DESCRIPTION
Block
rotation under the supervision of site directors, Dr. Batalautundu Lakshminarayanan, MD,
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: Teach interns and/or students to develop a comprehensive problem list,
differential diagnosis, and management plan.
Objective
4: Objectively evaluate and provide ongoing feedback to medical student,
interns, and residents.
Objective
5: Model appropriate professional attitudes and behaviors of time management
and punctuality, reliability, peer support, community teaching, and ethical
behavior.
Objective 6: Model effective leadership qualities for residents,
staff, and nursing, i.e., conflict resolution, and problem identification and
resolution.
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: Develop a teaching and supervisory skills to
include work rounds, formal brief patient presentations, procedures instruction
and supervision, imaging rounds, chart review, topic oriented discussion, and
literature review.
Objective
3: 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. medical
students, residents, pharmacist, physician's assistant, advanced practice
nurse, nurses, occupational and physical therapist, social worker.
III. METHODS
Team
The Care Team includes a senior resident,
interns, student clerks, admitting physicians, and
teaching attendings. The senior resident is the leader of the team, providing ongoing
supervision of the interns' clinical skills and positive support of the
interns' responsibility as primary physicians. The resident is responsible for
quality care of assigned patients and education of team members. S/he must be readily
available and coordinate care with the admitting physician. The primary
attending has final authority and responsibility for patient care.
Patient Care
The senior
resident must complete a timely evaluation of each patient assigned to his/her
team when patient responsibility is assumed. Through team rounds, chart rounds,
and individual rounds the resident must assure that his/her understanding of
each patient case is complete A senior progress note
must be written daily.
In strict
accordance with ACGME guidelines, when supervising one first–year resident, the
supervising resident must not be responsible for the ongoing care of more than
16 patients. When supervising more than one first-year resident, the
supervising resident must not be responsible for the ongoing care of more than
24 patients. Second- or third-year internal medicine residents and other
appropriate supervisory physicians, e.g. subspecialty residents or attendings,
with documented experiences appropriate to the acuity, complexity, and severity
of patient illness must be available at all time on-site to supervise
first-year residents. Residents from other specialties must not supervise
internal medicine residents on any internal medicine inpatient rotation.
Residents must write all orders for patients under their care, with appropriate
supervision by the attending physician. In those unusual circumstances when an
attending physician or subspecialty resident write an order on a resident’s
patient, the attending or subspecialty resident must communicate his/her action
to the resident in a timely manner.
Admissions
An
admission or an on-service note should document the history, physical
examination, and review of clinical data. The admission evaluation must
conclude with a thorough discussion of differential diagnosis and management
plan for each identified problem. Residents must write all orders for patients
under their care with appropriate supervision by the attending physician. The
admitting resident is contacted for all service admissions. 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
Residents
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.
Residents 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
The
senior is expected to be available in-house 0700 to 1600 weekdays, and 0700
until work is done on weekends and holidays. Schedules should allow for one
day/per week, on average, free of hospital duties for all team members in
strict accordance with ACGME work hours. A senior resident who carries
the code beeper is responsible to assure its functioning and must be
immediately responsive in house as the code team leader.
On-Call.
There must be
a resident on-call schedule and detailed check-out and check-in procedures so
residents learn to work in teams and effectively transmit necessary clinical
information to ensure safe and proper care of patients. The call schedule is
developed and posted by the chief resident as final. Any call changes must
occur with notification and approval of the Program Director. The senior
resident serves call in house. Pagers are on 24 hours per day when on call.
Intern admissions
exceeding five patients are the responsibility of the on-call senior until an
intern is assigned the following day. Interns should admit no more than five
patients during any one call period.
Teaching
The senior resident
develops a schedule with his/her team to facilitate timely patient care and
learning. This schedule includes team rounds, imaging rounds, chart-lab rounds,
and topic discussions.
The senior is
a primary teacher of interns, and shares responsibility with the interns for the
teaching of student clerks. The teaching must include an initial, careful
review of student goals, objectives and reading assignments, and review of all
student admissions including relevant pathophysiology, differential diagnosis,
plans, orders and progress notes.
The senior
resident is responsible for the educational process of the team. S/he
must assure student objectives are met as outlined in the student clerkship
manual. The senior discusses new cases with interns and students at admission,
clarifies important historical points, demonstrates physical findings, reviews
important accessory clinical data, and incorporates case-oriented teaching at
the end of the daily routine. The senior resident assists the intern
and/or student in developing a comprehensive problem list, differential
diagnosis, and management plan. The senior should provide useful
literature to supplement basic texts.
Seniors develop and coordinate a teaching, supervisory program
which includes team work rounds, formal brief patient presentations, procedures
instruction and supervision, imaging rounds, chart review, topic oriented
discussion, and literature review. This includes the fair delegation of tasks
to improve team efficiency and learning, and ongoing evaluation of students and
residents.
Feedback
Senior residents must provide frequent performance feedback to
those supervised. Senior residents evaluate interns and students on an ongoing
basis through frequent positive reinforcement and immediate and specific
feedback as needed.
IV. EVALUATION
ACGME Competencies
Patient Care will be evaluated by
global assessment of the attending physician, and additional information from
nursing staff and 1 Mini-CEX. Procedures performed will be documented electronically.
Medical Knowledge will be evaluated by
global assessment of the attending physician, additional information from
nursing staff, 1 Mini-CEX, and attending-reviewed chart audit.
Practice-Based
Learning and Improvement will be evaluated by attending-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
1 Mini-CEX.
Professionalism will be evaluated by
global assessment of attending physician and additional information from
nursing staff, patients and families; and attending-reviewed chart audit.
System-Based Practice will be evaluated by
global assessment of attending physician, 1 Mini-CEX and attending-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 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, attending-reviewed chart audit, and Mini-CEX. This tool will provide individual
learning, reflection and assessment. Additionally, residents will evaluate the
Adult Medicine rotation.
Cecil's
Textbook of Medicine . (current
edition)
Revised