Contents
A. General Information
a. PGY 1 Year
b. PGY 2 Year
c. PGY 3 Year
B. Curriculum
a. Cardiology
b. Critical Care
c. Endocrinology
d. Gastroenterology
e. General Medicine
f. Geriatrics / Palliative Care
g. Hematology
h. Infectious Diseases
i. Oncology
j. Pulmonary
k. Renal
l. Rheumatology
C. Rotation Information
a. Emergency Room
A. General Information
1. Organization and Structure
a. The Department of Medicine at the University of North Carolina at Chapel Hill
provides an integrated, progressive experience for residents in their 36- month
training period. The goal of our curriculum is to prepare residents to be welltrained general internists. We believe this type of training not only prepares our
residents for careers in General Internal Medicine but also provides the necessary
foundations for further training as a subspecialist.
The curriculum in the Department of Medicine changes greatly from the PGY 1
year to the PGY 3 year. The PGY 1 year consist of 9 months of inpatient rotations
and 3 months of ambulatory medicine. During the second and third years,
residents spend an increasing amount of time in the outpatient setting. The
curriculum will be specifically described for each of the 3 year of training.
The PGY 1 Year
Each PGY 1 resident must develop competence in the following categories:
Patient Care
Medical Knowledge
Practice Base Learning and Improvement
Interpersonal and Communication Skills
Professionalism
System Based Practice
In the context of monthly rotations, competency is defined for each of the
categories.
Patient Care- medical interviews, physical examinations, review of data,
procedural skills, diagnostic and therapeutic decision making
Medical Knowledge- basic and clinical science, evidence- based medicine, literature
searching
Practice Based Learning and Improvement- evaluation of own performance,
incorporation of feedback, use of technology for patient care and self improvement
Interpersonal and Communication Skills- establishment of relationships with
patients and families, education and counseling of patients, team skills with
colleagues
Professionalism- demonstration of respect, compassion, integrity, and honesty,
commitment to self assessment, acknowledges errors, considers needs of patients
and colleagues
System Based Practice- ability to utilize resources, use a systematic approach to
reduce errors and improve patient care
These competencies are reviewed with all residents and the faculty and serve as
the foundation for monthly evaluation. The evaluation tool includes a description of
each of the core competencies and a scale of evaluation for each from 1-9. A copy
of the evaluation took is included in Section ___.
------------------The PGY 1 curriculum consists of a series of monthly rotations linked with a
number of Departmental teaching conferences.
The monthly inpatient rotations for each PGY 1 resident are as follows:
Cardiology/MICU- 2 months
Inpatient General Medicine Ward- 2months
Inpatient Subspecialty Wards- 5months
On all inpatient rotations the role of the PGY 1 resident is to serve as the primary
physician for all of his/her patients. In this role the PGY1 resident:
1. Performs a history and physical examination on each new patient
2. Enters all orders
3. Communicates with the patient and ward team regarding daily
progress
4. Enters a history and physical and daily progress notes into the
patient record
5. Develops a diagnostic and therapeutic plan for each patient
6. Enters a discharge summary in to the patient record
Cardiology -consists of 32 beds covered by four teams. Each team is made up of one
upper level resident and one PGY 1 resident. One faculty member and one
subspecialty fellow are assigned to each team to assist in patient management and to
conduct teaching rounds. Didactic teaching rounds and bedside teaching occur daily.
Also, there is a weekly core curriculum lecture series that is case- based.
A copy of the Cardiology Curriculum is included in Section 2. Common
diagnoses of patients admitted to the cardiology service included myocardial
infarction, arrhythmias, and chronic heart failure. Residents follow patients in the CCU
(12 beds) and the general floor (20 beds). Residents on service place central lines
including Swan Ganz catheters and perform arterial blood gases and thoracenteses.
ICU- Consist of 19 beds in a MICU. There are 4 teams, each team consisting of one
upper level resident and one PGY 1 resident. One faculty member serves as the
attending in the MICU. There is also a Critical Care Fellow. Teaching rounds include
didactic presentations (30 min/day, 6 days/week), bedside teaching(2hours/day,
7days/week), and x-ray teaching (30 minutes/day,6days/week). There is a designated
curriculum (Section 2). Patients admitted commonly have the following diagnoses: GI
bleeding, septic shock, drug overdose, s/p cardiopulmonary arrest, DIC, COPD
exacerbation, cystic fibrosis exacerbation, rejection s/p lung transplant, and acute
renal failure. Residents perform all procedures.
Inpatient General Internal Medicine - consists of 2 general medicine services. For
each service, there is one attending, one upper level resident, and two PGY 1
residents. Teaching rounds occur for one hour, five times per week covering a number
of topics described in the Inpatient General Medicine curriculum (see Section 2).
Patients admitted have a variety of problems including: community acquired
pneumonia, COPD exacerbation, diabetic complications, and lupus complications.
Residents perform all procedures.
Also, residents rotate at Wake Hospital, a community hospital in Raleigh, NC.
There are four teams consisting of one attending, one upper level resident, and one
PGY 1 resident. Teaching rounds occur for one hour five times per week covering
topics in General Internal Medicine. Residents perform all procedures.
Inpatient Subspecialty WardsService
Medicine A-Geriatrics
Medicine B- Nephrology
20
Medicine E- Hematology/Oncology
Medicine G- Pulmonary
Medicine K- Infectious Disease
#beds
20
40
20
20
For each service there is one attending, one upper level resident, and two PGY 1
residents. Each of these services has daily work rounds and attending rounds. Each
service has designated reaching time occurring at a minimum of five hours per week.
During teaching time a series of topics pertinent to each service are reviewed. A copy
of each curriculum is included in Section 2. Residents perform all procedures on these
services.
The PGY 1 Curriculum also includes the following rotations:
Emergency Medicine- 1 month
Same Day Clininc-1 month
Continuity Care/Ambulatory Elective- 1 month
Emergency Room – faculty from the Department of Emergency Medicine supervise
PGY 1 residents. PGY 1 residents have a generic experience seeing medical, surgical,
and obstetrics/gynecology patients. There are four hours of didactic teaching per
week, which cover a wide variety of topics. Examples of monthly topics are included in
Section 3.
Same Day Clinic- This is a walk in clinic for the established IM patients and also serves
as an Urgent Care clinic. Faculty in the Division of General Internal Medicine supervise
PGY 1 residents. A variety of outpatient problems are encountered. Didactic teaching
takes place daily for 30 minutes. Subjects covered in the curriculum are included in
Section 3.
Continuity Care/Ambulatory Elective- PGY 1 residents spend one month in the General
Medicine clinics working with Faculty from the Division of General Medicine. Some of
the modules include enhanced care in anticoagulation, diabetes, pain management,
and travel medicine. Each resident also undertakes a CQI project. PGY 1 residents may
also rotate on a subspecialty service of the Department of Medicine. Consultations are
done on inpatients and outpatients and patients are also seen in subspecialty clinics.
Division faculty provide supervision. Curricula for each rotation are included in Section
3.
Teaching Conferences
PGY1 residents attend a series of Departmental Conferences. The daily work schedule
is set up to allow PGY 1 residents to attend the conferences (Table 1).
Table 1
UNC Department of Medicine- Schedule of Daily Activities
Time
0700
0745
0830
Monday
Pre Rounds
Residents
Report
Tuesday
Pre Rounds
Residents
Report
Wednesday
Pre rounds
Residents
Report
Thursday
Pre Rounds
Residents
Report
Friday
Pre Rounds
Residents
Report
0830
1030
1100
(flexible)
Work
Rounds
Attending
Rounds
Work
Rounds
Attending
Rounds
Work
Rounds
Attending
Rounds
Work
Rounds
Attending
Rounds
Work
Rounds
Attending
Rounds
1200
Core
Curriculum
Core
Curriculum
Intern
Conference
Grand
Rounds/
Morbidity
and
Mortality
Conference
EBM
Conference
Residents are expected to attend all conferences. The conferences are as follows:
Monday- Resident Core Curriculum Conference 1 hour
Tuesday- Resident Core Curriculum Conference 1 hour
Wednesday- Interns Conference 1 hour
Thursday- Grand Rounds 1 hour
Friday – EBM Conference 1 hour
The content of some of these conferences is briefly described. Lecture topics are
included in Section 4.
Monday and Tuesday- Residents Conference- Faculty in the Department of Medicine
presents a series of lectures covering focused topics.
Wednesday- Interns Conference- A lecture series o f Emergency Medicine Topics
mixed with case based group discussion.
Thursday- Grand Rounds
Thursday- Mortality and Morbidity- The morbidity and mortality conference centers on
a subject relating to patient care in the department. The Vice Chair of the department
conducts this lecture.
Friday- Evidence Based Medicine Conference- An evidence based medicine discussion
of selected literature by both faculty and residents.
The PGY 2 Year
Each PGY 2 resident must demonstrate competence in the following:
Patient Care
Medical Knowledge
Practice Based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
System Based Practice
Competency is defined as outlined above for PGY 1 residents and is used for monthly
evaluations of PGY 2 residents
The PGY 2 year is composed of a series of monthly rotations coupled with
Departmental teaching conferences.
The monthly inpatient rotations for a PGY 2 resident are as follows:
1. MICU- 1month
2.
3.
4.
5.
Cardiology- 2months
UNC inpatient Medicine Ward- 2-3 months
Wake Med- 1 month
Night Float- 2-3 2 week blocks
On inpatient rotations the role of the PGY 2 resident is to be in charge of the ward
team. In this role the PGY 2 resident:
1.
2.
3.
4.
5.
Performs a history and physical examination on each new patient
Reviews the treatment plan for each new patient with the PGY 1 resident
Reviews the performance of MS 3 students
Conducts daily work rounds
Supervises all procedures
On night float the PGY 2 resident reports at 7pm and until 7 am. They are responsible
for the primary evaluation and management of all non-intensive care patients
admitted to the Department of Medicine. At 7am the care of those patients goes to the
incoming team on call. The Attending Physician of the service provides supervision.
Cardiology/ICU/Inpatient General Medicine Wards/Inpatient Subspecialty Wards
-
These have been previously described under the PGY 1 resident. The role of
the PGY 2 resident on these services is supervisory. The PGY 2 resident evaluates all
patients on service and the PGY 2 resident is integral in constructing a plan of care,
which is carried out by the PGY 1 resident. Another major responsibility is teaching.
The PGY 2 resident teaches and supervises medical students on these services.
The PGY 2 curriculum also includes the following rotations:
Ambulatory General Internal Medicine- 2-3 months
Subspecialty Consultation- 2-3 months
Ambulatory General Internal Medicine – PGY 2 residents can choose from several
month blocks focusing on outpatient skills of the generalist. Some of the choices are:
Wake Hospital Ambulatory Rotation
Siler City- PGY 2 residents spend the month in a community setting supervised
by general internists.
Subspecialty Consultation- PGY 2 residents can choose among any subspecialty in the
Department of Medicine. Consultations are done on inpatients. Patients are also seen
in subspecialty clinics. Division faculty provides supervision. Curricula for each rotation
are included in Section 3.
Teaching Conferences
Like PGY 1 residents, PGY 2 residents attend a series of conferences, which are
integrated with the daily work schedule. Some have been described previously
including Monday Resident Core Curriculum, Tuesday Core Curriculum, Thursday
Grand Rounds and Friday Evidence Based Medicine. In addition, PGY 2 residents
attend Morning report. This is case- based with residents presenting unknown
patients to their peers. The presenting resident completes his /her presentation with a
review of a particular subject. This review like all presentations is posted on the
internet so that residents may review these at their leisure. These conferences are
coordinated by the Chief Residents. The curriculum is set by the chief residents; a list
of topics discussed is included in Section 4.
The PGY 3 Year
ACGME Competencies
Each PGY 3 resident must develop competency in the following:
Patient Care
Medical Knowledge
Practice Based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Systems Based Practice
Competency is defined as outlined above for the PGY 1 and PGY 2 residents and is
used in monthly evaluation.
In many ways the PGY 3 year is similar to the PGY 2 year in that the residents function
as described previously under the PGY 2 year, include teaching conferences. The
rotations however, are different and are as follows:
1.
2.
3.
4.
5.
6.
7.
8.
Wake Med- 1 month
UNC Internal Medicine Wards- 1-2 months
Same Day Clinic- 1 month
Ambulatory General Internal Medicine- 2-3 months
Subspecialty Consultations 2-3 months
Special electives – 1 month
MICU or Cardiology- 1-month
Night Float- 2-3 2 week blocks
Inpatient General Internal Medicine Wards/ Inpatient Subspecialty Ward- The role of
the PGY 3 resident is identical to that described previously for the PGY 2 resident.
Same Day Clinic- The role of the PGY 3 resident is identical to that of the PGY 1
resident
Ambulatory General Internal Medicine- PGY 3 residents can choose from several
month blocks including those described for PGY 2 residents. There are additional
choices as follows:
General Medicine Consults/Hospitalist Service- PGY 3 residents see patients on
other services, providing General Medicine Consultations. Also a small number of
inpatients are cared for. Supervision is provided by faculty from the Division of
General Internal Medicine Hospitalist group.
Geriatric Medicine- PGY 3 residents are exposed to management of this
population. Faculty trained in Geriatrics provide supervision
Subspecialty Consultations- The role of the PGY 3 resident is the same as described for
the PGY 2 resident on those rotations.
Special Electives- These rotations are designed to enhance individual training.
Residents pick a faculty mentor to conduct clinical or basic research. Rotations at other
institutions or international rotations can also be done.
COMPETENCY BASED CURRICULUM
General
Each inpatient service has designated teaching time, previously described in Section 1. It is the
responsibility of the division faculty when on service to review a series of topics during the monthly
rotation. The division faculty generates these topics with input from residents as well as data supplied
to each division from preceding In-Training Examination. A dominant theme for these conferences is
to review material a general internist must know about each discipline. The curricular goal for each
resident is to have a working knowledge of these subjects.
Cardiology Curriculum
UNC Internal Medicine Training Program
Cardiology Rotation Competency-based Goals and Objectives
Teaching site: 3 Anderson
Goals: The goal of this experience will be for the residents to gain experience in the inpatient
evaluation and management of patients with a broad spectrum of cardiac diseases.
1. Objectives
• Medical knowledge
Describe the epidemiology, genetics, natural history, clinical expression of the cardiac diseases
encountered in the inpatient setting.
Describe structure and function of the cardiovascular system
Summarize an approach to the evaluation of common cardiac presentations (chest pain,
shock, failure)
Distinguish non-cardiac chest pain from cardiac chest pain
Interpret diagnostic tests used in the evaluation of inpatients with suspected cardiac disease,
successfully risk stratify and treat
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of
inpatients with cardiac disorders.
• Patient care
Effectively perform a comprehensive history and complete physical examination in patients
with cardiac symptoms
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the
evaluation of cardiovascular disorders
Gain experience in procedures including central and arterial line placement, swan ganz
catheter indications and placement
Construct a comprehensive treatment plan and assess response to therapy.
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended
therapies.
Utilize validated instruments in the assessment of pain, function, and quality of life to monitor
and adjust therapy.
• Practice-based learning and improvement
Effectively use technology to manage information, support patient care decisions, and enhance
both patient and physician education.
Integrate and apply knowledge obtained from multiple sources to the care of inpatients
Demonstrate ability to critically assess the scientific literature
Set and assess individualized learning goals
Analyze clinical experience and employ a systematic methodology for improvement
Develop and maintain a willingness to learn from errors, and use errors to improve the system
or processes of care
• Systems-based practice
Discuss how the health care system affects the management of inpatients with cardiac
diseases.
Demonstrate effective collaboration with other health care providers, including nursing staff,
respiratory therapy, cardiac surgeons, and consult services in the care of patients with cardiac
diseases
Determine cost-effectiveness of alternative proposed interventions.
Design cost-effective plans based on knowledge of best practices
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the
health care system, cost of the procedure, insurance coverage, and resources utilized
• Interpersonal skills and communication
Apply empathy in all patient encounters
Demonstrate effective skills of listening and speaking with patients, families and other
members of the health care team
Reliably and accurately communicate the patient's and his/her family's views and concerns to
the attending
Compose clear and timely admission and progress reports and interval notes/letters, including
a precise diagnosis whenever possible, differential diagnosis when appropriate, and
recommend follow up or additional studies
Counsel patients, families and colleagues regarding side effects and appropriate use of specific
medications, providing written documentation when appropriate
• Professionalism
Be prompt and prepared for rounds
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed
consent, and equitable respect and care to all
Respect patients and their families, staff and colleagues
Model ethical behavior by reporting back to the attending and referring providers any key
clinical findings, following through on clinical questions, laboratory testing and other patient
care issues, and recognizing potential conflicts of interest
Demonstrate integrity, honesty and openness in discussion of therapeutic options with
patients and respect for patient’s preferences and multicultural differences
Respond to phone calls, pages and/or messages in a timely manner
Critical Care Curriculum
UNC Internal Medicine Training Program
Medical ICU Rotation Competency-based Goals and Objectives
Teaching site:
UNC Memorial Hospital Medical Intensive Care Unit
Goals: The goal of this experience will be for the residents to gain experience in evaluation and
management of patients requiring critical care medicine.
1. Objectives
• Medical knowledge
Describe the epidemiology, genetics, natural history, clinical presentation of conditions
commonly treated in the intensive care unit
Demonstrate knowledge of mechanical ventilation and demonstrate knowledge indications for
initiation of mechanical ventilation and extubation. Demonstrate competency in evaluation of
blood gases and ventilator management.
Summarize an approach to the evaluation and treatment of common conditions treatied in the
intensive care unit (sepsis, respiratory failure, drug overdoses)
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of
inpatients with critical illness.
Demonstrate a knowledge of the indications for common procedures, and a competency in
performing common procedures used in the intesive care unit, including central line
placement, arterial line placement, thoracentesis, paracentesis, and lumbar puncture
• Patient care
Effectively perform a comprehensive history and complete physical examination in patients
requiring treatment in the intensive care unit
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the
evaluation
Construct a comprehensive treatment plan and assess response to therapy.
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended
therapies.
Utilize validated instruments in the assessment of function and quality of life to monitor and
adjust therapy.
just therapy.
• Practice-based learning and improvement
Effectively use technology to manage information, support patient care decisions, and enhance
both patient and physician education.
Integrate and apply knowledge obtained from multiple sources to the care of ICU patients
Demonstrate ability to critically assess the scientific literature
Set and assess individualized learning goals
Analyze clinical experience and employ a systematic methodology for improvement
Develop and maintain a willingness to learn from errors, and use errors to improve the system
or processes of care
• Systems-based practice
Discuss how the health care system affects the management of inpatients with endocrine
diseases.
Demonstrate effective collaboration with other health care providers, including nursing staff,
diabetes educators, head and neck as well as neurosurgeons, and consult services in the care
of patients with endocrine diseases
Determine cost-effectiveness of alternative proposed interventions.
Design cost-effective plans based on knowledge of best practices
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the
health care system, cost of the procedure, insurance coverage, and resources utilized
• Interpersonal skills and communication
Apply empathy in all patient encounters
Demonstrate effective skills of listening and speaking with patients, families and other
members of the health care team
Reliably and accurately communicate the patient's and his/her family's views and concerns to
the attending
Demonstrate competency in documentation including appropriate history and physical,
progress, and discharge notes
Counsel patients, families and colleagues regarding side effects and appropriate use of specific
medications, providing written documentation when appropriate
• Professionalism
Be prompt and prepared for rounds and/or clinic
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed
consent, and equitable respect and care to all
Respect patients and their families, staff and colleagues
Model ethical behavior by reporting back to the attending and referring providers any key
clinical findings, following through on clinical questions, laboratory testing and other patient
care issues, and recognizing potential conflicts of interest
Demonstrate integrity, honesty and openness in discussion of therapeutic options with
patients and respect for patient’s preferences and multicultural differences
Respond to phone calls, pages and/or messages in a timely manner
Core Topics in Critical Care
Resuscitation
BCLS and ACLS
Shock: Causes, assessments, and treatment
Early goal directed therapy for septic shock
Pulmonary
Respiratory failure: Hypoxemic and hypercapnic
Intubation criteria, oral/nasal/tracheostomy complications
Mechanical ventilator modes, monitors and complications
Weaning criteria and techniques, daily spontaneous breathing trials
ARDS: Causes, physiology, therapy and complications
Asthma and COPD
Pulmonary embolism
Pulmonary hemorrhage
Cardiology
Shock: Differential diagnosis and initial treatment
Acute MI: Diagnosis, treatment and complications
Arrhythmias
Pericarditis, Tamponade, and Constrictive pericarditis
CHF and Pulmonary edema
Pulmonary artery catheter: indications, placement, and interpretation
Inotropic drugs
Nephrology
Acute renal failure: causes and treatment
Renal replacement therapy: continuous and intermittent
Electrolyte abnormalities: Na+,K+, C1Acid based disturbances and compensations
Metabolic acidosis: increased and normal anion gap
Urine electrolytes
Metabolism
Nutrition: assessment, requirements, enteral feeding, TPN
Diabetic ketoacidosis and non-ketotic hyperosmolar coma
Adrenal crisis and steroid therapy
Gastrointestinal
Upper GI hemorrhage
Lower GI hemorrhage
Liver disease: alcoholic, viral, other
Pancreatitis
The acute abdomen: causes and assessment
Poisons
Initial assessment and treatment options
Acetaminophen
Anti depressants
Salicylates
Alcohols
Infections
Pneumonias
Aspiration pneumonitis
Central line related bloodstream infections: prevention and management
Tuberculosis
Immunocompromised patients and opportunistic infections
Hematology
Anemia and transfusions
Thrombocytopenia, coagulopathy DIC
Hemolysis
Sickle cell disease
Administration and/Ethics
Admission and discharge criteria
Illness severity scores and prognoses
Advance directives
Use/limitation of life sustaining treatments
Practice and system based improvements: protocols and data monitoring
The Endocrine Rotation
Residents will work on a daily basis with the endocrinology team to include an attending (Dr. O’Connell
and/or Dr. DeCherney), an endocrine fellow, an endocrine nurse practitioner and possibly a diabetes
educator during their rotation. Other attendings with special interest will be invited to rounds
periodically when interesting cases are seen( i.e. Dr. Sharpless for interesting pituitary cases, Dr.
Rubin for interesting bone cases, etc.)
The resident will participate in the care of a wide variety of endocrine disorders seen in the hospital.
Inpatient diabetes management will be a major focus.
The residents will see patients one half day per week (usually Tuesday mornings, but days are
flexible) in the endocrine outpatient clinic (High gate Specialty Center off of 54 near Southpoint) under
the supervision of an attending.
The residents will learn from their interactions with the team members, managing complex endocrine
patients and from teaching while at the bedside. The endocrine curriculum will be provided and topics
selected for teaching on a daily/weekly basis reflecting the patient material encountered. We will
coordinate these teaching activities with the General Medicine Inpatient and Outpatient curriculum.
Additionally, the residents should attend the Endocrine Division’s weekly conferences held Thursday
afternoons from 3-5:30 in 2020 Bondurant. These sessions include a 3-4 pm didactic lecture given on
an array of topics by attendings from multiple departments (nuclear medicine, pathology,
ophthalmology, Endocrine, ect.) From 4-5 is journal club or a research presentation and from 5-5:30
is a case presentation by one of the fellows.
The goal of the inpatient endocrine service is to improve care of admitted patients with endocrine
disease. It is the hope of the Endocrine Division that the medicine residents will find this rotation an
enjoyable and educational experience and that after the rotation, they will be better prepared to
manage endocrine patients in both the inpatient and outpatient settings.
Endocrinology Curriculum
UNC Internal Medicine Training Program
Endocrinology Rotation Competency-based Goals and Objectives
Teaching site:
Consult Service: UNC Memorial Hospital
Clinic (1-2 half days per week): Highgate Subspecialty Clinic, 5316 Highgate Dr #125, Durham
Goals: The goal of this experience will be for the residents to gain experience in both the inpatient and
outpatient evaluation and management of patients with a broad spectrum of endocrine disorders.
1. Objectives
• Medical knowledge
Describe the epidemiology, genetics, natural history, clinical expression of the endocrine
disorders encountered in the inpatient and outpatient setting.
Describe function of the endocrine systems
Summarize an approach to the evaluation of common endocrine presentations
Interpret diagnostic tests used in the evaluation of in and outpatients with suspected
endocrine disease
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of
inpatients with endocrine disorders.
• Patient care
Effectively perform a comprehensive history and complete physical examination in patients
with endocrine symptoms
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the
evaluation of endocrine disorders
Construct a comprehensive treatment plan and assess response to therapy.
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended
therapies.
Utilize validated instruments in the assessment of function and quality of life to monitor and
adjust therapy.
• Practice-based learning and improvement
Effectively use technology to manage information, support patient care decisions, and enhance
both patient and physician education.
Integrate and apply knowledge obtained from multiple sources to the care of inpatients and
outpatients
Demonstrate ability to critically assess the scientific literature
Set and assess individualized learning goals
Analyze clinical experience and employ a systematic methodology for improvement
Develop and maintain a willingness to learn from errors, and use errors to improve the system
or processes of care
• Systems-based practice
Discuss how the health care system affects the management of inpatients with endocrine
diseases.
Demonstrate effective collaboration with other health care providers, including nursing staff,
diabetes educators, head and neck as well as neurosurgeons, and consult services in the care
of patients with endocrine diseases
Determine cost-effectiveness of alternative proposed interventions.
Design cost-effective plans based on knowledge of best practices
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the
health care system, cost of the procedure, insurance coverage, and resources utilized
• Interpersonal skills and communication
Apply empathy in all patient encounters
Demonstrate effective skills of listening and speaking with patients, families and other
members of the health care team
Reliably and accurately communicate the patient's and his/her family's views and concerns to
the attending
Compose clear and timely consult and clinic notes as well as interval notes/letters, including a
precise diagnosis whenever possible, differential diagnosis when appropriate, and recommend
follow up or additional studies
Counsel patients, families and colleagues regarding side effects and appropriate use of specific
medications, providing written documentation when appropriate
• Professionalism
Be prompt and prepared for rounds and/or clinic
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed
consent, and equitable respect and care to all
Respect patients and their families, staff and colleagues
Model ethical behavior by reporting back to the attending and referring providers any key
clinical findings, following through on clinical questions, laboratory testing and other patient
care issues, and recognizing potential conflicts of interest
Demonstrate integrity, honesty and openness in discussion of therapeutic options with
patients and respect for patient’s preferences and multicultural differences
Respond to phone calls, pages and/or messages in a timely manner
Goals and Objectives
When possible, residents should participate in the care of patients with the following
disorders. Reading should be geared towards patients encountered as well as disorders missed while
on rotation. At the close of the endocrine rotation, residents should exhibit proficiency in the
evaluation and treatment of the disorders listed in the curriculum below.
1. Diabetes Mellitus
Diagnosis and Classification
Treatment
Complications
Hypoglycemia in Non-diabetics
2. Disorders of the Pituitary Gland
Hypothalamic Disease
Hypopituitarism
Pituitary Tumors
Posterior Pituitary Deficiency and Excess
Pregnancy and Pituitary Disease
3. Disorders of the Thyroid Gland
Thyroid Physiology
Evaluation of Thyroid Function
Functional Thyroid Gland Disorders
Structural Diseases of the Thyroid Gland
Approach to the Thyroid Nodule
Medications that alter thyroid function
Effects of Non-Thyroidal Illness on Thyroid Function Tests
Thyroid Function and Disease in Pregnancy
Thyroid Emergencies
4. Disorders of the Adrenal Gland
Adrenal Insufficiency
Cushing Syndrome
Adrenal Incidentaloma
Pheochromocytoma
Primary Hypoaldosteronism
Adrenocortical Carcinoma
5. Reproductive Disorders
Basic Concepts and Common Features
Physiology of Male Reproduction
Female Reproductive Physiology
6. Calcium and Bone Disorders
Calcium Metabolism
Hypercalcemia
Hypocalcemia
Metabolic Bone Disease
Gastroenterology Curriculum
UNC Internal Medicine Training Program
Gastroenterology Rotation Competency-based Goals and Objectives
Teaching site: UNC Memorial Hospital
Instructions: Following morning report on your first day on service, page the fellow on call for your
consult service (Luminal or Hepatology). Tell them the days that you will be on service and which
days you have clinic or alternate coverage responsibilities.
Goals: The goal of this experience will be for the residents to gain experience in the inpatient
evaluation and management of patients with a broad spectrum of GI diseases.
1. Objectives
• Medical knowledge
Describe the epidemiology, genetics, natural history, clinical expression of the GI illness
encountered in the inpatient setting.
Describe structure and function of GI tract, liver and biliary systems
Summarize an approach to the evaluation of the common presentations of GI illness (GI bleed,
diarrhea, jaundice / transaminitis, etc)
Distinguish patients with functional bowel disorders from those with other "organic" bowel
diseases
Interpret diagnostic tests used in the evaluation of outpatients with suspected GI Illness
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of
outpatients with GI disorders.
• Patient care
Effectively perform a comprehensive history and complete physical examination in patients
with GI symptoms, abnormal liver function tests, or acute or chronic GI disorders
Construct an appropriate differential diagnosis
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the
evaluation of GI disorders
Construct a comprehensive treatment plan and assess response to therapy.
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended
therapies.
Describe the appropriate use of validated instruments in the assessment of pain, function, and
quality of life to monitor and adjust therapy.
• Practice-based learning and improvement
Effectively use technology to manage information, support patient care decisions, and enhance
both patient and physician education.
Integrate and apply knowledge obtained from multiple sources to the care of inpatients
Demonstrate ability to critically assess the scientific literature
Set and assess individualized learning goals
Analyze clinical experience and employ a systematic methodology for improvement
Develop and maintain a willingness to learn from errors, and use errors to improve the system
or processes of care
• Systems-based practice
Discuss how the health care system affects the management of outpatients with GI diseases.
Demonstrate effective collaboration with other health care providers, including nutritionists
and GI surgeons, in the care of patients with GI illness
Determine cost-effectiveness of alternative proposed interventions.
Design cost-effective plans based on knowledge of best practices
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the
health care system, cost of the procedure, insurance coverage, and resources utilized
• Interpersonal skills and communication
Approach patients with an empathetic and understandable manner
Demonstrate effective skills of listening and speaking with patients, families and other
members of the health care team
Reliably and accurately communicate the patient's and his/her family's views and concerns to
the attending
Compose clear and timely consultation reports and interval notes/letters, including a precise
diagnosis whenever possible, differential diagnosis when appropriate, and recommend follow
up or additional studies
Counsel patients, families and colleagues regarding side effects and appropriate use of specific
medications, providing written documentation when appropriate
• Professionalism
Exhibit punctuality for all assigned duties
Incorporate the principles of patient primacy, patient privacy, patient autonomy, informed
consent, and equitable respect in the care of patients
Demonstrate respect for patients and their families, staff and colleagues
Model ethical behavior by reporting back to the attending and referring providers key clinical
findings, following through on clinical questions, laboratory testing and other patient care
issues, and recognizing potential conflicts of interest
Demonstrate integrity, honesty and openness in discussion of therapeutic options with
patients and respect for patient’s preferences and multicultural differences
Respond to phone calls, pages and/or messages in a timely manner
GI Core Topics
1. Evaluation and treatment of diarrhea
2. Evaluation and treatment of jaundice
3. Inflammatory bowel diseases
4. Hepatitis - viral and non-viral
5. Diagnosis and management of peptic ulcer disease
6. Nutritional support - enteral and intravenous
7. Colonoscopy - indication and screening
8. Diagnosis and management of pancreatitis
9. Diagnosis of esophageal motility disorders
10. Evaluation and treatment of abdominal pain
11. Diagnosis and management of cirrhosis
12. Liver transplantation - indicators and outcomes
13. Diagnosis and management of GI bleeding
14. Appropriate use of radiologic studies of the gastrointestinal system
15. Evaluation and management of gallstones/gallbladder diseases
General Medicine Curriculum
UNC Internal Medicine Training Program
General Medicine Rotation Competency-based Goals and Objectives
Teaching site: UNC Memorial Hospital (Ward Teams U and W)
Goals: The goal of this experience will be for the residents to gain experience in the inpatient and
outpatient evaluation and management of patients with a broad spectrum of general medicine
disorders.
1. Objectives
• Medical knowledge
Become familiar with the epidemiology, diagnosis, and management of patients with common
medical conditions encountered on a general medicine service
Demonstrate competence in performing common procedures use on a general medicine
service, including paracentesis, thoracentesis, and lumbar puncture
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of
inpatients on a general medicine ward service
• Patient care
Effectively perform a comprehensive history and complete physical examination
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the
evaluation of patients on a general medicine ward service
Construct a comprehensive treatment plan and assess response to therapy
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended
therapies.
Utilize validated instruments in the assessment of function and quality of life to monitor and
adjust therapy
Demonstrate competency in documentation including appropriate history and physical,
progress, and discharge notes
• Practice-based learning and improvement
Effectively use technology to manage information, support patient care decisions, and enhance
both patient and physician education.
Integrate and apply knowledge obtained from multiple sources to the care of inpatients and
outpatients
Demonstrate ability to critically assess the scientific literature
Set and assess individualized learning goals
Analyze clinical experience and employ a systematic methodology for improvement
Develop and maintain a willingness to learn from errors, and use errors to improve the system
or processes of care
• Systems-based practice
Describe how the health care system affects the management of inpatients on a general
medicine service
Demonstrate effective collaboration with other health care providers, particularly subspecialty
consultants
Determine cost-effectiveness of alternative proposed interventions.
Design cost-effective plans based on knowledge of best practices
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the
health care system, cost of the procedure, insurance coverage, and resources utilized
• Interpersonal skills and communication
Apply empathy in all patient encounters
Demonstrate effective skills of listening and speaking with patients, families and other
members of the health care team
Reliably and accurately communicate the patient's and his/her family's views and concerns to
the attending
Counsel patients, families and colleagues regarding side effects and appropriate use of specific
medications, providing written documentation when appropriate
• Professionalism
Be prompt and prepared for rounds and/or clinic
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed
consent, and equitable respect and care to all
Respect patients and their families, staff and colleagues
Model ethical behavior by reporting back to the attending and referring providers any key
clinical findings, following through on clinical questions, laboratory testing and other patient
care issues, and recognizing potential conflicts of interest
Demonstrate integrity, honesty and openness in discussion of therapeutic options with
patients and respect for patient’s preferences and multicultural differences
Respond to phone calls, pages and/or messages in a timely manner
General Medicine Core Topics
Likelihood Ratios; testing
Community Acquired Pneumonia
Pulmonary Emboli
Chest Pain Evaluation; CAD
Diabetic ketoacidosis, complications
Meningitis
Venous Stasis Ulcers
Peripheral Vascular Disease
W/U of Diarrhea
COPD, acute exacerbation
Depression, mood disorders
Stroke, endarterectomy
Hypertension Emergencies
Common Biliary tract diseases, cholecystitis, cholangitis
Dementia
Delirium
Diverticulitis
Avitaminoses
Peripheral Neuropathy
Cellulitis
Pulmonary Nodule
Anemia of chronic disease, liver disease
Pancreatitis
Poisonings- ethylene glycol, arsenic
Geriatrics
Geriatrics Curriculum for Internal Medicine Residency Program
Updated 7/2011
Debra L. Bynum, MD
Program Director, Geriatric Fellowship
Assistant Director for Education, Geriatric Division of Medicine
Current requirements from the Residency Review Committee for Internal Medicine, as outlined by the
Accreditation Council for Graduate Medical Education, specify that “Residents must have formal
instruction and assigned clinical experience in geriatric medicine. The curriculum and clinical
experience should be directed by an ABMS- certified geriatrician. These experiences may occur at one
or more specifically designated geriatric inpatient units, geriatric consultation services, long-term
facilities, geriatric ambulatory clinics,, and/ or in home care settings.”
The Department of Medicine at the University of North Carolina at Chapel Hill currently has a separate
Division of Geriatric Medicine with faculty and fellows in graduate medical training who are dedicated
to the education of medical students and residents. Currently residents receive training in the care of
geriatric patients in both inpatient and outpatient settings. In addition to the core competencies of
training as defined for all Internal Medicine Residents by the ACGME, the American Geriatrics Society
in working with the American Medical Association, the American Board of Family Medicine, and the
Society of General Internal Medicine have developed a set of 26 geriatric competencies in 7 domains
(Transitions of Care; Hospital Patient Safety; Cognitive, Affective and Behavioral Health; Complex or
Chronic Illness; Medication Management; Ambulatory Care; and Palliative and End of Life Care).
MINIMUM GERIATRIC COMPETENCIES for IM-FM Residents
The graduating IM or FM resident, in the context of a specific older patient scenario (real or
simulated), must be able to:
MEDICATION MANAGEMENT
1 Prescribe appropriate drugs and dosages considering:
(a) age-related changes in renal and hepatic function, body composition, and CNS
sensitivity;
(b) common side effects in light of patient’s comorbidities, functional status, and other
medications; and (c) drug-drug interactions.
2 When prescribing drugs which present high risk for adverse events and interactions (these
medications include, but are not limited to, coumadin, NSAID’s, opioids, digoxin, insulin,
strongly anticholinergic drugs, and psychotropic drugs), discuss and document the rationale
for their use, alternatives, and ways to decrease side effects.
3 Periodically review patient’s medications (including meds prescribed by other physicians,
OTC and CAM) with the patient and/or caregiver to assess adherence, eliminate ineffective,
duplicate and unnecessary medications, and assure that all medically indicated
pharmacotherapy is prescribed.
COGNITIVE, AFFECTIVE, AND BEHAVIORAL HEALTH
4 Appropriately administer and interpret the results of at least one validated screening tool for
each of the following: delirium, dementia, depression, and substance abuse.
5 Recognize delirium as a medical urgency, promptly evaluate and treat underlying problem.
6 Evaluate and formulate a differential diagnosis and workup for patients with changes in
affect, cognition, and behavior (agitation, psychosis, anxiety, apathy).
7 In patients with dementia and/or depression, initiate treatment and/or refer as appropriate.
COMPLEX OR CHRONIC ILLNESS(ES) IN OLDER ADULTS
8 Identify and assess barriers to communication such as hearing and/or sight impairments,
speech difficulties, aphasia, limited health literacy, and cognitive disorders. When present,
demonstrate ability to use adaptive equipment and alternative methods to communicate (e.g.,
with the aid of family/friend, caregiver).
9 Determine whether an older patient has sufficient capacity to give an accurate history, make
decisions and participate in developing the plan of care.
10 In evaluating adults with undifferentiated illness, generate differential diagnoses that
include diseases that often present atypically in older adults (e.g., acute coronary syndromes,
the acute abdomen, urinary tract infection, and pneumonia).
11 Consider adverse reactions to medication in the differential diagnosis of new symptoms or
geriatric syndromes (e.g., cognitive impairment, constipation, falls, incontinence).
12 Demonstrate understanding of the major age-related changes in physical and laboratory
findings during diagnostic reasoning (e.g., S4 does not reflect CHF, pulse increase less
common with orthostasis, pO2 declines with age, abdominal pain may be less severe).
13 Discuss and document advance care planning and goals of care with all patients with
chronic or complex illness, and/or their surrogates.
14 Develop a treatment plan that incorporates the patient’s and family’s goals of care,
preserves function, and relieves symptoms.
PALLIATIVE AND END OF LIFE CARE
15 In patients with life limiting or severe chronic illness, assess pain and distressing non-pain
symptoms (dyspnea, nausea, vomiting, fatigue) at regular intervals and institute appropriate
treatment based on their goals of care.
16 In patients with life limiting or severe chronic illness, identify with the patient, family and
care team when goals of care and management should transition to primarily comfort care.
HOSPITAL PATIENT SAFETY
17 As part of the daily physical exam of all hospitalized older patients, assess and document
whether delirium is present.
18 In hospitalized medical and surgical patients, evaluate - on admission and on a regular
basis - for fall risk, immobility, pressure ulcers, adequacy of oral intake, pain, new urinary
incontinence, constipation, and inappropriate medication prescribing, and institute appropriate
corrective measures.
19 In hospitalized patients with an indwelling bladder catheter, discontinue or document
indication for use.
20 Before using or renewing physical or chemical restraints on geriatric patients, assess for
and treat reversible causes of agitation (e.g., use of irritating tethers [including monitor leads,
blood pressure cuff, pulse oximeter, intravenous lines and in-dwelling bladder catheters],
untreated pain, alcohol withdrawal, delirium, ambient noise). Consider alternatives to
restraints such as additional staffing, environmental modifications, and presence of family
members.
TRANSITIONS OF CARE
21 In planning hospital discharge, work in conjunction with other health care providers (e.g.,
social work, case management, nursing, physical therapy) to recommend appropriate services
based on: the clinical needs, personal values and social and financial resources of the patients
and their families (e.g., symptom and functional goals in the context of prognosis, care
directives, home circumstances and financial resources); and the patient’s eligibility for
community-based services (e.g., home health care, day care, assisted living, nursing home,
rehabilitation, or hospice).
22 In transfers between the hospital and skilled nursing or extended care facilities, ensure
that: for transfers to the hospital: the caretaking team has correct information on the acute
events necessitating transfer, goals of transfer, medical history, medications, allergies,
baseline cognitive and functional status, advance care plan and responsible PCP; and for
transfers from the hospital: a written summary of hospital course be completed and
transmitted to the patient and/or family caregivers as well as the receiving health care
providers that accurately and concisely communicates evaluation and management, clinical
status, discharge medications, current cognitive and functional status, advance directives, plan
of care, scheduled or needed follow-up, and hospital physician contact information.
AMBULATORY CARE
23 Yearly screen all ambulatory elders for falls or fear of falling. If positive, assess gait and
balance instability, evaluate for potentially precipitating causes (medications, neuromuscular
conditions, and medical illness), and implement interventions to decrease risk of falling.
24 Detect, evaluate and initiate management of bowel and bladder dysfunction in community
dwelling older adults.
25 Identify older persons at high safety risk, including unsafe driving or elder abuse/neglect,
and develop a plan for assessment or referral.
26 Individualize standard recommendations for screening tests and chemoprophylaxis in older
patients based on life expectancy, functional status, patient preference and goals of care.
Residents will work either on the Inpatient Medicine Service or in the Outpatient setting in order to
achieve these competencies. During the Outpatient rotation, residents will work in the Geriatric
Evaluation Clinic, Hospice/home visits, PMR, Geriatric Psychiatry, and Long Term Care settings. In
addition to patient care activities that are under the direct supervision of a Geriatric Faculty member,
the residents will be part of routine didactic sessions and have full access to our presentations and
other resources available through the Fellowship Web site.
Readings and other materials and resources can be found: http://www.med.unc.edu/aging/fellowship
References:
Williams B C, Warshaw G, Fabiny A R, Lundebjerg N, Sauvigne K, Schwartzberg J G, Leipzig R M.
(2010).
Medicine in the 21st century: Recommended essential geriatrics competencies for Internal Medicine
and
Family Medicine residents. Journal of Graduate Medical Education, 2(3), 373-383. Also available
Hematology / "Coags" Curriculum
UNC Internal Medicine Training Program
Hematology Rotation Competency-based Goals and Objectives
Teaching site: UNC Memorial Hospital
Instructions: Following morning report on your first day on service, page the fellow on call for your
consult service. Tell them the days that you will be on service and which days you have clinic or
alternate coverage responsibilities.
Goals: The goal of this experience will be for the residents to gain experience in the inpatient
evaluation and management of patients with a broad spectrum of hematologic diseases.
1. Objectives
• Medical knowledge
Describe the epidemiology, genetics, natural history, clinical expression of the hematologic
illness encountered in the inpatient setting.
Describe the functions and interplay of factors related to hemostasis and bleeding
Summarize an approach to the evaluation of the common presentations of hematologic
illnesses (bleeding, clotting, cytopenias, etc)
Interpret diagnostic tests used in the evaluation of inpatients with suspected hematologic
disorders
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of
inpatients with hematologic disorders
• Patient care
Effectively perform a comprehensive history and complete physical examination in patients
with hematologic symptoms, abnormal coagulation tests, or acute or chronic hematologic
disorders
Construct an appropriate differential diagnosis
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the
evaluation of hematologic disorders
Construct a comprehensive treatment plan and assess response to therapy.
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended
therapies.
Describe the appropriate use of validated instruments in the assessment of pain, function, and
quality of life to monitor and adjust therapy.
• Practice-based learning and improvement
Effectively use technology to manage information, support patient care decisions, and enhance
both patient and physician education.
Integrate and apply knowledge obtained from multiple sources to the care of inpatients
Demonstrate ability to critically assess the scientific literature
Set and assess individualized learning goals
Analyze clinical experience and employ a systematic methodology for improvement
Develop and maintain a willingness to learn from errors, and use errors to improve the system
or processes of care
• Systems-based practice
Discuss how the health care system affects the management of outpatients with hematologic
disorders
Demonstrate effective collaboration with other health care providers, including nursing,
counselors and transfusion medicine, in the care of patients with hematologic disorders
Determine cost-effectiveness of alternative proposed interventions.
Design cost-effective plans based on knowledge of best practices
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the
health care system, cost of the procedure, insurance coverage, and resources utilized
• Interpersonal skills and communication
Approach patients with an empathetic and understandable manner
Demonstrate effective skills of listening and speaking with patients, families and other
members of the health care team
Reliably and accurately communicate the patient's and his/her family's views and concerns to
the attending
Compose clear and timely consultation reports and interval notes/letters, including a precise
diagnosis whenever possible, differential diagnosis when appropriate, and recommend follow
up or additional studies
Counsel patients, families and colleagues regarding side effects and appropriate use of specific
medications, providing written documentation when appropriate
• Professionalism
Exhibit punctuality for all assigned duties
Incorporate the principles of patient primacy, patient privacy, patient autonomy, informed
consent, and equitable respect in the care of patients
Demonstrate respect for patients and their families, staff and colleagues
Model ethical behavior by reporting back to the attending and referring providers key clinical
findings, following through on clinical questions, laboratory testing and other patient care
issues, and recognizing potential conflicts of interest
Demonstrate integrity, honesty and openness in discussion of therapeutic options with
patients and respect for patient’s preferences and multicultural differences
Respond to phone calls, pages and/or messages in a timely manner
Infectious Disease Curriculum
UNC Internal Medicine Training Program
Infectious Disease Rotation Competency-based Goals and Objectives
Teaching site: UNC Memorial Hospital
Instructions: Following morning report on your first day on service, page the fellow on call for your
consult service. Tell them the days that you will be on service and which days you have clinic or
alternate coverage responsibilities.
Goals: The goal of this experience will be for the residents to gain experience in the inpatient
evaluation and management of patients with a broad spectrum of infectious diseases.
1. Objectives
• Medical knowledge
Describe the epidemiology, genetics, natural history, clinical expression of the infectious
diseases encountered in the inpatient setting.
Describe the functions and interplay of factors related to host defense, microbial infection and
treatment
Summarize an approach to the evaluation of the common presentations of infectious diseases
(HIV, pneumonia, urinary tract infections, sepsis, etc)
Interpret diagnostic tests used in the evaluation of inpatients with suspected infectious
diseases
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of
inpatients with infectious diseases
• Patient care
Effectively perform a comprehensive history and complete physical examination in patients
with infectious symptoms or chronic infectious disease states
Construct an appropriate differential diagnosis
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the
evaluation of infectious diseases
Construct a comprehensive treatment plan and assess response to therapy.
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended
therapies.
Describe the appropriate use of validated instruments in the assessment of pain, function, and
quality of life to monitor and adjust therapy.
• Practice-based learning and improvement
Effectively use technology to manage information, support patient care decisions, and enhance
both patient and physician education.
Integrate and apply knowledge obtained from multiple sources to the care of inpatients
Demonstrate ability to critically assess the scientific literature
Set and assess individualized learning goals
Analyze clinical experience and employ a systematic methodology for improvement
Develop and maintain a willingness to learn from errors, and use errors to improve the system
or processes of care
• Systems-based practice
Discuss how the health care system affects the management of outpatients with infectious
diseases
Demonstrate effective collaboration with other health care providers, including nursing,
counselors and the Department of Health, in the care of patients with infectious diseases
Determine cost-effectiveness of alternative proposed interventions.
Design cost-effective plans based on knowledge of best practices
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the
health care system, cost of the procedure, insurance coverage, and resources utilized
• Interpersonal skills and communication
Approach patients with an empathetic and understandable manner
Demonstrate effective skills of listening and speaking with patients, families and other
members of the health care team
Reliably and accurately communicate the patient's and his/her family's views and concerns to
the attending
Compose clear and timely consultation reports and interval notes/letters, including a precise
diagnosis whenever possible, differential diagnosis when appropriate, and recommend follow
up or additional studies
Counsel patients, families and colleagues regarding side effects and appropriate use of specific
medications, providing written documentation when appropriate
• Professionalism
Exhibit punctuality for all assigned duties
Incorporate the principles of patient primacy, patient privacy, patient autonomy, informed
consent, and equitable respect in the care of patients
Demonstrate respect for patients and their families, staff and colleagues
Model ethical behavior by reporting back to the attending and referring providers key clinical
findings, following through on clinical questions, laboratory testing and other patient care
issues, and recognizing potential conflicts of interest
Demonstrate integrity, honesty and openness in discussion of therapeutic options with
patients and respect for patient’s preferences and multicultural differences
Respond to phone calls, pages and/or messages in a timely manner
Infectious Disease Core Topics
Antibiotics I ( antibacterials)
Antibiotics II ( antivirals and antifungals)
HIV I
HIV II
Sepsis
Endocarditis
Skin and Soft Tissue Infection (Including osteomyelitits)
Diarrhea
Urinary Tract Infection
FUO
New and unusual infections, including Lyme disease and RMSF
Oncology Curriculum
UNC Internal Medicine Training Program
Oncology Rotation Competency-based Goals and Objectives
Inpatient Teaching site: UNC Cancer Hospital, 4th Floor Inpatient Unit
Goals: The goal of this experience will be for the residents to gain experience in the inpatient setting
and treatment of patients with a broad spectrum of cancers.
1. Objectives
• Medical knowledge
Describe the epidemiology, genetics, natural history, clinical expression of different types of
cancers encountered in the inpatient setting.
Summarize an approach to the evaluation of common cancer presentations
Exhibit understanding of the epidemiology, pathology, clinical presentation, diagnosis and
treatment of common complications of cancer, chemotherapy and radiation therapy, including
but not limited to tumor lysis syndrome, leukostasis, cord compression, neutropenic fevers
and pain crises.
Interpret diagnostic tests used in the evaluation of inpatients with suspected cancer
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of
inpatients with cancer.
• Patient care
Effectively perform a comprehensive history and complete physical examination in patients
with cancer and/or its complications
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the
evaluation of cancer and/or its complications
Construct a comprehensive treatment plan and assess response to therapy.
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended
therapies.
Utilize validated instruments in the assessment of function and quality of life to monitor and
adjust therapy.
• Practice-based learning and improvement
Effectively use technology to manage information, support patient care decisions, and enhance
both patient and physician education.
Integrate and apply knowledge obtained from multiple sources to the care of inpatients
Demonstrate ability to critically assess the scientific literature
Set and assess individualized learning goals
Analyze clinical experience and employ a systematic methodology for improvement
Develop and maintain a willingness to learn from errors, and use errors to improve the system
or processes of care
• Systems-based practice
Discuss how the health care system affects the management of inpatients with endocrine
diseases.
Demonstrate effective collaboration with other health care providers, including nursing staff,
therapists, counselors, surgeons, and consult services in the care of patients with cancer
Determine cost-effectiveness of alternative proposed interventions.
Design cost-effective plans based on knowledge of best practices
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the
health care system, cost of the procedure, insurance coverage, and resources utilized
• Interpersonal skills and communication
Apply empathy in all patient encounters
Demonstrate effective skills of listening and speaking with patients, families and other
members of the health care team
Reliably and accurately communicate the patient's and his/her family's views and concerns to
the attending
Compose clear and timely consult and clinic notes as well as interval notes/letters, including a
precise diagnosis whenever possible, differential diagnosis when appropriate, and recommend
follow up or additional studies
Counsel patients, families and colleagues regarding side effects and appropriate use of specific
medications, providing written documentation when appropriate
• Professionalism
Be prompt and prepared for rounds and/or clinic
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed
consent, and equitable respect and care to all
Respect patients and their families, staff and colleagues
Model ethical behavior by reporting back to the attending and referring providers any key
clinical findings, following through on clinical questions, laboratory testing and other patient
care issues, and recognizing potential conflicts of interest
Demonstrate integrity, honesty and openness in discussion of therapeutic options with
patients and respect for patient’s preferences and multicultural differences
Respond to phone calls, pages and/or messages in a timely manner
Pulmonary Curriculum
UNC Internal Medicine Training Program
Pulmonary Rotation Competency-based Goals and Objectives
Teaching site:
Consults: UNC Memorial Hospital
Clinic: ACC Building
Goals: The goal of this experience will be for the residents to gain experience in the inpatient
evaluation and management of patients with a broad spectrum of pulmonary diseases.
1. Objectives
• Medical knowledge
Describe the epidemiology, genetics, natural history, clinical expression of the pulmonary
disorders encountered in the inpatient and outpatient setting.
Demonstrate competenence in performing common procedures use on a general medicine
service, including paracentesis, thoracentesis, and lumbar puncture
Summarize an approach to the evaluation of common pulmonary disease presentations
Interpret diagnostic tests used in the evaluation of inpatients with suspected pulmonary
disease
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of
inpatients (outpatients on the clinic rotation) with pulmonary diseases.
• Patient care
Effectively perform a comprehensive history and complete physical examination in patients
with respiratory symptoms or known pulmonary diseases
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the
evaluation of pulmonary diseases
Construct a comprehensive treatment plan and assess response to therapy.
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended
therapies.
Utilize validated instruments in the assessment of function and quality of life to monitor and
adjust therapy.
• Practice-based learning and improvement
Effectively use technology to manage information, support patient care decisions, and enhance
both patient and physician education.
Integrate and apply knowledge obtained from multiple sources to the care of inpatients with
pulmonary diseases
Demonstrate ability to critically assess the scientific literature
Set and assess individualized learning goals
Analyze clinical experience and employ a systematic methodology for improvement
Develop and maintain a willingness to learn from errors, and use errors to improve the system
or processes of care
• Systems-based practice
Discuss how the health care system affects the management of inpatients with pulmonary
diseases.
Demonstrate effective collaboration with other health care providers
Determine cost-effectiveness of alternative proposed interventions.
Design cost-effective plans based on knowledge of best practices
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the
health care system, cost of the procedure, insurance coverage, and resources utilized
• Interpersonal skills and communication
Apply empathy in all patient encounters
Demonstrate effective skills of listening and speaking with patients, families and other
members of the health care team
Reliably and accurately communicate the patient's and his/her family's views and concerns to
the attending
Demonstrate competency in documentation including appropriate history and physical,
progress, and discharge notes
Counsel patients, families and colleagues regarding side effects and appropriate use of specific
medications, providing written documentation when appropriate
• Professionalism
Be prompt and prepared for rounds and/or clinic
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed
consent, and equitable respect and care to all
Respect patients and their families, staff and colleagues
Model ethical behavior by reporting back to the attending and referring providers any key
clinical findings, following through on clinical questions, laboratory testing and other patient
care issues, and recognizing potential conflicts of interest
Demonstrate integrity, honesty and openness in discussion of therapeutic options with
patients and respect for patient’s preferences and multicultural differences
Respond to phone calls, pages and/or messages in a timely manner
Pulmonary Core Topics
1. Pulmonary Physiology
a. Gas exchange
b. Mechanics
c. Measures of function
i. Arterial blood gases
ii. Lung volumes and DLCO
iii. Imaging techniques
2. Obstructive Pulmonary ( Airway) Disease
a. Chronic Bronchitis
b. Emphysema
i. Centrilbular
ii. Panacinar
c. Cystic Fibrosis
d. Bronchiolitis
i. Bronchiolitis obliterans
ii. BOOP
iii. Bronchiolitis obliterans associated with lung transplantation
e. Bronchiectasis
3. Asthma
a. Epidemiology and definition
b. Classification
i. “Intrinsic or nonallergic”
ii. “Extrinsic or allergic”
c. Pathogenesis
d. Clinical manifestations and diagnosis
e. Therapy
4. Respiratory Infections
a. Community acquired pneumonias
b. Infections in the immuncomprimised host
i. . AIDS
ii. Other causes of immunosuppression
c. Tuberculosis and nontuberculous mycobacteria
d. Anaerobic lung infections and aspiration
e. Empyema
5. Interstitial Lung Disease
a. Idiopathic pulmonary fibrosis
b. Drug induced
c. Connective tissue disease
d. Sarcoidosis
e. Esoinophillic granuloma
6. Lung Neoplasma
a. Carcinomas
b. Mesotheliomas
c. Benign tumors
d. Staging evaluation
e. Resectability
7. Lung transplantation
a. Indications
b. Common diseases transplanted
c. Single versus double lung transplants
d. Survival
e. Complications
8. Pulmonary Vascular Sisease
a. Pulmonary thromboemboli
b. Pulmonary hypertension
c. Pulmonary vasculitits
d. Alveolar hemorrhage/hemoptysis
9. Miscellaneous
a. Pleural disease
i. Effusions
ii. Pneumothorax
b. Occupational Lung disease
c. Sleep disorders
d. Lymphangioleiomyomatosis
Nephrology Curriculum
UNC Internal Medicine Training Program
Nephrology Rotation Competency-based Goals and Objectives
Teaching site: UNC Memorial Hospital
Instructions: Following morning report on your first day on service, page the fellow on call for your
consult service. Tell them the days that you will be on service and which days you have clinic or
alternate coverage responsibilities.
Goals: The goal of this experience will be for the residents to gain experience in the inpatient
evaluation and management of patients with a broad spectrum of renal disorders.
1. Objectives
• Medical knowledge
Describe the epidemiology, genetics, natural history, clinical expression of the renal
disorders encountered in the inpatient setting.
Describe the structure and function of the kidneys
Summarize an approach to the evaluation of the common presentations of renal disorders
Interpret diagnostic tests used in the evaluation of inpatients with suspected renal disorders
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of
inpatients with renal disorders
• Patient care
Effectively perform a comprehensive history and complete physical examination in patients
with renal symptoms, abnormal creatinine clearnce, or acute or chronic renal disorders
Construct an appropriate differential diagnosis
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the
evaluation of renal disorders
Construct a comprehensive treatment plan and assess response to therapy.
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended
therapies.
Describe the appropriate use of validated instruments in the assessment of pain, function, and
quality of life to monitor and adjust therapy.
• Practice-based learning and improvement
Effectively use technology to manage information, support patient care decisions, and enhance
both patient and physician education.
Integrate and apply knowledge obtained from multiple sources to the care of inpatients
Demonstrate ability to critically assess the scientific literature
Set and assess individualized learning goals
Analyze clinical experience and employ a systematic methodology for improvement
Develop and maintain a willingness to learn from errors, and use errors to improve the system
or processes of care
• Systems-based practice
Discuss how the health care system affects the management of outpatients with renal
disorders
Demonstrate effective collaboration with other health care providers, including nursing,
counselors and dialysis centers, in the care of patients with renal disorders
Determine cost-effectiveness of alternative proposed interventions.
Design cost-effective plans based on knowledge of best practices
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the
health care system, cost of the procedure, insurance coverage, and resources utilized
• Interpersonal skills and communication
Approach patients with an empathetic and understandable manner
Demonstrate effective skills of listening and speaking with patients, families and other
members of the health care team
Reliably and accurately communicate the patient's and his/her family's views and concerns to
the attending
Compose clear and timely consultation reports and interval notes/letters, including a precise
diagnosis whenever possible, differential diagnosis when appropriate, and recommend follow
up or additional studies
Counsel patients, families and colleagues regarding side effects and appropriate use of specific
medications, providing written documentation when appropriate
• Professionalism
Exhibit punctuality for all assigned duties
Incorporate the principles of patient primacy, patient privacy, patient autonomy, informed
consent, and equitable respect in the care of patients
Demonstrate respect for patients and their families, staff and colleagues
Model ethical behavior by reporting back to the attending and referring providers key clinical
findings, following through on clinical questions, laboratory testing and other patient care
issues, and recognizing potential conflicts of interest
Demonstrate integrity, honesty and openness in discussion of therapeutic options with
patients and respect for patient’s preferences and multicultural differences
Respond to phone calls, pages and/or messages in a timely manner
Renal Core Topics
1. Teaching materials
a. Reading material : selected articles and publications from journals and nephrology
data base
2. Topics to be discussed during Rounds:
a. Hemodialysis and peritoneal dialysis: techniques
b. Hemodialysis and peritoneal dialysis: dialysis prescription
c. Evaluation of kidney structure and function
1. Urinalysis
2. Measurement of GFR
3. Evaluation of proteinuria
4. Measurement of urinary electrolytes
5. Renal imaging techniques
d. Chronic Kidney disease
e. Acute Kidney injury
f. Metabolic acidosis
g. Metabolic alkalosis
h. Disorders of water metabolism ( hyponatremia and hypernatremia)
i. Disorders of potassium and magnesium metabolism
j. Disorders of calcium, phosphorus and bone metabolism
k. Overview of evaluation and treatment of hypertension
l. Glomerular syndromes
1. Nephritic syndrome
2. Nephrotic syndrome
m. Diabetic nephropathy
n. Principles of kidney transplantation
Rheumatology
Dear Residents:
Welcome to your rotation in Rheumatology. We are delighted that you will be joining us and look
forward to a productive experience. The rotation is designed to give you maximum exposure to
outpatient rheumatology. Interested residents may elect to spend time on the inpatient consultation
service.
All rheumatology clinics are held at Carolina Pointe II 3rd floor. Clinics begin at 8:30 am and are
usually finished by 5:30 pm. You will be working with different attendings each day as listed
below. If you will not be able to attend a clinic because of a conflict with your continuity clinic or if
you have been pulled to cover another service, please let the attending know as soon as possible. The
clinic phone number is 966-4191.
Monday
Fellows Clinic (Attendings rotate)
Tuesday
Dr. Mary Anne Dooley
Dr. Beth Jonas
Dr. Robert Roubey
Wednesday
Dr. Robert Berger
Dr. Alfredo Rivadeneira
Dr. Joanne Jordan
Thursday
Dr. Beth Jonas
Dr. Alfredo Rivadeneira
Dr. Robert Roubey
Dr. Teresa Tarrant
Friday
Dr. Alfredo Rivadeneira
Dr. Robert Berger
Dr. Amanda Nelson
Residents who wish to have exposure to outpatient Allergy/ Immunology should discuss this with Dr.
Jonas prior to the rotation, so this can be scheduled.
Rheumatology Grand Rounds are held on Friday at 8:30 am each week at the Thurston Arthritis
Research Center (TARC) on the 3rd floor of the Thurston Building. All residents are expected to
attend. Each week the conference is followed by case discussions with the faculty and fellows. The
conference is usually over at about 10 am and then the residents can attend the clinic. Once monthly
there is a radiology conference (in place of GR) which is held in the Radiology Conference Room in the
basement of the Women’s Hospital. You will get the schedule when you start your
rotation. Rheum/Allergy/Immunology Journal Club is held on Wednesdays at 1pm in the 3rd floor
conference room at TARC. This conference is optional.
Residents are expected to augment their clinical learning with reading. Prior to the beginning of the
rotation, residents are STRONGLY ENCOURAGED to read Kelley’s Textbook of Rheumatology Chapter
35: “History and Physical Examination of the Musculoskeletal System”. The book is available in
electronic format on the MD Consult section in the Health Sciences Library website. In addition to
Kelley’s textbook, other good sources for reading include the Primer on the Rheumatic Diseases
13th Edition, Harrison’s Rheumatology 2nd Edition and MKSAP 15 Rheumatology. A reading list is
available of good review papers of topics in rheumatology. If you are having trouble locating
resources, please discuss this with Dr. Jonas or any faculty member.
Please contact Dr. Jonas if you have any questions.
216-2664, phone 966-0560.
Contact information bjonas@med.unc.edu, pager
We look forward to working with you.
Beth L. Jonas, MD
Director, Rheumatology Fellowship Training Program
Thurston Arthritis Research Center
UNC- Chapel Hill
Rheumatology Curriculum
UNC Internal Medicine Training Program
Rheumatology Rotation Competency-based Goals and Objectives
Contact: Dr. Beth Jonas pager 216-2664
Teaching site: Carolina Pointe II 3rd floor clinic
Goals: The goal of this experience will be for the residents to gain experience in the outpatient
evaluation and management of patients with a broad spectrum of musculoskeletal and rheumatic
diseases.
1. Objectives
• Medical knowledge
Describe the epidemiology, genetics, natural history, clinical expression of the rheumatic
diseases encountered in the outpatient setting.
Describe structure and function of musculoskeletal tissues and joints
Summarize an approach to the evaluation of multi-organ inflammatory disorders
Distinguish non-rheumatic disorders from rheumatic diseases
Interpret diagnostic tests used in the evaluation of outpatients with suspected rheumatic and
musculoskeletal diseases
Demonstrate ability to critically appraise and cite literature pertinent to the evaluation of
outpatients with rheumatic disorders.
• Patient care
Effectively perform a comprehensive history and complete physical examination in patients
with rheumatic symptoms or abnormal immunologic tests
Appropriately select and interpret laboratory, imaging, and pathologic studies used in the
evaluation of rheumatic disorders
Gain experience in procedures including arthrocentesis and injections, compensated polarized
microscopy, and synovial fluid analysis
Construct a comprehensive treatment plan and assess response to therapy.
Counsel patients concerning their diagnosis, planned diagnostic testing and recommended
therapies.
Utilize validated instruments in the assessment of pain, function, and quality of life to monitor
and adjust therapy.
• Practice-based learning and improvement
Effectively use technology to manage information, support patient care decisions, and enhance
both patient and physician education.
Integrate and apply knowledge obtained from multiple sources to the care of outpatients
Demonstrate ability to critically assess the scientific literature
Set and assess individualized learning goals
Analyze clinical experience and employ a systematic methodology for improvement
Develop and maintain a willingness to learn from errors, and use errors to improve the system
or processes of care
• Systems-based practice
Discuss how the health care system affects the management of outpatients with rheumatic
diseases.
Demonstrate effective collaboration with other health care providers, including physical and
occupational therapists and orthopedic surgeons, in the care of patients with rheumatic
diseases
Determine cost-effectiveness of alternative proposed interventions.
Design cost-effective plans based on knowledge of best practices
Demonstrate awareness of the impact of diagnostic and therapeutic recommendations on the
health care system, cost of the procedure, insurance coverage, and resources utilized
• Interpersonal skills and communication
Approach patients with an empathetic and understandable manner
Demonstrate effective skills of listening and speaking with patients, families and other
members of the health care team
Reliably and accurately communicate the patient's and his/her family's views and concerns to
the attending
Compose clear and timely consultation reports and interval notes/letters, including a precise
diagnosis whenever possible, differential diagnosis when appropriate, and recommend follow
up or additional studies
Counsel patients, families and colleagues regarding side effects and appropriate use of specific
medications, providing written documentation when appropriate
• Professionalism
Be prompt and prepared for clinic
Recognize the importance of patient primacy, patient privacy, patient autonomy, informed
consent, and equitable respect and care to all
Respect patients and their families, staff and colleagues
Model ethical behavior by reporting back to the attending and referring providers key clinical
findings, following through on clinical questions, laboratory testing and other patient care
issues, and recognizing potential conflicts of interest
Demonstrate integrity, honesty and openness in discussion of therapeutic options with
patients and respect for patient’s preferences and multicultural differences
Respond to phone calls, pages and/or messages in a timely manner
2. Learning activities / methods
Competency
SCE
DID
SDL
DEM
Patient Care (PC)
x
x
x
x
Medical Knowledge
x
x
x
x
Practice Based Learning and Improvement
x
x
x
x
Personal and Communication Skills
x
Professionalism
x
x
x
x
x
Systems Based Practice
x
x
x
SCE - supervised clinical experience
DID – didactics – case conferences, lectures, meetings
SDL – self directed learning
DEM – demonstrations, e.g. joint injection, infusion of biologics
3. Assessment tools
Arthrocentesis logs
Supervised clinical experience
Formative evaluation
Summative evaluation
Emergency Medicine Curriculum
UNC Department of Emergency Medicine
The Emergency Department (ED) attendings work 8 hour shifts, 7a-3:00p, 1p-9p, 10 a-6p, 3p-11p, 6p-2a,
and 11p-7a. Two attendings are on duty, with the exception of the time period from 2a to 10a when one
attending is on duty.
The ED has 3 main areas. The Acute Care area has 24 beds including 2 cardiac rooms and 3 trauma
rooms. Team C is an adjacent area with 8 beds. Team C is open 9a to midnight daily. Pediatric Acute
Care is a separate unit staffed by Pediatric attending and residents. Pediatric Acute Care is open from
9a-2a daily. After those hours, pediatric patients (age 15 and below) are treated in the main ED. During
your rotation, you will be assigned shifts in both the Acute Care area of the ED and the Minor Trauma
area.
Guidelines for House officers
Introduction and General Principles
Welcome to the Department of Emergency Medicine! During this rotation, you will learn skills that are
essential to your medical education. You will be supervised by faculty members who are Board Certified
or Board Eligible in Emergency Medicine. Our faculty have practiced in a variety of institutions and
settings, and thus, your experience here will be enhanced by exposure to different styles of practice.
Emergency Medicine differs in many respects from the inpatient and clinic settings. During this rotation,
you will see a broad spectrum of illnesses ranging from the most trivial complaints to life-threatening
diseases. It is important to remember that all patients come to the ED for a reason. Many present to the
ED early in the course of their illness, therefore a serious disease may initially present to you as an
apparently benign compliant. Many may present with complaints that could be handled elsewhere. It is
our role to ensure our patients receive our best efforts to guide them through the increasing complex
healthcare system as well as to diagnose and treat acute care conditions. Remember the Emergency
Department is an important portal of entry into the hospital and provides a strong impression of the
institution to patients, their families, and referring physicians from other medical centers.
House Officer Requirements for Successful Completion of Emergency Medicine Rotation
1. Completion of the Online Orientation Module
Each house officer must complete the online orientation course and exam before starting their
Emergency Medicine rotation. The orientation module is available online at
www.med.unc.edu/wrkunits/2depts/emergmed.
2. Assigned shifts in the Emergency Department
Be prompt for your assigned shifts. If you are ill or must miss an assigned shift, you need to
contact:
a. Your Chief Resident. Chief Residents from each rotating
department will be responsible for providing
replacement coverage for their individual department
residents who are unable to fill an assigned shift.
b. The ED attending physician working at the time your
shift begins( 966-4721)
In order to successfully complete the ED rotation as required by your residency, you must
complete all assigned shifts. Illnesses are only excused if verified by your personal physician (not
a resident physician) or your residency director.
3. Resident Conferences
In order for the Department of Emergency Medicine, Medicine, Surgery, Family Medicine and
OB/GYN to meet the requirements of the Residency Review Committee, weekly attendance at
our Emergency Medicine Conferences is MANDATORY. These conferences are held on
Wednesday mornings from 7a to noon. The schedule of topics is available monthly. Emergency
Medicine interns/residents are required to attend conferences 5 hours per week. Off service
interns/residents are required attend 3 hours per week. During your rotation, you will likely be
scheduled in the ED on one or more Wednesday mornings. On these mornings you should
attend sign out rounds and check in with the ED attending prior to departing for conference.
When you are not scheduled to work in the ED, you should attend at least part of the
Wednesday morning conference. Attendance will be taken at these conferences and reported to
individual residency directors at the end of each rotation along with your final evaluation.
If you have questions or concerns, please feel free to contact:
Kevin Biese, MD
Assistant Professor
Education Director
966-6440
Important Items to Keep in Mind:
1. Although you will be quiet busy at times, make sure you speak to any family members or
visitors who may be in the waiting room after you have finished your evaluation. It is
important to let them know how well the patient is doing and give them an estimate of the
anticipated length of stay. Always overestimate the length of stay. Things may take longer
than you think.
2. Laboratory studies and X-Rays are ordered only if they impact on acute treatment,
immediate decision making, or are essential for the provision of follow up care. The
Emergency Department is not the place to begin an extensive workup of non-critical
problems.
3. Every patient should be given instructions for follow up care and referred to a follow up
physician, no matter how trivial the problem may seem. ( see documentation and charting
guidelines)
4. You should be able to arrive at a reasonable clinical diagnosis on most patients. If you lack a
definitive diagnosis, you must have formulated a clear differential diagnosis and have ruled
out all possible life treating conditions before the patient can be discharged safely.
5. Information concerning patients seen or discussed in the ED is confidential. It should not be
discussed anywhere else, other than medical conference setting. This means you must not
discuss patient information in the hallways, nor elevators, nor in downtown restaurants, etc.
You are a professional and must conduct yourself as such.
6. All patients who are seen in the Emergency Department are the ultimate responsibility of
the attending emergency physician. Consequently, THE EMERGENCY DEPARTMENT
ATTENDING MUST SEE EVERY PATIENT AND SIGN EVERY CHART PRIOR TO THE PATIENTS
DISCHARGE, ADMISSION OR TRANSFER.
7. Some patients have such serious illness at the time of presentation that they may
decompensate in a very short period of time. Because of this, there are certain
circumstances when it is vital for you to notify the attending physician of the patient’s
condition IMMEDIATELY AND POSSIBLY BEFORE YOU HAVE FINISHED YOUR INTIAL
EVALUATION. (You will find a list of these circumstances attached in this handout.) If you
think a particular patient is unstable, alert the attending on duty.
8. T System: All ED patients are tracked on a computer system called T System. When you
arrive in the ED, you will be instructed how to use this system to sign up as the provider for
the patients you are evaluating. In order to access this system, you must have a valid UNC
Hospital code and password.
9. As patients enter the Emergency Department, they are triaged by the nursing staff. The
triage designations are :
ESI-1
ESI-2
ESI-3
ESI-4
ESI-5
Stability of vital
functions
Unstable
Stable
Stable
Stable
Stable
Life-threat or organthreat
Obvious
Reasonably
likely
Unlikely
(possible)
No
No
Severe pain or
severe distress
Immediately
Sometimes
Seldom
No
No
Expected resource
intensity
Maximum: staff at
bedside continuously;
mobilization of
outside resources
High: multiple,
often complex
diagnostic
studies;
frequent
consultation;
continuous
(remote)
monitoring
Medium:
multiple
diagnostic
studies; or
brief
observation;
or complex
procedure
Low: one Low:
simple
exam
diagnostic only
study; or
simple
procedure
Med/staff response
Immediate team effort
Minutes
Up to 1 hr
Could be
delayed
Could be
delayed
Expected time to
disposition
1.5 hr
4 hr
6 hr
2 hr
1 hr
Examples
Cardiac arrest,
intubated/hypotensive
trauma patient, acute
(<3 hr) MI or stroke
Most chest
pain, stable
trauma (MOI
concerning),
elderly
pneumonia
patient,
altered mental
status,
behavioral
disturbance
Most
abdominal
pain,
dehydration,
esophageal
food
impaction,
hip fracture
Closed
extremity
trauma,
simple
lac,
simple
cystitis,
typical
migraine
Sore
throat,
minor
burn,
recheck
In general, patients should be seen in the order in which they arrive in the ED, however patients
triaged as “1” or “2” should be evaluated before those designated “3-4-5”. If you are
unsure which patient you should evaluate next, ask the attending or a senior resident to
direct you.
SCHEDULE
Housestaff will be assigned to one section of the department and will report ONLY to the attending
staffing that section.
RESPONSIBILITIES
Role of the Emergency Department Attending
The ED attending is primarily responsible for patient flow and consultation. The ED attending will be
responsible for the supervision of all medical students and house officers. Housestaff cannot sign
student orders.
Role of the PGY-III Resident
The PGY-III Emergency Medicine Resident has three main responsibilities in the ED:
1. Directly evaluate patients as the primary physician, with particular attention to critically ill
or injured patients.
2. Ensure that patient flow in the ED is maintained.
3. Supervise one or more PGY-I residents who are working in the ED.
4. Perform or supervise procedures required for patient care.
5. At times, these residents may take a turn at being “in charge” of the ED under the
supervision of the attending.
.
Role of the PGY-I and PGY-II Residents and Medical Students
The PGY-I resident and medical student are primarily responsible for patient evaluation and
management. Remember that you are here to learn and that specific questions are expected. It is
better to ask and ask early!
PATIENT CARE AND CASE PRESENTATION
It will be the responsibility of the EM PGY-III resident, all PGY-I residents, and medical students to pick up
new patients as they are added to the board by the triage nurse. Patients are to be seen according to
their time of entry into the ED unless another patient with a potentially life-threatening complaint has
not yet been evaluated. Patients with life-threatening complaints are designated by a triage
classification of “1” (in red) and should be seen promptly. If you are not certain whether a particular
patient is to be seen, ask the attending physician or triage nurse.
The residents will see and evaluate the majority of patients. This initial evaluation is to consist of a
history and physical examination, which may be “directed” if the patient has an obviously isolated
problem (such as a minor extremity injury). All other patients should have a complete history and
physical examination including social and family history, medications and allergies. This evaluation
should take no longer than 5 to 10 minutes to complete.
ANY PATIENT WITH A CONDITION WHICH MAY DETERIORATE PRECIPITOUSLY MUST BE CALLED TO
THE ATTENTION OF THE ED ATTENDING IMMEDIATELY, EVEN IF THE INITIAL EVALUATION IS NOT
COMPLETED. A list of such conditions is listed in this handout.
After formulating a differential diagnosis and treatment plan, but before writing orders, the intern is to
present the patient to the ED attending. At that time, an evaluation and treatment plan can be
formulated and orders written. No verbal orders are acceptable.
After all ancillary studies have been completed; the house officer is to present the case to the ED
attending again, this time noting the results of laboratory values, X-rays, etc. At this time a disposition
will be made and the patient will be either be discharged, admitted or transferred to a different
institution.
TYPES OF PATIENTS SEEN
Adult patients with a wide variety of complaints are seen in the Acute Care area of the ED. In addition to
evaluating and treating patients with general medical and surgical problems, you will gain experience
with patients whose complaints include the following:
Psychiatric - Our responsibility is medical clearance; be especially careful with elderly patients or
those with confounding medical problems; some psychiatric patients will be seen directly by the
Psychiatric consultants.
OB-Gyn - Women at 20 weeks or greater gestation are transferred directly to Labor and
Delivery. The exceptions to this are if they have any type of trauma or a complaint totally unrelated to
pregnancy. All women between ages10-60 should be assumed to be pregnant until proven otherwise by
a negative urine or serum pregnancy test.
Trauma - Major trauma patients, as determined by criteria, are seen by the Trauma team, EM
Attending and Senior Emergency Medicine Residents. Patients with lesser trauma are evaluated and
treated by the general ED staff.
Pediatrics (ages 15 and below) - These patients are seen directly by a Pediatric resident, either in
Pediatric Acute Care (9a-11p) or in the Acute Care ED at other times.
ANCILLARY SERVICES
Laboratory Studies
1.
Laboratory studies are ordered in writing on the order sheet.
2.
Laboratory reports results can be obtained on the computer. Be sure to check the
computer frequently for results so the patient can receive disposition in a timely manner
3.
All laboratory studies must be documented on the chart, including those that are pending
at the time of disposition.
Radiologic Studies
1.
If a patient needs an X-ray or other imaging study, write the order on the order sheet and
give the order sheet to the clerk. You need to write a reason for the X-ray study, i.e. chest
pain or SOB. The X-ray orders are entered into the computer by the nursing staff.
2.
Look at the patient’s X-rays even though the radiologist’s interpretation is available.
Remember that you have the advantage of knowing the patient’s clinical presentation and
thus may notice something the radiologist might have misses.
3. If you have any questions regarding the interpretation of a particular radiograph, you may
consult the radiology attending or resident by dialing 68850.
4.
All radiologic studies must be documented on the chart!
MEALS
Housestaff are encouraged to briefly leave the ED for nutrition breaks as patient flow permits, but only
after notifying the attending that they are leaving.
DOCUMENTATION STANDARDS
It is your responsibility to see that these standards are met on every chart. Charts will be returned to
you for completion if documentation standards are not met.
DISCHARGE INSTRUCTIONS AND FOLLOW-UP
All patients are to receive a discharge instruction sheet prior to leaving the Emergency Department.
There are specific items that must be included on the discharge form.
PATIENTS LEAVING THE EMERGENCY DEPARTMENT AGAINST MEDICAL ADVICE (AMA)
All patients who threaten to leave the Emergency Department against medical advice (AMA) must be
seen by the ED attending immediately. The patient is required to sign an AMA form on the back of the
chart and must be properly informed of the risks of departing AMA.
SECURITY AND PARKING
Escorts to the parking decks are available 24 hours a day. USE THEM!! Use the Point to Point Service
(962-7867) or have hospital security accompany you! You cannot park in the ED patient parking lot.
DRESS CODE AND IDENTIFICATION
Name badges must be worn at all times. Housestaff are expected to look and act like professionals at all
times. Scrub suits are acceptable for wear in the Emergency Department provided they are clean and in
good condition. Jeans, shorts, sweats and T-shirts are not permitted.
WHEN YOUR SHIFT ENDS
You must turn your patients over to an intern or resident on duty in the ED. If your patient is nearing
completion of their evaluation – please fill out the chart completely including the discharge form if
appropriate. If the evaluation is in progress, please have a clear plan to pass on to the next doctor.
Medical Conditions Requiring
Immediate Attending Physician Notification
The following is a list of conditions that require immediate notification of the Emergency Department
attending physician, regardless of your level of training. This list does not cover all possible situations,
and you should feel free to notify the attending immediately if you have a patient you feel may
deteriorate precipitously or if you are uncomfortable given your present level of training.
1. Any patient who presents with or develops acute cardiopulmonary arrest.
2. Any patient with a complete or partially obstructed airway.
3. Any patient who presents with or develops a significant cardiac arrhythmia, whether stable or not.
4. Any patient with acute onset Alteration of Mental Status (AOMS). This includes any patient
presenting with this as the chief complaint or any patient whose mental status deteriorates while in the
ED.
5. Any patient with significant hypotension or hypertension. For these purposes, significant
hypotension will be defined as blood pressure of less than 100 mmHg systolic and significant
hypertension will be defined as a blood pressure of greater than or equal to 180 mmHg systolic or
hypertension associated with acute alteration of mental status.
6. Any patient with severe respiratory distress. For these purposes, significant respiratory distress will
be defined as a respiratory rate greater than 30 breaths/minute, any patient with a pulse oximeter
reading of less than or equal to 90 mmHg, any patient with an acute elevation of pCO2 greater than or
equal to 60 mm Hg, any patient with a complaint of shortness of breath accompanied by diaphoresis,
use of accessory muscles of respiration, cyanosis, alteration of mental status, bradycardia, or any other
signs consistent with imminent respiratory failure.
7. Any patient with significant tachycardia or bradycardia. For these purposes, significant tachycardia is
defined as a heart rate greater than or equal to 150 beats/minute and significant bradycardia is defined
as a heart rate less than or equal to 60 beats/minute.
8. Any patient with a significant cardiac arrhythmia.
9. Any patient with either clinical or EKG evidence of acute myocardial infarction.
10. Any patient with a fever greater than 105 degrees Fahrenheit, any patient with significant alteration
of mental status associated with a fever, or any patient with a fever and a potentially
immunocompromised state (e.g. HIV disease, cancer patients, transplant patients, etc.)
11. Any patient with significant hypothermia. For these purposes, significant hypothermia is defined as
a rectal temperature less than or equal to 95 degrees Fahrenheit.
12. Any patient with severe abdominal pain or abdominal pain associated with peritoneal signs.
13. Any female with abdominal pain and a positive pregnancy test.
14. Any patient with significant upper or lower GI bleeding (whether hypotensive or not).
15. Any patient who develops seizure activity while in the Emergency Department.
16. Any patient with significant abnormality of any laboratory value (e.g. hypo/hypernatremia,
hypo/hyperkalemia, symptomatic hypercalcemia, hematocrit less than 28, etc.).
17. Any patient with a history of significant trauma.
18. Any patient with a pregnancy and sign/symptoms of a precipitous delivery.
19. Any patient with an overdose of prescription or over-the-counter medications.
20. Any patient or visitor who gives evidence of becoming significantly agitated, violent, or suicidal.
21. Any patient with a blood sugar of less than 70 mg/dL.
22. Any patient with a snake bite.
23. Any patient with significant bleeding, or bleeding associated with hemophilia (blood dyscrasias).
24. Any patient with a significant allergic reaction.
25. ANY PATIENT WHO YOU FEEL IS BEYOND YOUR PRESENT CAPABILITIES AS A RESIDENT, OR WHO
YOU THINK MAY DETERIORATE SUDDENLY.
Documentation Standards
The following information is required on all charts for all Emergency Department patients for legal and
billing purposes. Please review this in conjunction with the copy of the chart included in this packet.
1. The Emergency Department uses the T System for charting. Please complete the T System training
module before starting your first shift.
2. For all patient charts, documentation should reach a “level 5” by the standards of the T System
Documentation System. Please confirm this before signing your chart.
3. It is important to write a short summary of your assessment and plan in each chart..
Based on the differential problem list that you have established, it should be obvious by reviewing the
chart how you distinguished among the possibilities and came to your final diagnosis. Some examples:
GI cocktail given, patient with complete relief; Phenergan 25mg IV given, nausea relieved and patient
tolerating PO well.
If you make a clinical diagnosis without any work-up, you need to explain that. For example: 20 year old
white female with reproducible chest wall pain, no risk factors for CAD and no associated symptoms,
likelihood of cardiopulmonary disease as the underlying etiology is very low. We will treat her with
NSAID’s. Patient knows to return if symptoms change or worsen.
4. You need to list the medications the patient is taking and any drug allergies the patient has.
5. If the patient is in the Emergency Room for a significant length of time waiting for disposition or a
bed, you need to make note that you reevaluated the patient during this time. For example: 2:45 pm
Patient now afebrile and tolerating oral fluids well. Many conditions such as respiratory distress, chest
pain and abdominal pain require frequent reevaluation, and you need to document it.
6. If you call a consultant to see the patient, record the time and who you talked with. For example: 6
pm Discussed case with Dr. Smith (General Surgery) who will evaluate patient. “Curbside” consultations
are not official. If there is really a question, the patient must be seen by the consultant.
7. Record a procedure note for all procedures done on the patient including laceration repairs, lumbar
punctures, central lines, etc
.
8. Please select a disposition and diagnosis (often more than 1diagnosis) for each patient.
DISCHARGE INSTRUCTIONS
The T system has standard discharge instructions for many different diagnoses as well as medications
Every discharged patient should receive 1 or more of these instruction sets.
All patients should receive Follow-Up. Follow-up options include but are not limited to:
1. Follow-up with their own doctor (MUST BE NAMED) for a specific period of time. If the patient
is unable to identify an MD, a referral should be given.
2. UNC Clinic Appointment:
Options for obtaining this are:
* You can call and get an appointment for the patient (Mon-Fri 8a-5p)
* Fill out a clinic referral sheet available in the ED; these are faxed to a central office where
appointments are made,
* You can give the patient the phone number for a specific clinic (listed in the T system discharge
instructions) BUT, keep in mind, it may be several months before a patient can get an
appointment.
Welcome!
From the Nurses in the Emergency Department
The following handout details survival skills for your emergency department rotation. We hope that it
may be helpful to you.
The ED is divided into several sections:
1.
2.
3.
4.
Triage
Acute Area
Team C
Pediatric Acute Care
The nursing staff is assigned by “team.” One or two nurses are assigned to the triage area. These nurses
are responsible for screening all patients and prioritizing their care. The Acute Area is divided into Team
A and Team B. Two or more nurses are assigned to cover each of these teams.
There are three trauma bays, including a pediatric resuscitation bay. There are two cardiac
resuscitation rooms. The Acute Area is divided into the A and B teams which are each responsible for ½
the acute area of the department. Team C is a separate area that usually evaluates ESI score 4 and 5
patients (see above).
A charge nurse is assigned to coordinate the care of the ED patients. At various times, the charge nurse
will also have a patient care assignment. Two nurses are assigned to the trauma team. If there is a
trauma in progress and the nurse assigned to a certain area becomes unavailable, refer all questions to
the charge nurse.
Remember, if you are busy, so is the nursing staff!
This is a team-oriented department. Help us and each other!
General Information
 It is mandatory that you wear your name tag!
Familiarize yourself with the clean and dirty utility rooms on your first day. You will find this invaluable.
Most of the equipment you need is located in these areas. Equipment is secured in the PYXIS.
Tidy up after yourself after completing an exam or procedure. There are trash cans located at each
patient care bedside. (This includes the lounge!)
The ED staff is a life form in itself. The nursing assistants, clerks, nurses, and social worker can be great
resources for the inside scoop on usual routines, community resources, etc.
 Clerks can help you with phone calls and paging. Clerks answer the phones, even if you have paged
someone. Listen to the intercom for your name or the person you have paged. The key staff in the ED
has assigned intercom cell phones.
Nursing Assistants can perform the following:
1.
2.
3.
4.
5.
6.
simple wound preps
crutch set-up
lab transport
patient transport (excluding monitored patients)
room set-up
assist with procedures
Remove all needles and sharps from trays and dispose of them in the sharps box!
If a laceration needs sutures, anesthetize the wound prior to wound prep. The department’s infection
rate has been consistently 0% because the NA’s do an excellent job.
RN’s
1. Unless the patient is acutely ill, please allow the RN to triage the patient prior to beginning your exam
or Gathering information
.
2. ED nurses will assess the acuity of patients and institute treatment and diagnostic procedures prior
to you seeing the patient. For example: monitoring, IV access. Orders still need to be written for
the patient.
Educational Conferences
Emergency Medicine conferences are held Wednesday from 7:00 am to noon. All PGY1 residents
assigned to the Emergency Department each month will be expected to attend.
Scheduling in the Emergency Department
PGY-1 Medicine Interns will work 12 hour shifts beginning at 7 am, 10 am, or 7pm. These times will
rotate throughout the month.