General Internal Medicine Wards Curriculum

Department: Internal Medicine

Director: Mark Feldman M.D.,Chairman, Department of Internal Medicine

Hospital: Texas Health Presbyterian Hospital Dallas

Offered: All

Length of Rotation: 1 month

First Day Contact: Resident or intern assigned to your team. Teaching attending assigned to your team

First Day Time: 8:00 a.m. M-F, 8:00 a.m. Saturday and Sunday

First Day Place: Residents' Lounge

Days off: 4 assigned days off per month – see schedule

Vacation: None

Call Days: Every 4th day

Call Day Hours: PGY-1: 8:00 a.m. to midnight (16 hours) - PGY- 2 and PGY-3: 8:00 a.m. to 8:00 a.m. (24 hours)

Non-Call Day Hours: 8:00 a.m to 5:00 p.m. Monday through Friday - 8:00 a.m. to noon Saturday and Sunday

Course Goals: The goal of the General Medicine Ward experience is to develop in the house officer the knowledge, attitudes and skills required to care for the hospitalized patient. To that end, we have established patient care experiences, educational opportunities and evaluation tools to assure that this goal is met.

Patient Care Experience:

A. The on-call period is from 8:00 a.m. to 8:00 a.m. every 4th day.

B. Each PGY-1 resident can have a maximum of 10 patients on service at any time.

C. Each PGY-2 or PGY-3 resident supervising a team with one PGY-1 resident can have a maximum of 14 patients on service at any time.

D. Each PGY-2 or PGY-3 resident supervising a team with two PGY-1 residents can have a maximum of 20 patients on service at any time.

E. The number of admissions per PGY-1 resident per call day is at the discretion of the supervising PGY-2 or PGY-3 resident taking into account the above census caps as well as other factors including the complexity and acuity of the patients.

F. Residents have responsibility for dictated history and physical exam, orders, daily progress notes, discharge planning and implementation, with a discharge summary performed by the PGY-1 resident on the service.

G. PGY-2 and PGY-3 residents have responsibility for ovesight of the PGY-1 resident including rounding together at 8:00 a.m., daily review of all records, examination of the patients, and discussion with the PGY-1 regarding the plan of care.

Educational Experience

A. Attending Rounds from 10:30 a.m. to 12:00 p.m. usually on M-W-F with bedside teaching, review of the literature, laboratory interpretation, etc.

B. Morning Report – M through F at 9:00 a.m. for upper level residents with Dr. Mark Feldman, Dr. Sonya Merrill and core faculty where the previous night's admissions are presented by the PGY-2 or PGY-3 resident and an in-depth discussion of pathophysiology, differential diagnoses, and management is held.

C. Interns' Conference: Tuesdays at 11:00 a.m. to 12:00 p.m. with the PGY-1 residents on the ward rotation and Dr. Feldman or Dr. Goodman. One or two cases are presented and the pathophysiology, differential diagnoses and management issues are discussed in depth with Dr. Feldman or Dr. Goodman.

D. Daily noon conferences: Conferences are designed to address the curriculum for all areas of internal medicine.

E. Grand Rounds and Clinical Update - Wednesday conferences at 7:30 a.m. and 12:15 p.m. respectively for all residents and faculty.

Evaluations:

A. Attending Evaluation of Resident in the 6 areas of competency based on observation during rounds 3 days a week.

B. Attending observation of MINI-CEX.

C. Admitting attending evaluation of patient care provided by the resident.

D. Chart Review.

Specific Competency Goals:

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.

Objectives:

• Gather accurate, essential information from all sources, including medical interviews, physical examinations, medical records and diagnostic/therapeutic procedures. Example: Demonstrated in the intern's dictated history and physical and the resident's written admission note, as well as during a mini-CEX conducted by the teaching attending.
  
  
• Make informed recommendations about preventives, diagnostic and therapeutic options and interventions that are based on clinical judgement, scientific evidence, and patient preference. Example: Demonstrated during attending rounds and morning report. Demonstrated by assessments and plans written in the progress notes.
  
  
• Develop, negotiate and implement effective patient management plans and integration of patient care. Example: Demonstrated by the use of other health care professionals appropriately such as Social Work, Pharmacy, Physical Therapy, Home Health Care to implement effective patient care.
  
  
• Perform competently the diagnostic and therapeutic procedures considered essential to the practice of internal medicine. Examples: central line placement; ABG; airway management; paracentesis; thoracentesis; EKG reading; vaginal culture; joint aspiration; pelvic and pap test; nasogastric intubation; ACLS certification.

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

Objectives:

• Apply an open-minded, analytical approach to acquiring new knowledge. Examples: Demonstrated by active listening and participation during attending rounds, morning report and conferences.
  
  
• Access and critically evaluate current medical information and scientific evidence. Examples: Demonstrated by reading current literature regarding patients. Demonstrated by participation in journal club and residents' conference.
  
  
• Develop clinically applicable knowledge of the basic and clinical sciences that underlie the practice of internal medicine. Examples: Demonstrated by showing an understanding of the pathophysiology of disease and the pharmacology of drugs used in treating the disease. Demonstrated by resident's willingness to learn about new developments in the basic sciences by reviewing basic science journals.
  
  
• Apply this knowledge to clinical problem-solving, clinical decision-making, and critical thinking. Examples: Demonstrated by evidence of independent thinking in the appraisal and plan.

Practice-Based Learning and Improvement: Residents are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices:

Objectives:

• Identify areas for improvement and implement strategies to enhance knowledge, skills, attitudes and processes of care. Examples: Demonstrated by a resident's willingness to recognize his/her knowledge gaps and willingness to implement strategies to fill those knowledge gaps.
  
  
• Analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient practice. Examples: Demonstrated by the resident working with the process improvement committees (PIC's) of the hospital, as well as implementing process changes in the clinic to better care for patients.
  
  
• Develop and maintain a willingness to learn from errors and use errors to improve the system or processes of care. Example: Demonstrated by resident being open to admitting error and working to analyze and correct the error.
  
  
• 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 all available on-line resources.

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.

Objectives

• Provide effective and professional consultation to other physicians and health care professionals and sustain therapeutic and ethically sound professional relationships with colleagues and with patients and their families.
  
  
• Use effective listening, nonverbal, questioning, and narrative skills to communicate the patients.
  
  
• Use clear, concise, accurate communication in the orders and progress notes.

Professionalism: 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.

Objectives:

• Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues.
  
  
• Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues.
  
  
• Adhere to principles of confidentiality, scientific/academic integrity, and informed consent.
  
  
• Recognize and identify deficiencies in peer performance.

Systems-Based Practice: 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.

Objectives:

• Understand, access and utilize the resources, providers and systems necessary to provide optimal care. Example: Recoginize when it is important to consult a sub-specialist to help in the care of the patient.
  
  
• Understand the limitations and opportunities inherent in various practice types and delivery systems, and develop strategies to optimize care for the individual patient.
  
  
• Apply evidence-based, cost-conscious strategies to prevention, diagnosis, and disease management.
  
  
• 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: The resident should be able to implement a team approach in patient care, utilizing the allied health professional resources available such as physicial therapy, social work, and speech pathology.
  

III. Methods of instruction:

1. Didactic (schedule, topic, faculty)

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

Attending Rounds from 10:30 a.m. to 12:00 p.m. usually on M-W-F with bedside teaching, review of the literature, laboratory interpretation, etc.

Morning Report – M through F at 9:00 a.m. for upper level residents with Dr. Mark Feldman, Dr. Sonya Merrill and core faculty where the previous night's admissions are presented by the resident and an in-depth discussion of pathophysiology, differential diagnoses, and management is held.