General Internal Medicine Outpatient/Private Practice Curriculum

Department: Internal Medicine

Faculty Coordinator: Sonya Merrill, M.D., Ph.D.

Hospital: Texas Health Presbyterian Hospital Dallas

Periods offered: All

Length: 4 weeks

Max no. of residents for IM Outpatient: 2 or 3

First Day Contact: As arranged with Private Practice Internist

First Day Time: As arranged with Private Practice Internist

First Day Place: As arranged with Private Practice Internist

Requirements: 8:00 a.m. to 5:00 p.m. Monday through Friday

Weekends: None

1. Course Description:

A course designed to expose Internal Medicine Residents to outpatient internal medicine in the private practice setting. Residents will work one-on-one with a general internist in a private practice, seeing adult patients in the out-patient setting. If the supervising internist admits patients to the hospital, the resident will participate in the management of hospitalized patients as well. This course is designed to teach residents how to manage patients with actue and chronice disease as out-patients, how to evaluate patients for possible hospital admission from the out-patient setting, how to work the out-patient hospital and community resources, and some aspects of managing a private practice. The resident will be evaluated at the end of the rotation by the supervising physician based on the core competencies outlined below in Section II.

Hours: Monday through Friday, 8:00 a.m. to 5:00 p.m. (or as dictated by office hours and hospital rounds)

Phone contacts:

Texas Internal Medicine Assoicates: (214) 368-7787

Dr. Jeffrey Phillips, Dr. Mark Fleschler and Dr. Robert Harris

HealthCore Physicians Group: (972) 284-7000

Dr. Dorothy Sherwood, Dr. Paul Cary, Dr. Jacqueline Hubbard, Dr. Shamim Khambati, Dr. Young Lee, Dr. Susan McKinney, Dr. Andrew Phan and Dr. Randall Wooley

Jackson Internal Medicine Clinic (214) 345-8000

Dr. Mitch Carroll and Dr. Shounak Das

Private Practice:

Dr. Phillip Aronoff (214) 692-5229

Dr. Jamal Lone (214) 346-0602

Dr. Marilyn Horton (214) 239-1938

Dr. Kim Allen (214) 345-5999

II. Course Goals and Objectives: (based on ACGME competencies for resident education)

Patient Care:

Residents are expected to provide care that is compassionate, appropriate and effective for the promotion of health, prevention of illness, treatment of disease and at the end of life.

• Gather accurate, essential information from all sources, including medical interviews, physical examinations, medical records and diagnostic/therapeutic procedures. Examples: Use hospital medical records and outpatient records for data gathering; use complete or limited physical exam, as appropriate; order appropriate diagnostic tests to supplement exam.

• Make informed recommendations about preventives, diagnostic and therapeutic options and interventions that are based on clinical judgement, scientific evidence, and patient preference. Examples: Choose diagnostic and therapeutic procedures based on evidence-based practice recommendations; discuss risks/benefits of treatment options and with patients; use age-appropriate screening for health maintenance and early detection.

• Develop, negotiate and implement effective patient management plans and integration of patient care. Examples: Discuss treatment options with patient and family to make therapeutic plans; utlize outpatient resources, such as physical therapy and occupational therapy to optimze outcomes.

• Perform competently the diagnostic and therapeutic procedures considered essential to the practice of internal medicine. Examples: Basic skills practicing internists use include lab interpretation, EKG, basic x-ray, flex sig, urine analysis via microscope, stool for blood, culture techniques, stethoscope use, otoscope and ophthalmoscope use, literature search skills, computer basics, injections, charting and dictating skills, some concept of equipment purchase and maintenance as well as an inventory of equipment.

Residents are expected to demonstrate knowledge of established and evolving biomedical, clinical and social sciences, and the application of their knowledge to patient care and the education of others.

• Apply an open-minded, analytical approach to acquiring new knowledge. Examples: The database of a practicing internist is a fluid body and without continued reading and conference participation even a freshly graduated resident will be hopelessly behind in a short time. Discuss treatment options with patient and family to make therapeutic plans; utilize outpatient resources, such as physical therapy and occupational therapy to optimize outcomes.

• Access and critically evaluate current medical information and scientific evidence. Examples: Use literature searches in a directed manner; critically review the literature; examine other educational resources for strenghts and weaknesses.

• Develop clinically applicable knowledge of the basic and clinical sciences that underlie the practice of internal medicine. Examples: Understand the normal physiology of different age ranges; understand pharmacology of novel therapeutics, understand the impact of risk factors on strokes, cardiovascular disease, and malignancy.

• Apply this knowledge to clinical problem solving, clinical decision-making, and critical thinking. Examples: Examine and change prescription profiles based on medication interactions and underlying co-morbidities; perform diagnostic procedures based on normal and altered physiology of individual patient; synthesize individual patient plans based on individual risk factors, especially to modify risk factors which are present.

Residents are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices.

• Identify areas for improvement and implement strategies to enhance knowledge, skills, attitudes and processes of care. Examples: Work with multidisciplinary team within the office to maximize patient education and satisfaction with management of CHF, diabetes, and anticoagulation; identify inappropriate prescribing practices, such as polypharmacy in the elderly and inappropriate use of antibiotics; seek to build knowledge regarding community resources for patients.

• Analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient practice. Examples: The private rotation is an opportunity to see good and bad practice strategies. Actively participate in the quality improvement; review of prescribing practices of physicians.

• Develop and maintain a willingness to learn from errors and use errors to improve the system or processes of care. Examples: Perform self-evaluation regarding knowledge, skills and attitudes pertaining to the care of the outpatient; reflect on the errors of other physicans in order to avoid similar errors in your own practice.

• Use information technology or other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education. Example: Use of web based knowledge systems, like Ovid, Pubmed, or UpToDate to review current literature pertaining to the care of the ill or maintenance of the well patient; share pertinent literature with colleagues.

Interpersonal and Communication Skills:

Residents are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families and other members of health care teams.

• Provide effective and professional consultation to other physicians and health care professionals and sustain therapeutic and ethically sound professional relationships with patients, their families, and colleagues. Examples:Demonstrate ability to communicate to a referring physician; demonstrate ability to define role as a member of the health care team within the outpatient office; demonstrate clear and compassionate communication with the patients and their families.

• Use effective listening, nonverbal, questioning, and narrative skills to communicate the patients. Examples: Time is your most critical commodity. You cannot be stingy, hurried, or harassed and communicate with a patient. The hand on the door, the shuffling of feet, and other obvious non-verbal hurry-up clues never work. The time spent listening to the problems is the single most efficient time saver you have. Use active listening skills and open-ended questions to encourage full responses to question; demonstrate listening skills by successful recall of complicated history in patients with difficult histories.

• Interact with consultants in a respectful, appropriate manner. Examples: Learn your teammate's skills and weaknesses, or match the problem and the patient's personality to the consultant. Good consultants need to be honored and respectully consulted with practical considerations to their time and family. Develop the skill of succinctly communicating patient information to the consultant and develop the habit of calling consulting physicians personally, especially for consults that are complicated and urgent.

• Maintain comprehensive, timely, and legible medical records. Examples: Often insurance and legal threats are listed as reasons for keeping good records. The reason for keeping good records is so that you and your partners know what is going on with the patient. Dictate at the time of the visit and never take charts home. Office notes should be legible and completed on the same day as the office visit; current medications should be updated with every visit; pertinent labs should be included in the patient record in a timely fashion, according to the office's usual practice.

Residents are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession, and society.

• Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues. Example: Develop skills of communicating with an angry patient or family member in a professional manner, develop skills of breaking bad news in a compassionate way; demonstrate willingness to bring the patient and family comfort.

• Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues. Example: Make concessions for patient modesty during physical exams by providing a closed environment with gowns and lap drapes; demonstrate respect by addressing patients by formal terms, unless invited to do otherwise.

• Adhere to principles of confidentiality, scientific/academic integrity, and informed consent. Examples: Do not discuss patient information in public areas; always discuss procedures with the patients, obtaining formal informed consent prior to the procedure; provide medically and ethically sound diagnoses and treatments, even when the diagnosis/treatment may expose a previous mistake in judgment.

• Recognize and identify deficiencies in peer performance. Examples: Good doctors work with other good doctors. Find the obvious best players and ask who they consult and do the same until you have your own database. Identify evidence of ageism or racism in peers and other medical personnel; recognize breach of confidentiality within the office setting.

Residents are expected to demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care.

• Understand, access and utilize the resources, providers and systems necessary to provide optimal care. Examples: In the medical community an amazing amount of resources are available and it is a lifetime task to find them. Ask the respected, good doctors you work with where they look for resources to start your own database. Utilize the resources offered by the multi-disciplinary care team within the office or medical community; demonstrate/seek knowledge of community resources for patient population served.

• Understand the limitations and opportunities inherent in various practice types and delivery systems, and develop strategies to optimize care for the individual patient. Examples: Politics, managed care, practice and hospital structure, the skills of the medical community at large are all variables. Keep in mind that you do not work for an insurance company, medical practice, or hospital, you work for the patients. Demonstrate knowledge of the Medicare requirements for home health care and outpatient therapy; demonstrate knowledge of the payment systems for home health care and new/continued medical care.

• Apply evidence-based, cost-conscious strategies to prevention, diagnosis, and disease management. Examples: Review ordering practices for lab and imaging services; use national guidelines to optimize treatment of hypertension, use medical literature to order only appropriate imaging studies within each clinical context.

• Collaborate with other members of the health care team to assist patients in dealing effectively with complex systems and to improve systematic processes of care. Examples: It is important to attend committee meetings, practice meetings, staff meetings, etc.

III. Methods of instruction: Rounds, patient involvement, reading conferences, and computer research.

1. Didactic (schedule, topic, faculty)

   Daily residents conference (M, T, Th, F) 12:00-1:00 p.m. - IM Training Room
   Wednesday mornings 7:30-8:00 a.m. - Clinical Ground Rounds - IM Training Room
   Wednesday afternoons 12:15-1:00 p.m. - Internal Medicine Update - Haggar Hall
   Friday mornings 7:30 - 8:00 a.m. - Coffee with Cardiology - IM Training Room

2. Clinical