UTMB Internal Medicine Residency
Emergency Medicine
Goals, Competencies, Methods, and Assessments
Overall Goal
To make physicians into specialists in Internal Medicine by equipping them with
requisite knowledge, skills, and attitudes essential for them to demonstrate competence in
patient care, knowledge, practice-based learning and improvement, systems-based
practice, professionalism, and interpersonal and communication skills relevant to the
knowledge and skills of Emergency Medicine.
Patient Care
Goal
Residents must be able to provide patient care that is compassionate, appropriate, and
effective with the patient care skills relevant to Emergency Medicine.
Competencies - Residents are taught how to:
 Demonstrate accurate and relevant history-taking related to the diagnosis and
treatment of diseases seen in the ER. LSC/DO
 Demonstrate the ability to perform an accurate physical examination related to the
diagnosis and treatment of diseases seen in the ER. LSC/DO
 Demonstrate the ability to generate a differential diagnosis for diseases seen in the
ER. LSC/DO
 Demonstrate the ability to effectively present the results of a patient encounter
orally and in writing and to defend the clinical assessment, differential diagnosis,
and diagnostic and management plans for diseases seen in the ER. LSC/DO
 Demonstrate the ability to identify life-threatening conditions, identify the most
likely diagnosis, synthesize acquired patient data, and properly sequence critical
actions for patient care and to complete disposition of patients using available
resources. LSC/DO
 Demonstrate the ability to assess and treat critically ill or critically injured
patients. LSC/DO
 Demonstrate familiarity with the sub-catagories of emergency medicine,
including toxicology, sports medicine, paramedic base station communications,
emergency transportation and care in the field, out-of-hospital personnel, disaster
planning and drills, air ambulance units, and pediatric emergency medicine.
LSC/DO
 Demonstrate familiarity with procedures and techniques associated with major
resuscitations, including monitoring unstable patients, defibrillation, cardiac
pacing, treatment of shock, intravenous use of drugs (e.g., thrombolytics,
vasopressors, neuromuscular blocking agents), and invasive procedures (e.g., cut
downs, central line insertion, tube thoracostomy, endotracheal intubations).
LSC/DO
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Medical Knowledge
Goal
Residents must demonstrate knowledge of established biomedical, clinical,
epidemiological, and social-behavioral sciences, as well as the application of this
knowledge to the care of patients with emergency diseases.
Competencies – Residents are taught how to:
 Demonstrate a core fund of knowledge of the fundamental aspects of emergency
medicine and the diagnosis and treatment of diseases frequently seen in the ER.
LSC/DO
 Demonstrate a core fund of knowledge related to the procedures, medications, and
technology mentioned above under patient care. LSC/DO
Practice- Based Learning and Improvement
Goal
Residents must demonstrate the ability to investigate and evaluate their care of patients,
to appraise and assimilate scientific evidence, and to continuously improve patient care
based on constant self-evaluation, life long learning, and continuous quality or practice
improvement.
Competencies – Residents are taught how to:
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Demonstrate the ability to identify strengths, deficiencies and limits in their
knowledge and access and assess the emergency medicine literature to remediate
deficiencies. LSC/DO
Demonstrate the ability to incorporate formative evaluation feedback into daily
practice. LSC/DO
Systems-Based Practice
Goal
Residents must demonstrate an awareness of and responsiveness to the larger context and
system of health care, as well as the ability to call effectively on other resources in the
system to provide optimal health care.
Competencies - Residents are taught how to
 Demonstrate the ability to work effectively in various health care delivery settings
and systems. LSC/DO
Professionalism
Goal
Residents must demonstrate a commitment to carrying out professional responsibilities
and an adherence to ethical principles that they know.
Competencies - Residents are taught how to:
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Demonstrate an understanding of and commitment to all elements of
professionalism, including respect, compassion and integrity toward their patients,
patient families, and other health care professionals. LSC/DO
Interpersonal and Communication Skills
Goal
Residents must demonstrate interpersonal and communication skills that result in the
effective exchange of information and teaming with patients, their families, and
professional associates.
Competencies – Residents are taught how to:
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Demonstrate the ability to generate and maintain appropriate medical records,
procedure reports, and other written communication. LSC/DO
Teaching Methods
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MPC – Mentored Patient Care: Practical teaching and role modeling during direct
patient care during clinical rotations.
LSC - Lectures/Seminars/Conferences
 Grand Rounds
 Noon Conference
 Residents Conference
 Clinic Conference
 Morning Report
 Journal Club
 Morbidity and Mortality
 Clinical-Pathological Conference
 Board Review Sessions
 Quality Improvement Course
 Palliative Care Course
 Ultrasound Course
 Procedure Simulation
 Coding Course
 Professionalism
WRT - Weekly Reading/Testing/Feedback
Methods and Tools for Assessing Residents
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WT – Weekly Tests evaluating knowledge base for all competencies and
subspecialties.
DO - Direct Observation of competency-based performance by qualified faculty
guided by PGY-specific, milestone-based assessment tools. Included in MSF.
DO –P - Direct Observation by Peers evaluation of competency-based
performance, guided by PGY-specific, milestone-based assessment tools.
Included in MSF.
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ITE - In-Training Exam
Duty Hours for Residents
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The residency program follows the ACGME Duty Hour Requirements.
Duty hours are limited to 80 hours per week, averaged over a four-week period,
inclusive of all in-house call and moonlighting activities.
Residents must be scheduled for a minimum of one day free of duty every week
(when averaged over four weeks). At-home call cannot be assigned on these free
days.
Duty periods of PGY-1 residents must not exceed 16 hours in duration.
Duty periods of PGY-2 residents and above may be scheduled to a maximum of
24 hours of continuous duty in the hospital. Programs must encourage residents to
use alertness management strategies in the context of patient care responsibilities.
Strategic napping, especially after 16hours of continuous duty and between the
hours of 10:00p.m. and 8:00 a.m., is strongly suggested.
It is essential for patient safety and resident education that effective transitions in
care occur. Residents may be allowed to remain on-site in order to accomplish
these tasks; however, this period of time must be no longer than an additional four
hours.
Residents must not be assigned additional clinical responsibilities after 24 hours
of continuous in-house duty.
In unusual circumstances, residents, on their own initiative, may remain beyond
their scheduled period of duty to continue to provide care to a single patient.
Justifications for such extensions of duty are limited to reasons of required
continuity for a severely ill or unstable patient, academic importance of the events
transpiring, or humanistic attention to the needs of a patient or family. Under
those circumstances, the resident must: appropriately hand over the care of all
other patients to the team responsible for their continuing care; and, document the
reasons for remaining to care for the patient in question and submit that
documentation in every circumstance to the program director.
PGY-1 residents should have 10 hours, and must have eight hours, free of duty
between scheduled duty periods.
Residents in the final years of education (PGY2 and 3) must be prepared to enter
the unsupervised practice of medicine and care for patients over irregular or
extended periods. This preparation must occur within the context of the80-hour,
maximum duty period length, and one-day off-in-seven standards.
While it is desirable that residents in their final years of education have eight
hours free of duty between scheduled duty periods, there may be circumstances
when these residents must stay on duty to care for their patients or return to the
hospital with fewer than eight hours free of duty.
In unusual circumstances, residents may remain beyond their scheduled period of
duty or return after their scheduled period of duty to provide care to a single
patient. Justifications for such extensions of duty are limited to reasons of
required continuity of care for a severely ill or unstable patient, academic
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importance of the events transpiring, or humanistic attention to the needs of the
patient or family. Such episodes should be rare, must be of the residents’ own
initiative, and need not initiate a new ‘off-duty period’ nor require a change in the
scheduled ‘off duty period.’
Residents must not be scheduled for more than six consecutive nights of night
float.
PGY-2 residents and above must be scheduled for in-house call no more
frequently than every-third-night.
Responsibilities, Supervision, Lines of Authority
EMERGENCY DEPARTMENT ROTATION
INFORMATION FOR RESIDENTS
Welcome.
The information contained here should help orient you to the UTMB Emergency
Department (ED). We look forward to working with you as part of our efforts to provide
the best care possible for our patients and their families in a professional and patient
centered Emergency Department.
ED LAYOUT
The Emergency Department has several separate but interconnected areas:
Triage and medical screening: this is the patients’ first point of contact; nurses perform
screening exams to determine the level of acuity and then place patients into the ED
system accordingly
Minor Emergency Treatment Area (META): Nurse Practitioners see lowest acuity
patients
Specialty Care Area/ Surge Area: Admitted patients are cared for in this area and
managed by their admitting team until beds are available in the main hospital
Acute Care: patients with the highest level of acuity are seen here by physicians. This is
where you will spend your time.
ED TEAMS
There are 2 teams working in the acute care area: Blue and Gold. Each team consists of:
One ED attending (EDa)
One resident/intern
One or two 4th year medical students and/or physician assistant students
3-4 RNs
One or two patient care technicians (PCTs)
Blue team: rooms 101-116 (work room 126) includes Trauma
Gold team: rooms 117-129 (work room 130) performs MSE and covers Rapid Medical
Evaluation Area
Each team has a corresponding physician work room with 3-4 work stations and PACS
station.
The medical students will work under the direct supervision of the EDa, but whenever
possible please include them in your evaluation and management of patients .
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YOUR RESPONSIBILITIES
Your shifts will be assigned to you. You are to be present at the start of the shift and
remain in the ED until the close of the shift or until excused by your EDa. There may be
times when you will be required to stay beyond the close of your shift (eg. to stabilize an
unstable patient, complete a procedure).
If you leave the ED for any reason be sure your EDa knows you are leaving and when
you will return, and assign another resident to manage your patients in your absence.
Leaving the ED for breaks and meals is often not feasible so it is recommended that you
bring food with you at the start of your shift.
If you cannot come to your assigned shift (eg. significant illness), it is your responsibility
to call the EDa on your shift. Attending shifts are 7A-7P and 7P to 7A, so if you need to
miss your day shift call in at 7A; don’t wait until the start of your shift at 8A to call in.
You can reach EDas at the following phone numbers:
409-772-4080, 409-772-4064 or 409-772-4065
PATIENT CARE
When you arrive for your shift, find the other resident who is working the same shift and
decide between you where each of you will work (Gold or Blue team). Blue team
includes Trauma and most pediatrics.
At the start of your shift you will be responsible for the following patients:
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patients who are undergoing evaluation and management by the resident going off
shift. Resident are to give and receive a sign-out comprehensive enough that a smooth
transition of management will occur. At the minimum, sign-out should include:
presenting problem; history of conditions/illnesses that may impact presenting
problem; diagnostic evaluations completed and pending; differential diagnoses and
expected disposition.
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ICU patients being held in the ED until a bed becomes available in the ICU. You are
responsible for the management of these patients during your entire shift or until they
are moved to the ICU or downgraded to a medical (non-ICU) status and seen by the
admitting resident. Sign out should be comprehensive enough that the oncoming
resident can immediately assume management.
During your shift you will assign yourself to new patients as they arrive. At the
discretion of the ED attending, you will either see the patient and then present to the EDa,
or see the patient with the EDa. Regardless of the initial contact, you are then responsible
for that patient during his/her entire ED visit from start to final disposition. The number
of patients you are managing at any given time will depend upon the level of acuity of
each patient and your comfort level with managing multiple patients. Your attending
can help you determine an appropriate number for your level of training. If you see a
patient that is unstable or potentially unstable, notify the EDa immediately; don’t wait
until your workup is completed because ED patients can decompensate quickly.
EPIC ED EMR AND TRACK BOARD
Managing patients in the ED through EPIC is similar to hospital and clinic management
but the ED EMR has several unique features. The ones you’ll need immediately are
described here. You’ll familiarize yourself with other features in the first few days of
your rotation.
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When you arrive, select ED-EMERGENCY DEPT for your log in location.
Next, click on ED Manager, then click Sign in and put your name in the box.
Next, familiarize yourself with the Track Board. The icons in the row below the
REFRESH icon sort patients into groups. The two groups you use most often will be
My Patients (all patients assigned to you) and Acute Care (all patients in rooms 104129).
When a new patient is placed into a room, the patient’s name will be high-lighted in red
on the Track Board. When you are ready to see the patient, right-click on the name and
click on “assign me” and also assign the EDa you are working with. This will change
the patient name from red to blue (blue means “in process”) Wait times are closely
monitored for ED patients so your careful attention to assigning patients as you begin to
see them and not after you have seen them will help keep an accurate account of wait
times.
Once a patient’s discharge instructions have been printed the name on the Track Board
changes from blue to bright green. Patients who have been admitted turn light green.
The other colors are described in the Legend icon to the far right of the REFRESH icon.
When you open a patient chart there are two columns that divide the chart into sections.
The column on the far left looks much like hospital and clinic charts; the ED Navigator
sections are unique to the ED. Most are self-explanatory, but the discharge section can
be challenging at first.
When you first open the chart, click on MEDICATIONS and ALLERGIES
respectively, review them and then hit the button that indicates you’ve reviewed each
section. If you do not do this you cannot print discharge instructions.
When you are ready to discharge a patient do the following:
To write prescriptions, click on ORDERS on the ED Navigator menu, then find
DISCHARGE ORDERS and fill in the prescription information there. If you select ED
ORDERS the medications will be given to the patient in the ED. Prescriptions from
DISCHARGE ORDERS will print in the nurses’ area.
Next, go to Discharge Instr . All patients will need discharge instructions; they do not
need to be elaborate but should include, at the minimum, recommendations for follow up
and precautions about when to return in case of complications. Hit the PRINT AVS key
to print the discharge instructions, which will print in your work area. Take the
instructions to the nurses’ area, pull the prescriptions from that printer, sign them and
give it all to the RN or clerk.
DOCUMENTATION
You will write a PROGRESS NOTE (not H and P) on each patient you see. Ideally this
note will be completed by the end of your shift and sent to your attending for a
cosignature. There are emergency department templates available in EPIC and you are
encouraged to use them when appropriate. However, be sure to edit the note before it is
sent to the attending. There are several problems that have been encountered with the use
of templates:
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Many templates “blow in” information that is contradictory to your note. For example,
if you choose one that blows in laboratory values and you put the template in your note
before the labs are finalized, one section of your note will read “NO LABS
AVAILABLE FOR THIS VISIT”. This is in direct contrast most times with a later
section of your note that will include the labs you cut and paste into your note. Delete
any extraneous phrases before your send the note to the EDa.
Most templates have a section labeled IMPRESSION. If you leave that section blank
the coders will assume that no impression (ie. assessment or final diagnosis) was decided
upon EVEN IF YOU GIVE YOUR IMPRESSION IN ANOTHER SECTION of the note.
Be sure to find that phrase and either fill it in or delete it if your impression is elsewhere.
Keeping a blank IMPRESSION statement in your note counts against you and the ED
when Quality Assurance reviews are conducted. When a blank IMPRESSION is
encountered, the reviewer stops looking and assigns that encounter a deficiency even
when you’ve noted the impression elsewhere.
A long note is not necessarily a good note. Avoid indiscriminately including unnecessary
information like medication lists that haven’t been updated or diagnostics that are not
new or pertinent to the present encounter. This is potentially misleading and hampers
patient care. A suitable note contains the following elements:
Chief complaint: short, succinct (“knee pain”; “fever”)
History of present illness: succinct yet comprehensive enough to form a differential
diagnosis
Review of Systems: pertinent to the presenting problem
Past medical, family and/or social history: pertinent to the presenting problem
Medication and allergy review: you can review these and sign off by using the sign-off
clicks on the screen, and then you do not need to copy the medication list to your note.
Exam: must include review of vital signs. This can be done by typing .vs before your
physical exam and the most current vital signs will be placed into your note. Describe
any + or – exam findings pertinent to the presenting problem.
A review of diagnostics ordered in ED: it is not sufficient to write “all labs normal”;
neither is it necessary to copy all diagnostics into the note. In some cases it will be
sufficient to say “cxr reviewed by radiologist : no infiltrates or effusions”; or “CBC
normal except WBC 12 and segs 90% with no bands”. Your interpretation of EKGs must
be included in the note since it will be the only record of it having been read. Give the
time you read it and your impression.
Impression (eg acute pharyngitis; COPD with acute exacerbation); if you’re not using a
template, typing .diag will blow in the diagnoses you have chosen in the Order Entry
section.
Disposition (eg. home with PCP follow up; admitted to medicine service)
All procedures must have a procedure note written separately; it can be in the body of
your PROGRESS NOTE but must include the following elements:
Description of informed consent: (risks and benefits of LP including infection,
headache, bleeding, were described to patient and all questions answered; patient signed
consent form)
Preparation: (“Area was cleaned with betadyne and draped in sterile fashion”)
All details of the procedure including equipment used (“standard adult LP kit used;
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patient positioned sitting up and leaning forward; area cleaned as above; vertebral
interspace L3-4 identified….”)
Statement of complications (“no complications encountered; patient tolerated..”)
Disposition (“patient moved with assistance from sitting to supine position and instructed
to lie flat..”)
Blood loss, if any.
Disposition of samples (“CSF tubes labeled and given to PCT for transport to lab”).
PROBLEMS/COMPLICATIONS
If you encounter a problem or a situation during your rotation that cannot be addressed by
your EDa, you may contact Dr. Mileski 409-771-8146 or by email
wmileski@utmb.edu
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