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DESCRIPTION
Two week block rotation under the supervision of Mehtab Mizan , MD for senior residents to provide training in perioperative and consultative medicine. Residents rotate with hospitalist attendings and perform inpatient consults. Each senior resident provides care for a maximum patient load of ten (10).
The senior resident is expected to be involved in full patient management, including writing orders. The senior resident will be available for consultations 0700 to 1700 Monday through Friday, excused for Continuity Clinic, Core Conference and other mandatory conferences.
Demonstrate knowledge, skills and attitude necessary for optimum pre-operative, peri-operative and post-operative management of complex patients.
Demonstrate a team approach to care of complex surgical and medical patients with the appropriate use of inpatient resources, and improved patient care.
Residents will work collaboratively in multidisciplinary teams to provide patient safety and systems improvement.
Objective 1: Develop and implement effective and appropriate patient management plans.
a. Elicit patient complaints associated with cardiac and pulmonary diseases, especially effort tolerance; symptoms of coronary artery disease; endocrine dysfunction; liver and renal disorders.
b. Identify history of previous surgical procedures and family history of adverse outcome from anesthesia.
c. Perform a complete physical examination focusing particularly on cardiovascular and pulmonary examination.
d. Recognize cardiovascular and pulmonary complications, and other adverse events in the perioperative period and risk of significant morbidity and mortality.
e. Recognize the signs of cardiac compromise such as S3 and S4, crackles and murmurs.
f. Perform thorough examination of lungs for signs of disease.
g. Evaluate the patient for potential complications recommending diagnostic or therapeutic interventions as indicated to reduce risk.
Objective 2: Provide informed recommendations made based on clinical judgment and literature review.
Objective 3: Educate patients and families of effects of underlying medical disease on surgery and vice versa.
Objective 4: Procedure Skills : The resident is expected to perform and become adept at the following procedural skills during his/her residency training:
a. Advanced Cardiac Life Support documented by American Heart Association
b. Central venous line placement
c. Defibrillation, cardioversion and emergency cardiac pacing
d. Diagnostic and therapeutic arthrocentesis
e. Diagnostic or therapeutic paracentesis
f. Diagnostic or therapeutic thoracentesis
g. Electrocardiogram interpretation
h. Intravenous lines and arterial lines
i. Lumbar puncture
B. MEDICAL KNOWLEDGE
Objective 1: Make appropriate recommendations for patient care based on scientific evidence when performing consultation.
a. Recognize basics of preoperative evaluation
b. Implement prophylaxis for endocarditis and deep venous thrombosis
c. Manage patients receiving anticoagulation for medical conditions, e.g. atrial fibrillation, and other post operative complications.
d. Identify role of statins in perioperative risk reduction
e. Adhere to best practices for blood glucose control
f. Recognize indication for perioperative beta blockade
g. Recognize best practices for prevention of postoperative delirium
h. Provide recommendations for management of underlying chronic medical problems
i. Recognize co-management issues for orthopedic
Objective 2: Recognize and implement knowledge of American Heart Association recommendations regarding prophylaxis for endocarditis, guidelines for prevention of deep vein thrombosis prophylaxis, and conditions, e.g. malignant hyperthermia.
C. PRACTICE-BASED LEARNING AND IMPROVEMENT
Objective 1: Analyze and evaluate own performance when dealing with patients on other services and develop strategies to continually improve the quality of patient care.
Objective 2: Effectively utilize laboratory data to make recommendations.
D. INTERPERSONAL AND COMMUNICATION SKILLS
Objective 1: Effectively communicate diagnosis, risk factors, treatment and prognosis to the patient and family.
Objective 2: Effectively communicate the assessment and recommendations to primary providers using evidence-based approach, verbally and in writing.
E. PROFESSIONALISM
Objective 1: Demonstrate respect, compassion, integrity, trustworthiness, and altruism in relationships with patients, families, and colleagues.
Objective 2: Adhere to high ethical and moral standards and principles of confidentiality, scientific/academic integrity, and informed consent.
F. SYSTEMS-BASED PRACTICE
Objective 1: Make recommendations, as a member of the consultative team, for further investigations to determine patient's risk for surgery, e.g., stress test, echocardiogram.
Objective 2: Order appropriate tests, evaluate and utilize the results in patient management, e.g. arterial blood gases, chest radiograph, echocardiography and stress tests in patient suspected of Coronary Artery Disease, complete blood count, complete metabolic panel, urinary analysis and venous duplex study.
Objective 3: Serve as guide to primary providers and facilitate patient work ups.
III. METHODS
Consultations are primarily requested by physicians on surgical or medical patients for preoperative optimization, determination of risk for surgery, and management of patients' medical conditions. The resident will be expected to make recommendations on the subject of management of coronary artery disease, hypertension, diabetes, airway diseases, anticoagulation, and current recommendations for endocarditis prophylaxis.
The resident will obtain a history, perform physical examination, review the data and formulate an assessment, including risk to patient from the planned procedure and anesthesia. He/she will present the case to the attending, who will verify resident's findings, review the notes and make amendments as appropriate. The attending will provide one-on-one instruction and evaluation to the resident during the rotation. The resident will be encouraged to read material from textbooks, journals and syllabus on topics related to the patient care. The attending will provide handouts as related to patient care.
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 resident. All chart notes must be complete at time of discharge. Residents with delinquent charts will be subject to disciplinary action.
Service Hours
Residents are to be available in-house from 7:00 a.m. - 5:00 p.m. weekdays, and on weekends and holidays from 7:00 a.m. until patient care is complete. Residents must be immediately available by pager during those hours. Work hours must strictly conform to ACGME standards. During Continuity Clinic, coverage will be provided by the hospitalist team.
Didactic experiences
The attending will provide one-on-one several lectures to the assigned resident. Topics included:
IV. EVALUATION
ACGME Competencies
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 Mini-CEX. Procedures performed will be documented.
Medical Knowledge will be evaluated by global assessment of the attending physician and senior resident, additional information from nursing staff, and Mini-CEX.
Practice-Based Learning and Improvement will be evaluated by assessment of attending physician
Interpersonal and Communication Skills will be evaluated by global assessment of attending physician and additional information from nursing staff, patients and families and Mini-CEX.
Professionalism will be evaluated by global assessment of attending physician and additional information from nursing staff, patients and families.
System-Based Practice will be evaluated by global assessment of attending physician and senior resident, and Mini-CEX.
The evaluation method is primarily accomplished electronically. Residents' performance in Medical Consultation 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 Medical Consultation rotation in portfolios, e.g. procedures performed, peer-reviewed chart audit. This tool will provide individual learning, reflection and assessment. Additionally, residents will evaluate the Medical Consultation 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 Medical Consultation curriculum and teaching faculty. As part of the electronic evaluation each resident is queried regarding Free Days to assure that averaged 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).