Revised 3/21/08
RESIDENT CURRICULUM FOR THE INPATIENT GENERAL
MEDICINE ROTATION 2008-2009
Rotation Coordinator:
Sandhya Wahi-Gururaj, MD
Program Director
Associate Professor of Medicine
Department of Internal Medicine
University of Nevada School of Medicine
Suite 300, 2040 W. Charleston Blvd.
(702) 671-2345
I. PURPOSE
The purpose of this four week rotation is to provide education and experience in
the care of patients requiring acute inpatient hospitalization. At the conclusion of
this rotation, residents will have gained insight into the diagnosis and management
of acute inpatient medical problems, the role of subspecialty consultation,
diagnostic methods, the natural history of disease and strategies for cost-effective
and evidence-based evaluation and treatment.
II. COMPETENCY-BASED GOALS AND OBJECTIVES:
R-1, R-2, R-3 is level (year) of Internal Medicine training
Patient Care: R-1 LEVEL
Clinical Skills/Judgment:
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Gather accurate, essential information by medical interviewing patient
(and/or family) thorough physical examination review. Existing laboratory
data (including blood work, body fluid analysis and radiological studies), and
pertinent prior medical records from UMC or other hospitals.
Provide care to patients with acute unexpected problems during call days
(cross coverage) with senior resident assistance, consultant and supervision
Achieve and maintain provider status in Basic Life Support BLS (basic life
support) and ACLS (advanced cardiac life support).
Write initial orders for patient care during hospital admissions. To include
nutrition, IV fluids, pain management, therapeutics including antibiotics; and
to confer with resident for comprehensive orders. Use protocol orders for
review after formulatory treatment plan in progress notes.
Initially observe; then perform under resident/faculty supervision ABIM core
diagnostic and therapeutic procedures. Be familiar with indications,
contraindications, and complications of procedures as well as understanding
and recording the patient’s informed consent and a note describing the
procedure in the patient’s medical records.
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Clinical judgment- stays in close consultation with more senior residents via
work rounds and direct communication.
Patient Care: R-2 LEVEL
Clinical Skills/Judgment: Including all learning objectives R-1 and the
following:
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Direct the initial evaluation and management of patients with illnesses requiring
hospitalization.
Leadership of resident team in absence of R-3 resident or when on-call.
Uses risk/benefit approach to determine necessity of procedures and
interventions.
Performs required Internal Medicine procedures certified with appropriate
supervision.
Reviews or directs the review of prior medical records.
Utilizes all resources at hand (phone consultation, medical knowledge) to
effectively manage an ill patient for 12 hours.
Reviews and develops understanding of diagnostic study results by utilizing all
necessary resources. Reviews radiologic studies with radiologist.
Clinical judgment - makes informed decisions and recommendations about
prevention, diagnostic and therapeutic options and interventions based on sound
scientific evidence, patient preference after informed consent, and consultation,
with more senior physicians and consultants.
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Patient Care: R-3 LEVEL
Clinical Skills/Judgment: Including all learning objectives R-1 and R-2 and
the following:
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Efficiently and effectively direct the initial evaluation and continued
management of patients requiring hospitalization including appropriate
discharge planning.
 Having obtained certification in required Internal Medicine procedures,
provides these procedures while instructing junior physicians in their
completion (teaches procedures to junior residents).
 Systematically obtains and reviews all prior/obtainable medical records
pertinent to patient care.
 Understands significance of all diagnostic test results affecting patient care.
 Clinical judgment – makes informed decisions using risk/benefit analysis based
on sound scientific evidence, patient performance after informed consent and
consultation with consultants and more senior physicians (attending).
 Utilizes resources at hand so as to effectively manage an ill patient for 24 hours.
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MEDICAL KNOWLEDGE: R-1 LEVEL
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Demonstrate knowledge of the established basic biomedical, clinical and social
sciences from at least one source.
Evaluate medical data from available resources while on call, admitting, and cross
covering for specific patient problems (look up and review the differential
diagnosis and diagnostic evaluation plan for the patients).
Acquire and critically evaluate current medical information and scientific
evidence (at least one source).
Become familiar with each medication ordered for patient including common side
effects.
MEDICAL KNOWLEDGE: R-2 LEVEL
Including all learning objectives R-1 and the following:
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Apply medical knowledge toward clinical problem solving and clinical decision
making for individual patients.
Review, correct, and instruct more junior physicians and students in medical
knowledge.
Have familiarity with each medication prescribed and common and uncommon
side effects.
Apply this knowledge effectively (good patient outcomes).
Use at least 2 sources of medical information.
MEDICAL KNOWLEDGE: R-3 LEVEL
Including all learning objectives R-1 and R-2 and the following:
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Develops medical knowledge about each patient illness so as to be able to make
independent decisions based on scientific evidence and patient preference.
 Demonstrates knowledge by leading discussions on areas of pathophysiology
concerning patient care including ongoing management of hospitalized patients.
 Demonstrates ability to access information from 3 different sources and to
synthesize sources into an in-depth understanding.
PRACTICE-BASED LEARNING AND IMPROVEMENT- R1 LEVEL
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Accepts guidance from more experienced physicians and uses scientific evidence
and practice outcomes for practice improvement.
Readily acknowledges practice omissions (errors) determined by self or
supervisors and takes corrective measures.
Uses medical informatics to improve decision-making.
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PRACTICE-BASED LEARNING AND IMPROVEMENT- R2 LEVEL
Including all learning objectives R-1 and the following:
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Becomes familiar with statistical analysis.
Reduces level/rate of practice omissions from R-1 level (errors).
Improves efficiency of patient care (timelines) while maintaining quality and
thoroughness.
PRACTICE-BASED LEARNING AND IMPROVEMENT- R3 LEVEL
Including all learning objectives R-1 and R-2 and the following:
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Continues to progressively reduce practice omissions/commissions from R-1, R-2
levels.
From medical knowledge and patient care experiences is able to question patient
care practices not supported by scientific evidence/evidenced based care.
INTERPERSONAL AND COMMUNICATION SKILLS-R1 LEVEL
 Maintain comprehensive, timely and legible medical records.
 Effectively communicate with consultants, peers, other allied health professionals,
as well as patients and their families.
 Communicate with patients and their families regarding end-of-life issues,
categorization, organ donation and requests for autopsies.
 With difficult patients families or situations, involves a more senior physician
(senior resident or attending) to clarify issues.
INTERPERSONAL AND COMMUNICATION SKILLS – R-2 AND
R-3 LEVEL
Including all learning objectives R-1 and the following:
 Supervise, lead, manage and teach more junior housestaff and medical students.
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Analyze the source and meaning of conflict with difficult patients and take the
course that reflects the patient’s best interest (angry patient-consider
antidepressant, counseling, anxiolytic or patient advocate).
Interact effectively with consultants.
PROFESSIONALISM- R-1 AND R-2 LEVEL
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Demonstrate respect, compassion, integrity, and altruism in relationships with
patients, families, and colleagues while maintaining confidentially.
Demonstrate sensitivity and responsiveness to the gender, age, culture,
religion, sexual preference, socioeconomic status, beliefs, behaviors and
disabilities of patients and professional colleagues.
Always act in a moral, honest professional manner, and maintain appropriate
relations with patients.
Responsibly represent this residency program, the department of Internal
Medicine, the University of Nevada School of Medicine, the University
Medical Center and the profession of Medicine.
Respect and defend each patient’s autonomy and privacy and always act in the
patients’ best interest.
PROFESSIONALISM- R-3 LEVEL
Including all learning objectives R-1 & R-2 and the following:
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Become familiar with actual or potential conflicts of interest; particularly
those involving personal financial gain.
Become familiar with pharmaceutical marketing impact on physician
behavior.
SYSTEMS-BASED PRACTICE – R-1
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Understand and access all resources available and necessary to provide
optimal patient care.
Collaborate with other members of the health care team to assist patients and
improve patient care.
Learn appropriate use of medical and non-medical subspecialties.
SYSTEMS-BASED PRACTICE- R-2 AND R-3
Including all learning objectives R-1 and the following:
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Apply evidence-based and cost-conscious strategies toward disease
prevention, diagnosis and disease management.
Develop lifelong strategies to optimize care for individual patients.
Participate in Quality Improvement activity, Mortality Reviews and Chart
Stimulated Recall.
II. CLINICAL EXPERIENCES that may be encountered during this
rotation
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cardiology (arrhythmia’s, ischemia and infarction, systolic or diastolic failure,
valvular heart disease, pericardial disease, and endocarditis)
endocrine (thyroid, adrenal, and pituitary disorders, diabetes mellitus and its
complications)
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gastroenterology (upper and lower hemorrhage, hepatitis, cirrhosis,
pancreatitis, biliary diseases, small bowel, colon disorders)
hematology (bleeding diatheses, leukemia’s, lymphomas, diagnosis and
treatment)
infectious diseases (FUO, HIV / AIDS, as well as other viral, parasitic,
bacterial and fungal infections), diabetic infections and pneumonias
neurology (altered mental status, cerebrovascular diseases, seizures,
neuropathies)
oncology (solid tumors, chemotherapy, and oncologic emergencies (crosscoverage)
pulmonary (asthma, COPD, interstitial lung disease, and infections), smoking
cessation
nephrology (glomerulonephritis, management of fluid and electrolytes
nephrosis, and indications for hemodialysis) and acute renal failure
rheumatology (SLE, vasculitis) diseases
psychiatric (suicide ideation and attempt, drug overdose and toxicity,
drug/alcohol withdrawal)
IV. PRINCIPAL TEACHING METHODS
A. Training Sites
University Medical Center
All of the inpatient general ward service experience occurs at University
Medical Center (UMC).
B. Patient Characteristics
A diverse patient population, male and female, of all ages from adolescent
to geriatric, representing most ethnic and racial backgrounds, from all
social and economic strata. The hospital serves primarily the indigent
population of Clark County but any patient, presenting to UMC who
requires admission, without a primary physician in Clark County or one
who does not admit to UMC, is admitted to the resident service.
C. Mix of Diseases
The patients seen will represent a very wide spectrum of medical problems
encountered in an inpatient setting. Most of the patients are admitted
through the Emergency Department and display either an initial
presentation of an acute problem or an exacerbation of a chronic condition.
There are very few elective admissions or tertiary referrals. On occasion, a
patient will be accepted in transfer from the Air Force Hospital at Nellis
AFB, the VA ambulatory clinic, or an outside hospital.
D.
Faculty – Teaching Methods
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Responsibility: Faculty will provide a minimum of two medical
literature articles per week per team for resident review and discussion
on teaching rounds.
b) Bedside rounding will occur on the post-call day and one other day of
the four-day cycle. Bedside rounding will focus on history taking,
physical examination skills, chart review, and review of medical
records.
c) The Attending Physician will be responsible for rounds starting and
stopping on time so that:
1) Work-hour restrictions are met.
2) Resident can attend Morning Report and Noon conferences
(exceptions may be made for post-call days and emergencies)
3) 4 ½ hours of teaching rounds occur each week.
4) Approval of all days off at the beginning of the month.
Days off during the week are strongly discouraged.
5) Be available or arrange coverage during all attending days to
Respond to resident calls and evaluate seriously ill patients if
needed.
a)
Approval of all days off must occur at the beginning of the month. Days off
during the week are strongly discouraged.
Didactic Teaching
Morning Report
Residents are required to maintain greater than 60 % attendance at morning report.
Morning Report begins at 8 a.m. on Monday through Thursday and at 8:30 a.m.
on Friday.
Noon Conference
Residents are required to maintain greater than 60 % attendance at noon
conference. Noon conference occurs daily, Monday through Friday. These
sessions cover the basic core curriculum, and other curriculum topics such as
ethical issues, geriatrics, computer systems and informatics, health care systems,
occupational and environmental health issues, and other topics of concern.
Attending Rounds
Didactic discussions will be held regarding all primary inpatients occurring during
the month. Teaching rounds by the attending physician will occur every day for
45 - 60 minutes after regular management rounds.
E. Types of Clinical Encounters
In all instances, residents will have first contact with the patients and will be
supervised by the attending physician. The patient encounters are consistent with
what is typically seen on an inpatient resident service. Patients will be followed
from admission (largely through the emergency department) through their ward
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hospitalization to discharge. The residents are the primary physicians for each
patient on the hematology/oncology service (cross cover). For each patient under
their care, they will conduct and dictate or write an admission history and physical
examination, and formulate a diagnostic and therapeutic plan. The residents will
examine each patient daily and write daily progress notes. The resident is also
responsible for dictating the discharge summary on each patient. The history,
physical examination and subsequent orders and progress notes will be reviewed
by the attending physician. The resident is expected to evaluate every patient
under his/her care on a daily basis. The resident is to confer with the attending
physician if there are any questions about the diagnostic or therapeutic plan on any
patient. The residents with also provide general medicine consults in conjunction
with the attending physician. The resident will review the patient record, obtain a
patient history and perform a physical examination. The resident will review all
available laboratory and imaging data and then formulate a differential diagnosis
and recommendations for continued evaluation and treatment. The resident will
also discuss the patient with the attending physician. Patients are also accepted in
transfer from both the ICU and CCU. The residents will interview and examine
each patient and write a transfer-accept note. Residents will also provide crosscoverage of patients on the residents services during off hours (weekends,
holidays and nights). Most patients will also be seen after discharge in the
outpatient clinic thus ensuring continuity of care.
The general medical ward service is comprised of four teams. Each team has two
first-year residents (interns), two senior residents (second- or third-year residents),
and one attending physician. The two interns rotate call every fourth night and are
required to stay overnight. The senior residents rotate call every fourth day. The
short call resident takes admissions from 7 a.m.-4 p.m. and the team’s night-float
takes admission from 4 p.m. until 7 am the next morning with up to six additional
hours for transfer of care. Patients admitted before 3 pm will be the responsibility
of the short call resident.
F. Procedures
Abdominal Paracentesis
Thoracentesis
Central Venous Line Placement (internal jugular; subclavian, femoral)
Lumbar Puncture
Breast Examination
Pelvic Examination
Rectal Examination
V. CORE EDUCATIONAL MATERIALS
Educational Resources
Work rounds with resident and/or attending physician (daily)
Attending physician management and/or teaching rounds (daily)
Morning Report daily
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Department Noon Conference Series (daily)
Intern Report (Friday 8:30 a.m.)
UMC Grand Rounds (Friday 7:30 a.m.)
Department M & M Conference (monthly)
Journal Club (quarterly)
Department of Medicine Reference Library
UMC Library (hard copy and on-line references)
Hours: Monday - Friday, 7:30 am – 4:00 pm
UNSOM Savitt Medical Library (on-line)
Reading List
Harrison’s Principle’s of Internal Medicine, Kasper DL (editor), 16th ed.,
McGraw Hill
Cardinal Manifestations of Disease, pp. 53-360.
Oncology and Hematology, pp. 493-730.
Infectious Diseases, pp. 749-1206.
Disorders of the Cardiovascular System, pp. 1229-1345.
Disorders of the Respiratory System, pp. 1407-1419.
Disorders of the Kidney and Urinary Tract, pp. 1495-1574.
Disorders of the Gastrointestinal System, pp. 1579-1737.
Disorders of the Immune System, Connective Tissue, and Joints, pp. 17531928.
Endocrinology and Metabolism, pp. 1965-2214.
Neurologic Disorders, pp. 2277-2503.
VI.
EVALUATION
A. Of Residents
At the completion of each rotation, all clinical faculty are required to complete the
standard ABIM resident evaluation form. All clinical faculty are required to
provide face-to-face feedback with the residents. In addition, residents may
receive interim feedback utilizing the ABIM’s Praise and Early Warning cards.
B. Of Rotation and Preceptor
All residents are strongly encouraged to evaluate the rotation, and the
clinical faculty member, at the completion of the rotation. These evaluations are
then converted to type and shared anonymously with the clinical faculty quarterly.
The program director also discusses the rotation with the residents to
ensure rotation quality and satisfaction. This will be done at the form completion
monthly meeting or separately.
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Inpatient General Medicine Rotation Resident Check List
1. Evaluation reviewed at mid-month and end of rotation by the supervising faculty
member and resident.
2. Completed assigned readings
3. Attended all assigned activities (excluding scheduled time away, required clinics and
emergencies).
4. Completed required case report abstracts and/or posters if assigned by the supervising
faculty member.
5. Demonstrated understanding of the basic principals of medical diagnosis and
management
6. Received verbal feedback from attending at end of rotation.
Intern/Resident Signature_________________________
Date___________________
Supervising Attending Signature ___________________
Date__________________
All items must be completed for rotation credit and checklist returned to the
Department of Medicine by the rotation’s end.
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