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Block rotation under the supervision of local directors, Dr. Batalautundu Lakshminarayanan, Provena Covenant Medical Center ; Dr. Mehtab Mizan, Carle Foundation Hospital; and Dr. Anil Gopinathi, Veterans Administration Illiana Health Care System in the direct experience in progressive responsibility for patient treatment and competent care management.
Additional adult inpatient training takes place longitudinally throughout all 3 years, specifically, block rotations in PGY II and PGY III. Other Adult Medicine education occurs during weekly conferences, and Grand Rounds, Quality Review, and Journal Club.
Demonstrate attitudes, skills and knowledge for diagnosis, treatment and competent care management of patients with common and uncommon medical problems, acting as a primary physician in the hospital setting.
A. PATIENT CARE:
Objective 1: Demonstrate clinical skills of comprehensive medical interview, history and physical examination at the patient bedside, including functional assessment and mental status as needed.
Objective 2: Demonstrate clinical skills in the diagnosis and medical management of acute and chronic illness.
Objective 3: Generate a differential diagnosis and problem list in accepted format.
Objective 4: Perform and record procedures
a. Procedure Skills : The resident is expected to perform and become adept at the following procedural skills during his/her residency training:
B. MEDICAL KNOWLEDGE
Objective 1: Demonstrate knowledge of the natural history, pathophysiology, clinical presentation, diagnosis through differential diagnosis and management of clinical problems
Objective 2: Describe and evaluate a pharmacotherapeutic approach which includes definition of therapeutic objectives and options, selection of dose and parameters to be monitored, and measurement of therapeutic response and outcome.
Objective 3: Assimilate knowledge of patient condition to recognize when consultation is indicated
C. PRACTICE-BASED LEARNING AND IMPROVEMENT
Objective 1: Demonstrate evidenced based practice through appraisal and assimilation of scientific information, e.g. scientific journals, related to patient care
Objective 2: Demonstrate ability in medical decision making, which incorporates medical assessment and patient values and preferences.
D. INTERPERSONAL AND COMMUNICATION SKILLS
Objective 1: Create an atmosphere of positive regard for the patient and family to promote the best medical outcome through accessibility, affability and continuity.
Objective 2: Incorporate psychosocial and ethical concerns of the patient and family in the development of the care management plan.
Objective 3: Dictate timely, comprehensive patient care notes, including admission and discharge summaries, and write thorough, succinct daily progress notes in accepted format.
E. PROFESSIONALISM
Objective 1: Demonstrate compassionate use of medical skills for patients. This includes high-quality care and technology and, in the event of terminal illness, an awareness of the limits of medical intervention and the obligation to provide humane care.
Objective 2: Recognize the legal requirements of advanced directives and describe the process of assessing a patient's advance directives, including the patient's perspective.
Objective 3: Model appropriate professional attitudes and behaviors of time management and punctuality, reliability, peer support, objective peer evaluation, community teaching, and ethical behavior.
F. SYSTEM-BASED PRACTICE
Objective 1: Recognize financial issues of heath care, with emphasis on understanding acute and chronic care, and medication coverage and the role of the Centers for Medicare and Medicaid Services (CMS), and other third party payers.
Objective 2: Actively participate in the multidisciplinary approach to caring for patients, including appropriate recognition of other health professional and paraprofessionals' roles and demonstrate competence in team interactions, i.e. pharmacist, physician's assistant, advanced practice nurse, nurses, occupational and physical therapist, social worker.
This rotation emphasizes direct interaction between resident and attending physician with the patient, at the bedside, with resident demonstration of interview and physical examination skills.
Residents are assigned to a site, i.e. Carle Foundation Hospital , Provena Covenant Medical Center, Veterans Administration Illiana Health Care System (VAIHCS) and a team for the rotation. Responsibilities are to the education rotation with progressive responsibility for patient treatment and competent care management, excluding one half day per week at Continuity Clinic and one half day per week at afternoon conference.
Teams at each rotation site vary in composition. Generally, each PGY I resident works on a team with a senior resident, attending physician, and a third-year medical student assigned to a required Medicine clerkship. The PGY I resident is responsible for the primary management of his/her patients, writing orders, and closely communicating with the senior resident on patient management decisions. The attending physician has final authority and responsibility for patient care.
Admissions
Interns admit new patients to the teaching service, and perform a complete history, physical and write-up, and problem list. In strict accordance with ACGME, the intern does not admit the day following night call. Interns are not assigned more than five new patients per admitting day; an additional 2 patients may be assigned if the patients are in-house transfers from the medical services. An intern may not be assigned more then 8 new patients in a 48-hour period. An intern has maximum responsibilities for the ongoing care of 12 patients. A complete history, physical examination, assessment, problem list and orders are required of all admissions within 24 hours of admission. On average, a census of 8 to 12 patients is optimal. The intern is to report any concerns regarding non-adherence to ACGME requirements for admissions and hours-worked to the site Chief Resident. The admission format is outlined in Bates, B et al., A Guide to Physical Examination and History Taking, 6th edition, J.B. Lippincott Co., (current edition.)
Orders and Progress Notes
Interns write orders for all patients under their care. Orders and progress notes must be dated, timed, legible, and written as early in the day as possible. Interns are encouraged to print his/her name to facilitate nursing and other care. Rubber name stamps are required for all non-emergency orders and progress notes. Standing orders are to be avoided, e.g. daily CBC. Orders are reviewed daily for appropriateness e.g., frequency. Drug names, not trade names, are required. Abbreviations are discouraged. Complex diagnostic and radiology procedures and examinations, and invasive procedures should be discussed with and approved by the teaching attending prior to being ordered. Orders must be written stating the resident physician coverage for weekend or leave days. Progress notes are problem focused and written in SOAP format.
Discharge Summary/Chart Completion
All radiology reports, electrocardiogram, pathology reports, and other diagnostic tests are reviewed and initialed by the intern. All chart notes must be complete at discharge for the resident to dictate the discharge summary. Residents with delinquent charts will be subject to disciplinary action.
Service Hours
Interns are to be available in-house from 0700 - 1700 weekdays, and on weekends and holidays from 0700 until patient care is complete. Interns must be immediately available by pager during those hours. Work hours must strictly conform to ACGME standards. Chief residents must assure interns have 24 hours off every 7 days. Adequate time for rest and personal activities must be provided to include a 10 hour time period between all daily duty periods and after in-house call. Coverage is arranged by shared cross-coverage by another intern or senior resident. Interns are encouraged to keep pagers on 24 hours per day. During Continuity Clinic, coverage requires passing pagers to another team intern or the senior resident.
On-call
On-call schedules are final when posted by the chief resident. The intern is responsible for all medical problems on the adult medicine teaching services, new admissions, and documentation. Interns must write dated, timed, legible orders on all patient medical problems. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may remain on duty for up to 6 additional hours to participate in didactic activities, transfer patient care, conduct outpatient clinics, and maintain continuity of medical and surgical care. For interns scheduled as Backup On-call, this requires the intern to be readily available by pager or phone throughout the day and night, and to see patients in-house as needed. Readily available is defined as a distance of 60 minutes.
According to Accreditation Council of Graduate Medical Education (ACGME), training and evaluation must include the following competencies: Patient Care, Medical Knowledge, Practice–Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and System-Based Practice.
Patient Care will be evaluated by global assessment of the attending physician and senior resident, and additional information from nursing staff and 2 Mini-CEX. Procedures performed will be documented electronicallySs.
Medical Knowledge will be evaluated by global assessment of the attending physician and senior resident, additional information from nursing staff, 2 Mini-CEX, and peer-reviewed chart audit.
Practice-Based Learning and Improvement will be evaluated by senior-reviewed chart audit.
Interpersonal and Communication Skills will be evaluated by global assessment of attending physician and additional information from nursing staff, patients and families and 2 Mini-CEX.
Professionalism will be evaluated by global assessment of attending physician and additional information from nursing staff, patients and families; and senior-reviewed chart audit.
System-Based Practice will be evaluated by global assessment of attending physician and senior resident, 2 Mini-CEX and senior-reviewed chart audit.
The evaluation method is primarily accomplished electronically. Residents' performance in Adult Medicine is evaluated by the attending physician. Evaluations are reviewed with the residents for formal feedback. Face to face interaction between the attending physician and the resident is the required method. At the midway point of the rotation, the resident/intern team is encouraged to approach the attending to assess and discuss performance. In addition, ongoing feedback is provided related to residents' patient care responsibilities and activities.
Residents will document the Adult Medicine rotation in portfolios, e.g. procedures performed, senior-reviewed chart audit, and Mini-CEX. This tool will provide individual learning, reflection and assessment. Additionally, residents will evaluate the Adult Medicine rotation.
Residents provide input on the Adult Medicine core lecture series, which is used in scheduling future topics and speakers. Periodically, residents are surveyed to evaluate the Adult Medicine curriculum and teaching faculty. As part of the electronic evaluation each resident is queried regarding free days to assure that a veraged over the rotation, the resident had at least 1 day in 7 free of patient care duties (4 days during a 4 week rotation).
Cecil's Textbook of Medicine (current edition)
Harrison 's Principles of Internal Medicine (current edition)
Washington University School of Medicine's Manual of Medical Therapeutics. Little Brown and Co. (current edition).