KING SAUD UNIVERSITY
COLLEGE OF MEDICINE
DEPARTMENT OF MEDICINE
I NT ERNA L M E D IC I NE
RE SI DE NC Y PROG RA M
KING SAUD RESIDENCY PROGRAM
CURRICULUM, PROTOCOLS AND POLICIES
OCTOBER 2007
From the desk of the Chairman
On behalf of the faculty and staff, I welcome you to the Internal Medicine training
program at King Saud University, School of Medicine. We hope that the time you spend
with us will be both educational and enjoyable.
My office is always open, and I encourage open communication with all faculty and staff.
I am looking forward to a productive year and wish you all the success during your
residency and for the rest of your career.
Best Wishes,
DR. ABDULKAREEM ALSUWAIDA
Chairman
Department of Medicine
King Khalid University Hospital
King Saud University
i
From the desk of the Residency Training Director
Great residency training starts with motivated residents, enthusiastic staff and
organized program. We at King Saud University, Department of Medicine is proud of
our graduates – the extraordinary residents over the passed years since the program
started on 1981 where many of them now have an outstanding career.
The Postgraduate Residency Training Program in Internal medicine, King Khalid
University Hospital spans for four years. Our overall goal is to train highly,
competitively responsible and ethical physicians. As of October 2005, the program was
reformed and the objectives were redefined to reach a better standard.
Further, this program is organized to provide early clinical, emergency and procedural
skills to junior residents; allowing senior residents to consolidate more on their
subspecialties and consultations skill across the four years training. In the same way,
affording senior residents the opportunity to teach, supervise and mentor the junior
residents is also a privilege.
With its ratification, our residents are uniformly of the highest caliber, dedicated and
committed to excellence. They are, in fact, the greatest strength of our training
program. The commitment of our Department to residents’ education is reflected
through activities including a weekly Academic Half-Day. The residency program
committee of the department at the university had extremely supported the program.
Indeed, we expanded further to involve residents to rotate at other major hospitals in
Riyadh area this year. With it, we proudly were the first internal medicine postgraduate
program in the region to implement OSCE exams at end-of-the-year evaluation.
All details of our residency program are in this manual. Please take the time to go
though it and please do not hesitate to contact me for suggestions or inquiries.
It was not too long ago that I was once a resident, and for me it was the best time of my
life. I wish you all the same.
DR. AHMED HERSI
Director, Residency Training Program
Department of Medicine
King Khalid University Hospital
King Saud University
ii
Warm Welcome from the Chief Resident
Dear Residents,
Welcome from King Khalid University Hospital.
interested in our Residency Program.
We are delighted that you are
It is our great expectation that Internal Medicine Training Program at King Saud
University progress to occupy a leading position among other programs and to become
the focus of doctors attention globally.
However, that will only happen with the absolute commitment to ethics, full discipline
and good communications, as well as active involvement in the different educational
activities and the scientific researches.
I have complete faith in you and your abilities to handle this responsibility and face this
challenge.
Therefore, let us work hand in hand to achieve our goal, qualifying ourselves to make
our program one of the best programs, not only in kingdom but in the whole wide world.
Best Wishes,
DR MOHAMMAD ALKHOWAITER
Chief Resident
iii
INTERNAL MEDICINE RESIDENCY
TABLE OF CONTENTS
Table of Contents
iv
Introduction
1
Definition and Description
2
General Goals and Objectives of the Residency Program
3
Curriculum Structure
5
Rotation Schedules
8
Program Goals by Year of Training
9
Procedure Log Book
11
Research Elective
12
Resident’s Benificiary
13
Specific Rotation Objectives
Anesthesia
14
Cardiology and Coronary Care unit
16
Emergency Medicine
19
Endocrinology
22
Gastroenterology
27
Haematology & Oncology
35
Infectious Disease
39
Intensive Care Unit
42
Nephrology
45
Neurology
52
Pulmonology
54
Radiology
58
Rheumatology
60
On-Calls Policies and RespoNsibilities
64
Vacation and LeavePolicy
66
Resident’s Day Activity 2007 – 2008
67
Internal Medicine Academic Activities
70
Performance and Evaluation Process
77
iv
INTRODUCTION
Internal Medicine Residency Program, College of Medicine, in King Saud University is
structured to provide a comprehensive core curriculum in internal medicine. This is
accomplished through supervised daily patient care activities as well as other
educational activities.
The residency program is structured to ensure that each resident has the opportunity
to acquire the knowledge, clinical skills, interpersonal skills, professional attitudes and
behaviors, and experience required to become an outstanding general internist or
subspecialist.
For each required and elective rotation, the curriculum defines the educational
purpose, training objectives, principal teaching methods, educational content,
educational methods, and evaluation methods.
The curriculum covers the full range of general internal medicine and all
subspecialties. It also provides an educational framework for clinical experiences in the
related specialties of dermatology, neurology and diagnostics medical specialties.
OVERVIEW GOALS:





Provide the educational and academic environment, formal and informal
instruction, and clinical material necessary to train physicians for the practice of
internal medicine or for subspecialty fellowship training.
The R1 year focuses on fundamentals of differential diagnosis and clinical problem
solving. Residents in the first year master the techniques of history taking and
physical examination, gain expertise in the care of patients in a variety of inpatient
and ambulatory settings and develop competence in procedural skills. At the
conclusion of the R1 year, residents are prepared to assume responsibility for
supervising patient care. In addition to rotations on the medical floors and
intensive and coronary care units, residents have an opportunity to rotate in
emergency medicine
From the second (R2) year of core training, residents continue to evolve on the
clinical teaching units in a progressively more senior role. They are expected to
continue to broaden their knowledge base, develop teaching skills and acquire
consultancy skills.
In the Third (R3) and Fourth (R4) year of training the resident will be exposed to
more medical problems ( medical condition of pregnancy, preoperative care,
critical care, procedural skills, non-invasive cardiology) and they will be involved
with other multidisciplinary specialties and he/she will be encourage to participate
in research project. They will participate actively in academic activities and will
be encouraged to develop special areas of interest. In general the fourth year
resident will have more senior and supervisor role and to act as co-consultant level
in decision making and patient care.
Throughout the core training years a minimum of one half day a week is spent in
an ambulatory care setting under the supervision of faculty staff member. Daily
and weekly lectures, conferences and workshops form an integral part of the
teaching program. In-training evaluations are completed for every rotation
and composite reports are prepared every six months. Residents are encouraged
to review and discuss these with the attending physician supervisor and the
program director.
1
DEFINITION AND DESCR IPTION
This section defines the terms used throughout the present document.
Residency Program: King Saud Residency Program of Internal Medicine, College of
Medicine, King Saud University
Academic Year: The academic year commences October 1 and finish on September
30. Occasionally the resident may be out of phase (e.g.: starting date other than Oct 1 st)
Block: a block is 4-weeks duration. There are 13 blocks in the academic year.
Rotation: a rotation referred to the content of the experience, and it may be of any
duration or more than one block (one block minimum to 3 blocks maximum)
Medicine Postgraduate Office (MPO): it is an office primarily focused on
providing information, services, and support to residents, chief residence and
residency program.
Resident: all resident approved and registered by Post Graduate Medical Education
(PGME) in KSU or/and Saudi Council of Health Specialties (SCHS)
Chief Resident: Senior resident that act as coordination of organizing academic
activities, on-call schedules and annual leaves for residents
Residency Unit Supervisor (RUS): Nominated by the unit to orient the residents
to the unit, organize and supervise teaching activity and communicate and report to
the program director any concerns or resident misbehavior.
Departmental Residency Committee (DRC): committee chaired by program
director and consists of deputy program director, two consultant and chief resident.
Departmental Residency Committee

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Dr Abdulkareem Al Suwaida
Dr Ahmed Hersi
Dr Ahmed Al Sagheir
Dr Fahad Al Majed
Dr Abdulrahman Al Arfaj
Dr Nahla Azzam
Dr Aamer Aleem
Dr Mohammad Al Khowaiter
Committee Chairman
Program Director
Deputy Program Director
Member
Member
Member
Member
Member (non-voting)
2
GENERAL GOALS AND OB JECTIVES OF THE RESI DENCY PROGRAM
Goal I
Residents must demonstrate the ability to provide patient-centered care
that is appropriate, compassionate and effective for treatment of health
problems and the promotion of health.
Objectives:
 Residents will gather essential and accurate information by performing
complete and clinically-relevant history and physical exam.
 Residents will understand how to order and interpret appropriate diagnostic
tests.
 Residents will make diagnostic and treatment decisions by analyzing and
synthesizing information.
 Residents will understand the limits of their knowledge and expertise.
 Residents will develop and carry out care plans.
 Residents will perform procedures competently.
 Residents will effectively counsel patients and families.
 Residents will use consultants and referrals appropriately.
Goal II
Residents will investigate and evaluate their patient care practices,
evaluate and use current medical information and scientific evidence for
patient care.
Objectives:
 Residents will demonstrate mastery of core basic and clinical science necessary
to internal medicine practice.
 Residents will be able to access information and evaluate the medical literature.
 Residents must demonstrate habits consistent with life-long learning.
 The resident will exhibit evidence of self-evaluation.
 The resident will use feedback to improve practice.
 The resident will apply these processes to improve patient care.
 The resident will participate in the education of patients, families, students,
residents, and other health professionals.
Goal III
Residents must demonstrate interpersonal and communication skills that
result in effective information exchange, and collaboration with patients,
families, and health professionals.
Objectives:



Residents will demonstrate the ability to develop highly effective therapeutic
relationships with patients and families.
Residents will exhibit communication that is characterized by socio-cultural
effectiveness.
Residents will communicate respectfully and effectively with other health
professionals.
3


Residents will be able to act in a consultative role to other physicians and
health professionals.
Residents will maintain comprehensive, timely, effective and legible medical
records.
Goal IV
Residents will demonstrate a commitment to professionalism, ethical
behaviour and a commitment to the development of cultural humility.
Objectives:





The resident demonstrates integrity, honesty and compassion, empathy and
altruism.
The resident acknowledges errors and limitations.
The resident demonstrates responsibility, accountability, dependability,
commitment and encourages continuity of care.
The resident respects patient and family privacy and autonomy.
The resident exhibits a commitment to the development of cultural humility.
Goal V
Residents will practice quality health care that is cost-effective and
advocates for patients within the health system.
Objectives:




The resident demonstrates care coordination and a knowledge of medical
practice and delivery systems.
The resident advocates for patients and for populations of patients.
The resident understands and practices cost-effective health care that does not
compromise quality of care.
The resident understands the quality improvement process and how to work
with health care managers and providers to assess, coordinate and improve
care.
4
CURRICULUM STRUCTURE
For the resident to reach above objectives the program curriculum is structured to
enhance and evaluate the resident in four domains (APPENDIX I):
A.
B.
C.
D.
A.
Knowledge
Communication
Professionalism
Scholarship
The Knowledge
The curriculum is structured to occur though regular teaching sessions,
journal clubs, and most significantly in the patient-care context. The
resident should be provided with adequate resources in this context including written
and electronic references.
Regular evaluation of a resident's knowledge, skill, and attitudes in this
domain are part of the periodic scheme for each clinical rotation. The resident's
knowledge and skills in this domain will also be evaluated as part of the annual oral
examination, as well as other examinations implemented by the KSU or the SMCHS.
As a result;

The resident will be able to perform a complete and reliable history and
physical examination, recognizing the normal from the abnormal.

The resident will select appropriate investigations in a logical sequence,
recognizing normal from abnormal results, and their significance.

The resident will formulate a comprehensive problem list, synthesize an
effective diagnostic and therapeutic plan, and establish appropriate follow-up.

The resident will demonstrate effective consultation skills, presenting welldocumented assessments and recommendations both verbally and in writing.

The resident will be knowledgeable in both common and uncommon
diseases.

The resident will demonstrate technical expertise in performing the
following procedures while knowing their indications and complications:

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Central venous catheter insertion
Lumbar puncture
Peripheral arterial catheter insertion
Abdominal paracentesis
Endotracheal intubation
Thoracentesis
Knee joint aspiration
Electrocardiographic interpretation
5

The resident's knowledge, attitudes, and skills in this context will show
appropriate evolution over the four years of training, with appropriate
mastery of more advanced concepts and skills in this field as the resident's
clinical training progresses.
B.
Communication
The curriculum is structured to occur through regular teaching, academic
sessions and in the patient-care context through the recognition and application
of the principles of verbal and written communication with patients, families,
colleagues, and other health-care professionals, and in discussions and presentations
with health-care professionals.
Regular evaluation of a resident's knowledge, skill, and attitudes in this domain are
part of the periodic evaluation scheme for each clinical rotation. Furthermore, directly
observed patient interviews occur on a regular basis as part of the annual practice oral
exam.
As a result;






C.
The resident will be able to establish a therapeutic relationship with
patients and families based on trust and respect, recognizing the fundamental
importance and benefits of this relationship.
The resident will be able to obtain and synthesize a relevant history from
patients and families, given specific challenges (for example, language or
other communication barriers). The relevant history will include not only
information about the disease, but also patient beliefs, concerns, and
expectations about the illness.
The resident will be able to listen effectively.
The resident will be able to discuss appropriate information with patients,
families, and the health-care team. Specifically, the resident will be able to
communicate in a humane and understandable manner that fosters
discussion and promotes patient understanding.
The resident will recognize the importance of cooperation and
communication among health-care providers, and recognize the importance
of delivering consistent messages to patients.
The resident's knowledge, attitudes, and skills in this context will show
appropriate evolution over the four years of training, with appropriate
mastery of more advanced concepts in communication as the resident's
clinical training progresses.
Professionalism
The curriculum is structured to occur primarily through the patient-care context. It
is in this context that the resident participates in the day-to-day care of in-and outpatients, as a collaborative member of the health-care team whose goal is the provision
of optimal patient care, education, and research.
The resident will show professionalism in:


Punctuality, discipline and reliability
Integrity, honesty and compassion
6
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Leadership and management skills
Attitude toward patient, patient’s family and other health-care providers
Personal and interpersonal behavior
Understanding the ethical and medico-legal aspects of health problems
Implementing the standard of care taking in consideration the patient wellbeing at all time regardless of cultural or belief diversity.
Regular evaluation of a resident's knowledge, skill, and attitudes in this domain are
part of the periodic evaluation scheme for each clinical rotation.
D.
Scholarship
The curriculum is structured to occur through regular journal clubs, academic
sessions and through the completion of a research project.

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Residents are strongly encouraged to participate in research, and meet with
their assigned research coordinators to assist them in this area. Teaching in
epidemiology will be arranged in yearly bases in collaboration with
department of medical education to improve the resident's knowledge and
skills in this area.
The resident will be encouraged and supported to have regular opportunities
to present clinical cases and topic reviews at various clinical meeting.
The resident will be able to facilitate the learning of patients, students,
residents, and other healthcare professionals.
The resident will contribute to the development of new knowledge.
The resident will be able to develop and implement a personal continuing
education strategy.
The resident's knowledge, attitudes, and skills in this context will show
appropriate evolution over the four years of training, with appropriate
mastery of more advanced concepts in clinical epidemiology, teaching, and
research as the resident's clinical training progresses.
7
ROTATION SCHEDULES
First Year R1 Resident: 13 periods
 4 weeks Vacation
 4 weeks Emergency Medicine
 4 weeks ICU
 4 weeks Anesthesia
 4 weeks Neurology
 8 weeks Cardiology/CCU
 8 weeks Riyadh Medical Complex
 16 weeks Medical floors
 Compulsory requirement : Log Book , ACLS
Second Year R2 Resident
 4 weeks Vacation
 4 weeks Elective
 4 weeks CCU
 8 weeks ICU (Affiliated Hosp)
 8 weeks Security Forces Hospital
 24 weeks Medical Floors
 Compulsory requirement: FCCS
Third Year R3 Resident
 4 weeks vacation
 4 weeks ICU
 8 week RMC
 8 weeks CCU/Cardiology
 4 weeks electives
 24 weeks Medical Floors (Consultations + Admission)
 Other requirement : Research
Fourth Year R4 Resident
 4 weeks vacation
 4 weeks ICU
 4 weeks RMC
 8 weeks CCU/Cardiology
 8 weeks electives
 24 weeks Medical Floors
 Other requirement : Research
See Appendix II
8
PROGRAM GOALS BY YEA R OF TRAINING
FIRST YEAR RESIDENTS (Foundation)
The first year residency has been carefully structured to provide all trainees with
high quality clinical exposure, appropriate balance between independence and
supervision, and emphasis upon core skills that will be used throughout each
trainee's career. The year is divided into 13 blocks including Inpatient Medicine,
ICU, CCU, emergency medicine. This blend of experiences provides a broad-based
exposure to a multitude of teachers and medical disciplines. During the year have
day offer the residents more medical knowledge with emphasis on medical skills of
physical examination, history taking, doctor-patient communication, teaching
skills, Evidence Based Medicine, clinical reasoning skills and clinical research.
The goal of the first year is to allow the resident to recognize acuity of illness and to
initiate care in common acute-care settings. They will learn how to manage
individual cases and, after initiating interventions, effect and co-ordinate care. A
major goal is improvement of efficiency and development of early skills in multitasking. Residents will learn how to performed basic medical procedures.
Procedural log book will be mandatory in the first year to fulfill such requirement.
Specific learning opportunities are directed for the early levels of residents in
training and these include: Crash course; a series of emergency and acute care
medical topics. ACLS coarse will be arranged for all R1 residents to develop their
acute care skills prior to becoming a supervisory house officer.
SECOND YEAR RESIDENTS (Continuous Growth)
Second year residents will continue their rotation in general inpatient wards, ICU
and CCU. The Subspecialty rotation in gastroenterology, hematology, nephrology,
and oncology will be part of second year rotation. These rotations will provide
more depth in more specialized field of medicine. The residents should be more
knowledgeable and confident in dealing with acute care cases, handling On call,
run a resuscitation code and performing medical procedures
THIRD YEAR RESIDENTS (Decision Maker)
Third year rotations will now have the knowledge and skills to be general internal
medicine physician. He should be confident in dealing with acute and chronic care
medicine with some depth in subspecialties' knowledge. The residents will have
rotation in general inpatient wards, ICU and CCU. With more orient rotation
toward leadership, supervising junior and involved in academic teaching
FOURTH YEAR RESIDENTS (Final Product)
This is a very important year as it represents the last phase of training before
residents leave to begin practice or to pursue subspecialty fellowship. During the
9
fourth year, the goal is to greatly enhance the depth of that knowledge base and
further refine clinical skills. Forth year will have similar rotation like previous year
but with emphasis on consultation service in subspecialty units. The remaining
flexible rotation time during the R4 year is structured by the resident with faculty
guidance to continue to help prepare the resident for their specific career choice.
For those residents who have not completed a research project, they may continue
to work on it during the 4th year.
10
PROCEDURE LOG BOOK
The first year resident should have a procedure log book (appendix 1)
To use the log book fill in the type of procedure performed, date, patient name, and/or
medical record number. Substantiation of your clinical competence in performing
procedures is the responsibility of the supervisor (qualified physician) who observes
you, evaluates your cognitive and technical abilities, signs the log book, and indicates
whether any improvements in your skills are needed.
Qualified physician is defined as the individual who is competent to perform as well
as authorized to teach the procedure. Ultimately this individual should attest to your
competence to conduct the procedure independently.
Cognitive skill is defined as your competency in understanding the indications,
limitations, contraindications, and complications of the designated procedure and
interpreting the results.
Technical skill is defined as your competency in performing the procedure.
The resident will have two years to enable to understand and able to perform the
procedures. THE LOG BOOK SHOULD BE SUBMITTED TO THE RESIDENCY OFFICE NO
LATER THAN LAST WEDNESDAY OF THE MONTH OF AUGUST IN R2 LEVEL
Procedures Required for Certification in Internal Medicine requires that
candidates must be judged competent by their program directors in:
o Performing the following procedures; understanding their indications,
limitations, contraindications, and complications; and interpreting their
results:











o
Advanced cardiac life support
Abdominal paracentesis
Arterial puncture
Arthrocentesis
Central venous line placement
Lumbar puncture
Nasogastric intubation
Thoracentesis
Urethral catheterization
Endotracheal intubation
Interpreting electrocardiograms.
The review of evidence-based literature for these procedures does not support
any correlation of the number of times procedures must be performed to
achieve competence. Accordingly, the general guideline of FOUR as the
minimum number of directly supervised, successfully performed
procedures below which confirmation of competent performance is not
credible.
11
RESEARCH ELECTIVE
The general objective of a research elective during core internal medicine training is to
provide an introduction to the conduct of clinical or basic science research, in a field
relevant to internal medicine. More specifically, the elective should be an opportunity
to learn about research from the investigator's standpoint. Hence the resident research
experience should include all phases of a project, from design through data collection,
analysis, interpretation, and reporting. Experience of a purely technical nature--work
ordinarily performed by a research assistant or technician--is not suitable.
The scope of the project must reflect the limited time available. However, it is crucial
that you be able to claim primary intellectual ownership of the work done. Hence it is
preferable to complete a small project than to undertake one component of a larger
one. To maximize the yield of "protected" research time, the planning stages should be
completed before the research block-including study design, preparation of relevant
data collection tools, and ethics committee approval (required for nearly all clinical
studies, including chart reviews). This requires organization and input from both
resident and supervisor. The research elective itself should be devoted to data
collection, analysis, and potentially preparation of results for presentation/
publication.
The resident is encouraged to be involved in at least one research project during the
last two years of residency training.
Failure of the resident to submit his/her research at the end of his/her
training, his/her training will be considered incomplete and he/she will
not be promoted to the final examination. This is applied from 2006 in all
third year residents and below.
Please be advised that residents who undertake a research must:
1. Submit a summary of the planned project, including a description of the
resident's role, this summary must be signed by both resident and supervisor,
2. Include a statement as to the target venue for presentation of the results: the
name of the local, national, and/or international conference targeted, and/or
the target peer-reviewed journal,
3. Upon completion of the rotation, have their supervisors complete a regular
evaluation form with comments.
4. Submit a report of their research experience and of their results to the
residency office.
5. Present the research at the annual Resident Research Day.
Presentation, critical review, and dissemination of results are crucial elements of the
research process. Hence presentation of results at a relevant conference is essential,
and publication of a manuscript in a peer-reviewed journal is strongly encouraged.
Financial support is available to offset travel and conference costs, potentially in
conjunction with the research supervising funding.
12
RESIDENT’S BENIFICIA RY
Lab Coat
Two white coats are provided in the first year then one white coat there after each year
for the residents. The resident has to fill application form and submitted to the
department of medicine secretary. Laundry is free of charge.
Pager
The resident will be provided with a pager. A form has to be signed and will be
submitted to medical engineering department.
Lockers
If possible each resident in training will be provided with a locker. The locker will be
allocated each year according to the availability
Photocopy Service
The resident will be provided with photocopy card with limited number of copies a
year. The photocopy can be accessible in the medical library
Computer Service
A personal computer with internet access, printer and scanner is located in the
residency on call room. In case of presentation, laptop computer can be borrowed from
residency office. Please book the computer a head of time because of limited
availability.
Books and Medical Journal
Books and access to medical journal is available in the main medical library. E-books
and internet journal subscription could be accessed from on call room computer.
Meals
Meals are provided for free for the on call resident.
13
SPECIFIC ROTATION OB JECTIVES
ANESTHESIA
Rotation Supervisor
Teaching Methods:

Daily Rounds

Independent reading
Goal
A.
The Knowledge

Obtain a history and physical examination, and interpret laboratory data to
enable to recognize patient with high risk or comorbid medical or surgical
condition.

Able to performed preoperative assessment for medical patients and know
the preoperative nursing and medication orders.

Able to describe, performed and know the indication, contraindication and
contraindication of common anesthetic procedure;
o Endotracheal intubation
o Venipuncture
o Central venous line access
o Arterial blood gas sampling and interpretation
o Spinal puncture
o Spirometry and interpretation

Should have a basic knowledge of the pharmacology of common anesthetic
agents (indications and contraindications)

Should have knowledge of pain management and side effect and
complication 0f common analgesic agents

Should be able to early recognize and have an approach to the management
of common intraoperative problems
o
o
o
o
o
o
o
o
o
o
Hypertension and hypotension
Cardiac arrythmias
Anaphylaxic and anaphylactoid reaction
Laryngeospasm and bronchospasm
Aspiration pneumonia and aspiration risk
Hypoxemia and hypercapnia
Oliguria and polyuria
Transfusion reaction
Pathological bleeding
Difficult airway management
14
o

Able to identify and have systemic approach to patients with postoperative
complications including
o
o
o
o
o
o
o
o
B.
Demonstrate patient-centered interviewing techniques; a compassionate
approach to history taking; the ability to modify interview techniques in
response to the patient's demeanor, cultural and/or religious background,
and level of competency.
Professionalism




D.
Delay ventilatory weaning
Hemodynamic abnormalities
Fever
Electrolytes disturbance
Renal impairment
Liver function abnormality
Bleeding
Delirium
Communication

C.
Coma
Appreciate the impact of surgery on patients' quality of life and their
relationships with family and friends.
Discuss some of the common ethical issues that face patients and their
families with emphasis in preoperative assessment and risk of anesthesia or
surgery.
Appreciate the effects of cultural and religious background on the patient's
approach and attitudes toward decision making, their disease and
treatment.
Systems-based Practice
Scholarship
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
Practice Based Learning and Improvement
Develop a willingness and ability to learn from errors and use them to
improve individual practice and the health care delivery system.
Maintain an attitude of healthy skepticism and curiosity, as evidenced by
thoughtful questioning, independent study, and critical analysis of
published materials.
Utilize information technology to enhance patient education.
Be able to critically appraise sources of medical information.
Be able to educate patients and their families regarding their medical
condition.
Be able to teach medical students, residents, and other health-care
professionals.
Be able to contribute to the development of new knowledge, through the
completion of or participation in a research project.
15
CARDIOLOGY AND CORONARY CARE UNIT
Rotation Supervisor:
Teaching Methods:



Daily rounds
Daily morning meeting + conferences
Independent reading
Goals
Cardiology is the prevention, diagnosis, and management of disorders of the
cardiovascular system, including ischemic heart disease, cardiac dysrhythmias,
cardiomyopathies, valvular heart disease, pericarditis and myocarditis, endocarditis,
congenital heart disease in adults, hypertension, and disorders of the veins, arteries,
and pulmonary circulation. Management of risk factors for disease and early diagnosis
and intervention for established disease are important elements of cardiology. The
general internist should be able to provide primary and secondary preventive care and
initially manage the full range of cardiovascular disorders.
The Internal Medicine Resident is expected to achieve competency in the areas
described below during their rotation in Cardiology.
The resident is expected to:
A.
The Knowledge





Obtain a history and physical examination, and interpret laboratory data to
diagnose cardiac disease in a wide variety of patients on other medical or
surgical inpatient services.
Evaluate and manage a wide range of cardiac disorders, including: ischemic
heart disease, hypertensive heart disease, valvular heart disease, adult
congenital heart disease, cardiac dysrhythmias, congestive heart failure
management, cardiomyopathy assessment, and discuss the implications of
systemic disease processes on the heart, endocarditis, the implications of
vascular disorders, COPD and chronic renal failure on the heart.
Arrhythmias :
o Describe the pathophysiology of recurrent ventricular and
supraventricular arrhythmias.
o Develop competence in the use of anti-dysrhythmic drugs to treat acute
arrhythmias.
Congestive Heart Failure
o Describe the pathophysiology of pulmonary edema.
o Integrate specific test results into the clinical presentation as developed
from a history, physical examination, and laboratory data for patients
with acute and chronic ischemic heart disease and congestive heart
failure.
o Discuss issues regarding the appropriate selection of medical therapy
for congestive heart failure.
o Clinically manage patients with pulmonary edema and low cardiac
output.
Coronary Artery Disease
16
Discuss the importance of risk-factor modification in primary and
secondary prevention.
o Describe the pathology, pathogenesis, and pathophysiology of acute
ischemic syndromes, chronic ischemic heart disease, and congestive
heart failure.
o Discuss issues regarding the appropriate selection of medical therapy
for ischemic syndromes.
o Discuss the importance of medical therapy, percutaneous
revascularization, and surgical therapy for the treatment of ischemic
heart disease.
Systemic Disease
o Discuss the importance of co-morbid disease processes such as
hypertension, diabetes, systemic disease, chronic obstructive pulmonary
disease, and chronic renal failure on ischemic heart disease and heart
failure diagnosis and management.
Valvular, endocardial and pericardial Diseases
o Describe the pathophysiology of acute valvular disease, e.g.
endocarditis.
o Describe the pathophysiology and treatment of acute aortic dissection.
o Manage patients with pulmonary hypertension.
o Describe the natural history of multiple cardiac disease processes and
the importance of aging on these disease processes.
o Describe the pathophysiology and treatment of acute pericardial
disease, including: tamponade and constriction.
o Develop an understanding of heart disease in women during pregnancy.
o Know the indications for medical and surgical therapy for cardiac
complications of endocarditis, pericardial disease, aortic disease,
peripheral vascular disease, cardiac trauma, and tumors.
Appropriately utilize electrocardiograms, echocardiograms, and exercise
treadmill tests in planning for diagnostic and therapeutic decisions.
Describe the indications for electrophysiology, cardiac catheterization,
intervention, and cardiac nuclear medicine studies in the evaluation and
management of complex patients.
Develop competence in applying non-invasive pacing techniques.
Interpret clinical exercise stress tests in patients.
Interpret electrocardiograms
o







B.
Communication




Communicate with primary care and/or subspecialty physicians on their
patient in the inpatient units about the patient’s course, the results of
specific tests, the long-term follow-up plans, issues regarding risk-factor
modification, and rehabilitation where appropriate.
Develop an appreciation of the necessary cooperation of the
anesthesiologist and the surgeon in developing collective treatment goals
for patients.
Develop an organized approach to the post-discharge treatment and
communication regarding patients being seen in consultation.
Develop a working relationship with colleagues on non-cardiac services.
17
C.
Professionalism










D.
Be able to identify the need to and benefit of consulting other physicians
and health-care professionals, specifically cardiovascular surgeons when
coronary artery bypass or other surgery is being contemplated.
Be able to contribute effectively to interdisciplinary team activities.
Be able to use information technology to optimize patient care.
Be able to use health-care resources cost-effectively.
Be able to work efficiently and effectively.
Be able to educate and counsel patients and families regarding cardiac risk
factors like smoking cessation, exercise, nutrition, and other risk factors to
optimize a patient’s health.
Be able to apply knowledge of the professional codes and norms of
behaviors that govern the behavior of physicians in clinical practice.
Be able to apply knowledge of the legal codes and norms of behaviors that
govern the behaviors of physicians in clinical practice.
Be able to recognize and resolve ethical issues as they arise in clinical
practice.
Be able to recognize and deal with unprofessional behaviors in clinical
practice.
Scholarship







Critically review cardiac clinical trial data in the medical literature.
Develop skills in presenting clear explanations of the current literature
regarding the management of wide range of acute and chronic heart disease
issues.
Utilize the current literature to make appropriate diagnostic and
therapeutic plans.
Be able to critically appraise sources of medical information.
Be able to educate patients and their families regarding their medical
condition.
Be able to teach medical students, residents, and other health-care
professionals.
Be able to contribute to the development of new knowledge, through the
completion of or participation in a research project.
18
EMERGENCY MEDICINE
Rotation Supervisor:
Teaching Methods:



Daily rounds
Daily morning meeting + conferences
Independent reading
Goal
The goal of the emergency medicine rotation is for residents to gain skills in the initial
assessment, diagnosis, stabilization, and management of a variety of urgent and
emergent conditions.
A.
The Knowledge

Gather essential and accurate historical and physical examination
information from and about patients to assess the following concerns:
o Abdominal pain
o Acute loss of vision
o Cardiac arrest
o Chest pain
o Coma or altered mental status
o Dehydration
o Diarrhea
o Dyspnea
o GI bleeding
o Headache
o Hemoptysis
o Leg swelling
o Palpitations
o Severe hypertension
o Shock
o Vomiting
o Wheezing

Order the appropriate diagnostic tests to evaluate, therapeutic interventions
to treat, and educate patients and families about the following conditions:
o Acid-base disorders
o Acute abdomen
o Acute arthritis
o Acute complications of hyperthyroidism & hypothyroidism
o Acute diarrhea
o Acute liver failure
o Acute loss of vision & red eyes
o Acute myocardial infarction
o Acute pancreatitis
o Acute renal failure
o Acute respiratory failure
o Addisonian crisis
19
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

Anemia and Polycythemia
Arrhythmias
Ascites
Asthma
Bowel obstruction
Cardiopulmonary arrest
Chronic renal failure
Coma
Common overdoses or poisonings
Congestive heart failure
COPD
Diabetic ketoacidosis
Domestic violence
Easy bruising, purpura, petechiae
Electrolyte disorders
Epistaxis or vertigo
Gallstones and cholecystitis
GI bleeding
Headache
Herpes simplex & zoster infection
HIV infection & exposure
Hypertensive emergencies
Hypoglycemia
Hypothermia & Hyperthermia
Leukopenia & Leukocytosis
Low back pain
Meningitis
Nephrolithiasis
Otitis externa and media
Pharyngitis
Pneumonia and bronchitis
Pneumothorax
Prostatitis, urethritis, epididymitis
Pulmonary Embolism (and deep venous thrombosis)
Renal colic
Seizure
Sepsis
Severe airway obstruction
Sexually transmitted diseases
Shock
Sinusitis
Stable and unstable angina
Stroke
Subarachnoid hemorrhage
Thoracic or aortic aneurysms
Thrombocytopenia & Thrombocytosis
Transient ischemic attack
Tuberculosis
Uncontrolled diabetes mellitus
Upper respiratory tract infections
Urinary tract infections including pyelonephritis
Viral hepatitis
After receiving informed consent, perform the following procedural skills
with confidence and minimal discomfort to patients:
20
o
o
o
o
o
o
o

B.


Communicate effectively with colleagues when signing out patients.
Communicate effectively with patients and families in a stressful ED
environment.
Communicate effectively with other physicians regarding the care of the
patients in the ER.
Complete all documentations in a timely manner.
Professionalism





D.
Provide health care services aimed at maintaining health and preventing
illness with special attention paid to the following areas:
o Preventing tetanus infections
o Wound care
Communication


C.
ACLS
Arterial blood gas sampling
Arthorocentesis
Central venous catheter insertion
Endotracheal intubation
Placement of an NG tube
Suturing lacerations
Demonstrate a personal sense of altruism by consistently acting in one’s
patients’ best interest.
Know how to inform patients and obtain voluntary consent for the general
plan of medical care and specific diagnostic and therapeutic interventions.
Apply evidence-based, cost-conscious strategies to prevention, diagnosis,
and disease management
Facilitate the safe and timely transfer of admitted patients from the ER to
the appropriate inpatient service.
Understand and utilize the multidisciplinary resources necessary to care for
patients in the ED.
Scholarship




Be able to critically appraise sources of medical information.
Be able to educate patients and their families regarding their medical
condition.
Be able to teach medical students, residents, and other health-care
professionals.
Be able to contribute to the development of new knowledge, through the
completion of or participation in a research project.
21
ENDOCRINOLOGY
Rotation Supervisor:
Teaching Methods:



Daily rounds
Daily morning meeting + conferences
Independent reading
Goal
Endocrinology is the diagnosis and care of disorders of the endocrine system. The
principal endocrine problems handled by the general internist include goiter, thyroid
nodules, thyroid dysfunction, diabetes mellitus, hyper- and hypocalcemia, adrenal
cortex hyper- and hypofunction, endocrine hypertension, gonadal disorders, hyperand hyponatremia, certain manifestations of pituitary tumors, disorders of mineral
metabolism, and hyperlipidemias. Obesity is not strictly an endocrine disorder but is
considered part of the spectrum of endocrinology because it frequently enters into the
differential diagnosis of endocrine disease and is a major element in the management
of non–insulin-dependent diabetes. Prevention efforts focus on complications of
hyperlipidemias, obesity, thyroid dysfunction, and diabetes mellitus, and on
endocrinologic side effects of pharmacologic glucocorticoids and other medications.
The general internist must be able to evaluate and manage common endocrine
disorders and refer appropriately. He or she must also be able to evaluate and identify
the endocrinologic implications of abnormal serum electrolytes, hypertension, fatigue,
and other nonspecific presentations. The general internist plays a key role in managing
endocrine emergencies, particularly those encountered in the intensive care unit,
including diabetic ketoacidosis and hyperosmolar nonketotic stupor, severe hyper- and
hypocalcemia, and addisonian crisis.
A.
The Knowledge
 Diabetes mellitus
 Understand the different etiologies, pathophysiologic processes, and
clinical presentations of type I, type II, and secondary diabetes
 Understand the laboratory diagnosis of diabetes mellitus: utilization and
interpretation of glycosylated hemoglobin, islet cell and insulin antibody
levels
 Understand specific therapeutic modalities including oral agents and
conventional and intensive insulin therapy
 Discuss the rationale for and use of diabetic diets, prescription of exercise
programs
 Describe the use of glucose monitoring devices, and their use in reaching
treatment objectives
 Diagnose and manage acute complications such as diabetic ketoacidosis,
hyperosmolar coma, and hypoglycemia
 Diagnose and manage chronic complications such as retinopathy,
nephropathy, neuropathy, dermopathy, arteriosclerotic vascular disease,
and infections
22
Perform funduscopic examination and make appropriate referral of
patients with retinopathy
 Provide care for the diabetic foot and list indications for referral
 Understand psychosocial effects of diabetes mellitus
 Recognize the importance of patient and community education
Hypoglycemic syndromes
 Utilize and interpret diagnostic tests, including prolonged fasts screen for
the use of hypoglycemic agents
 Understand the psychosocial aspects of factitious hypoglycemia
 Describe therapies for specific causes of hypoglycemia
Thyroid disorders
 Interpret thyroid function tests in thyroidal and non-thyroidal illness
 Use and interpret radionuclide, ultrasound, and radiographic imaging
 Describe use of antithyroid medications and thyroid hormone replacement
therapy
 List the differential diagnosis, evaluation, and appropriate treatment of
thyrotoxicosis
 Discuss use of radioactive iodine in the treatment of hyperthyroidism and
thyroid cancer
 Evaluate and treat of hypothyroidism. Refer patients with thyroid nodules
for appropriate diagnostic testing
 List the appropriate use of surgery in the treatment of thyroid diseases
Hypothalamic and pituitary diseases
 Recognize and evaluate patients with known or suspected functioning or
nonfunctioning pituitary tumors
 Interpret tests measuring hypothalamic-pituitary-end organ function
(including baseline and dynamic testing)
 Utilize and interpret radiographic and magnetic resonance imaging
procedures
 Evaluate and treat patients with known or suspected hypothalamic
disorders
 Evaluate and treat patients with pituitary or hypothalamic hormone
deficiencies
 Understand the roles of pharmacologic, surgical, and radiotherapeutic
interventions in the treatment of diseases of the pituitary and
hypothalamus
Disorders of calcium and skeletal metabolism
 Understand the physiology and pathophysiology of calcium, magnesium,
and phosphorus metabolism
 Use and interpret serum and urine electrolytes as well as biochemical
markers of mineral metabolism
 Evaluate and treat patients with metabolic bone diseases including, but not
limited to, hyperparathyroidism, osteoporosis, osteomalacia, and Paget
disease of bone
 Recognize the interaction between systemic processes and bone
metabolism (e.g., Cushing’s syndrome, hyperthyroidism, growth hormone
deficiency, and hypogonadism)
 Evaluate and treat patients presenting with nephrolithiasis
 Understand the effects of renal function and nutrition on mineral
metabolism
 List the differential diagnosis, evaluation and treatment of hypercalcemia
 Use and interpret radiographic and radionuclide imaging of bone
 Evaluate and treat patients with abnormalities of vitamin D metabolism
Disorders of fluid, electrolyte and acid-base metabolism






23
Discuss the physiology and pathophysiology of water, electrolyte, and acidbase homeostasis
 List the differential diagnosis, evaluation, and treatment of patients with
polyuria and polydipsia
 Interpret serum and urine measurements of electrolyte, osmolarity, and
pH
 Evaluate and treat patients presenting with abnormal electrolytes and
disorders of osmolarity or acid-base status
Endocrine hypertension
 Evaluate
for
secondary
causes
of
hypertension,
including
pheochromocytoma and syndromes of mineralocorticoid excess
 Interpret biochemical and dynamic testing in the diagnosis of secondary
causes of hypertension
 Discuss the appropriate use of radiologic, radionuclide, and magnetic
resonance imaging in the diagnosis of secondary causes of hypertension
 Discuss the use of medical and surgical therapy for secondary causes of
hypertension
 Evaluate and treat orthostatic hypotension
Adrenal disorders
 Understand the biologic effects of glucocorticoids, mineralocorticoids, and
adrenal androgens
 Interpret hormonal testing in the evaluation of adrenal disease
 Recognize symptoms and signs of glucocorticoid excess, knowledge of
differential diagnosis of Cushing’s syndrome
 Demonstrate proficiency in the evaluation of Cushing’s syndrome
 Understand the roles of medical treatment, surgery, and radiation therapy
in the management of Cushing’s syndrome
 Diagnose adrenal insufficiency, determining its etiology, and initiating
appropriate therapy
 Understand the pharmacology of steroid hormone therapy, demonstrating
proficiency in both treatment and tapering regimens
 Recognize, evaluate, and treat congenital adrenal hyperplasia and virilizing
disorders
 Diagnose, evaluate, and manage adrenal masses and adrenal cancer
Disorders of lipid metabolism
 Understand the physiology of lipid metabolism, including nutritional
factors and the relationships between lipids and lipoprotein particles
 Categorize lipid disorders based on lipoprotein measurements.
 Recognize genetic and secondary forms of hyperlipidemia
 Discuss appropriate use of diet, exercise, and lipid lowering agents in the
management of hyperlipidemia
 Describe the appropriate use of screening procedures for hyperlipidemia
 Understand the complications associated with hyperlipidemia
Nutrition and obesity
 Recognize, evaluate, and treat vitamin and mineral deficiency states
 Recognize, evaluate, and treat eating disorders including bulimia, anorexia
nervosa, and obesity
 Understand the appropriate use of hyperalimentation in nutritionally
deprived individuals
Male reproductive endocrinology and sexual function
 Understand the physiology of spermatogenesis and erectile function
 List causes of primary and secondary hypogonadism
 List the differential diagnosis of hormonal causes of infertility
 Discuss indications and appropriate use of hormone replacement therapy in
hypogonadal men






24
Recognize and evaluate the vascular, neurologic, hormonal, and
psychologic causes of impotence
Female reproductive endocrinology
 Understand the normal physiology of menarche, menstrual cycle, and
menopause
 Understand disorders of menstruation, ovulation, and sexual response
 Diagnose, evaluate, and manage hirsutism and virilization
 List the differential diagnosis, evaluation, and treatment of primary and
secondary amenorrhea
 List the differential diagnosis of hormonal causes of infertility
 Discuss the efficacy and side effects of various forms of contraception
 Understand age-related changes in endocrine function and the appropriate
use of hormonal therapies in the treatment of age-related disorders
 Evaluate and treat premenstrual syndrome
Hormone-producing neoplasms
 Diagnose syndromes of ectopic hormone production
 Interpret and use radiographic and radionuclide imaging for suspected
hormone-producing neoplasms
 Understand the medical and surgical treatments for hormone-producing
neoplasms
 Understand the pathophysiology associated with hormone-producing
tumors, including, but not limited to, carcinoid syndrome, multiple
endocrine neoplasia, pheochromocytoma, insulinoma, gastrinoma, and
small cell cancer
Disorders of growth and development
 Understand the normal physiology of growth and puberty
 Diagnose, evaluate, and treat precocious puberty
 Evaluate and treat delayed puberty
 Evaluate and treat short stature
 Evaluate primary and secondary amenorrhea
 Understand how systemic diseases, nutritional factors, and endocrine
abnormalities impact on growth and sexual development
 Interpret dynamic endocrine testing in the evaluation of disorders of
growth and sexual development
 Discuss endocrine adaptations to systemic disease
Thyroid function
 Carbohydrate and lipid metabolism
 Hypothalamic-pituitary-end organ responses
 Electrolyte metabolism
 Growth and development
 Calcium and bone regulation
Endocrine aspects of psychiatric disease
 Recognize, evaluate, and treat undiagnosed endocrine disorders presenting
as psychiatric illness
 Understand neuroendocrine abnormalities in patients with psychiatric
illness
 Understand the possible effects of hormonal therapy on psychiatric disease
 Understand the possible effects of psychiatric medications on endocrine
function
 Aspiration of the thyroid.






B.
Communication
 Complete all dictations, letters, and consultation requests in a timely manner.
25
 Conduct all interviews with patients and their families in a compassionate,
culturally-effective, and patient-centered manner. Practice-based Learning and
Improvement
 Develop a willingness and ability to learn from errors and use them to improve
individual practice and the health care delivery system.
 Maintain an attitude of healthy skepticism and curiosity, as evidenced by
thoughtful questioning, independent study, and critical analysis of published
materials.
 Utilize information technology to enhance patient education.
C. Professionalism
 Demonstrate a personal sense of altruism by consistently acting in one’s
patients’ best interest.
 Know how to inform patients and obtain voluntary consent for the general plan
of medical care and specific diagnostic and therapeutic interventions.
 Provide meaningful feedback to colleagues and students regarding performance
and behavior.
D. Scholarship
 Apply evidence-based, cost-conscious strategies to prevention, diagnosis, and
disease management.
 Interact with and utilize social workers, nurses, medical assistants, ors, and
referral coordinators to provide effective, comprehensive patient care.
26
GASTROENTEROLOGY
Rotation Supervisor:
Teaching Methods:



Daily rounds
Daily morning meeting + conferences
Independent reading
Goal
Gastroenterology encompasses the evaluation and treatment of patients with disorders
of the gastrointestinal tract, pancreas, biliary tract and liver. It includes disorders of
organs within the abdominal cavity and requires knowledge of the manifestations of
gastrointestinal disorders in other organ systems, such as the skin. Additional areas
include knowledge of nutrition and nutritional deficiencies and screening and
prevention, particularly for colorectal cancer.
The general internist should have a wide range of competency in gastroenterology and
should be able to provide primary and in some cases secondary preventive care,
evaluate a broad array of gastrointestinal symptoms, and manage many
gastrointestinal disorders. The general internist is not expected to perform most
technical procedures with the important exception of flexible sigmoidoscopy. However,
he or she must be familiar with the indications, contraindications, interpretation and
complications of these procedures.
The Internal Medicine Resident is expected to achieve competency in the areas
described below during their rotation in Gastroenterology.
The resident is expected to:
A.
The Knowledge



Be able to elicit, present, and document a history that is relevant and
appropriate to the clinical presentation in gastroenterology.
Be able to perform an accurate physical examination of the
gastroenterological system, with emphasis on:
o Peripheral signs of cirrhosis
o Differentiate kidney from spleen
o Ascites
o Extra-intestinal manifestations of IBD, including eye, skin, and
articular findings
o Venous drainage of abdomen in normal and disease states
o Signs of malnutrition
o Full abdominal examination, including liver and spleen examination
Be able to provide a reasonable approach to the differential diagnosis,
work-up and management of the following scenarios:
General Gastroenterology
 Upper GI Bleed
27













Lower GI Bleed
Recurrent gastric and/or duodenal ulcer
Oesophagitis
Dyspepsia
Nausea & vomiting
Dysphagia
Diarrhea, acute and chronic
Constipation
Abdominal pain
Malabsorption
Weight loss
Melena, haematochezia
Pancreatitis
Hepatology
 Abnormal transaminases
 Abnormal cholestatic liver enzymes
 Spontaneous bacterial peritonitis
 Hepatic encephalopathy
 Jaundice
 Ascites
 Hepatitis
 Cirrhosis and its complications, including hepatic encephalopathy
indications for referral to liver transplantation centre



D.
Demonstrate an understanding of the pathophysiology, manifestations,
diagnostic work-up, and management of the following conditions:
 Peptic ulcer disease, including helicobacter pylori
 Esophageal dysmotility, in particular achalasia
 Gastroparesis
 Crohn's disease
 Ulcerative colitis
 PBC/Sclerosing cholangitis
 Viral hepatitis
 Hemochromatosis
 Alcoholic liver disease
 Cirrhosis
 Ischemic bowel
 Celiac disease
 Whipple's disease
 Neoplasia (oesophageal,
gastric,
intestinal,
colonic,
pancreatic,
hepatoma)
Understand the indications for and complications of gastroscopy, colonoscopy,
ERCP, liver biopsy and paracentesis.
Be able to perform a paracentesis.
Communication

Be able to communicate effectively with patients and their families with
respect to their medical conditions.
28




C.
Professionalism








D.
Be able to interact effectively with other health-care professionals.
Be able to document the patient's clinical condition and plan accurately
with emphasis on the relevant issues.
Be able to identify the need to and benefit of consulting other physicians
and health-care professionals. Specifically, be able to initiate a referral for a
pre-transplant assessment in cases of cirrhosis.
Be able to contribute effectively to interdisciplinary team activities.
Be able to apply a knowledge of the professional codes and norms of
behaviour that govern the behaviour of physicians in clinical practice.
Be able to apply a knowledge of the legal codes and norms of behaviour that
govern the behaviour of physicians in clinical practice.
Be able to recognize and resolve ethical issues as they arise in clinical
practice.
Be able to recognize and deal with unprofessional behaviours in clinical
practice.
Be able to use information technology to optimize patient care.
Be able to use health-care resources cost-effectively.
Be able to work efficiently and effectively.
Be able to educate and counsel patients and families regarding the role of
lifestyle modification in the control of peptic ulcer disease,
gastroesophageal reflux disease, inflammatory bowel disease, cirrhosis and
celiac disease.
Scholarship




Be able to critically appraise sources of medical information.
Be able to educate patients and their families regarding their medical
condition.
Be able to teach medical students, residents and other health-care
professionals.
Be able to contribute to the development of new knowledge, through the
completion of or participation in a research project.
29
Gastroenterology – Outpatient
Goal
Gastroenterology encompasses the evaluation and treatment of patients with disorders
of the gastrointestinal tract, pancreas, biliary tract and liver. It includes disorders of
organs within the abdominal cavity and requires knowledge of the manifestations of
gastrointestinal disorders in other organ systems, such as the skin. Additional areas
include knowledge of nutrition and nutritional deficiencies, screening and prevention,
particularly for colorectal cancer.
The general internist should have a wide range of competency in gastroenterology and
should be able to provide primary and in some cases secondary preventive care,
evaluate a broad array of gastrointestinal symptoms and manage many gastrointestinal
disorders. The general internist is not expected to perform most technical procedures
with the important exception of flexible siegmoidoscopy. However, he or she must be
familiar with the indications, contraindications, interpretation and complications of
these procedures.
A.
The Knowledge




Dysphagia
o Differentiate oropharyngeal from esophageal
o Know the general approach to diagnosis
 Oropharyngeal dysphagia
 Use of barium esophagogram/swallowing study
 Use of endoscopy
 Use of ENT/speech pathology
o Know the general approach esophageal dysphagia
 Use of endoscopy
 Use of barium esophagogram
 Know causes of esophageal dysphagia
 Rings
 GERD
 Stricture
 Pill esophagitis
 Cancer
o Know when to include radiology, gastroenterology
Gastroesophageal reflux
o Know common symptoms
o Know common complications (Barrett’s esophagus, stricture,
esophageal dysplasia, esophagitis)
o Know use of endoscopy/x-ray
o Know step up/step down treatment of GERD
o Know how to differentiate GERD/NERD
o Know when to involve gastroenterology/surgery
Chest pain (Non-cardiac)
o Know common symptoms of esophageal chest pain
o Know the roles of x-ray/endoscopy/esophageal manometry/24 hr pH
monitoring
o Know how to use PPI, antimotility agents, antidepressants
o Know the role of psychology/psychiatry in management
Esophageal cancer
o Know risk factors/alarm symptoms
o Know use of endoscopy/x-rays
30
o
o
Know the roles of surgery/endoscopic treatment/chemoradiation
Know the role for hospice/family support

Esophageal dysmotility
o Know criteria for/common presentations of:
 Esophageal spasm
 Nutcracker esophagus
 Hypertensive LES
 Non specific esophageal motility
 Know presentation/pathophysiology/management-Achalasia
 X-ray/manometric criteria
 Know treatment algorithms in usual patients/patients with
comorbidity

Dyspepsia
o Know general approach
o Know empiric treatment strategy
o Know when diagnostic testing is indicated
o Know roles of gastric emptying studies/endoscopy/H. pylori/visceral
sensitivity
o Know natural history and follow up

Peptic ulcer disease
o Know role of H. pylori, NSAIDs, acid hypersecretion
o Know initial treatment of H. pylori/follow-up strategies
o Know risk factors for NSAID induced ulcers
o Know options for preventing/treating NSAID ulcers
o Know risk factors/diagnosis/treatment of acid hypersecretion
(gastrinoma)

Diarrhea
o Know causes of acute diarrhea
o Know initial treatment of acute diarrhea
o Know the approach to chronic diarrhea
o Fecal weight
o Osmotic/secretory diarrhea
o Role of endoscopy/biopsy
o Know risk factors for secretory diarrhea
o Endocrine tumors
o Diabetes
o Bacterial overgrowth
o Laxative use
o Know how to evaluate fat malabsorption
o Fecal fat collection
o Small intestinal biopsy
o Pancreatic function tests
o Risk factors/tests for bacterial overgrowth
o Know causes/tests for vit. B12/folate deficiency
o Know how to use Schilling test
o Evaluation for celiac sprue/pancreatitis/post surgical causes
o Know about small bowel tumors
o Lymphoma
o Adenocarcinoma
o Carcinoid tumor
31

Colon cancer
o Know prevention/screening strategies
o Know use/limitations of colon cancer strategies
o Fecal blood screening
o Flexible siegmoidoscopy
o Colonoscopy
o Barium x-rays
o Virtual endoscopy
o Genetic stool studies
o Know diagnosis/treatment strategies for colon polyps
o Know roles of surgery/adjuvant therapy/radiation/chemoprevention

Inflammatory bowel disease (acute)
o Know acute versus chronic inflammatory bowel disease
o Know ischemic/radiation/pill induced colitis
o Know acute infectious causes including c. difficile/EHEC
o Initial diagnosis/treatment options

Irritable bowel syndrome
o Know differentiation from Inflammatory Bowel Disease
o Know pathophysiology/causative factors
o Know criteria (Rome Criteria) for diagnosis
o Know treatment strategies/limitations
o Know novel treatments

Chronic colonic bleeding
o AVMs, Diverticulitis, ischemia, radiation-diagnosis/treatment

Chronic GI bleeding
o Know approach to diagnosis
o Role of colonoscopy/EGD/enteroscopy/wireless capsule endoscopy
o Know treatment options for blood loss anemia
o Iron supplementation
o Use of erythropoietin
o Know role of transfusion of blood

Anal dysfunction
o Know approach to fecal incontinence
o Treatment of hemorrhoid
o Diagnosis/treatment anal fissure

Defecation disorders
o Diverticular disease
o Know criteria for diverticulitis
o Know initial treatment options
o Recognize complications of diverticular disease/cause/treatment
o Abscess
o Obstruction
o Fistula
o Bleeding
o Know radiology/surgery role

Constipation
o Differentiate from IBS
o Know causes (particularly drug induced)
32
o
o
o
o
o
o

B.
C.
Know definition/management colonic inertia
Know tests for constipation
Colonic marker tests
Nuclear medicine testing
Anorectal manometry
Defacography/balloon expulsion tests
Chronic pancreatitis
o Know common causes chronic pancreatitis
o Know usual presentations/treatment of chronic pancreatitis
o Pancreatic pseudocyst
o Biliary obstruction
o Pancreatic insufficiency
o Chronic pain
o Role of radiology/endoscopic/surgical treatment
Communication

Adapt history-taking skills to the mental status and psychosocial
presentation of the patient and family.

Communicate with patients and other professionals (other house officers,
the attending physician, other services and other non-University facilities).

Obtain informed consent for procedures, weighing the patient's autonomy
and participation in health care decisions.
Professionalism

Anticipate and address the complexities of family care at home, potential
abusive relationships, possible medical compliance problems and financial
limitations of health care.

Describe the issues surrounding substance abuse and chronic liver disease,
especially in the context of liver transplantation. The issues include
substance abuse and alcoholism in a patient to be considered for liver
transplantation or in a patient already listed for a liver transplant.

Discuss issues of palliation for patients with gastrointestinal malignancies
including the use of laser therapy, luminal stents, blood transfusions,
enteral and parenteral alimentation, radiation and chemotherapy, hospice
care, effects on employment and family.

Discuss when the DNR status is appropriate and when this issue should be
brought up to patients and families, in the patient with end-stage liver
disease, gastrointestinal malignancy and other life-threatening diseases.
Negotiate appropriate management for the hostile or narcotic-seeking
patient.
Systems-based Practice
Discuss cost issues, directed work-up, indications for endoscopy, potential
complications of therapies.
Discuss cost-effectiveness of various treatment modalities.




33

D.
Interface with non-health care professionals to assist in initial and longterm (post discharge) patient management (interns).
Scholarship








Practice Based Learning and Improvement
Develop a willingness and ability to learn from errors and use them to
improve individual practice and the health care delivery system.
Maintain an attitude of healthy skepticism and curiosity, as evidenced by
thoughtful questioning, independent study, and critical analysis of
published materials.
Utilize information technology to enhance patient education.
Be able to critically appraise sources of medical information.
Be able to educate patients and their families regarding their medical
condition.
Be able to teach medical students, residents, and other health-care
professionals.
Be able to contribute to the development of new knowledge, through the
completion of or participation in a research project.
34
HAEMATOLOGY & ONCOLO GY
Rotation Supervisor:
Teaching Methods:



Daily rounds
Daily morning meetings + conferences
Independent reading
Goal
Hematology
The discipline of hematology relates to the care of patients with disorders of the blood,
bone marrow, and lymphatic systems, including anemias, hematological malignancies
and other colonal processes and congenital and acquired disorders of hemostasis,
coagulation and thrombosis.
The general internist should be competent in 1) the detection of abnormal physical,
laboratory, and radiological findings relating to the lymphohematopoietic system; 2)
the assessment of the need for bone marrow aspirate and biopsy and lymph node
biopsy; 3) the initial diagnostic evaluation and management of the hemostatic and
clotting system; 4) the assessment of the indications and procedure for transfusion of
blood and its separate components; 5) the management of therapeutic and
prophylactic anticoagulation; 6) the diagnosis and management of common anemias;
7) the pharmacology and use of common chemotherapies; and 8) the management of
neutropenia/immunosuppression.
The range of competencies expected for a general internist will vary depending on the
availability of a hematologist in the primary care setting. For example, in some
communities a general internist may be responsible for bone marrow examination and
administration of chemotherapy for certain disorders in conjunction with consultative
assistance from appropriate hematologist and pathologist colleagues.
Interns and residents will be able to approach, diagnose and manage a variety of
hematologic and oncologic disorders in the outpatient and inpatient settings.
Oncology
Medical oncology is the diagnosis and management of malignant neoplasms. The
general internist should have a wide range of competencies in the evaluation and
management of neoplastic disease. He or she must be able to 1) identify patients at risk
for malignancy and counsel them regarding risk reduction and screening; 2)
investigate clinical syndromes suggestive of underlying malignancy;
3) undertake the palliative care of patients with common solid and hematologic
tumors;
4) identify neoplasms with a potential for cure and direct affected patients to the
appropriate centers or providers; and 5) participate in the difficult decisions regarding
all aspects of management, including diagnostic evaluation and screening, treatment
and palliative care. In addition, the general internist must be familiar with the
administration, side effects and drug interactions of therapeutic agents commonly
used for the treatment of malignant disease.
Whether a generalist assumes full responsibility for any or all of these functions will
depend on the clinical setting of his or her practice. The general internist should seek
35
subspecialty consultation early in the care of patients with malignant disease who may
be candidates for aggressive treatment with curative intent.
The Internal Medicine Resident is expected to achieve competency in the areas
described below during their rotations in Haematology & Oncology.
The resident is expected to:
A.
The Knowledge















Describe the symptoms that may assist in characterizing and/or localizing
the site, extent and severity of disease in patients with common
hematologic or oncologic disorders.
Perform a physical examination that is appropriate and adequate to
determine the severity and extent of the patient's hematologic or oncologic
disease. This may include serial measurements of palpable tumor masses.
Describe the symptoms that may assist in characterizing and/or localizing
the site, extent and severity of disease in patients with common
hematologic or oncologic disorders.
Perform a physical examination that is appropriate and adequate to
determine the severity and extent of the patient's hematologic or oncologic
disease. This may include serial measurements of palpable tumor masses.
Solicit information pertaining to the genetic, environmental, lifestyle and
life events that may impact the risk of developing hematologic or oncologic
disorders.
Utilize multiple sources of information to provide a complete and thorough
evaluation of a patient's hematologic or oncologic disorder (including the
patient, previous medical records and the patient's family members).
Describe the basic pathophysiology and natural course of the common
coagulation disorders (bleeding and hypercoaguable); multiple myeloma;
lymphomas (non-Hodgkin's and Hodgkin's disease); acute leukemias; and
cancers of the breast, lung, prostate, head and neck, GI system (e.g.
esophagus, colon, pancreas), melanoma, kidney and soft tissues (sarcomas).
Understand and gain experience with the proper use of blood products.
Describe the common presentations of patients with bleeding disorders,
thromboembolic diseases, low blood counts, high blood counts, lymphomas
(non-Hodgkin's and Hodgkin's disease), acute leukemias, and specific solid
tumor malignancies.
Describe the general role of oncogenes and tumor suppressor genes in the
development of some malignancies.
Describe the physical signs that may assist in characterizing the etiology,
location, extent and/or severity of hematologic and oncologic diseases.
Identify the signs that correspond to co-morbidities associated with
underlying hematologic and oncologic diseases or that may impact the
disease course or its therapy.
Recognize and explain the importance of the following in the development
of hematologic and oncologic disorders: genetics, environment exposures,
life style (including sexual orientation or behavior, socioeconomic status,
diet, use of recreational drugs, use of tobacco products) and life events
(including previous or co-existing diseases and/or therapies, travel history,
age).
Discuss the general process of performing a bone marrow aspirate and
biopsy or tumor biopsy.
Interpret a peripheral blood smear.
36








B.
Communication



C.
Practice Based Learning and Improvement.
Review the relevant literature identified on the Hematology/Oncology
Reading List.
Read the identified literature and discuss with your Attending physician.
Perform electronic searches of medical literature to identify articles relevant
for the hematologic and oncologic problems of your patient.
Be able to elicit, present and document a history that is relevant and
appropriate to the hematopoeitic system.
Be able to perform an accurate physical examination of the hematopoeitic
system, with emphasis on:
o Splenomegaly
o Lymphadenopathy
Be able to provide a reasonable approach to the differential diagnosis,
work-up and management of the following scenarios:
o Anemia
o Thrombocytopenia
o Bicytopenia/pancytopenia
o Polycythaemia
o Eosinophilia
o Lymphadenopathy
o Splenomegaly
o Warfarin use in patient care: management and counseling
o Patients with bleeding diatheses and abnormal coagulation testing
Demonstrate the ability to recognize and manage common symptoms and
complications of patients with cancer:
o Emergency care:
 Tumor lysis syndrome
 Spinal cord compression
 Hypercalcemia
 Febrile neutropenia
 Pleural effusions
 Ascites
o Pain & symptom control
o Secondary effects of commonly used chemotherapeutic agents:
 Nausea/vomiting
 Febrile neutropenia
 Cardiomyopathy
 Hemorrhagic cystitis
Appreciate the impact of hematologic and oncologic disorders on patients'
quality of life and their relationships with family and friends.
Assist patients in decision-making regarding treatment options, end-of-life
care and discharge planning.
Demonstrate patient-centered interviewing techniques; a compassionate
approach to history taking; the ability to modify interview techniques in
response to the patient's demeanor, cultural and/or religious background
and level of competency.
Professionalism

Appreciate the impact of hematologic and oncologic disorders on patients'
quality of life and their relationships with family and friends.
37








D.
Be able to negotiate appropriate management and discharge planning of
patients (and/or their families) who are angry, belligerent or
demonstrating antisocial behavior.
Discuss some of the common ethical issues that face patients and their
families with emphasis in treatment options and disease/treatment
outcome; including end-of-life and resuscitation issues.
Appreciate the effects of cultural and religious background on the patient's
approach and attitudes toward decision making, their disease and
treatment.
Recognize the potential problems that may impact the treatment and
outcome of hematologic and oncologic disorders, including possible
personal economic factors and compliance with the recommended
treatment.
Recognize the implications, at a personal and societal level, of identifying
genetic risks of disease on family members of a patient including patient
confidentiality, potential impact on family members should they find out
that they may carry a genetic risk of disease, and the pursuit of potential
prophylactic options.
Systems-based Practice
Recognize the appropriate inpatient, outpatient or home setting for
diagnosing and treating hematologic and oncologic diseases.
Recognize the role of non-physician health care professionals in assisting
patients and their families prepare for hospital discharge, home
management of disease.
Scholarship








Practice Based Learning and Improvement
Develop a willingness and ability to learn from errors and use them to
improve individual practice and the health care delivery system.
Maintain an attitude of healthy skepticism and curiosity, as evidenced by
thoughtful questioning, independent study and critical analysis of
published materials.
Utilize information technology to enhance patient education.
Be able to critically appraise sources of medical information.
Be able to educate patients and their families regarding their medical
condition.
Be able to teach medical students, residents and other health-care
professionals.
Be able to contribute to the development of new knowledge, through the
completion of or participation in a research project.
38
INFECTIOUS DISEASES
Rotation Supervisor:
Teaching Methods:



Daily rounds
Daily morning meeting + conferences
Independent reading
Goal
Infectious diseases medicine requires an understanding of the microbiology,
prevention, and management of disorders caused by viral, bacterial, fungal, and
parasitic infections, including the appropriate use of antimicrobial agents, vaccines
and other immunobiologic agents. Important elements include the environmental,
occupational and host factors that predispose to infection, as well as basic principles of
the epidemiology and transmission of infection.
The general internist should be able to provide appropriate preventive (including
optimal use of immunization and chemoprophylaxis), diagnostic and therapeutic care
for most infections. He or she should also be able to evaluate symptoms that may be
caused by a wide range of infectious disorders.
The Internal Medicine Resident is expected to achieve competency in the areas
described below during their rotations in Infectious Diseases.
The resident is expected to:
A.
The Knowledge










Construct chronologies of symptoms (e.g., fever), possible exposures or risk
factors and treatments that the patient may have received
Know how to take a thorough exposure history for infectious diseases
Make use of multiple sources of information to assemble a patient database,
including previous records (both written and electronic), medication
administration records, flow charts and on-line reports
Assess the depth and extent of open or infected wounds
Distinguish common rashes associated with infections and with antibiotic
allergy
Interpret the appearance of respiratory secretions and other potentially
infected body fluids
Recognize physical signs of intravascular infections (e.g., endocarditis)
Recognize signs of infected medical devices
Recognize and explain the importance of certain life styles and life events in
the risk for specific infections, including intravenous drug use, sexual
orientation or behavior, socioeconomic status, travel, animal exposure,
environmental exposure
Recognize the role of the following in predisposing to or altering the
presentation of infectious diseases: advanced age, diabetes mellitus,
malnutrition, renal failure, COPD and cardiovascular disease and
congenital or acquired immunodeficiency (including HIV infection)
39










B.
Communication



C.
Select antimicrobial therapy, balancing the individual needs of patients
with the good of the community and the hospital environment. This
requires a knowledge of antimicrobial choices, an understanding of the risk
and benefits of specific antimicrobials and a current understanding of local
antimicrobial resistance patterns
Suggest a differential diagnosis for fever in association with other
symptoms, such as headache, altered mental status, cough, diarrhea,
abdominal pain, dysuria, back pain, joint pain or swelling, rash and new
neurological abnormality
Suggest a logical evaluation and differential diagnosis for fever of unknown
origin
Understand the basic pathophysiology and natural course of the sepsis
syndrome and infections of organ systems:
o Upper and lower respiratory tract infections
o Urinary tract infections
o Skin and soft tissue infection
o Bone and joint infection
o Infection of the reproductive tract (including STDs)
o Intravascular infection (including cardiovascular infection)
o CNS infection
o Gastrointestinal infection (food poisoning, hepatitis and colitis)
o Intra-abdominal infection (including peritonitis)
o Infections of the eye
Understand the psychological context of certain chronic infectious disease
(e.g., AIDS, viral hepatitis) and distinguish psychiatric morbidity from
organic consequences of disease
Cope with end-of-life issues as they pertain to the treatment of
opportunistic and hospital-acquired infections
Perform and interpret a Gram’s stain
Recognize potential problems that may impact on the treatment of
infectious diseases and their complications, including personal economic
factors and compliance with medical therapy
Understand fundamental medical microbiological procedures
Identify parameters to monitor care and maintain a high level of currency
with developments in these parameters as well as the patients’ overall
progress
Interpersonal and Communication Skills
Communicate with personnel in the Microbiology Laboratory to obtain
timely information about microorganisms detected in patient samples
Understand the essential elements of a thoughtful consultation report in
order to be useful to the consulting physician and the patient
Professionalism



Understand the ethical conflict between the care of the individual and the
good of the community as it affects issues of antimicrobial therapy,
preventive measures and vaccination
Appreciate how personal and cultural characteristics impact efforts to
prevent the spread of communicable diseases
Have familiarity with the system for initiating and managing intravenous
antibiotic therapy in the outpatient setting
40


D.
Understand the ethical issues relating to transmission of an infectious agent
and the responsibility of the physician to protect uninfected individuals and
the public
Recognize when the urgency of an infectious disease requires ongoing
monitoring of or direct action within the health care system in order to
assure timely management of potentially life-threatening infections
Scholarship








Practice Based Learning and Improvement
Develop a willingness and ability to learn from errors and use them to
improve individual practice and the health care delivery system.
Maintain an attitude of healthy skepticism and curiosity, as evidenced by
thoughtful questioning, independent study, and critical analysis of
published materials.
Utilize information technology to enhance patient education.
Be able to critically appraise sources of medical information.
Be able to educate patients and their families regarding their medical
condition.
Be able to teach medical students, residents and other health-care
professionals.
Be able to contribute to the development of new knowledge, through the
completion of or participation in a research project.
41
INTENSIVE CARE UNIT
Rotation Supervisor:
Teaching Methods:



Daily rounds
Daily morning meeting + conferences
Independent reading
The Internal Medicine Resident is expected to achieve competency in the areas
described below during their rotations in the Intensive Care Unit. It is expected that a
resident's knowledge, skills and attitudes will evolve as they progress from a first-year
resident to a third-year resident in the Intensive Care Unit.
The resident is expected to:
A.
The Knowledge





Be able to elicit, present and document a history that is relevant and
appropriate to the critically ill patient. In particular, be able to perfect the
skill of history-taking from third parties and other sources when patients
are unable to communicate given the severity of their medical conditions.
Be able to perform an accurate physical examination of the critically ill
patient, with emphasis on:
Differentiating distributive shock from pump failure
Be able to provide a reasonable approach to the differential diagnosis,
work-up, and management of the following scenarios:
o Shock/SIRS
o Indications for and complications of inotropic and vasopressor support;
knowledge of agents
o Indications for and complications of mechanical cardiac support
(including IABP, CVT consultation)
o Respiratory failure (hypercapnoeic, hypoxaemic)
o Indications for and complications of non-invasive ventilation,
intubation and extubation
o Indications for and complications of renal replacement therapy
o Indications for and complications of enteral vs parenteral nutritional
support
o Indications for and complications of blood products
o Elevated intra-cranial pressure
o Coma, including GCS
o Indications
for
and
complications
of
sedation/anxiolysis/analgesia/paralysis
o Interpretation of hemodynamic tracings
Demonstrate an understanding of the pathophysiology, manifestations,
diagnostic work-up and management of the following conditions:
o Allergy/Immunology: Anaphylaxis
o Dermatology: Stevens-Johnson's syndrome
o Endocrinology: Thyroid storm, myxedema coma, Addisonian crisis,
DKA/HONK
42
o
o
o
o
o
o
o
o





B.
Understand the indications for and complications of central venous access,
peripheral arterial access, endotracheal intubation, Swan-Ganz catheter, and
temporary transvenous pacemaker.
Be able to interpret arterial blood gas results.
Be able to perform central venous catheter insertion, peripheral arterial
catheter insertion and endotracheal intubation.
Demonstrate an understanding of the indications for admission to and
discharge from a monitored unit.
Demonstrate an understanding of the issues surrounding the transport of
critically ill patients within the hospital and to other centers.
Communication



C.
Gastroenterology: GI bleed (including variceal hemorrhage),
pancreatitis, hepatic encephalopathy
Hematology: coagulopathy and DIC, massive thrombosis and
pulmonary embolism
Hypertensive urgencies and crisis
Infectious Diseases: sepsis, febrile neutropenia, severe infections in HIV
infected patients
Nephrology: acute renal failure and alterations in renal output
Neurology: coma, Guillain-Barré syndrome, meningitis
Respirology: ARDS, COPD, status asthmaticus
Other emergencies:
 Poisoning: ASA, methanol, TCA, acetaminophen
 Injuries: smoke inhalation and CO inhalation, electrocution
 Near drowning
 Hypo-and hyperthermia
 Cardiac arrest/ACLS guidelines
Be able to communicate effectively with patients and their families with
respect to their medical conditions. Specifically, be able to communicate
with critically-ill patients, recognizing that these patients pose unique
challenges that require unique solutions. Furthermore, be able to
communicate with families of critically-ill patients in order to address their
concerns while being realistic in terms of prognosis.
Be able to interact effectively with other health-care professionals of all
sorts that are often involved in the care of the critically-ill patient.
Be able to document the patient's condition and progress accurately while
in hospital with emphasis on the relevant issues, in the context of multisystem and complex patients in rapid evolution.
Professionalism




Be able to apply a knowledge of the professional codes and norms of
behaviour that govern the behaviour of physicians in clinical practice.
Be able to apply a knowledge of the legal codes and norms of behaviour that
govern the behaviour of physicians in clinical practice.
Be able to recognize and resolve ethical issues as they arise in clinical
practice. Specifically, be able to understand and deal with the ethical issues
that arise in the critically-ill patient including:
Consent and capacity
o Level of intervention discussions and end-of-life decisions
43







D.
o Substitute decision-makers
o Advance directives
Be able to recognize and deal with unprofessional behaviours in clinical
practice.
Be able to identify the need to and benefit of consulting other physicians
and health-care professionals.
Be able to contribute effectively to interdisciplinary team activities.
Be able to use information technology to optimize patient care.
Be able to use health-care resources cost-effectively.
Be able to work efficiently and effectively in the context of multiple
demands on a resident's time while managing critically-ill patients.
Be able to educate and counsel patients and families regarding important
factors affecting their health.
Scholarship




Be able to critically appraise sources of medical information.
Be able to educate patients and their families regarding their medical
condition.
Be able to teach medical students, residents, and other health-care
professionals.
Be able to contribute to the development of new knowledge, through the
completion of or participation in a research project.
44
NEPHROLOGY
Rotation Supervisor:
Teaching Methods:



Daily rounds
Daily morning meeting + conferences
Independent reading
Goal
Nephrology involves disease of the kidneys, its contiguous collecting system, and its
vasculature. The kidneys play a key role in fluid, electrolyte, and acid-base regulation
and are affected by a wide range of systemic disorders, drugs, and toxins.
The general internist should be competent to evaluate and appropriately refer patients
with glomerular disorders, asymptomatic urine abnormalities, tubulointerstitial
diseases, renal vascular disease, renal failure, nephrolithiasis, tubular defects, and
infections and neoplasms of the kidneys, bladder, and urethra and should also be able
to provide principal treatment for some of these conditions. He or she should be able
to manage fluid, electrolyte and acid-base disorders; understand the ways in which
systemic diseases may affect the kidneys; and recognize the potential nephrotoxicity of
various therapeutic and diagnostic agents.
The general internist must also be familiar with guidelines for pre-dialysis
management of patients with renal failure and be able to recognize indications for
dialysis and for referral to a nephrologist. The range of competencies in managing
renal disease will depend on the availability of a nephrologist to the primary care
internist. Although all general internists should know the indications for dialysis, in
some cases (for example, if a nephrologist is unavailable), the general internists may be
responsible for initiating and maintaining patients on peritoneal dialysis. In most
situations, hemodialysis will be the responsibility of a nephrologist, as will renal
biopsies and nephrostomy tube placement.
The Internal Medicine Resident is expected to achieve competency in the areas
described below during their rotations in Nephrology.
The resident is expected to:
A.
The Knowledge



Utilize the extensive resources electronic, paper-based, and person-based
(physician consult services, social work, nursing, pharmacy, practice
management other allied health professionals) available to help residents
taking care of patients with nephrology related problems
Demonstrate ability to use the serum creatinine concentration to estimate
Glomerular Filtration Rate
o Explain the assumption of steady-state concentration.
o Discuss shortcomings of creatinine-based methods of estimating GFR
Demonstrate ability to interpret a spot protein-to-creatinine ratio and/or a
spot albumin-to-creatinine ratio on a random urine sample as a marker of
kidney damage and a quantitative measure of proteinuria.
45
o
o
o
Relate this test to 24-hour urine results.
Recognize that 24 hour urine collections for the purposes of GFR
estimation from creatinine clearance
Diagnosing and following proteinuria are not superior to the spot tests
above (in the majority of situations)



Know the patient populations at risk for chronic kidney disease
Discuss risk factors for acute renal failure in out- and in-patient settings
Categorize based on both frequency of occurrence and on dominant
pathological site(s) of injury (Pre-renal, Intra-renal [includes vascular,
glomerular, tubular and interstitial and Post-renal) the causes of:
o Chronic Kidney Disease
o Acute Renal Failure

Define and List the most common causes of:
o Nephrotic syndrome
o Rapidly progressive glomerulonephritis
o Define and List the most common causes of:
o Isolated hematuria (i.e. without other abnormalities)
o Isolated proteinuria (i.e. without other abnormalities)
o Hematuria and proteinuria without a decreased GFR
Discuss the physiological concept of clearance and apply this to:
o Native renal function (GFR) and,
o Principles governing solute clearance by peritoneal dialysis,
intermittent hemodialysis and continuous renal replacement therapy
o Principles governing handling of medications by the kidney
Discuss the pathophysiology underlying normal and abnormal proteinuria
Define nephrotic-range proteinuria, glomerular proteinuria, tubular
proteinuria, Benz-Jones protein
Describe the basic metabolic, homeostatic regulatory functions and
endocrine functions of the kidney
History-Taking
o Elicit history of / distinguish risk factors for acute and chronic renal
disease
o Demonstrate consistent ability to use history and historical records
thoroughly to determine temporal duration of kidney disease
o Elicit specific symptoms of a genitourinary systems review
o Elicit symptoms of uremia
o Elicit symptoms of systemic disease and understand the diagnostic and
therapeutic importance of seeking associated renal involvement
o Elicit medication history (prescribed and over-the-counter) and
completely explore potential contributions and ongoing risks for
adverse drug effects
o Elicit family history of kidney disease
o Elicit symptoms of comorbid conditions and complications related to
kidney failure (diabetes, accelerated atherosclerosis, hypertension,
anemia, salt and water retention, mineral and bone disease,
malnutrition, neuropathy, sexual dysfunction, electrolyte and acid-base
disturbance)






Physical Exam
o Demonstrate performance of physical exam to accurately assess:
o Blood pressure
o Cardiovascular system
46
o
o
o
o
o
o
o
o





Volume status: signs of overload or depletion
Signs of Uremia
Presence of enlarged urinary bladder
Presence of ballotable kidneys and/or kidney transplant
Evidence of atherosclerotic disease
Evidence for cormorbid diseases (including systemic diseases such as
SLE and vasculitis)
Evidence of atheroembolic disease
Signs of complications of uremia
Urinalysis
o Demonstrate ability to read a urine dipstick
o Demonstrate ability to recognize RBCs, WBCs, tubular, transitional and
squamous epithelial cells and bacteria on microscopy of urine sediment.
o Discuss potential sources of origin of each constituent
o Demonstrate ability to recognize hyaline, granular and cellular casts
(red cells, white cells and tubular epithelial cells).
o Discuss pathophysiology of their formation and source of origin.
o Demonstrate an ability to interpret quantitative estimates of proteinuria
(dipstick, spot protein-to-creatinine ratio, 24 hour urine collection)
o Discuss the pathophysiology leading to abnormal proteinuria
Integrate core knowledge, history taking, physical exam, serum chemistries
and urinalysis and plan further diagnostic evaluation
For each of the clinical problems and/or disease processes listed below,
describe expected presentations in terms of symptoms, signs, serum
chemistries and pattern of urinalysis findings and discuss differential
diagnosis:
o Pre-renal renal failure
o Diabetic nephropathy
o Hypertensive nephrosclerosis
o Atheroembolic kidney disease
o Renovascular disease
o Nephritic Syndrome
o Nephrotic syndrome
o Acute tubular necrosis
o Tubulo/interstitial renal diseases
o Cystic kidney diseases
o Iatrogenic renal toxins (e.g., NSAIDs, contrast dye, etc.)
o Renal stone disease
o Post-renal renal failure
Demonstrate ability to interpret in the context of varied clinical
presentations, and in an integrative manner, measurements of serum
electrolytes and osmolarity, arterial blood gas parameters, urine electrolytes
and osmolarity. Be able to use these interpretations to assist in formulating
differential diagnoses of patients with:
o Acute renal failure
o Chronic kidney disease
o Clinical disorders of salt and water metabolism
o Clinical disorders of major electrolytes (K+, Ca2+, Mg2+, PO42- )
o Clinical acid-base disorders
o Renal stone disease
Define the implications for urgency of diagnostic evaluation of a decreased
GFR of acute or undetermined duration in contrast to a chronic duration
47









Define the implications for urgency of diagnostic evaluation of an active
urine sediment (white and red cells, granular casts, +/- cellular casts) in the
setting of a decreased GFR
Describe the relative merits, indications for and information gained from
diagnostic imaging studies including ultrasound, CT, IVP, conventional and
MR angiography, MR urography, antegrade and retrograde urography,
cystoscopy, and radioisotope studies in investigations of:
o Hypertension
o Hematuria
o Acute renal failure
o Chronic Kidney Disease
o A patient with a renal cyst, mass or abnormality of the lower urinary
tract
o Lower urinary tract disease
Describe, in the context of the pretest probabilities for specific renal
diseases, the discriminant value and appropriate ordering of the following
serologic tests:
o Serum complement components
o Anti-neutrophil cytoplasmic antibody
o Anti-glomerular basement membrane antibody
o ANA, anti double-stranded DNA, Anti-cardiolipin antibodies
o Hepatitis serologies
o Cryoglobulins
o Serum Protein Electrophoresis
o Urine Immunoelectrophoresis
o Serum and urine eosinophils
List the indications for renal biopsy
List the risks and relative and absolute contraindications of renal biopsy
Discuss the implications for patient choice if there is a low versus high
probability for underlying treatable disease
Discuss the implications of the possibility of a rapidly progressive yet
potentially treatable underlying disease for urgency of biopsy
Effective Patient Management Plans
o Be able to coordinate multidisciplinary care and develop management
plans based on medical evidence for patients across the full spectrum of
diseases and presentations that lead to:
o Acute renal failure
o Chronic kidney disease
o Be able to coordinate multidisciplinary care and develop management
plans based on medical evidence for patients across the full spectrum of
diseases and presentations that lead to:
o Clinical disorders of salt and water metabolism
o Clinical disorders of major electrolytes (K+, Ca2+, Mg2+, PO42- )
o Clinical acid-base disorders
o Infections of upper and lower urinary tract
o Other lower urinary tract disease
Blood Pressure Control
o Recognize importance of achieving blood pressure control to prevent
progression of chronic kidney disease. Know the evidence for this.
o Identify blood pressure control targets for preventing progressive
disease
o Discuss the role of converting enzyme inhibitors and/or angiotensin
receptor blockers in preventing kidney disease progression
o Vascular Risk factor reduction
48
Identify chronic kidney disease as an indications for aggressive
cardiovascular risk factor reduction
Develop and apply specific skills appropriate to the management of:
o Fluid and electrolytes in patients with Acute Renal Failure
o Fluid and electrolytes in patients with chronic kidney diseases
o Hypertensive urgencies and emergency
o Avoidance of unnecessary nephrotoxic exposures
o Prophylaxis of radiocontrast associated nephropathy in at-risk patients
o Dietary modification in the acute and chronic renal failure
o Anemia and iron deficiency in kidney disease
o Ca, Phosphorus and parathyroid hormone in kidney disease
o Upper and lower urinary tract infection
o Nephrolithiasis
Recognize the need for coordinated disease-specific management plans in:
o Patients with various glomerulonephritides
o Patients with renal vasculitis
o Patient with lupus nephritis
o Patients with acute interstitial nephritis
o Patients with progressive chronic kidney diseases
Dialysis for End-stage renal disease (ESRD) and Acute Renal Failure
Know the appropriate GFR for initiating timely (well enough in advance of
anticipated end-stage kidney disease):
o Patient education regarding ESRD
o Renal replacement modality selection
o Transplant evaluation
o Vascular access preparation
o Discuss referral of chronic kidney disease patients to nephrology clinic
o Be able to describe:
o Indications for dialysis acute and chronic
o Relative advantages / disadvantages of hemodialysis vs. peritoneal
dialysis
o Concept of adequate /optimal dialysis
o Preferred vascular access for maintenance hemodialysis
o The large burden of morbidity accruing from catheter-related infections
o Relative merits of continuous renal replacement (CVVHD) vs.
Intermittent hemodialysis in acute renal failure
Kidney Transplantation
o Recognize the need for early kidney transplant evaluation to:
 Facilitate early identification of potential living donors
 Facilitate preemptive transplantation where possible
Be able to describe:
o Side effects, drug interactions and blood level monitoring of common
transplant immunosuppressive drugs
o Discuss antibiotic and antiviral prophylaxis post transplant
o Differential diagnosis and investigation of increased creatinine in
transplant patients and the role of transplant renal biopsy
o







Recognize the symptoms and signs and discuss the diagnosis, management
and prevention of:
o Acute rejection
o Cyclosporin nephrotoxicity
o Chronic allograft nephropathy
o Cytomegalovirus infection
o Other opportunistic infections
o Allograft pyelonephritis
49




B.
o Post-transplant lymphoproliferative disease
o Neoplasia – skin, other
o Atherosclerotic vascular disease
o Hypertension
o Post-transplant bone disease
o Recurrent kidney disease
Drug Dosing
o Be able to access information to guide:
o Drug dosing adjustments based on GFR
o Drug interactions in patients with kidney diseases
Procedures
o Perform a dipstick urinalysis and prepare urine sediment for
microscopy
o Perform bladder catheterization
Practice Based Learning and Improvement
o Be able to access and utilize the extensive resources electronic, paperbased and person-based (physician consult services, social work,
nursing, pharmacy, practice management, other allied health
professionals) available to help residents taking care of patients with
nephrology related problems
Be able to access clinical practice guidelines:
o National Kidney Foundation K/DOQI clinical practice guidelines for
standards of care in chronic kidney disease and maintenance dialysis
patients
o Perform independent research for evidence-based practice in response
to specific clinical questions arising from patient-care experiences
Communication







Effectively coordinate multidisciplinary involvement (primary in-patient
service, physician consult services, social work, nursing, pharmacy, practice
management, other allied health professionals) in patient care
Communicate effectively with patients, family members, dieticians, social
work, nursing, other physicians, other providers in the care of ESRD
patients
Coordinate effectively multidisciplinary patient care
Accurately describe the risks and benefits of renal replacement therapy for
informed consent
Discuss the impact of renal replacement therapy on quality of life
Conduct all interviews with patients and their families in a compassionate,
culturally-effective and patient-centered manner.
Complete all dictations, letters and consultation requests in a timely
manner.
50
C.
Professionalism












D.
Discuss ethical principles in clinical practice
Describe present approaches to counseling patients on end-of-life decision
making in ESRD (including withdrawal from dialysis)
Demonstrate a personal sense of altruism by consistently acting in one’s
patients’ best interest.
Know how to inform patients and obtain voluntary consent for the general
plan of medical care and specific diagnostic and therapeutic interventions.
Provide meaningful feedback to colleagues and students regarding
performance and behavior.
Systems Based Practice
Interact with and utilize social workers, nurses, medical assistants, billing
coordinators and referral coordinators to provide effective, comprehensive
patient care.
Apply evidence-based, cost-conscious strategies to prevention, diagnosis
and disease management
Review the epidemic growth in end-stage renal disease and describe
contributions of diabetes and/or hypertension
Describe individual and societal costs of ESRD
Acknowledge the extent of undiagnosed and inadequately treated chronic
kidney disease
Discuss the systematic scope for prevention of ESRD
Scholarship




Be able to critically appraise sources of medical information.
Be able to educate patients and their families regarding their medical
condition.
Be able to teach medical students, residents and other health-care
professionals.
Be able to contribute to the development of new knowledge, through the
completion of or participation in a research project.
51
NEUROLOGY
Rotation Supervisor:
Teaching Methods:



Daily rounds
Daily morning meeting + conferences
Independent reading
Goal
The internal medicine resident rotates for several months on the inpatient neurology
floor of University Hospital. During this time, the resident works with a neurology
team to evaluate and treat a wide range of neurological patients. These patients have a
variety of diagnoses which are seen in primary care practice. Inpatients on the
neurology service may have acute strokes; seizures, including status epilepticus;
neuromuscular weakness; primary brain tumors; movement disorders; autoimmune
diseases such as CNS lupus or multiple sclerosis; and primary psychiatric disorders.
Procedures performed during the rotation are lumbar punctures and occasionally
arterial and central lines placed in NICU patients.
The Internal Medicine Resident is expected to achieve competency in the areas
described below during their rotations in Neurology.
A.
The Knowledge





B.
Communication


C.
Describe the standard neurological approach to the evaluation and
treatment of common problems encountered by a neurologist in the
inpatient setting.
Perform an efficient, complete neurological examination.
Participate in the care of seriously ill neurological patients, including those
patients in the ICU setting
Discuss the complex interactions between neurological symptoms and
medical problems.
Understand when a neurological consultation is appropriate.
Conduct all interviews with patients and their families in a compassionate,
culturally-effective and patient-centered manner.
Complete all dictations, letters and consultation requests in a timely
manner.
Professionalism


Demonstrate a personal sense of altruism by consistently acting in one’s
patients’ best interest.
Know how to inform patients and obtain voluntary consent for the general
plan of medical care and specific diagnostic and therapeutic interventions.
52




D.
Provide meaningful feedback to colleagues and students regarding
performance and behavior.
Systems Based Practice
Interact with and utilize social workers, nurses, medical assistants, billing
coordinators and referral coordinators to provide effective, comprehensive
patient care.
Apply evidence-based, cost-conscious strategies to prevention, diagnosis
and disease management
Scholarship








Practice Based Learning and Improvement
Develop a willingness and ability to learn from errors and use them to
improve individual practice and the health care delivery system.
Maintain an attitude of healthy skepticism and curiosity, as evidenced by
thoughtful questioning, independent study, and critical analysis of
published materials.
Utilize information technology to enhance patient education.
Be able to critically appraise sources of medical information.
Be able to educate patients and their families regarding their medical
condition.
Be able to teach medical students, residents, and other health-care
professionals.
Be able to contribute to the development of new knowledge, through the
completion of or participation in a research project.
53
PULMONOLOGY
Rotation Supervisor:
Teaching Methods:



Daily rounds
Daily morning meeting + conferences
Independent reading
Goal
Pulmonary medicine is the diagnosis and management of disorders of the lungs, upper
airways, thoracic cavity, and chest wall. The pulmonary specialist has expertise in
neoplastic, inflammatory, and infectious disorders of the lung parenchyma, pleura, and
airways; pulmonary vascular disease and its effect on the cardiovascular system; and
detection and prevention of occupational and environmental causes of lung disease.
Other specialized areas include respiratory failure and sleep-disordered breathing.
The general internist should be able to evaluate and manage cough, dyspnea, fever
with infiltrates, mass or nodule on the chest radiograph, pleurisy, and pleural effusion.
He or she should also be able to diagnose and manage patients with common
respiratory infections; initiate the diagnostic evaluation of respiratory neoplasm; and
manage the initial approach to patients with respiratory failure, including those in
intensive care units.
The internist will usually be assisted by the pulmonary specialist for diagnostic
procedures and complicated conditions such as advanced respiratory failure. If such
expertise is not available, the internist, with additional training, may have to assume
these roles.
The Internal Medicine Resident is expected to achieve competency in the areas
described below during their rotations in Pulmonology/ICU.
The resident is expected to:
A.
Knowledge


Perform an adequate physical examination including:
o Knowing extrapulmonary signs and symptoms of lung diseases
o Abnormalities in the pattern of breathing: Kussmaul, Cheyne-Stokes,
abdominal-thoracic asynchrony ("paradoxical respiration"), accessory
muscle use
o Thoracic Cage Abnormalities
o Kyphosis, scoliosis, pectus excavatum and carniatum, straight back,
barrel chest, ankylosis
Lung Exam
o Inspection
o Percussion (dullness, hyper resonance)
o Palpation (fremitus, diaphragmatic excursions, tracheal location,
subcutaneous emphysema)
o Auscultation(crackles, rhonchi, wheezing, bronchial breathing, stridor,
friction rub, decreased breath sounds, abnormal expiratory phase)
54

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
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
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

Cardiac Exam
Extremity Exam (clubbing, cyanosis, edema)
Take an orderly, problem oriented history of complaints, including but not
limited to:
o Dyspnea, nature and severity
o Cough
o Wheezing
o Stridor
o Hemoptysis
o Past history of pulmonary illness
o Past history of tuberculin testing or TB exposure
o Occupational history including exposures
o Previous surgical procedures including thoracic procedures
o Prior chest roentgenograms
Family history of pulmonary disease
History of occupational or environmental risk
Distinguish among different causes of pleural effusion, including infectious
(parapneumonic and emphysema), inflammatory and malignant
Identify the differences in clinical presentations of typical vs atypical
obstructive lung disease, including asthma, COPD, cystic fibrosis,
bronchiectasis, bronchiolitis and allergic bronchopulmonary aspergillosis
Know the microbiology of community acquired pneumonia
Manage an inpatient with the following conditions:
o Community acquired pneumonia
o Obstructive lung disease
o Inflammatory lung disease
o Pleural disease
o Lung abscess
o Tuberculosis
o Alveolar hemorrhage syndromes
o Lung cancer
o Pulmonary vascular disease, including pulmonary embolic disease,
pulmonary hypertension (primary and secondary), pulmonary vasculitis
o Mediastinal disease, including infectious, inflammatory, malignant,
idiopathic
o Respiratory muscle disorders
o Thoracic cage disorders
o Sleep disorders
o Idiopathic disorders including alveolar proteinosis, pulmonary
infiltrates with eosinophilia, lymphangioleimyomatosis, eosinophilic
granuloma, hemosiderosis
o HIV related lung disease
o Mycotic lung disease, including histoplasmosis, blastomycosis,
cryptococcosism coccidiomycosis, aspergillosis, phycoses
o Pulmonary disease in the immunocompromised
Understand the possible need for and role of special diagnostic studies
including:
o Endotracheal intubation
o Noninvasive mechanical ventilation
o BiPAP
o Nasal positive pressure ventilation
o Bronchoscopy
o Bronchoalveolar lavage
o Needle biopsy (Wang)
o Transbronchial biopsies
55


o Endobronchial biopsies
o Protected brush biopsies
o Fluoroscopy
o CT (including high resolution techniques)
o Pulmonary function studies
o Exercise testing
o Polysomnography
o Lung scan
o Pulmonary arteriography
o Tube thoracostomy
o Pleural sclerosis
o Pleural biopsy
o Surgical biopsy
o Thoracoscopy
o Thoracotomy
o Mediastinoscopy
o Tracheostomy
Diagnose the following conditions:
o Community acquired pneumonia
o Obstructive lung disease, including asthma, COPD, cystic fibrosis,
bronchiectasis, bronchiolitis, and allergic bronchopulmonary
aspergillosis
o Inflammatory lung disease, including idiopathic pulmonary fibrosis,
sarcoidosis, collagen vascular associated disease, Wegener's
granulomatosis,
occupational
lung
disease,
hypersensitivity
pneumonitis
o Pleural disease, including pleural effusion, pneumothorax, pleural
masses, and subcutaneous emphysema
o Lung abscess
o Tuberculosis (sputum analysis)
o Alveolar Hemorrhage Syndrome
o Lung cancer
o Pulmonary vascular disease
o Mediastinal disease (Chest x-ray, CT, PET, MRI)
o Respiratory muscle disorders
o Thoracic cage disorders
o HIV related lung disease
o Mycotic lung disease
o Sleep disorder breathing
o Pulmonary disease in the immunocompromised
Interpret the following laboratory studies:
o Chest x-ray
o Chest CT
o Pulmonary function testing
o Spirometry (obstruction)
o Flow volume measurement (restriction, hyperinflation)
o Diffusion capacity
o Muscle pressures
o Arterial blood gases
o Pleural fluid analysis
o Cell count and differential
o Cytology
o Chemistries (pH, LDH, total protein, glucose, amylase, ANA)
o Gram stain
o Cultures
56

B.
Communication


C.
Complete all dictations, letters and consultation requests in a timely
manner
Conduct all interviews with patients and their families in a compassionate,
culturally-effective and patient-centered manner.
Professionalism






D.
o Pleural biopsy
o Sputum analysis (bacterial, mycotic, mycobacterial, PCP)
o ACE
o Skin testing
o Sweat Chloride
Obtain studies appropriate for the diagnosis of:
o inflammatory lung disease (radiographic presentation and physiologic
studies)
o pleural disease (chest x-ray and CT)
o lung abscess (chest roentgenography and CT)
o tuberculosis (sputum analysis)
o mediastinal disease (chest x-ray, CT, PET, and MRI)
o respiratory muscle disorders (physiologic assessment)
Demonstrate a personal sense of altruism by consistently acting in one’s
patients’ best interest.
Know how to inform patients and obtain voluntary consent for the general
plan of medical care and specific diagnostic and therapeutic interventions.
Provide meaningful feedback to colleagues and students regarding
performance and behavior.
Systems Based Practice
Apply evidence-based, cost-conscious strategies to prevention, diagnosis,
and disease management
Interact with and utilize social workers, nurses, medical assistants, billing
coordinators and referral coordinators to provide effective, comprehensive
patient care.
Scholarship








Practice Based Learning and Improvement
Develop a willingness and ability to learn from errors and use them to
improve individual practice and the health care delivery system.
Maintain an attitude of healthy skepticism and curiosity, as evidenced by
thoughtful questioning, independent study and critical analysis of
published materials.
Utilize information technology to enhance patient education.
Be able to critically appraise sources of medical information.
Be able to educate patients and their families regarding their medical
condition.
Be able to teach medical students, residents and other health-care
professionals.
Be able to contribute to the development of new knowledge, through the
completion of or participation in a research project.
57
RADIOLOGY
Rotation Supervisor:
Teaching Methods:



Daily rounds
Daily morning meeting + conferences
Independent reading
The Internal Medicine Resident is expected to achieve competency in the areas
described below during their rotation in Radiology.
The resident is expected to:
A.
The Knowledge




B.
Understand the indications for and be able to interpret chest X-rays and CT
scan of thorax, with emphasis on:
o Solitary lung nodule
o Pleural effusion
o Congestive heart failure
o Lobar collapse
o Interstitial vs airspace disease
o Pulmonary fibrosis
o Pulmonary hypertension
o Hilar adenopathy
Understand the indications for and be able to interpret abdominal X-rays
and CT scan of the abdomen, with emphasis on:
o Small/large bowel obstruction
o Bowel edema/inflammation
o Liver masses/cysts
o Renal masses/cysts
Understand the indications for and be able to interpret CT scan of the head,
with empasis on:
o Masses/cysts
o Hemorrhage
o Ischemic infarcts
Understand the indications for:
o MRI
o Angiograms/interventional radiology procedures
o Bone/Gallium scans
o Other nuclear medicine scans
o Ultrasounds
Communication

Be able to interact effectively with other health care professionals and
discuss the results of various radiological tests.
58
C.
Professionalism









D.
Be able to apply a knowledge of the professional codes and norms of
behaviour that govern the behaviour of physicians in clinical practice.
Be able to apply a knowledge of the legal codes and norms of behaviour that
govern the behaviour of physicians in clinical practice.
Be able to recognize and resolve ethical issues as they arise in clinical
practice.
Be able to recognize and deal with unprofessional behaviours in clinical
practice.
Be able to identify the need to and benefit of consulting other physicians
and health-care professionals.
Be able to use information technology to optimize patient care.
Be able to use health care resources cost-effectively.
Be able to work efficiently and effectively.
Be able to educate and counsel patients and their families regarding the
factors that impact on their health.
Scholarship


Be able to critically appraise sources of medical information.
Be able to teach medical students, residents and other health-care
professionals.
59
RHEUMATOLOGY
Rotation Supervisor:
Teaching Methods:



Daily rounds
Daily morning meeting + conferences
Independent reading
Goal
Rheumatology deals with medical diagnosis and treatment of a broad range of
disorders that involve the musculoskeletal system - at least in part - which often have
an immunologic basis. Further, these disorders are often accompanied by an array of
laboratory phenomena that may support or refute a considered diagnosis, but are
almost never diagnostic. Most patients with rheumatic disorders are encountered and
managed in the clinic. Of the learning objectives listed below, many can be met and
may be best learned in an outpatient setting. Hospitalized patients for whom a
rheumatology consultation is requested present a challenging array of problems. These
can range from regional complaints unrelated to the patient's reason for
hospitalization to complex multisystem dysfunction for which an explaining diagnosis
seems elusive.
The general internist needs to have competency in the initial diagnosis and
management of acute arthritis and musculoskeletal disorders and in the long-term care
of systemic disorders. He or she must also be proficient in monitoring the effects of
anti-inflammatory, immunosuppressive, and cytotoxic drugs.
The Internal Medicine Resident is expected to achieve competency in the areas
described below during their rotations in Rheumatology.
The resident is expected to:
A.
The Knowledge

Be able to recognize and initiate management of common complications
and/or co-morbidities in patients with rheumatic disorders:
o Systemic lupus erythematosus with:
 Fever
 glomerulonephritis
 cytopenias
 nervous system involvement
 thrombosis (arterial or venous)
o Rheumatoid arthritis with:
 infection
 pulmonary impairment
 precipitous decline in functional status
o Polymyositis/dermatomyositis with:
 worsening muscle weakness on treatment
 respiratory complaints
 profound impairment and/or critical visceral involvement
o Scleroderma with:
60
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










 gastrointestinal complaints interfering with adequate nutrition
 respiratory complaints
 hypertension and/or renal crisis
 acute peripheral vascular compromise
o Vasculitis with:
 declining renal function
 end-organ ischemia
 infectious complications
Confirm the diagnosis, start the evaluation and initiate treatment in
patients with "classic" systemic rheumatic diseases, including:
o rheumatoid arthritis
o systemic lupus erythematosus
o Sjögren's syndrome
o polymyositis/dermatomyositis
o scleroderma
o systemic vasculitidies (polyarteritis nodosa, Wegener's granulomatosis,
giant cell or temporal arteritis, Takayasu’s arteritis, cryoglubulinemia)
o spondyloarthropathies (ankylosing spondylitis, Reiter’s syndrome,
psoriatic arthritis, inflammatory bowel disease-associated arthritis)
Discuss the indications, usage, and major side effects of drugs commonly
used to manage rheumatic disorders:
o non-steroidal anti-inflammatory drugs (NSAIDs) and specific COX-2
inhibitors
o corticosteroids
o anti-malarials
o sulfasalazine
o gold salts
o antimetabolites
(azathioprine,
methotrexate,
leflunomide,
mycophenolate mofetil)
o cytotoxic agents (cyclophosphamide, chlorambucil)
o biologic agents (etanercept, infliximab, anakinra)
o hypouricemic agents (probenecid, allopurinol)
o colchicine
Formulate a systematic approach to the patient with multisystem
complaints who may have a rheumatic disease diagnosis.
elicit historical clues to the presence of a systemic inflammatory illness
(fevers, sweats, weight loss, fatigue, stiffness)
examine the patient's musculoskeletal system and identify sites of
abnormality, characterized by any of the cardinal signs of inflammation,
weakness, or impaired movement
elicit historical clues and assess by physical exam any end-organ
dysfunction that might point to a rheumatic disease
understand the patterns of end-organ dysfunction that suggest specific
rheumatic diseases
collect and interpret data to assess the presence and severity of any endorgan dysfunction
collect and interpret data pertaining to a systemic inflammatory state
choose and interpret appropriate immunologic tests to support or refute a
considered diagnosis
choose appropriately from available imaging and tissue-sampling
modalities to judge type and severity of process contributing to end organdysfunction or systemic features
Formulate a systematic approach to the patient with regional complaints
who may have a rheumatic disease diagnosis:
61
recognize the possible anatomic derangements from which the patient's
complaints may arise
o detect a joint effusion, then aspirate and analyze synovial fluid
o confirm or refute other diagnostic possibilities (define anatomy) by
appropriate physical examination, imaging studies, or physiologic tests
(such as EMG)
o initiate appropriate therapy and monitor response to therapy in acute
disorders
Identify precipitating environmental insults for the development of
rheumatic diseases.
Obtain a family history for autoimmune diseases.
Understand how disability is determined.
Interpret basic laboratories often pertinent to rheumatic disease
assessment (urinalysis, blood counts and exam of peripheral smear,
chemistries reflecting kidney and liver function/injury, muscle enzymes);
parameters of systemic inflammation (ESR, SPEP, c-reactive protein) and
the effect of acute phase response on other lab tests (e.g., CBC, iron, ferritin,
complement); autoantibodies (rheumatoid factor, ANA, ENAs, anti-dsDNA,
ANCA, Jo-1, Scl-70); and other serum proteins pertinent to rheumatic
processes (complement components, cryoglobulins, immunoglobulins by
class and subtype)
Interpret cerebrospinal fluid studies pertinent to CNS involvement by
rheumatic disorders ("basics", myelin basic protein, oligoclonal bands, IgG
index)
Interpret synovial fluid findings, including:
o preliminary classification based on macroscopic characteristics
examination under polarized light microscopy and identification of
monosodium urate and CPPD)
o fluid cell counts
List the indications for and limitations of and be able to interpret the
following imaging studies:
o X-rays: ("inflammatory" vs. "degenerative" changes, marginal erosions,
chondrocalcinosis, osteopenia)
o Ultrasound
o MRI/CT
o angiography (cerebral, visceral, limb)
Assess functional limitations associated with rheumatic diseases and refer
appropriately for physical and occupational therapy.
Be able to perform:
o Arthrocentesis
o Injection of painful soft tissue structures (e.g. , bursae, tendon sheaths)
o Nail fold capillary microscopy
Recognize the indications for and refer patients appropriately for the
following procedures:
o muscle biopsy
o minor salivary gland biopsy
o EMG/NCT
o arthroscopy
o peripheral (sural) nerve biopsy
o
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B.
Communication

Complete all dictations, letters and consultation requests in a timely
manner.
62
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C.
Conduct all interviews with patients and their families in a compassionate,
culturally-effective and patient-centered manner.
Know when to involve other specialists (e.g., ophthalmology, dentists,
surgeons) to prevent or treat complications of rheumatologic disease.
Listen carefully and respond appropriately to the patients concerns.
Understand the impact of chronic pain, fatigue and cognitive disturbance
on family and workplace.
Professionalism

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Demonstrate a personal sense of altruism by consistently acting in one’s
patients’ best interest.
Know how to inform patients and obtain voluntary consent for the general
plan of medical care and specific diagnostic and therapeutic interventions.
Provide meaningful feedback to colleagues and students regarding
performance and behavior.
Understand confidentiality with respect to chronic illness.
D. Scholarship
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Practice Based Learning and Improvement
Develop a willingness and ability to learn from errors and use them to
improve individual practice and the health care delivery system.
Maintain an attitude of healthy skepticism and curiosity, as evidenced by
thoughtful questioning, independent study and critical analysis of
published materials.
Utilize information technology to enhance patient education.
Be able to critically appraise sources of medical information.
Be able to educate patients and their families regarding their medical
condition.
Be able to teach medical students, residents and other health-care
professionals.
Be able to contribute to the development of new knowledge, through the
completion of or participation in a research project.
63
ON-CALLS POLICIES AND R ESPONSIBILITIES
During your internal medicine clerkship, you will be assigned to take in-house call at a
frequency of maximum 1 in 4 nights. There will be 3 residents on call in-house each
night.

One will cover the medical floors admission

One will cover the medical floors complain/medical consultations

One will cover ICU and CCU
Occasionally because of staff shortage one resident may cover the admission and
complain calls.
The on-call experience is very important in medical education, and provides
opportunities for residents to see patients with new and developing medical problems
in the Emergency Room and on the inpatient wards. The educational experience is
dependent to some extent on the resident’s own initiative and enthusiasm while on
call. While on call, the resident will also develop technical skills, such as venipuncture,
arterial puncture for blood gases, and performing and interpreting electrocardiograms
and chest radiography.
The senior resident is responsible for organizing the on-call schedules. The task is
time-consuming, and many factors are considered when the schedule is drawn up. As a
result, it is not desirable to make changes in the on-call schedule once it has been
organized.
I-
On average, the resident will be scheduled on call one night during each week,
which may includes weekend days Thursday/Friday.
II-
Every effort will be made to equalize designation as Floor or Emergency Room
on call. This designation does not exclude the resident from participating in
experiences on either the Floor or in the Emergency Room while on call.
III- Once the schedule has been drawn up, changes will not be allowed unless there
are extenuating circumstances. The resident will be responsible for finding a
replacement for his/her call night and it will be his/her responsibility to notify
the hospital switchboard, Chief Residents, resident's secretary and other house
staff on-call that evening.
IV- In the event of an emergency or illness approve documentation is mandatory
otherwise an extra call may be given to the resident during current or next
rotations.
V-
On call will not be accepted as an excuse for not performing resident’s schedule
tasks next day.
64
VI- If resident have any questions about the on- call experience, please do not
hesitate to contact the Chief Residents
Responsibilities
General Ward Calls

Care of medical patients on ward

Supervising a medical intern, if one is present

Covering Medical consultation for in-patients

Code team member
Admission Call

Admit patients from ER to ward

Covering medical consultation from ER

Code team member
Cross Coverage On-Call (Floater)

For resident doing electives in other department than medicine and are not
involved in that department in-house on call scheduled they will have in-house
call for the department of medicine from 2-4 calls per period. Such calls
usually start at 4:00pm on the week days or 8:00am on weekends and end by
8:00am next day.

Clear sign out should be given to the floater from the morning coverage
physician including pending admission.
65
VACATION AND LEAVE POLICY
Residents are required to attend all assigned rotations, clinic sessions, conferences,
night or weekend coverage responsibilities, lectures or other assignments as
determined by the program.
ALL LEAVES CANNOT BE CARRY-OVER TO NEXT YEAR
Annual Vacation
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A total of four weeks vacation leave per year, which may split into two (2),
depending on the department's requirements.
Annual vacation should be applied at least 4 months before your leaving date
to enable us to arrange your coverage
The vacation should occupy not more than 25% of your current rotation (for
example if you have rotation for 4 weeks you can take a maximum of 1 week
during this rotation) otherwise the rotation is not credited and it has to be
repeated.
All leaves have to be approved by the head of the rotation unit, program
director and chief residents
Emergency Medical Leaves (Maternity, sickness, death in family)


The emergency leave for serious personal illness or injury is subtracted from
your annual vacation. Any sick leave with valid reason for three months or less
should be approved by residency committee and it should be compensated
during training or at the end of training period.
All leaves have to be approved by the head of the rotation unit, program
director and chief residents
Study leave

Residence may apply individually for maximum of 7 days of leave per year,
subjects to approval of department of residency committee and the chairman of
department (proof is required). Study leave cannot be combined with other
leaves.
Eid holiday leave

Only ONE Eid holiday (5 days) per year, and it is preferable to alternate
between the two eids each year.
Leave of absence

Leave without pay is not allowed.
66
RESIDENT’ S DAY ACTIVITY 2007 - 2008
“A knowledge is the only instrument of Productive that is not subject to
diminishing return.”
The Department of Medicine at KKUH continues to carry the torch of preparedness of
mind completed with the serendipity in the “RESIDENT’S DAY ACTIVITY”. No less
than thirty (30) activity project are scheduled to be presented by the trainees.
With the beginning of this academic year October 2007, we are pleased to arrange
Resident’s Day Activity which will be held the whole year except in summer (On
Sunday’s 12:30 – 4:00 PM) which contains variable topics and activities in Medicine
and in other skills. Our purpose is to improve our clinical sense and our approach to
reach a proper diagnosis and to provide an update of the management of the disease.
This activity is divided into two parts:
 Crash Course
 Resident’s half day activity
First part:
CRASH COURSE
Two weeks of daily scheduled lectures (except weekend) for one hour that contains 11
topics which will be held from 20 October 2007 (08.Shawwal.1428) until 31 October
2007 (19 Shawwal 1428).
A case of 11 inspiring lecture in internal medicine presented by specialists to build-up
our approach to management of most common medical emergencies.
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Second part:
HALF DAY ACTIVITY:
The resident’s half-day academic activity is each Sunday from 12:30 – 4:00 pm. Each
academic cycle consists of four Sundays. The residents are going to discuss a
particular system each cycle through a variety of related subjects (except for ECG,
Epidemiology Course) in different ways as follows:
ECG Session
1st
week Pathophysiology
MCQ/ Miscellaneous
Epidemiology Course
2nd
Mega Round
week
Clinical Approach Round
ECG Session
3rd
Topic Review & Up-to-Date
week
Show & Tell
Epidemiology Course
4th
Mega Round
week
Guidelines
The attendance for all residents is mandatory. All residents are released and excused
from their clinics, consultations and ward coverage during this time.
ECG SESSION
The resident will have an ECG session every other week (1st & 3rd Sunday) with Dr.
Ahmed Hersi, Consultant Cardiology and Electrophysiology. Through this session, the
resident will get exposed to variety of ECGs to be able to read the ECG in systematic
way, know the resident’s level findings and to pick-up the serious abnormalities that
need emergent intervention.
PATHOPHYSIOLOGY OF DISEASE
Through pathophysiology, the resident will going to understand the reason beyond the
disease, how to treat and how to avoid or delay the possible complications.
Pathophysiology will make things easy.
CLINICAL APPROACH
Through an organized approach, the resident will investigate appropriately and reach
the diagnosis easily. The aim of the clinical approach activity is to achieve this goal and
to make the goal directed way of thinking as a habit.
MCQ
This activity is purposed to stimulate our comprehension in particular subjects and to
have an exam oriented discussion.
TOPIC REVIEW & UP-_TO - DATE:
In this activity, the resident will have a reviews in different topics in medicine with
updated information in the new methodology of making-up diagnoses and the new
modalities in the management of specific disease.
EPIDEMIOLOGY COURSE
Every other week (2nd and 4th Sunday), the residents will have sessions (based on
specific curriculum) with some of our consultants who are certified in epidemiology.
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The goal of this course is to improve the resident’s knowledge, skills and judgment to
be able to critically appraise studies in the literature to perform their researches in the
future.
GUIDELINES
The goal of this activity is to review the international guidelines of managing different
diseases aiming to keep the residents aware and updated about the recommendations
of well-known international medical associations.
SHOW & TELL
In this activity, the resident is responsible for showing his/her colleagues different and
interesting slides to test their ability of picking up the abnormality, knowing and
passing the pitfalls, approaching the case and managing the disease.
MEGA ROUND
Every other week (2nd and 4th Sunday) of each cycle, one of the consultants who is
specialized in the system that the residents are discussing during the cycle will have a
talk for one hour explaining a particular topic in this system. The residents should
prepare the topic, and the questions to have the maximum benefits from the expert
presence.
On behalf of my colleagues and myself, I would like to thank our Dr. Ahmed Hersi
our Program Director for his great support and encouragement.
Dear Residents, the commitment cooperation and the active involvement is the way to
success our activities. Let’s join forces to achieve our goals.
DR MOHAMMAD AL KHOWAITER
Chief Resident
69
INTERNAL MEDICINE AC ADEMIC ACTIVITIES
Internal medicine is consider to be one of the most rapidly changing sciences where
there are new data emerge frequently. As an academic institute, we have the obligation
to our patients and our community to maintain our professional integrity and to
update our medical knowledge periodically. Therefore, we need to update our
academic program to meet such objectives. One of the changes we feel necessary is to
do minor modification to our academic rounds. These rounds will help us to reach our
target and meet the new standards and guideline that were recently adopted by the
Saudi council for health specialties and the King Saud University postgraduate center
to maintain program integrity and accreditations.
Please these activities for you attending is mandatory
(Attending less than 90% of the activities will result in disciplinary
actions)
Your continuous assessment will depend on some part on your
attendance and your contribution to the rounds. Have a look at the new
schedule of activities so that you know when your contribution is needed.
MORNING REPORT
Goals and Objectives
The main goals of the morning report are to practice and discuss:
1. The presentation of a detailed medical history
2. The presentation of a focused physical examination
3. The summarization of a complicated medical patient presentation
4. The formulation of a problem based differential diagnosis
5. The use of appropriate laboratory and radiological investigations in a cost
effective manner.
6. The formulation of an evidence based and cost effective management plan
Target population:
1. Internal medicine residents
2. Interns rotating in the department of medicine
3. Secondary target population:
 Registrars and senior registrars in different specialties of Internal medicine.
Presented case:
 The case presented has to be instructive or interesting in one of the major
domains of discussion (history taking, physical examination, investigations or
management)
 The case should preferably be from the night before but could be from previous
nights.
 The case must be presented by the resident.
70
Distribution of seating:
Males:
 All Interns must occupy the front row of the auditorium only
 All internal medicine residents should occupy the second row of the auditorium
only
 Medical students should occupy the left wing of the auditorium only
 Registrars, senior registrars, and consultants may sit wherever they desire
except the above designated areas
Females:
 All female interns should be seated in the third and fourth rows of the right
wing of the auditorium
 All female residents should be seated in the 5th and 6th row of the right wing of
the auditorium only
 When female students are present they should be seated in the left wing of the
auditorium
 Female registrars, senior registrars, and consultants may be seated wherever
they desire in the right wing of the auditorium.
Moderators:
 A moderator schedule will be formulated every three months.
 The moderators will be responsible for their days and must appoint someone
instead of them if they are not able to attend.
 Any member of staff who likes to moderate the morning report should contact
the coordinators and he or she will be welcomed
 The function of the moderator is to facilitate and organize the discussion and
not to dominate the discussion.
 The moderator is responsible for starting the morning report on time exactly at
7:45
Format:
Timing:
 7:45-7:55 : Presentation of the detailed history and physical examination,
with questions and comments from the audience on the
presentation
 7:55-8:10 : discussion regarding the differential diagnosis
 8:10-8:15 : discussion of the approach to this medical problem
 8:15-8:30 : discussion on the investigations and management of this problem
The above timing is just a guide; the moderator has the right to modify it according to
his own judgment and the predominant domain of the discussed case
Structure:
 Most of the discussion regarding the history, physical examination, and initial
differential diagnosis should be run by the Interns and junior residents
 More detailed differential diagnosis and investigations should be discussed by
the senior residents
 Management issues should be discussed by the senior residents and
registrars/S. registrars
 The on call team role is to present the case and investigations and add to the
differential diagnosis set up by the audience and not be on the “hot seat”.
 The consultant’s role is to add in missing points, emphasize important clinical
issues, correct some common misconceptions, and act as a resource in their
71

area of expertise. Their comments should be instructive, positive, and as short
as possible.
More time needs to be spent in the area of greatest interest in the presentation.
This should be discussed between the presenting team and the moderator
before round.
Attendance:
 Attendance will be taken from 7:30-7:50 am every day. No attendance will be
recorded if beyond 7:50 am
 All students and sub-interns attached to the department of medicine MUST
attend morning report daily on time
 All male and female Interns rotating in the department of medicine MUST
attend the morning report on time. Minimum attendance will be 80% of all
morning reports held at the time of the rotation. No intern will be passed in the
rotation of internal medicine without achieving this attendance record.
 All male and female residents rotating in the department of medicine MUST
attend the morning report on time. Minimum attendance will be 75% of all
morning reports held at the time of the rotation. No resident will pass the
rotation of internal medicine without achieving this attendance record.
 All registrars and S. Registrars must attend.
 A representative consultant from each division and unit in the department
must attend the morning report. It is the responsibility of the head of each unit
to assign a person to attend (e.g. on call consultant, distribute days….). The
chairman of the department of medicine will be following that personally.
 Follow-up case can be presented for 15 minutes at every Sunday. The presenter
should provide a brief summary about the case and the progress and the followup.
72
UNIT’S ROUNDS
Goals and Objectives
Present in detail a difficult case from the sub-specialty assigned in an intention to:
1. Highlight the important features of the history and important tips in history
taking
2. Highlight important physical findings
3. Discuss the differential diagnosis of difficult clinical problems
4. Outline an evidence based approach to management of difficult clinical
problems
Format
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Each unit will be assigned a specific Tuesday
The scheduled consultant will have to arrange the case and the presentation
beforehand with the presenting person (like the old grand round format)
The case will be presented as usual similar to the morning report but these will
usually be “cold” cases
A consultant member of the team will be the moderator
Additional time may be spent in a quick review of the topic or reviewing the
evidence
Presenter
Resident, registrar, senior registrar/fellow
Target audience
Resident and above
Date
Every 1st & 4th Tuesday of the month
Time
7:45-8:30
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GRAND ROUNDS
Goals and Objectives
To provide the audience with an in-depth topic review in the area of specialty focusing
on updated evidence based state of the art approach to issues in the specialty.
Presenters
Consultants only
Target audience
Resident and above
Format
According to speakers discretion
Day
Every Monday
Time
12:30-1:30 pm
CLINICAL APPROACH ROUNDS
Goals
1. To help trainees formulate a practical approach to common clinical problems
2. To help trainees master interpretation of physical findings
3. To help trainees master the skills in laboratory data interpretation (CBC, LFT,
U&E, ABG…..)
4. To help trainees master the skills in other non laboratory investigations (ECG, CxR,
PFT….)
Format
These rounds will be distributed according to the division
It will be left to the divisions’ discretion to choose the most appropriate format to
deliver the message
Presenter
Consultant or senior registrar/fellow
Target population
Interns and residents
Day
Every 1st & 3rd Sunday
Time 7:45-8:30 am
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RESIDENT’S ROUNDS
Goals
1. To stimulate and introduce residents to the knowledge of evidence based medicine
2. To help residents master in the field of research and epidemiology
3. To help resident in reading, analyzing, and criticizing a scientific paper
4. To introduce to residents the to how to formulate a research question and how to
design a
study
5. To help resident to master the history taking and physical examination
6. To help resident to acquired a knowledge of other communication and professional
skills
(writing a paper, presenting in rounds, ethical dilemmas, patient doctor
relationship .etc)
Target population
Internal medicine residents
Speakers
Residence will arrange to round, under supervision of consultants (a rotation schedule
will be arranged alphabetically)
Day
Every Saturdays & Mondays, 2nd Tuesday, 1st & 3rd Wednesday of the month
Time
7:45-8:30 pm
INTERNAL MEDICINE UPDATE
Internal Medicine Update conference (IMU) is considered to be one of the most
important event in the department of medicine. The attendance of such meeting is
mandatory in all in training residents. The residents will be, as much as possible,
exempted from their clinical, on-call and clinic duty during the days of conference. As
in training residents will have no applicable fees and they will be sponsored by the
department of medicine.
Time
Month of March
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RESIDENT’S DAY
Residents Day is a new organized event that residents will have whole day of academic
activity that will be oriented to their needs. The objective of this event is to orient
resident to several other aspect of patients care including; communication skills,
ethical issues, using computer and multimedia in the field of medicine and others. The
resident will have opportunity to present selective education cases to present (Case of
the Year). At the end of the day the distinguished resident and academic staff will be
honored.
Time
Month of October/November
CRASH COURSE
At the start of each academic year a 2-3 weeks of scheduled one hour lectures will be
presented to 1st year residents. The objectives are to introduce and discuss the daily
encounter common emergency conditions can be faced by residents. The presenter will
discuss with residents the practical and evidenced paced medicine approach. Other
topics including data interpretation and nursing issues will be also presented
Time
(To be announced)
OTHER GUIDELINES
Audio-visual
Department of internal medicine will try to provide the speaker with all the audiovisual
support provided that it is requested ahead of time. The Department encourages all
speakers to request laptop computers, laser pointer, and any other equipment from the
academic secretaries and they will try their best to accommodate such request. LCD
projectors are available in all lecture theaters.
Printed Documents
The residents will provide their audience with documents (articles, hands out...etc)
please contact the academic secretary at least one week before the presentation that
will give the secretaries enough time to provide residents with photocopies.
CME Credits
Internal medicine department is working to get CME credits of all its activities, enable
all participants to acquired credits hours. Such program if applied it will be provided to
registered individual in monthly bases.
76
PERFORMANCE AND EVAL UATION PROCESS
I. PERFORMANCE AND EVALUATION PROCESS
A. The internal medicine residency has both subjective evaluation as a form of
rotation evaluation by attending staff and objectives evaluation as a form of
clinical examination
B. The resident will be promoted to next year level if he/she has (see below)
1. Satisfactory performance evaluation of clinical rotation during the year
2. Passing the end of year examination
C. After a proper investigation and after approval from DRC and PGTB if the
resident had two below average or one fail evaluation he/SHE his
file will be forwarded to the post-graduate department for
discussion and possible panelties.
II. CONTINOUS ASSESSMENT
A. Resident Evaluations
1. Attending faculty members will evaluate each resident at the end of each
block (not rotation).
2. Evaluations will be in writing and performance will be reviewed
3. The form includes evaluation of clinical skills, medical knowledge, clinical
judgment, humanistic qualities, professional attitude, medical care, and
overall competence.
4. Resident will have structured clinical assessment based on end of year
examination (see below)
5. First Year Residents will maintain log books for documentation of invasive
procedures.
6. The program director will evaluate each resident at least semiannually.
7. The program will follow institutional policies for academic due process to
assure fairness and allow resolution of disputes.
8. The program director (and preferably the head of the unit of concerned
rotation) will discuss the evaluation with the resident.
9. Any disapproval or concerns of the evaluation by the residents will be
discussed with residency committee, residency unit supervisor and the head
of the unit.
B. Structural Assessment
Residents will have structural clinical evaluations during their years as;
1.
Long Case Examination: the resident will have a long case
examination will be conducted in the last 4 months of each academic
year
a. Objectives: To assess the ability of residents to;
i. Gather essential and accurate information by performing
complete and clinically-relevant history and physical exam.
ii. Understand how to order and interpret appropriate diagnostic
tests.
iii. Make informed diagnostic and treatment decisions by analyzing
and synthesizing information.
iv. Understand the limits of their knowledge and expertise.
b. Format: The candidate will be examined by two consultants after
one hour of examination time. Each examiner will evaluate the
patients separately.
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2.
OSCE Examination: the residents will have a OSCE examination that
will be conducted once a year (between the month of June and August)
a. Objectives: The exam will assess:
i. Data interpretation
ii. consultation skills
iii. communication skills
iv. procedural skills
b. Format: (Appendix IV)
i. 7-10 minutes stations between 10 stations
ii. It should contain
iii. 2 physical examination stations
a. 3 data interpretation
b. 3 case scenario
c. 1 skills station (procedural..etc)
d. 1 rest
PERCENTAGE OF EACH SECTION OF THE CONTINUOUS ASSESSMENT OF THE DEPARTMENT
OF MEDICINE RESIDENCY PROGRAM
Residency
Long Case
OSCE
Log Book*
Research**
Year
R1
40%
40%
20%
R2
40%
60%
R3
40%
60%
R4
20%
50%
30%
*You have One year to submit your log book, you will not be promoted to second year if
your log book will not be completed before month of September at your first residency
year.
**You can submit and present your research at any time of the four year residency.
3.
OTHER Examinations :
Residents of King Saud Fellowship Program in Internal Medicine are
encourage to register for other examinations including;
1. Saudi Council for Health Specialties Internal Medicine Program
2. Arab Board of Internal Medicine
3. Royal College of Physician of UK
III.
Training completion
 The resident will spend no more than double the minimal program
duration, to complete the program. The same applies to the period spent for
the junior residency and the senior residency periods. The resident is
allowed to repeat the same year for maximum of three times
IV.
Program interruption
 Program interruption, as a result of extended absence, will not be allowed.
Any period of absence beyond the allowable leave time within a training
year may be exceptionally approved by postgraduate center and SCHS.
 A request should be submitted through program director who will present it
to the DRC which will then submit to the PGME and to vice dean for
postgraduate and continuing medical education or to SCHS, when
applicable.
78


V.
Absence of three months or less continuously, that year will be
considered a full training year. However, the resident will compensate
this absence at any time during remaining period of the program, or
immediately after the end of the training program.
Absence beyond three and up to twelve months continuously, that year
will not be considered full year. The resident will repeat the training level
at the start of new academic year.
Disciplinary Actions
Disciplinary action process shall be escalated first, from the director of
Residency Training Program; then to the Departmental Residency Committee;
then to the Postgraduate Office and up to the respective institution residents
whom responsible.
A.
Withdrawal or Absence from the Examination:
1. Withdrawal from the examination with no legitimate excuse will be
consider as failure and the mark for that exam will be counted as
zero.
2. In case of documented emergency events, exam may be arranged in
later date.
B.
Unsatisfactory Evaluation
1.
Rotation Evaluation
Residents getting 60% and below from unit’s evaluation is failure.
Obtaining such grade shall be subject for corresponding penalty as
follows:
a. 1(one) rotation failure
The committee shall pronounce either of the following sanctions to
the resident depending on their discretion:
Option 1: Counseling
Option 2: Repeating of the rotation
Option 3: Repeating of the 6-months rotation
b. 2(two) rotations failure – Repeating of the one-year rotation
2. Attendance (Morning Round and Academic Activity)
All residents who have below 90% attendance in the Morning Round
and with the Academic Activity per block shall be subject to the
subsequent penalty:
1st Offense – Verbal Reprimand
2nd Offense – Written Reprimand
3rd Offense – Letter address to the Postgraduate and Saudi Council
informing unsatisfactory attendance
4th Offense – Repeat of the block
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3. Absence from a Service or On-call
The Postgraduate office shall not tolerate any absences from service or
on-call with no legitimate excuse. Resident who incurred absent/s must
submit document proving reasons for this act; failure to do so shall
make the Residency office issues penalty with corresponding offense as
follows:
1st Offense – Written Reprimand and discussion with the committee
2nd Offense – Repeat of the Rotation
3rd Offense – Expel-out from the Program
C. Appealing for Unsatisfactory Evaluation
1. Residents have the right to an appeal process on decisions or actions
affecting their training and their evaluation. The maximum allowable
time to start an appeal process is fifteen (15) calendar days from the
time the resident receives written notification of the unsatisfactory
evaluation(s) from the program director. If no written notice of appeal
is received within the fifteen (15) day period, the resident shall be
deemed to have waived any right to appeal.
2. If a resident is dissatisfied with the evaluation report, he/she should
first indicate in writing on the evaluation sheet this dissatisfaction to the
Program Director, and in discussion with the Program Director see if an
alteration or upgrading of the evaluation is forthcoming.
3. If this does not result in a change in the evaluation report satisfactory to
the resident, the Program Director will summarize in writing to the
resident the reason for the unfavorable evaluation and recommendation
and advise the resident of his/her right to appeal as hereinafter set
forth.
4. Any appeal action shall be initiated by the resident advising the
Associate Dean of Postgraduate Medical Education in writing of his/her
intention to appeal the evaluation within fifteen (15) days of receipt of
the written evaluation. The written submission must include the
reasons for appeal.
5. Upon receiving the written notice of appeal, the Associate Dean of
Postgraduate Medical Education will strike an Appeal Committee. This
Appeal Committee shall function as an appeal body for residents in
academic matters.
6. The Appeal Committee shall review the evaluation report, the written
submissions by the appellant as set out in the notice of intention to
appeal and, if the Appeal Committee in its sole discretion deems it
necessary, interview the resident and the Program Director. The Appeal
Committee shall have the power to uphold the decision of the Program
Director or request that the Program Director modify the evaluation. If
the Appeal Committee requests the Program Director to modify the
evaluation and.
7. The Program Director refuses, the matter shall be referred to the
Associate Dean of Postgraduate Medical Education who will review all
of the evidence and make a recommendation to the Dean of Medicine.
The Dean of Medicine will review all of the evidence and render a
decision.
80
D. Regulations for Dealing with Disciplinary Action
1. Immediate action may be necessary by reasons of clinical inadequacy,
clinical incompetence, or other disciplinary problems on the part of a
resident.
2. Any complaint concerning clinical inadequacy, clinical incompetence, or
disciplinary problems must be delivered in writing to the Residency
Training Program Director. These complaints will then be discussed by
the Residency Committee which have four alternatives:
a. To dismiss the charges if they could be found to be unjustified.
b. If the situation is not deemed serious enough to require suspension,
to place the resident on probation and allow him/her to continue
his/her duties pending a suitable investigation.
c. If the situation is not deemed serious enough to require suspension,
to place the resident on probation and allow him/her to continue
his/her duties as modified by agreement between the Committee
members pending a suitable investigation.
d. If the situation is deemed serious enough, to impose a temporary
suspension pending further investigation.
3. In situation #2, #3, and #4 the Program committee should submit
written documentation to the Post Graduate Medical Education Office
with committee decisions. In all cases the Associate Dean of
Postgraduate Medical Education, the head of internal medicine
department must receive a timely report on the nature of the complaint
and subsequently on the action taken
81
Table shows the four domains of the curriculum, the learning skills from each domain, the
source of where these skills can be acquired and the tools of domain’s evaluation
Domain
Knowledge
Learning Skills
-History and physical
-Investigational skills
-Data interpretation
-Differential diagnosis and
problem list
-Procedural skills
-Prognosis and follow-up
-Communicate to senior
colleagues
-Communicate to junior
colleagues
Communication
-Communicate with supporting
service personnel
-Communicate with patients
and family
Professionalism
Scholarship
-Research
-Obtaining knowledge
-Presentation skills
-Computer skills
Source
-Inpatient’s context
-Daily rounds
-Morning rounds
-Unit’s rounds
-Resident’s round
-Clinical approach
round
-ACLS
-On-call
-Consultations
-Ambulatory Care
-Conferences
-Self-learning
-Inpatient’s context
-Daily rounds
-On-call
-Consultation
-Resident’s round
-Self-learning
-Inpatient context
-Daily round
-On-call
-Consultation
-Self-learning
-Grand round
-Unit’s round
-Resident’s round
-Conferences
-Self-learning
Evaluation
-Unit’s feedback
-Monthly
evaluation
-Log book
-Long case exam
-OSCE
-Unit’s feedback
-Monthly
evaluation
-Long case exam
-OSCE
-Unit feedback
-Monthly
evaluation
-Research
-Resident’s round
-Evaluation
Appendix I
PROCEDURE LOG BOOK
RESIDENT NAME
PATIENT NAME
HOSPITAL
DATE
TIME
SUPERVISOR NAME
PAGER
PROCEDURE DATA
Type of procedure
_______________________________________________________
The resident was able to (please give mark out of 10 in the boxes for each point)
Explain the procedure to the patient and take his/her consent
Understand the indication and contraindication of the procedure
Understand how to performed the procedure
Identify the procedure complications and its management
FOR SUPERVISOR
Recommendation______________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Supervisor Signature ________________________ Date ________________
Appendix II
Block*
R1
Inpatient
Medicine
1
R2
Inpatient
Medicine
R3
R4
Inpatient
Medicine
Inpatient
Medicine
RMC
RMC
2
3
4
5
6
RMC
7
SFH
8
CCU
Cardiology
CCU
Cardiology
ICU
ICU
CCU
Cardiology
CCU
Cardiology
ICU
Elective
Elective
12
ICU
Anesth
ER
13
Vacation
Vacation
Vacation
Vacation
9
10
11


Clinics
One block is four weeks
Anesth=anesthesia, CCU=Coronary Care Unit, ER= Emergency
Medicine, ICU= Intensive Care Unit, RMC= Riyadh Medical Complex,
SFH = Security Forces Hospital
Appendix III
Resident’s Evaluation of Rotation
Resident of
Resident Level
Internal Medicine
R1
Others _________________________
R2
R3
R4
R5
Unit of
__________________________________________________
Rotation Period
Block__________________ (You need to fill a form for each block)
Please mark the following items as 1 is Poor and 5 is Excellent
During the rotation at the Unit:
1. Able to develop learning and clinical problem solving skills
1
2
3
4
5
N/A
2. Actively involved in patient care
1
2
3
4
5
N/A
3. Provided with direction and feedback
1
2
3
4
5
N/A
4. A staff was always accessible for help and support
1
2
3
4
5
N/A
5. There was dedicated time for academic activities
1
2
3
4
5
N/A
6. Overall The Rotation was (circle one)
Poor
Average
Good
Very Good
Excellent
Comments:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________





Remember: your evaluation is to help us to improve the residency program.
Your evaluation and comments will always be confidential.
Comments may be printed on a separate sheet and attached
Return your evaluation to Residency Office by the end of your rotation.
You MUST complete these form to ensure completion of your rotation.
Appendix IV
Format of OSCE examination
Date
Format
:
:
Between mid of June and mid of August
10 stations, 8-10 minutes each station
The station will be divided as follow:
 Two stations physical examinations:
o A clinical scenario will be presented in brief and the candidate will do focused
physical examination in standardized patient.
o The candidate should express the ability to integrate the clinical information with
clinical skill.
o The candidate will be evaluated using standardized check list.
 Three stations data interpretations:
o Radiological data interpretation, ECG interpretation AND/OR laboratory data
interpretation
o The candidate will write a brief description and interpretation of the data
o The candidate will gave list of differential diagnosis of presented data
 Three stations Clinical Scenarios:
o The candidate will be presented with ambulatory clinical scenario with several
questions
o The cases may include;
 Common medical problems
 Pre-operative assessment
 Post procedure complications
 Pregnancy related medical conditions
 One station emergency medicine/procedural skills
o The candidate will be presented with one of the following case scenario
 Cardiac emergency
 Respiratory emergency
 Neurological emergency
 Procedural skill
OR


One station for communication or scholarship skills
o The candidate will be presented with a clinical scenario and the candidate should
show effective communication skills with colleagues, patients or other personals
o The candidate will be given an abstract and he/she should answer related questions
One station resting station
Appendix V