Family Medicine Residency Program

Curriculum for 

INTERNAL MEDICINE IN-PATIENT ROTATION

Introduction

Internal Medicine service is an in-patient rotation for the first and second year residents. It consists of one block(4 weeks) rotation in the first year and second year. The rotation focuses on in-patient care training under the supervision of different Board certified internists at SJGH.

Goals

1. To provide in-patient care experience for the first and second year residents.
    
2. To provide in-patient care for the unassigned patients (without primary care provider) admitted through the emergency department, and the patients from the Attending’s practice if applied.
    
3. To become competent in managing the top ten most common in-patient, clinical problems among adults at SJGH.  

Objectives for PGY 1

1. Perform an initial comprehensive history and examination of adult patients regardless of age, sex, ethnic and social background or type of problem, under the supervision of the PGY 2 or an Internal Medicine Attending. Component skills include:
   1. Obtain a comprehensive medical and psychosocial history which contain the following components: CC,HPI,PMH,PSH,ROS,FH/SH, Medication, immunization and allergy.
   2. Review old records if available.
   3. Perform a thorough physical examination.
2. Organize a rational diagnostic work up of the patient’s presenting problem. Component skills include:
   1. Formulate a working diagnosis and a list of probable differential diagnosis.
   2. Order and interpret appropriate diagnostic studies to confirm or rule out the working diagnosis.
   3. Able to present and discuss the diagnostic plan with the PGY 2 and/or the Attending.
3. Render appropriate emergent and on-going medical treatment of the working diagnosis under the supervision of PGY 2 and/or Attending:
   
   Component skills include:
    
   1. a. Apply the principle of Evidence-based medicine. (clinical guidelines, hospital pathways, treatment protocol, POEMs and best evidence)
       
   2. b.  Apply clinical pharmacology. (Indication of medication, dosing regimen, adverse
      reaction, drug-drug interaction and renal adjustment)
       
   3. d. Utilize appropriate consultants as necessary. (Timely communication with consultants)
   4. e. Utilize other health professionals in the hospitals. (Physical therapist, respiratory therapist, speech therapist, wound-care specialist, and dietitian,)
       
4. 5. Co-ordinate a cohesive, and patient-centered plan of treatment under the supervision of the PGY 2 and/or the Attending.
   
   Component skills include:
    
   1. Commit to be the patient advocate.
   2. Communicate clearly with the patient and family in regard to diagnosis, treatment options, prognosis and follow-up car. (Respect patient’s preference and autonomy)
   3. Able to discuss effectively and compassionately with patient and family in regard to issues such as health care proxy, living will, DNR, hospice care and other end of life issues.
   4. Organize discharge planning and follow-up care. (Notify patient’s primary care provider if applied at the time of discharge, along with a concise and useful discharge summary and appropriate referral for community services through the hospital social service department.
       
5. Maintain a medical record in a comprehensive and concise fashion. Component skills include:
    
   1. Write pertinent and meaningful daily progress notes legibly. (Must reflect thought process)
   2. Dictate admission history and physical within 12 hours and discharge summary within 24 hours after discharge.
   3. Sign all physician orders and notes in accordance to the medical staff by-laws of SJGH.
       
6. Obtain basic knowledge of interpreting a 12 leads electrocardiogram, under supervision.
    
7. Obtain basic knowledge of interpreting common X rays such as plain chest X ray, abdominal X ray and etc. (review all X rays in the department)
    
8. Able to perform appropriate diagnostic and therapeutic procedures under supervision. Component skills require:
    
   1. Able to list and discuss the indications and potential adverse complications of the procedure. (Informed and written consent)
       
   2. Observe/Assist procedure under supervision.
       
9. Cultivate professional consulting behaviors. Component skills require:
    
   1. Define the problem and appropriate questions for consultants
       
   2. Communicate clearly with the consultants through out the whole process. 

Objectives for PGY 2

1. Perform the duty of a supervisor. Component skills include:
    
   1. Demonstrate leadership skill in the team. (To initiate, co-ordinate and oversee the in-patient care with the PGY 1 and service Attending)
       
   2. Assist and guide the PGY 1 to meet the rotation objectives.
       
   3. Communicate with the Attending and consultants in a timely manner.
       
2. Continue to make progress in all knowledge, skills and attitudes of in-patient care. (Objectives for PGY 1, 1-10). Component skills include:
    
   1. Able to perform a complete initial history and physical which has no deficiency in all the required components. (CC,HPI,PMH,PSH,ROS,FH/SH, Medication, immunization and allergy, complete examination)
       
   2. Able to develop a working diagnosis and comprehensive action plan which are specific to the patient’s presenting problem and best evidence available.
       
   3. Able to ask and find the best answer to a relevant clinical, patient oriented outcome question. (Internet literature search)
       
   4. Able to correctly interpret a 12 lead electrocardiogram. (³75%)
       
   5. Able to correctly interpret common X ray films such as a plain X ray chest and abdomen. (³75%)
       
   6. Able to perform procedures proficiently that is appropriate to the training of family physicians. (Phlebotomy, peripheral IV access, insertion of N-G tube and Foley’s catheter, central vein access and etc)
       
   7. Able to work effectively with the PGY1, attending, consultants, nurses, ward clerks, social workers and etc,
       
   8. Able to discuss and engage the patient and the family in every management decision.
       
   9. Able to organize appropriate post-hospital care with assistance and resources from the community.
       
   10. Maintain proper documentation and record keeping.

Implementation 

Each first year and second year resident will have 4 weeks of Internal Medicine in–patient service under the supervision of Board-certified Internists in the department of Internal Medicine at SJGH.
The residents on service will attend all teaching rounds and conferences provided by the department of Internal Medicine. They will comply with all the additional rules and regulation of the department of Internal Medicine while on rotation. 

Evaluation of PGY 1

The resident will be evaluated on the basis of competency of the following six areas:

1. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. (Objectives 1-9)
    
2. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. (Objectives 1,2,3a,3b ,6 ,7 ,8)
    
3. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. (Objectives 3a, 3c, 3d)
    
4. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals. (Objectives 4b, 4c, 9)
    
5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. (Objectives 1, 4a, 5,10)
    
6. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. (Objectives 4d, 4c) 

Evaluation of PGY 2

The resident will be evaluated on the basis of competency of the following six areas:

1. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. (Objectives 2 a, b, h, i)
    
2. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. (Objectives 2 b d, e, f,)
    
3. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. (Objectives 2 c)
    
4. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals. (Objectives 2 g, h)
    
5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. (Objectives 1 a, b, c, 2 j)
    
6. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. (Objectives 2 i)

Methods of evaluation of PGY 1 and 2

The competence of the resident will be evaluated by multiple people with multiple methods:

1. Formative evaluation:
    
   1. The Internal Medicine Attending will provide ongoing and regular feedback throughout rotation to advise the resident of the status of his/her performance and suggestions for improvement where and when necessary.
       
   2. Methods: Portfolio, checklist procedure log, specific patient, exam oral, chart review, global rating,
      and survey.
       
      1. The resident is to keep an updated in-patients log (medical record number, gender, age, diagnosis, and primary care provider). This information will be entered into the resident’s portfolio of clinical experience. (Portfolio)
      2. Direct conversation with the resident in regard to his/her patient care during daily hospital round. (Checklist, Specific patient)
      3. Direct examination of the resident’s ability to interpret ECG, X rays and abnormal lab reports during daily hospital round. (Exam oral)
      4. Direct observation of the proficiency of the resident’s medical knowledge and procedure skills. (Specific patient, exam oral)
      5. Direct evaluation of the resident’s record keeping in the patients’ charts. (Checklist, chart review)
          
2. Summative evaluation:
    
   1. The Internal Medicine service attending will complete a formal evaluation form at the end of the rotation. (global rating)
       
   2. Five surveys will be sent to the primary care physicians if available, to assess the ability of the resident to organize post-hospital care and his/her communication skills. This is an evaluation of the area of Interpersonal and communication skill, professionalism and system-based practice. (Survey)
       
   3. Five random in-patient satisfaction surveys will be sent out at the end of rotation.
       
   4. Four random in-patients charts under the care of the service resident will be reviewed at the end of the rotation, by the Internal medicine program director. (Chart review) Result are added to the resident quarterly review folder.
       
   5. Two admission history and physical from each resident are reviewed by the Internal medicine program director.(Chart review) Results are added to the resident quarterly review folder.
       
   6. Compliance of medical records keeping is monitored by the Hospital Medical Record department, and results are added to the resident quarterly review folder. (Chart review)
       
   7. The result of the resident in-training exam will be evaluated by the Faculty Advisor and discussed with the resident and during the resident quarterly review. It will be kept in the resident review folder. (MCQ)
       
3. Each resident will evaluate the teaching/supervising Attending at the end of the rotation, as well as evaluates the curriculum of the rotation itself. The Attending evaluations are done anonymously. (Global rating)

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