge summary evaluated and formally graded using a standardi+ed evaluation form( wit' feed*ac/ given t'e resident on areas needing improvement <Patient care( communication( 9CM Juality ims( 0,P=) d= Pre and post tests *ased on assigned readings administered at *eginning of mont' and su*se4uent mont' <Medical /nowledge= e= Monitoring and recording of adverse events as determined at morning report and *y report of nurses to attending <Patient care( practice *ased learning( professionalism=) f= Monitoring of patient complaints to nurses( attendings( 'ospital) 0cores on patient satisfaction surveys <Patient care( P,?( 0ystems1 *ased practice( 9CM Juality ims= g= Prospective monitoring of compliance wit' specific patient care guidelines suc' as community ac4uired pneumonia( acute coronary syndrome( alco'ol wit'drawal( potassium infusion( and ot'er protocols <Patient care( 0MP= '= 3raded essays and presentations on topics germane to patients seen on rotation( su*mitted to portfolio as directed *y attending <Medical /nowledge( P,?=) i= ttendance at re4uired conferences <Professionalism( P,?=) -= 8or/ 'ours report to ensure no more t'an ;0 'ours wor/ per wee/ in accordance wit' RRC guidelines <0,P( Professionalism=)

/= Monitoring of D7C cost( ?C0( and outcome data for team and individual mem*ers <Patient care( 0,P( 9CM Juality ims= l= 6ormal grading of patient evaluation and management via Cne .5 system <all competences=) $) Provision of 6eed*ac/ a) Daily feed*ac/ is to *e given to residents *y superiors regarding performance in all domains as appropriate: encouraging goodGe2cellent *e'avior( and facilitating recognition of areas needing improvement and means to improve) *) Mid rotation feed*ac/ is to *e given to residents *y superiors regarding overall performance in all 6 competencies and all 6 4uality domains) 8'en possi*le t'is s'ould *e written( wit' specific goals for improvement during t'e remainder of t'e rotation) .) Documentation of evaluation: !valuation will *e documented *y completion of forms a*ove( written documentation of significant negative or positive feed*ac/ <to program director=( and end of rotation completion of Cne .5 on line evaluation *y t'e attending( as well as peer evaluations *y residents) 5) &ransmission of evaluation to resident a= !nd of rotation out*rief: at end of rotation( attending will meet wit' resident to discuss performance and means of improvement) *= 8ritten evaluation on Cne .5) c= Compilation of all reports into personal performance file and resident portfolio)