Family Medicine Residency Program

Curriculum for

FAMILY MEDICINE IN-PATIENT NIGHT FLOAT ROTATION

Introduction

Family practice medicine night float rotation is an in-patient service rotation for the second year and third year residents. It consists of two blocks, one block in the second and one in the third year. The resident will work with different Board certified Family Medicine Attending, admitting patients from the Family Medicine Center as well as patients of the Faculty during the night. He/she will also supervise the 1st year resident on call.

Goals

1. To provide additional acute in-patient care experience for the second and third year residents.
    
2. To provide continuity care for all patients from the Family Medicine Center and in-patient care for all patients from the Faculty practice sites.
    
3. To become competent in the initial management of the top ten most common in-patient clinical problems among adult and pediatric population during the night at SJGH. (Appendix A)
    
4. To teach and supervise the first year resident and/or a medical student if present.

Objectives PGY 2 & 3

1. Perform an initial comprehensive history and examination of patients regardless of age, sex, ethnic and social background or type of problem. 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 hospital records if available. (Contact night supervisor for record assistance)
   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. Render appropriate emergent and on-going medical treatment of the working diagnosis. Component skills include:
    
   1. Apply the principle of Evidence-based medicine. (Clinical guidelines, hospital pathways treatment protocol, POEMs and best evidence)
   2. Apply clinical pharmacology. (Indication of medication, dosing regimen, adverse reaction, drug-drug interaction and renal adjustment)
   3. Utilize appropriate consultants as necessary. (Timely communication with consultants is especially critical during the night shift.)
   4. Assist in initial stabilization of the patient: (Starting IV, airway and fluid management and etc)
       
4. Co-ordinate a cohesive, and patient-centered plan of treatment. Component skills include:
    
   1. Commit to be the patient advocate. (Proper sign out with the Family Practice service resident in the following morning.)
   2. Communicate clearly with the patient and family in regard to diagnosis, treatment options, and immediate prognosis. (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 at the time of admission.
       
5. Maintain a medical record in a comprehensive and concise fashion. Component skills include:
    
   1. Write pertinent and meaningful initial admission note. (Must reflect thought process)
   2. Dictate admission history and physical within 12 hours.
   3. Sign all physician orders and notes in accordance to the medical staff by-laws of SJGH.
       
6. Able to correctly interpret a 12 leads electrocardiogram, under supervision.
    
7. Able to correctly interpret 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. Perform procedure proficiently without unexpected complications.
       
9. Cultivate professional consulting behaviors. Component skills require:
    
   1. Define the problem and appropriate questions for the consultants
   2. Communicate clearly with the consultants through out the whole process.
   3. Serve as a consultant to other physicians on family practice in- patients who are under the care of another Attending. (Timely communication with referral physicians)
       
10. Triage out-patient calls for all the patients from the Family Practice Center.
     
11. The second/ third year resident will perform supervisory functions over the first year resident/intern, medical students, nursing and ancillary personnel when present.

Implementation

Each second and third year resident will have one block of rotation of in–patient service at night, from 8:00 PM to 8:00 AM, under the supervision of a Board-Certified Family medicine Attending. The night float resident will supervise the first year resident on call. He/she will present the admissions and attend the morning report conference before signing off.

Evaluation

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 1-10)
    
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,9,10)
    
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,5,9
    
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)

Methods of evaluation

Multiple people with multiple methods will evaluate the competence of the resident:

1. Formative evaluation:
    
   1. The family practice service attending and the 2nd/3rd year resident will provide ongoing and regular feedback throughout rotation, to advise the 1st year resident of the status of his/her performance and suggestions for improvement, where and when necessary.
       
   2. Methods: Portfolio, procedure log, checklist, specific patient, exam oral, chart review, global rating.
       
      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 admission at night. (Checklist, Specific patient)
      3. Direct examination of the resident’s ability to interpret ECG, X rays and abnormal lab reports by the Attending during admission at night. (Exam oral)
      4. Direct observation of the proficiency of the resident’s medical knowledge and procedure skills by the Attending during admission at night. (Specific patient, exam oral, Procedure log)
      5. Direct evaluation of the resident’s record keeping in the patients’ charts during admission at night by the Attending after admission. (Checklist, chart review)
      6. The family practice attending will provide ongoing and regular feedback throughout rotation to advise the 2nd/3rd year resident of the status of his/her supervisory performance and suggestion for improvement, where and when necessary. (Checklist, Weekly meeting with Attending)
          
2. Summative evaluation:
    
   1. The family practice service attending will complete a formal evaluation form of the 2Nd/3rd resident at the end of the rotation. (Global rating)
       
   2. The 2nd/3rd resident will complete a formal evaluation form of the 1st year resident at the end of the rotation. (Global rating)
       
   3. The overnight admission history and physical will be reviewed and signed off by the service Attending.
       
   4. Two admission history and physical from the resident are reviewed by the Associate program director. (Chart review) Results are added to the resident quarterly review folder.
       
   5. 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)
       
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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