Department of
Medicine
2008-2009
Curriculum
2
A. General Information
1. Organization and Structure
a.
The Department of Medicine at the University of North Carolina at Chapel
Hill provides an integrated, progressive experience for residents in their 36month training period. The goal of our curriculum is to prepare residents to
be well-trained general internists. We believe this type of training not only
prepares our residents for careers in General Internal Medicine but also
provides the necessary foundations for further training as a subspecialist.
The curriculum in the Department of Medicine changes greatly from the
PGY-1 year to the PGY-3 year. The PGY-1 year consists of 9 months of
inpatient rotations and 3 months of ambulatory medicine. During the
second and third years, residents spend an increasing amount of time in the
outpatient setting, so that by the time a resident is in the PGY-3 year, a
majority of rotations occur in ambulatory medicine. The curriculum will be
specifically described for each of the 3 years of training.
The PGY-1 Year
Competency- based Goals and Objectives
The PGY-1 curriculum is taught in a series of monthly rotations linked with a
number of Departmental teaching conferences. On all rotations the role of the PGY-1
resident is to serve as the primary physician for all of his/her patients. In this role the
PGY-1 resident:
1.
2.
3.
4.
5.
6.
Performs a history and physical examination on each new patient
Enters all orders
Communicates with the patient and ward team regarding daily
progress
Enters a history and physical and daily progress notes into the
patient record
Develops a diagnostic and therapeutic plan for each patient
Enters a discharge summary into the patient record
The monthly rotations for each PGY-1 resident are as follows:
Cardiology/MICU - 2 months
Inpatient General Medicine Ward - 2 months
Inpatient Subspecialty Wards - 5 months
Emergency Room - 1 month
Same-Day Clinic - 1 month
Ambulatory Elective-1 month
Cardiology - consists of 30 beds covered by four teams. Each team is made up of 1 upper
level resident and 1 PGY-1 resident. One faculty member and one subspecialty resident
are assigned to each team to assist in patient management and to conduct teaching
rounds. Didactic teaching rounds and bedside teaching occur daily. Also, there is a
weekly core curriculum lecture series that is case-based.
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3
A copy of the Cardiology Curriculum is included in Section 2. Common diagnoses
of patients admitted to the cardiology service include myocardial infarction, arrhythmias,
and chronic heart failure. Residents follow patients in the CCU (12 beds) and the general
floor (20 beds). Residents on service place central lines including Swan Ganz catheters
and perform arterial blood gases and thoracenteses.
ICU - consists of 19 beds in a MICU. There are 4 teams, each team consisting of 1 upperlevel resident and 1 PGY-1 resident. One faculty member serves as attending in the
MICU, another in the RICU. There is also a Critical Care Fellow. Teaching rounds
include didactic presentations (30 min/day, 6 days/week), bedside teaching (2
hours/day, 7 days/week), and x-ray teaching (30 minutes/day, 6 days/week). There is a
designated curriculum (Section 2). Patients admitted commonly have the following
diagnoses: GI bleeding, septic shock, drug overdose, s/p cardiopulmonary arrest, DIC,
COPD exacerbation, cystic fibrosis, rejection s/p lung transplant, and acute renal failure.
Residents perform all procedures.
Inpatient General Medicine - consists of 2 general medicine services. For each service,
there is 1 attending, 1 upper level resident, and 2 PGY-1 residents. Teaching rounds
occur for 1 hour, 5 times per week covering a number of topics described in the Inpatient
General Medicine curriculum (see Section 2). Patients admitted have a variety of
problems including: community -acquired pneumonia, COPD exacerbation, diabetic
complications, and lupus complications. Residents perform all procedures.
Also, residents rotate at Wake Hospital, a community hospital in Raleigh, NC.
There are four teams consisting of 1 attending, 1 upper level resident and 1 resident.
Teaching rounds occur for 1 hour five times per week covering topics in General Internal
Medicine. Residents perform all procedures.
Inpatient Subspecialty Wards
Medicine
Medicine
Medicine
Medicine
Medicine
Service
A - Geriatrics
B - Nephrology
E - Hematology/Oncology
G - Pulmonary
K - Infectious Diseases
# Beds
24
24
48
24
24
For each service there is one attending, one upper level resident, and two PGY-1
residents. Each of these services has daily work rounds and attending rounds. Each
service has designated teaching time occurring at a minimum of 5 hours per week.
During teaching time a series of topics pertinent to each service are reviewed. A copy of
each curriculum is included in Section 2. Residents perform all procedures on these
services.
Emergency Room - faculty from the Department of emergency medicine supervise PGY-1
residents. PGY-1 residents have a generic experience seeing medical, surgical, and
obstetrics/gynecology patients. There are four hours of didactic teaching per week,
which cover a wide variety of topics. Examples of monthly topics are included in Section
3.
3
4
Same-Day Clinic - faculty in the Division of General Internal Medicine supervise PGY-1-3
residents. A variety of outpatient problems are encountered. Didactic teaching takes
place daily for 30 minutes to 1 hour. Subjects covered in the curriculum are included in
Section 3.
This is a walk-in clinic for the established IM patients.
Ambulatory Elective – PGY-1 residents spend one month on a subspecialty service of the
Department of Medicine. Consultations are done on inpatients and outpatients and
patients are also seen in subspecialty clinics. Division faculty provides faculty
supervision. Curricula for each rotation are included in Section 3
Teaching Conferences - PGY-1 residents attend a series of Departmental Conferences. The
daily work schedule is set up to allow PGY-1 residents to attend the conferences (Table
1).
TABLE 1
UNC Department of Medicine - Schedule of Daily Activities
Time
0700
0730
1000
1000
1100
1200
Monday
Pre-Rounds
Work Rounds
Tuesday
Pre-Rounds
Work Rounds
Wednesday
Pre-Rounds
Work Rounds
Thursday
Pre-Rounds
Work Rounds
Friday
Pre-Rounds
Work Rounds
Residents Report
Attending
Rounds
Core Curriculum
Residents Report
Attending
Rounds
Core Curriculum
Residents Report
Attending
Rounds
Intern Conference
Residents Report
Attending
Rounds
Grand Rounds/
Morbidity and
Mortality
Conference
Residents Report
Attending
Rounds
EBM Conference
4
5
Residents are expected to attend all conferences. The conferences are as follows:
Monday – Residents Core Curriculum Conference - 1 hour
Tuesday – Residents Core Curriculum Conference - 1 hour
Wednesday - Interns Conference - 1 hour
Thursday - Grand Rounds - 1 hour
Friday - EBM Conference - 1 hour
The content of some of these conferences is briefly described. Lecture topics are
included in Section 4.
Monday and Tuesday - Residents Conference - Faculty in the Department of Medicine
presents a series of lectures covering focused topics.
Wednesday - Interns Conference - A lecture series of Emergency Medicine Topics mixed
with case-based group discussion.
Thursday – Grand Rounds
Thursday-Mortality and Morbidity–The morbidity and mortality conference centers on a
subject relating to patient care in the department. The Vice-Chair of the
department conducts this conference
Friday – Evidenced Based Medicine Conference – An evidence-based medicine discussion
of selected literature by both faculty and residents.
The PGY-1 year
ACGME Competencies
Each PGY-1 resident must develop competence in the following:
Patient Care
Medical Knowledge
Practice-based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
System-based practice
In the context of the above rotations, competency is defined for each of the categories
Patient care- medical interviews, physical examinations, review of data, procedural skills,
diagnostic and therapeutic decision making
Medical Knowledge – basic and clinical science, evidence-based medicine, literature
searching
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6
Practice-based Learning and Improvement – evaluation of own performance,
incorporation of feedback, use of technology for patient care and self-improvement
Interpersonal and Communication Skills – establishment of relationship with patients
and families, education and counseling of patients, team skills with colleagues
Professionalism – demonstration of respect, compassion, integrity, and honesty,
commitment to self-assessment, acknowledges errors, considers needs of patients and
colleagues
System-based Practice – ability to utilize resources, uses a systematic approach to reduce
errors and improve patient care
These competencies are reviewed with all residents and faculty and serve as the
foundation for monthly evaluation.
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7
The PGY-2 Year
Competency-based Goals and Objectives
The PGY-2 year is also composed of a series of monthly rotations coupled with
Departmental teaching conferences. On inpatient rotations the role of the PY-2 resident
is to be in charge of ward team. In this role the PGY 2 resident:
1.
2.
3.
4.
5.
Performs a history and physical examination on each new patient
Reviews the treatment plan for each new patient with the PGY 1 resident
Reviews the performance of MS 3 students
Conducts daily work rounds
Supervises all procedures
On night float the resident assumes primary responsibility for the care of new patients in
a role like that of the PGY 1 resident.
Monthly rotations for a PGY-2 resident are as follows:
6.
7.
8.
9.
10.
11.
12.
MICU – 1 month
Cardiology - 2 months
UNC Inpatient Medicine Ward – 2-3 months
Ambulatory General Internal Medicine – 2-3 months
Subspecialty Consultation – 2-3 months
Wake Med – 1 month
Night Float 2-3 2 week blocks
Cardiology/ICU/Inpatient General Medicine Wards / Inpatient Subspecialty
Wards- These have been previously described under the PGY-1 resident. The
role of the PGY-2 resident on these services is supervisory. The PGY-2 resident
evaluates all patients on service and the PGY-2 resident is integral in
constructing a plan of care, which is carried out by the PGY -1 resident. Another
major responsibility is teaching. The PGY-2 resident teaches and supervises
medical students on these services.
Ambulatory General Internal Medicine - PGY-2 residents can choose from several
month blocks focusing on outpatient skills of the generalist. Some of the choices
are:
Wake Hospital Ambulatory Rotation Siler City - PGY-2 residents spend the month in a community setting,
supervised by general internists.
Subspecialty Consultation - PGY-2 residents can choose among any subspecialty
in the Department of Medicine. Consultations are done on inpatients. Patients
are also seen in subspecialty clinics. Division faculty provides supervision.
Curricula for each rotation are included in Section 3.
Night Float - PGY 2 residents report at 7 PM and until 7 AM and are responsible
for the primary evaluation and management of all non-intensive care
patients admitted to the Department of Medicine. At 7 AM the care of
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8
those patients goes to the incoming team on call. The Attending
Physician of the service provides supervision where the patient is
admitted.
Teaching Conferences - Like PGY-1 residents, PGY-2 residents attend a series of
conferences, which are integrated with the daily work schedule. Some have been
described previously including Monday Resident Core Curriculum Tuesday Core
Curriculum, Thursday - Grand Rounds, and Friday Evidence Based Medicine. In
addition, PGY-2 residents attend Morning Report. This is case-based with
residents presenting unknown patients to their peers. The presenting resident
completes his/her presentation with a review of a particular subject. This review
like all presentations is posted on the internet so that residents my review this at
their leisure. These conferences are coordinated by the Chief Residents. The
curriculum is set by the chief resident. A list of topics discussed is included in
Section 4.
The PGY-2 Year
ACGME Competencies
Each PGY-2 resident must demonstrate competence in the following:
Patient Care
Medical Knowledge
Practice-based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
System-based Practice
Competency is defined as outlined above for PGY 1 residents and is used for the monthly
evaluation of PGY-2 residents
The PGY-3 Year
Competency –based Goals and Objectives
In many ways the PGY-3 year is similar to the PGY-2 year in that the residents function
as described previously under the PGY-2 year, include teaching conferences. The
rotations however, are different, and are as follows:
1.
2.
3.
4.
5.
6.
Wake Med – 0-1 Month
UNC Inpatient Medicine Wards – 1-2 months
Same Day Clinic - 1 month
Ambulatory General Internal Medicine – 2-3 months
Subspecialty Consultations – 2-3 months
Special Electives - 1 month
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9
7.
8.
MICU or Cardiology – 1 month
2-3 2 Week blocks night float
Inpatient General Medicine Wards / Inpatient Subspecialty Wards - The role of the PGY-3
residents is identical to that described previously for the PGY-2 resident.
Same –Day Clinic - The role of the PGY-3 residents is identical to that of the PGY-1
resident.
Ambulatory General Internal Medicine - PGY-3 residents can choose from several month
blocks including those described for PGY-2 residents. There are additional
choices as follows:
General Medicine Consults- PGY-2 or 3 residents see patients on other services,
providing General Medicine Consultations. Supervision is provided
faculty from the Division of General Internal Medicine.
Geriatric Medicine - In a one-month block, PGY2-3 residents are exposed to
outpatient management of this population. Faculty trained in Geriatrics provide supervision
Subspecialty Consultations - The role of the PGY-3 resident is the same as described for
the PGY-2 resident on those rotations.
Special Electives - These rotations are designed to enhance individual training. Residents
pick a faculty mentor to conduct clinical or basic research. Rotations at other institutions can
also be
done.
The PGY-3 Year
ACGME Competencies
Each PGY-3 resident must develop competence in the following:
Patient Care
Medical Knowledge
Practice-based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Systems-based Practice
Competency is defined as outlined above for PGY 1 residents and is used in monthly evaluation.
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SECTION 2
INPATIENT CURRICULUM
Cardiology
Intensive Care Unit
General Medicine
Geriatrics
Nephrology
Hematology/Oncology
Pulmonary
Infectious Diseases
Neurology
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Section 2
Inpatient Curriculum
General
Each inpatient service has designated teaching time, previously described in Section 1. It
is the responsibility of the division faculty to review a series of topics during the monthly
rotation. The respective division generates these topics with input from faculty and
residents as well as data supplied to each division from the preceding In-Training
Examination. A dominant theme for these conferences is to review material a general
internist must know about each discipline. The curricular goal for each resident is to
have a working knowledge of these subjects.
CARDIOLOGY INPATIENT CURRICULUM
OBJECTIVE 1. Takes a history
Demonstrates knowledge necessary to obtain an orderly history on patients suspected of having
cardiovascular diseases and recognizes the importance of
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Dyspnea (resting, exertional, nocturnal, positional)
Chest pain (specifically, what constitutes “typical angina)
Edema
Palpitations/arrhytbinias
Exercise tolerance, semiquantitative
History of hypertension and u~eatrnent
History of rheumatic fever
History of congenital heart disease
History of cardiac murmurs or valvular disease
Cardiovascular risk factors, including family history
Presyncope and syncope
Claudication
OBJECTIVE 2. Performs a physical examination
Demonstrates knowledge necessary for performing an orderly, systematic and adequate physicaL
examination of patients with cardiovascular problems and recognizes the importance of
A. ARTERIAL SYSTEM & JUGULAR VENOUS PULSE
1.
Reports and demonstrates the correct method of measuring arterial blood pressure
2.
Is familiar with difficulties in measuring arterial blood pressure accurately:
a. Variation between extremities, position, and level of extremity
b. The auscultatory gap
c. Proper cuff size
3.
Is familiar with normal and common abnormal findings found by inspection or
palpation of the venous and arterial pulses, inc1uding the foilowing:
a. a,c,v, waves; visual estimation of central venous pressure; hepatojugular
reflux
b. effect of inspiration on neck veins
c. pulsus alternans, pulsus bisferiens, pulsus paradoxus
d. act-tic regurgitation and stenosis
B.
EXAMINATION OF THE HEART
1.
Discusses normal and common abnormal findings found by inspection and
palpation of anterior chest. including the following:
a. Right and left ventricular heaves: palpable A-waves
b. Thrills
2.
Understands the events of the cardiac cycle and the genesis of:
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a.
b.
c.
d.
e.
f.
g.
h.
Si, S2, S3, S4, summation of gallop, splitting of 52 (normal & reversed), and
opening snap
mitral valve clicks
semilunar valve ejection sounds
Artificial valve sounds (normal & abnormal)
Innocent murmurs, including flow murmurs, venous hums, mammary souffles
Murmurs of vaivular stenosis and regurgitation
Maneuvers that alter murmurs, i.e. Valsalva, squatting, inspiration, expiration
Pericardial rubs
OBJECTIVE 3. Orders or performs diagnostic studies and interprets laboratory data in a
reasonable and cost-effective manner
A.
ELECTROCARDIOGRAPHY (EKG)
1. General knowledge of the range of normal variation in P, QRS, ST, T wave
2. Understanding of EKG diagnosis of LVH, left atrial enlargement, acute ischemia and
patterns of mvocardial infarction
3. Basic understanding of the diagnostic utility of the EKG in the diagnosis of
arrnytbmias
B.
CHEST X-RAY
1. General knowledge of normal chest x-ray findings
2. Apvreciation of abnormalities- seen in:
a. heart failure
b. valvular disease
c. hypertensive disease
d. ischemic heart disease
e. common congenital abnormalities seen in adulthood
C.
NON-INVASIVE TESTING
1.Basic appreciation of the indications for:
a. echocardiographic assessment (transthoracic and transesoDhageal) including 2D
and Doppler echocard.iography
b. ambulatory EKG (Holter) monitor
c. exercise testing with and without perfusion scintigraphv. Including an
understanding of the meaning of sensitivity and specificity with regards to the
latter test in the diagnosis of coronary disease
d. tomograpbic imaging techniques, including MRI and CT
D. INVASIVE TESTING
1. Basic knowledge of the methodology involved in performing coronary angiographv,
left ventricular hemodynamic assessment and electrophysioiogic testing;
understands the indications and risks of invasive diagnostic procedures
OBJECTIVE 4. Understands the pathophysiology, natural history, clinical presentation,
diagnostic workup and management of:
A. HEART FAILURE
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1.
2.
3.
4.
Altered myocardial hemodvnamics as well as abnormal neuroendocrine responses
Precipitating causes of worsened heart failure
Mechanisms and importance of diastolic dysfunction
Therapy including relative value and limits of diuretics. digoxin. vasodilators, beta
blockers, inotropes, fluid restriction, and other pharmacologic and nonpharmacologic therapies
B. CORONARY ARTERY DISEASE
1. Risk factors for coronary artery disease and their modification
2. Differential diagnosis of chest pain
3. Chronic and acute ischemic syndromes (unstable angina and acute MI) with
emphasis on proper history taking 4. Noninvasive and invasive testing in patients with suspected coronary artery disease
5. Complications in acute post-myocardial infarction syndromes such as arrhythmias,
sudden death, mechanical lesions, pericarditis and cardiac rupture
6. Indications for coronary angiography
7. Role of interventional procedures (e.g. PTCA) and cardiac surgery in treatment of
coronary artery disease
C. ARRHYTHMIAS
I.
Bradyarrhythmias including various forms of conduction disturbances and AV block,
with emphasis on the indications for pacing
2. Tachyarrhythmias, including an emphasis on the EKG diagnosis of wide complex
tachycardias
a. atrial
1. atrial tachycardia/AV nodal reentrant tachycardia
2. atrial fibrillation
3. atrial flutter
b. ventricular
1. premature ventricular contractions (PVCs)
2. ventricular tachycardia
3. torsades de pointes
4. ventricular fibrillation
c. pre-excitation syndromes (e.g. Wolff-Parkinson-White)
3. Understands the importance of the use of catheter ablation techniques in treatment
of
supraventricular arrhythmias, including atrial fibrillation
D. CARDIOMYOPATHY
E.
1. Differential diagnosis and laboratory assessment
2. Treatment including indications for cardiac transplantation and mechanical cardiac
support
3. Follow-up of the post-transplant patient
VALVULAR HEART DISEASE
1.
2.
3.
4.
Acute rheumatic fever, including diagnostic criteria
Aortic stenosis/regurgitation
Mitral stenosis/regurgitation
Tricuspid stenosis/regurgitation
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5. Pulmonary stenosis/regurgitation
6. Mitral valve prolapse
F. PERICARDITIS
1. Acute: etiologv, symptoms and diagnosis
2. Chronic: including large pericardial effusion, cardiac tamponade and the indications for
pericardiocentesis
3. Diagnosis and management of constrictive pericarditis
G.
CARDIAC TUMORS
1. Cardiac involvement in metastatic cancer
2. Myxoma
H.
CONGENITAL HEART DISEASE
1.
Diagnosis, history and physical of the adult with congenital heart disease especially for
the diagnosis of
a.
b.
c.
d.
e.
atrial septal defect
ventricular septal defect
aortic stenosis
pulmonic stenosis
coarctation of the aorta
2. Basic understanding of the adult with partially corrected congenital heart disease and
post-op complications of the more common repair procedures such as:
a. transposition of the great vessels
b. tetralogy of Fallot
a. Ebstein’s anomaly
PULMONARY HEART DISEASE
1.
2.
3.
J.
Cor pulmonale
Pulmonary embolism
Primary pulmonary hypertension
CARDIAC INVOLVEMENT IN SYSTEMIC ILLNESSES
1.
2.
3.
4.
5.
6.
Diabetes mellitus
Thyroid disease
Obesity
Thiamine deficiency
Pheochromocytoma
Rheumatic disorders including scleroderma, SLE, temporal arteritis. polyarteritis nodosa
and rheumatoid arthritis
7. Pulmonary embolism and deep venous thrombosis
8. Arterial embolism
K. PERIPHERAL VASCULAR DISEASE
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1.
Arteriosclerosis obliterans (ASO)
2. Aneurysms
a. abdominal aortic
b. thoracic aortic (including aortic dissection)
c. peripheral vascular
L. MISCELLANEOUS CARDIAC CONDITIONS
1. Trauma to the heart and great vessels
2. Infectious diseases
a. viral myocarditis
b. infectious endocarditis
3.
Assess preoperative risk for non-cardiac surgery
OBJECTIVE 5. Develops treatment plan for common cardiac problems
A. For each major disease of the cardiovascular system identifies the appropriate therapeutic
approach
B. Understands the indications for and can perform the following:
1.
2.
3.
4.
5.
Cardiopulmonary resuscitation and advanced life support
Emergency cardioversion
Carotid massage
Central venous pressure catheter insertion
Recognizes the possible need, and requests medical consultation, for the performance
of the following therapeutic procedures:
a.
b.
c.
d.
transvenous pacemaker
pericardiocentesis
Swan-Ganz catheter insertion
elective cardioversion
C. For each of the treatments and drug types listed below identifies indications, dose,
mechanism of action, main effects, side effects, adverse reactions, interactions, cost, efficacy,
and appropriate follow-up:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Digitalis and other inotropic agents
Antiarrhythmic drugs
Diuretics
Calcium channel entry blockers
Beta blockers
Angiotensin-converting enzyme inhibitors
Vasodilators
Anticoagulants & thrombolytic therapy
Antihypertensive agents
Lipid-lowering agents
Rheumatic fever prophylaxis
Endocarditis prophylaxis
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13.
14.
15.
16.
Nitrates
Angiotensin receptor blockers
Aldosterone antagonists
Inotropes
D. Informed, aware, and able to participate in and teach to patients, students, medical
personnel and
colleagues regarding:
1.
2.
3.
4.
5.
6.
7.
Preventive cardiology and patient education
Psychological aspects of cardiac disease
Behavioral therapy including stress management, risk factor reduction, etc.
Proper nutrition, especially regarding lipid management and obesity
Medical “cost/benefit” including different national systems and medical care rationing
Preventive cardiology
The clinical trial and meta-analysis
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INTENSIVE CARE UNIT INPATIENT CURRICULUM
Resuscitation
BCLS and ACLS
Shock: Causes, assessment and treatment
Early Goal Directed Therapy for Septic Shock
Pulmonary
Respiratory failure: Hypoxemic and Hypercapnic
Intubation criteria, oral/nasal/tracheostomy, complications
Mechanical ventilator modes, monitors and complications
Weaning criteria and techniques, daily spontaneous breathing trials
ARDS: Causes, Physiology, Therapy and Complications
Asthma and COPD
Pulmonary embolism
Pulmonary hemorrhage
Cardiology
Shock: Differential diagnosis and initial treatment
Acute MI: Diagnosis, treatment, and complications
Arrhythmias
Pericarditis, Tamponade and Constrictive Pericarditis
CHF and Pulmonary edema
Pulmonary artery catheters: Indications, placement, and interpretation
Inotropic drugs
Nephrology
Acute Renal failure: Causes and treatment
Renal Replacement Therapy: Continuous and intermittent
Electrolyte abnormalities: Na+, K+, C1Acid-Base disturbances and compensations
Metabolic acidosis: Increased and normal anion gap
Urine electrolytes
Metabolism
Nutrition: Assessment, requirements, eternal feeding, TPN
Diabetic ketoacidosis and non-ketotic hyperosmolar coma
Adrenal crisis and steroid therapy
Gastrointestinal
Upper GI hemorrhage
Lower GI hemorrhage
Liver disease: Alcoholic, viral, other
Pancreatitis
The acute abdomen: Causes and Assessment
Poisons
Initial assessment and treatment options
Acetaminophen
Anti-depressants
Salicylates
Alcohols
Infections
Pneumonias: Community-acquired, hospital-acquired including VAP
Aspiration pneumonitis
Central Line Related Bloodstream Infections: Prevention and management
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Tuberculosis
Immunocompromised patients and opportunistic infections
Hematology
Anemia and transfusions
Thrombocytopenia, coagulopathy and DIC
Hemolysis
Sickle Cell Disease
Administration/Ethics
Admission and discharge criteria
Illness severity scores and prognoses
Advance Directives
Use/limitation of life sustaining treatments
Practice and Systems Based Improvements: protocols and data monitoring
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GENERAL MEDICINE INPATIENT CURRICULUM
Likelihood Ratios; testing
Community Acquired Pneumonia
Physical Examination
Pulmonary Emboli
Chest Pain Evaluation; CAD
Diabetic Ketoacidosis, complications
Meningitis
Venous Stasis Ulcers
Peripheral Vascular Disease
W/U of Diarrhea
COPD, acute exacerbation
Depression, mood disorders
Stroke, endarterectomy
Hypertension Emergencies
Common Biliary Tract Diseases, Cholecystitis, Cholangitis
Dementia
Delirium
Diverticulitis
Avitaminoses
Peripheral Neuropathy
Cellulitis
Pulmonary Nodule
Anemia, chronic disease, liver disease, etc.
Pancreatitis
Poisonings, ethylene glycol, arsenic, etc.
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Geriatrics Inpatient Curriculum
Geriatrics Curriculum for Internal Medicine
Residents
Current requirements from the Residency Review Committee for Internal Medicine, as outlined by
the Accreditation Council for Graduate Medical Education, specify that “Residents must have
formal instruction and assigned clinical experience in geriatric medicine. The
curriculum and clinical experience should be directed by an ABMS –certified geriatrician.
These experiences may occur at one or more specifically designated geriatric inpatient
units, geriatric consultation services, long-term care facilities, geriatric ambulatory
clinics, and/or in home care settings.”
The Department of Medicine at the University of Chapel Hill currently has a separate Division of
Geriatric Medicine with faculty and fellows in graduate medical training who are dedicated to the
education of medical students and residents.
Currently residents receive training in the care of geriatric patients in both the inpatient and
outpatient settings.
Inpatient Geriatric Curriculum:
UNC currently has a Geriatric Inpatient Service that is always staffed by one of the faculty from
the Division of Geriatric Medicine. Internal Medicine residents who rotate on this service work
closely with the Geriatrics Faculty Attending in the care of older adults with acute medical
illnesses.
Based upon the guidelines as outlined by the AGS Education Committee in 2004, resident
trainees on this rotation will meet the following goals in attitudes, knowledge and skills required
for the appropriate care of older patients.
1.
Attitudes: This training program encourages respect for older people and their
autonomy. The rotation on the inpatient service promotes compassionate, high quality
care. Residents gain an appreciation for the heterogeneity in older people in respect to
functional status, health, values and personal preferences. The resident learns the skills
needed to negotiate the goals of care with the patient and family. Our inpatient service
offers a truly multidisciplinary experience and the resident learns the importance of this
approach to caring for older patients. The resident on our service works closely with a
Geriatric Nurse Practitioner, Recreational Therapist, Physical Therapy service, social
worker and specialized nurses interested in the care of older adults. The resident on this
service truly gains an appreciation for the fact that the maintenance of function and
quality of life may be more the goal than cure.
2.
Knowledge: Internal Medicine residents who complete a rotation on the inpatient service
will know:
a.
b.
c.
d.
e.
f.
Age related changes
Pharmacokinetics and the importance of polypharmacy
Appropriate history and physical exam
Decision making capacity, competence, autonomy, ethical considerations
Role of exercise and rehabilitation
Comprehensive geriatric assessment
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g. Recognition of malnutrition
h. Preoperative evaluation and postoperative care in older patients
i. End of life care, palliative treatments including management of pain,
dyspnea, and other symptoms
j.
Evaluation and management of :
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
Cognitive impairment/dementia
Depression
Incontinence
Gait and balance disorders, falls
Immobility
Pressure ulcers
Polypharmacy
Sensory impairment
Pain
Delirium
k. Difference in incidence, natural history, presentation, management, and
outcomes of medical problems when they occur in elderly patients
3.
Skills: The resident will be able to:
a. Perform assessments of basic and Instrumental Activities of Daily Living
(ADL and IADL), cognitive function, and gait and mobility
b. Work within an interdisciplinary team to develop a plan of care
c. Facilitate medical decision making with older patients, incorporating
medical assessment and patient values and preferences
d. Diagnose and manage acute and chronic multiple illnesses in older
patients
e. Conduct discussions regarding goals of care and end of life care
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NEPHROLOGY INPATIENT CURRICULUM
I.
Teaching materials
1. Reading materials: Selected articles and publications from journals and
nephrology database. (Up to Date)
II.
Topics to be discussed during Rounds:
1.
Hemodialysis and peritoneal dialysis: techniques
2.
Hemodialysis and peritoneal dialysis: dialysis prescription
3.
Evaluation of kidney structure and function
a.
Urinalysis
b.
Measurement of GFR
c.
Evaluation of proteinuria
d.
Measurement of urinary electrolytes
e.
Renal imaging techniques
4.
Chronic kidney disease
5.
Acute kidney injury
6.
Metabolic acidosis
7.
Metabolic alkalosis
8.
Disorders of water metabolism (hyponatremia and hypernatremia)
9.
Disorders of potassium and magnesium metabolism
10.
Disorders of calcium, phosphorus and bone metabolism
11.
Overview of evaluation and treatment of hypertension
12.
Glomerular syndromes
a.
nephritic syndrome
b.
nephrotic syndrome
13.
Diabetic nephropathy
14.
Principles of kidney transplantation
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24
HEMATOLOGY/ONCOLOGY INPATIENT CURRICULUM
Hematology/Oncology Inpatient Curriculum
Updated 6/2008
Goals: This rotation should acquaint you with the general principles of diagnosing and treating Hematologic
and Oncologic diseases. The inpatient services are divided into one that focuses on patients with malignant
hematologic diseases such as the leukemias(E1)and lymphomas and the other (E2) on the rest of oncology.
While there is some overlap in the services, we suggest that you focus you reading on the service you were
assigned to. Every effort will be made for you to do the other service at least once during your residency. A
case based teaching program to supplement your reading that combines patients from both services is done
from 11:30 to 12:15 on Mondays, Tuesdays, Wednesdays and Fridays.
1.
Acute Leukemia
a. ALL
b. AML
i. Genetics of AML
c.
Clinical Presentation of Acute Leukemia
i.
Laboratory Diagnosis
ii. Bone Marrow Examination
D. General Therapy for Acute Leukemia’s
i. Therapy for ALL
ii. Therapy for AML
Tallman MS, Nabhan G: Acute promyelocytic leukemia.Blood 2002;99:759-67.
2.
3.
Sickle Cell Disorders
Febrile Neutropenia
and infected catheters
Mermel LA et al: Guidelines for the management of intravascular catheter related infections. Clin Infect Dis
32:1249, 2001
4. Thrombotic Disorders
a. Major Risk Factors
b. Laboratory testing in thrombotic disorders
c. Management of a thombotic defect
d. Treatment and prevention of Thrombosis
5. Breast Cancer
a.
Risk Factors for breast cancer and risk reduction strategies
b. W/U of a suspicious breast mass
c. Primary therapy for a newly diagnosed breast cancer
d. Systemic therapy for breast cancer
e. Quality of life in breast cancer survivors
Fisher B et al: Twenty-year follow-up of a randomized trail comparing total mastectomy, lumpectomy, and
lumpectomy plus irradiation of the treatment of invasive breast cancer. N Engl J Med 347:1233, 2002
Wong ZW, Ellis MJ: First –line endocrine treatment of breast cancer: Aromatase inhibitor or antiestrogen?
Br J Cancer 90:20, 2004
Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an
overview of the randomized trails. Lancet 2005; 365, 1687
Ravdin PM et al: Computer program to assist in making decisions about adjuvant therapy for women with
early breast cancer. J Clin Oncol 2001; 19:980m
.
6. Colorectal Cancer
a. Risk factors for colorectal cancer
b. Clinical features of colorectal cancer
c. Staging of colorectal tumors
d. Management of resectable colorectal tumors
e. Post resection surveillance in colorectal cancer
f.
Management of patients with metastatic colorectal cancer
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25
Baron J et al: A randomized trial of aspirin to prevent colorectal adenomas. N Engl J Med 348:391, 2003
Walsh JME, Terdiman JP: Colorectal cancer screening; JAMA 289:1288, 2003
7.
Lung Cancer
a. Clinical presentation of lung cancer
b. Diagnosis and treatment of lung cancer
c. Non-Small Cell Lung cancer
d. Small Cell Lung cancer
American College of Chest Physicians: Diagnosis and management of lung cancer: ACCP evidence based
guidelines. Chest, 123:1S, 2003
8.
Cancer
a.
b.
c.
of Unknown Primary Site
Adenocarcinoma of Unknown primary site
Squamous cell carcinoma of unknown primary site
Poorly differentiated carcinoma of unknown primary site
Hainsworth JD, Greco FA: Management of patients with cancer of an unknown primary site. Oncology
14:563, 2000
9.
Lymphadenopathy, lymphoma and Multiple Myeloma
Diehl V et al: Hodgkin’s lymphoma---Diagnosis and treatment. Lancet Oncol 5:19, 2004
Barlogie B et al: Treatment of multiple myeloma. Blood 103:20, 2004
10. Prostate Cancer
a. The screening controversy
b. Treatment of prostate cancer
c. The Gleason Score
d. Comparison of Treatment modalities
e. Sequelae of treatment in prostate cancer
f.
Management of recurrent prostate cancer
Nelson WG et al: Prostate cancer. N Engl J Med 349:366, 2003
11. Testicular Cancer
Bosl GJ et al: Testicular germ-cell cancer. N Engl J Med 337:242, 1997
12. Oncologic Emergencies
a. Metabolic Emergences (Hypercalcemia, Hyperuricemia, and Hyponatremia)
b. Hematologic Emergency: DVT
c. Mechanical Emergencies (Spinal Cord Compression, SVC, Pericardial Effusión and
Tamponade)
Strewler GJ: The parathryid hormone-related protein. Endocrinol Metab Clin. North Amer 29:629,2000
Yim BT et al: Rasburicase for the treament and prevention of hyperuricemia. Ann Pharmacotherapy
37:1047, 2003
13. Chemotherapy, biotherapy and hematopoietic colony stimulate factors:
American Society of Clinical Oncology : Update of recommendations for use of hematopoietic colony
stimlating factors: Evidence-based clinical practice guidelines. J Clin Oncol 2000: 20;3558-85
14. Antiemetics
Wiser, W.Practical management of chemotherapy-induced nausea and vomiting
Oncology 2005;5: 637-45
15. Pain Management
Levy MH: Pharmacologic treatment of cancer pain. N Engl J Med 335:1124, 1996
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Pulmonary Inpatient Curriculum
Pulmonary Physiology
Gas Exchange
Mechanics
Measures of Function
Arterial blood gases
Lung volumes and DLCO
Imaging techniques
Obstructive Pulmonary (Airway) Diseases
Chronic Bronchitis
Emphysema
centrilobular
panacinar
Cystic Fibrosis
Bronchiolitis
Bronchiolitis obliterans
BOOP
Bronchiolitis obliterans associated with lung transplantation
Bronchiectasis
Asthma
Epidemiology and definition
Classification
"Intrinsic or nonallergic"
"Extrinsic or allergic"
Pathogenesis
Clinical manifestations and diagnosis
Therapy
Respiratory Infections
Community acquired pneumonias
Infections in the immunocompromised host
AIDS
Other causes of immunosuppression
Tuberculosis and nontuberculous mycobacteria
Anaerobic lung infections and aspiration
Empyema
Intersitial Lung Disease
Idiopathic pulmonary fibrosis
Drug induced
Connective tissue diseases
Sarcoidosis
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Eosinophilic granuloma
Lung Neoplasms
Carcinomas
Mesotheliomas
Benign tumors
Staging evaluation
Resectability
Lung Transplantation
Indications
Common diseases transplanted
Single versus double lung transplants
Survival
Complications
Pulmonary Vascular Disease
Pulmonary thromboemboli
Pulmonary hypertension
Pulmonary vasculitis
Alveolar hemorrhage/hemoptysis
Miscellaneous
Pleural diseases
Effusions
Pneumothorax
Occupational Lung diseases
Sleep disorders
Lymphangioleiomyomatosis
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MEDICAL HOUSESTAFF ACTIVITIES ON THE PULMONARY
INSERVICE ROTATION
1. Each houseofficer will be expected to prepare a minimum of three 20-30 minute, informal
lectures to be given to the rest of the team throughout the month.
2. Houseofficers are expected to attend Chest X-ray Rounds Monday, Wednesday and Fridays
at 2:30 PM.
3.
The medical houseofficers are encouraged to attend the pulmonary lectures and
conferences (Conference schedule enclosed).
MED G SYLLABUS JOURNAL ARTICLES
ASPIRATION PNEUMONIA
Aspiration Pneumonia. Lung Abscess, and Emphysema
ASTHMA
Review Article-Asthma
The Assessment and Management of Adults with Status Asthmaticus
COMMUNITY ACQUIRED PNEUMONIA
American Thoracic Society Clinical Guidelines for the Initial Management of Adults with
Community-Acquired Pneumonia
Current Concepts-Community Acquired Pneumonia
ATS-Guidelines for the Initial Management of Adults with Community -acquired Pneumonia:
Diagnosis, Assessment of Severity, and Initial Antimicrobrial Therapy
COPD
Management of Chronic Obstructive Pulmonary Disease-James F. Donohue, MI)
Current Concepts-Management of Chronic Obstructive Pulmonary Disease
CYSTIC FIBROSIS
Review Article-Drug Therapy Management of Pulmonary Disease in Patients with Cystic
Fibrosis
HEMOPTYSIS
Massive Hemoptysis: Assessment and Management
HOSPITAL-ACQUIRED PNEUMONIA
Hospital-acquired Pneumonia in Adults: Diagnosis, Assessment of Severity, Initial
Antimicrobial Therapy, and Preventative Strategies
LUNG MALIGNANCIES
Pulmonary Manifestations of Extrathoracic Management Lesions
Staging Systems of Lung Cancer
MYCOBACTERJAL DISEASES
Clarithromycin Regimens for Pulmonary Mycobacterium avium Complex
Control of Tuberculosis in the United States
Treatment of Tuberculosis and Tuberculosis Infection in Adults and Children
PNEUMOCYSTIS CARINII PNEUMONIA
Mayo Clinic Proceedings-Pneumocystis carinii Pneumonia in Patients without Acquired
Immunodeficiency Syndrome:
Associated Illnesses and Prior Corticosteroid Therapy
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29
Pneumocystis Carinii Pneumonia in Patients with the Acquired Immunodeficiency Syndrome
PULMONARY VASCULAR DISEASES
Invasive and Noninvasive Diagnosis of Pulmonary Embolism-Preliminary Results of the
Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-ped)
Clinical Features of Pulmonary Embolism-Doubts and Certainties
Value of the Ventilation/Perfusion Scan in Acute Pulmonary Embolism-Results of the
Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED)
Anticoagulation in the Prevention and Treatment of Pulmonary Embolism
Venous Thromboembolism
SARCOID
Conferences and Reviews-Enigmas in Sarcoidosis
SLEEP APNEA
Current Concepts-Obstructive Sleep Apnea
Treatment of Obstructive Sleep Apnea-A Review
MISCELLANEOUS
Mayo-Rare Pulmonary Neoplasms
Mechanisms of Disease -Hvpercania
Review Article-Mechanisms of Disease-Pathophysiology of Dyspnea
Dyspnea: Mechanisms, Assessment, and Management: A Consenus Statement
Review Article-Primary Pulmonary Hypertension
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INFECTIOUS DISEASE INPATIENT CURRICULUM
Antibiotics I (antibacterials)
Antibiotics II (antivirals and antifungals)
Pneumonia
HIV I
HIV II
Sepsis
Endocarditis
Skin and Soft Tissue Infection (including osteomyelitis)
Diarrhea
Urinary Tract Infection
FUO
New and unusual infections, including Lyme Disease and RMSF
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NEUROLOGY INPATIENT CURRICULUM
CURRICULAR COMPONENT: NEUROLOGY WARD ROTATION
I. OVERALL EDUCATION GOAL:
The goal of the ward rotation for residents is to learn the evaluation and management of
common neurological problems seen in the inpatient neurology setting. The resident will
be part of the Neurology ward team consisting of the neurology attending, neurology senior
resident, medicine and psychiatry interns, and medical students who are involved in the
care of inpatients on the Neurology ward service.
II. OBJECTIVES:
1. The resident will become competent in obtaining a neurological history and performing a
neurological exam on patients presenting to the Neurology inpatient service.
2. The resident will learn to effectively present neurological cases.
3. The resident will gain skill in the localization of various neurological symptoms and
findings seen on the Neurology inpatient service.
4. The resident will learn to generate a differential diagnosis for common neurological
symptomatology and findings seen on the inpatient service.
5. The resident will become an integral part of the Neurology team with the ability to both
synthesize cases for presentation to the neurology senior resident and attending.
6. The resident will gain competence and skill in the assessment of common neurological
problems seen on the Neurology inpatient service including TIA, stroke, delirium, intractable
epilepsy, Parkinson’s disease, myasthenia gravis, acute and chronic inflammatory
demyelinating polyneuropathy, polymyositis, acute low back pain, intractable headache,
multiple sclerosis, and myelopathic disorders.
7. The resident will learn the appropriate and cost effective evaluation of patients presenting
with various problems to the Neurology inpatient service.
8. The resident will gain ability in the use of laboratory tests, lumbar puncture, EMG/nerve
conduction studies, EEG, evoked potentials, CT, MRI, and other studies in the evaluation
and management of neurology inpatients.
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III. EVALUATION:
The residents will be evaluated directly by the faculty member assigned to the Neurology
ward service. The faculty members will directly observe the residents’ presentation of cases,
and their assessment and plan for the management of patients with neurological disorders.
The attending will provide feedback to the resident during the rotation regarding their skills
in the assessment and management of neurological patients. In addition, the faculty member
will assess the resident’s ability to be an integral member of the Neurology ward team,
including their ability to interact with other members of the ward team and ancillary
personnel. At the end of the rotation, the faculty member will complete a standard evaluation
form, which will be keyed to the learning objectives of the rotation.
IV. LEARNING ACTIVITIES OF THE ROTATION:
Residents on the Neurology rotation will round with the neurology ward team each weekday
and on one weekend day. They will have an opportunity to present cases and be critiqued on
both their evaluation and management ability. Residents will have the opportunity to observe
the attendings history taking and neurological examination on neurology inpatients. The
residents will also be present when the attending discusses their assessment of neurology
inpatient cases with the neurology inpatient ward team, as well as didactic presentations by
the attending on various neurological issues. The resident will have the opportunity to review
neuroimaging studies with the Neuroradiology staff and the neurology inpatient attending.
The neurology resident will also have the opportunity to review clinical neurophysiology
studies done with the clinical neurophysiology attending staff. Throughout the rotation, the
resident may attend the daily noon resident lectures which will cover various neurological
topics, including the evaluation and management of a variety of disorders seen on the
neurology inpatient service. This will include the Clinical Lecture Series, and other
conferences.
Topics to be Covered
Intracranial Mass Lesions
Review of the Neurologic Exam
Spinal Cord Injury
Neuroradiology - What Study to Order
Coma
Management of Acute Spinal Disorders
Head Injury
Neuromuscular Disorders
Head CT and MRI Interpretation
Management of Back Pain
Pediatric Neurosurgery
Pain Management
Seizures
Pediatric Rehabilitation
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Physical and Occupational Therapy
Headache
Neuro-opthalmologic Evaluation
Stroke
Introduction to Rehabilitation
Management of Acute Spinal Disorders
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SECTION 3
AMBULATORY CURRICULUM
Emergency Room
Same-day Clinic
Cardiology
Endocrinology
General Medicine
Hematology/Oncology
Pulmonary Disease
Digestive Disease
Infectious Disease
Rheumatology
Nephrology
Adolescent Medicine
Geriatric Medicine
PGY -1 Continuity Elective
PGY – 2/3 Continuity Elective
Enhanced Care Elective
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Section 3
Ambulatory Curriculum
General
Each rotation has designated teaching times. The responsibility for teaching is given to
the respective department or a division in the Department of Medicine. The topics are generated
by the faculty with input from the Department of Medicine. These curricula are designed for
consultation as well as direct patient care.
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EMERGENCY MEDICINE CURRICULUM
UNC Department of Emergency Medicine
The Emergency Department (ED) attendings work 8 hour shifts, 7a-3:00p, 1p-9p, 10a-6p, 3p11p, 6p-2a, and 11p-7a. Two attendings are on duty, with the exception of the time period from
2a to 10a when one attending is on duty.
The ED has 3 main areas. The Acute Care area has 24 beds including 2 cardiac rooms and 3
trauma rooms. Team C is an adjacent area with 8 beds. Team C is open 9a to midnight daily.
Pediatric Acute Care is a separate unit staffed by Pediatric attendings and residents. Pediatric
Acute Care is open 9a-2a daily. After those hours, pediatric patients (ages 15 and below) are
treated in the main ED. During your rotation, you will be assigned shifts in both the Acute Care
area of the ED and the Minor Trauma area.
Guidelines for Houseofficers
Department of Emergency Medicine
The University of North Carolina at Chapel Hill
Introduction and General Principles
Welcome to the Department of Emergency Medicine! During this rotation, you will learn skills
that are essential to your medical education. You will be supervised by faculty members who are
Board Certified or Board Eligible in Emergency Medicine. Our faculty have practiced in a variety
of institutions and settings, and thus, your experience here will be enhanced by exposure to
different styles of practice.
Emergency Medicine differs in many respects from the inpatient and clinic settings. During this
rotation, you will see a broad spectrum of illness ranging from the most trivial complaints to lifethreatening disease. It is important to remember that all patients come to the ED for a reason.
Many present to the ED early in the course of their illness, therefore a serious disease may
initially present to you as an apparently benign complaint. Many may present with complaints
that could best be handled elsewhere. It is our role to ensure our patients receive our best efforts
to guide them through the increasingly complex healthcare system as well as to diagnose and
treat acute care conditions. Remember the Emergency Department is an important portal of
entry into the hospital and provides a strong impression of the institution to patients, their
families, and referring physicians from other medical centers.
House officer Requirements for Successful Completion of
Emergency Medicine Rotation
1. Completion of the Online Orientation Module
Each houseofficer must complete the online orientation course and exam before starting their
Emergency Medicine rotation. The orientation module is available online at
www.med.unc.edu/wrkunits/2depts/emergmed.
2. Assigned Shifts in the Emergency Department
Be prompt for your assigned shifts. If you are ill or must miss an assigned shift, you need to
contact:
Your chief resident. Chief residents from each rotating department will be
responsible for providing replacement coverage for their individual department
residents who are unable to fill an assigned shift.
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The ED attending physician working at the time your shift begins (9664721).
In order to successfully complete the ED rotation as required by your residency, you must
complete all assigned shifts. Illnesses are only excused if verified by your personal physician (not
a resident physician) or your residency director.
3. Resident Conferences
In order for the Departments of Emergency Medicine, Medicine, Surgery, Family Medicine and
OB/Gyn to meet the requirements of the Residency Review Committee, weekly attendance at our
Emergency Medicine Conferences is MANDATORY. These conferences are held on Wednesday
mornings from 7a to noon. The schedule of topics is available monthly. Emergency Medicine
interns/residents are required to attend conferences 5 hours per week. Off-service
interns/residents are required attend 3 hours per week. During your rotation, you will likely be
scheduled in the ED on one or more Wednesday mornings. On these mornings you should
attend sign out rounds and check in with the ED attending prior to departing for
conference. When you are not scheduled to work in the ED, you should attend at least part of
the Wednesday morning conference. Attendance will be taken at these conferences and reported
to individual residency directors at the end of each rotation along with your final evaluation.
If you have questions or concerns, please feel free to contact:
Kevin Biese, MD
Assistant Professor
Education Director
966-6440
Guidelines for Housestaff:
Department of Emergency Medicine
The University of North Carolina at Chapel Hill
Important Items to Keep in Mind:
1. Although you will be quite busy at times, make sure you speak to any family or visitors who
may be in the waiting room after you have finished your evaluation. It is important to let them
know how well the patient is doing and give them an estimate of the anticipated length of stay.
Always overestimate the length of stay. Things take longer than you think.
2. Laboratory studies and X-rays are ordered only if they impact on acute treatment, immediate
decision making, or are essential for the provision of follow-up care. The Emergency Department
is not the place to begin an extensive workup of non-critical problems.
3. Every patient should be given instructions for follow-up care and referred to a follow-up
physician, no matter how trivial the problem may seem. (see documentation and charting
guidelines)
4. You should be able to arrive at a reasonable clinical diagnosis on most patients. If you lack a
definitive diagnosis, you must have formulated a clear differential diagnosis and have ruled-out
all possible life-threatening conditions before the patient can be discharged safely.
5. Information concerning patients seen or discussed in the ED is confidential. It should not be
discussed anywhere
else, other than in a medical conference setting. This means you must not discuss patient
information in the hallways,
nor the elevators, nor in downtown restaurants, etc. You are a professional and must conduct
yourself as such.
6. All patients who are seen in the Emergency Department are the ultimate responsibility of the
attending emergency physician. Consequently, THE EMERGENCY DEPARTMENT
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ATTENDING MUST SEE EVERY PATIENT AND SIGN EVERY CHART PRIOR TO THE
PATIENT’S DISCHARGE, ADMISSION OR TRANSFER.
7. Some patients have such serious illness at the time of presentation that they may
decompensate in a very short period
of time. Because of this, there are certain circumstances when it is vital for you to notify the
attending physician of the
patient’s condition IMMEDIATELY AND POSSIBLY BEFORE YOU HAVE FINISHED YOUR
INITIAL
EVALUATION. (You will find a list of these circumstances attached in this handout.) If you
think a particular
patient is unstable, alert the attending on duty.
8. T System: All ED patients are tracked on a computer system called T System. When you
arrive in the ED, you will
be instructed how to use this system to sign up as the provider for the patients you are
evaluating. In order to access
this system, you must have a valid UNC Hospital code and password.
9. As patients enter the Emergency Department, they are triaged by the nursing staff.
triage designations are:
Stability of
vital functions
Life-threat or
organ-threat
Severe pain or
severe distress
Expected
resource
intensity
The
ESI-1
Unstable
ESI-2
Stable
ESI-3
Stable
ESI-4
Stable
ESI-5
Stable
Obvious
Reasonably
likely
Sometimes
Unlikely
(possible)
Seldom
No
No
No
No
Medium:
multiple
diagnostic
studies; or
brief
observation;
or complex
procedure
Low: one
simple
diagnostic
study; or
simple
procedure
Low:
exam
only
Up to 1 hr
Could be
delayed
6 hr
2 hr
Could
be
delayed
1 hr
Immediately
Maximum: staff at
bedside continuously;
mobilization of outside
resources
Med/staff
response
Immediate team effort
High:
multiple,
often complex
diagnostic
studies;
frequent
consultation;
continuous
(remote)
monitoring
Minutes
Expected time
to disposition
Examples
1.5 hr
4 hr
Cardiac arrest,
intubated/hypotensiv
e trauma patient,
acute (<3 hr) MI or
stroke
Most chest
Most
Closed
Sore
pain, stable
abdominal
extremity
throat,
trauma (MOI
pain,
trauma,
minor
concerning),
dehydration, simple
burn,
elderly
esophageal
lac,
recheck
pneumonia
food
simple
patient,
impaction,
cystitis,
altered
hip fracture
typical
mental
migraine
status,
behavioral
disturbance
In general, patients should be seen in the order in which they arrive in the ED, however
patients triaged as “1” or “2” should be evaluated before those designated “3-4-
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5”. If you are unsure which patient you should evaluate next, ask the attending
or a senior resident to direct you.
SCHEDULE
Housestaff will be assigned to one section of the department and will report ONLY to the
attending staffing that section.
RESPONSIBILITIES
Role of the Emergency Department Attending
The ED attending is primarily responsible for patient flow and consultation. The ED attending
will be responsible for the supervision of all medical students and houseofficers. Housestaff
cannot sign student orders.
Role of the PGY-III Resident
The PGY-III Emergency Medicine Resident has three main responsibilities in the ED:
1.
Directly evaluate patients as the primary physician, with particular attention to
critically ill or injured patients.
2.
Ensure that patient flow in the ED is maintained.
3.
Supervise one or more PGY-I residents who are working in the ED.
4.
Perform or supervise procedures required for patient care.
5.
At times, these residents may take a turn at being “in charge” of the ED under the
supervision of the attending.
.
Role of the PGY-I and PGY-II Residents and Medical Students
The PGY-I resident and medical student are primarily responsible for patient evaluation and
management. Remember that you are here to learn and that specific questions are expected. It
is better to ask and ask early!
PATIENT CARE AND CASE PRESENTATION
It will be the responsibility of the EM PGY-III resident, all PGY-I residents, and medical students to
pick up new patients as they are added to the board by the triage nurse. Patients are to be seen
according to their time of entry into the ED unless another patient with a potentially life-threatening
complaint has not yet been evaluated. Patients with life-threatening complaints are
designated by a triage classification of “1” (in red) and should be seen promptly. If you are
not certain whether a particular patient is to be seen, ask the attending physician or triage nurse.
The residents will see and evaluate the majority of patients. This initial evaluation is to consist of
a history and physical examination, which may be “directed” if the patient has an obviously
isolated problem (such as a minor extremity injury). All other patients should have a complete
history and physical examination including social and family history, medications and allergies.
This evaluation should take no longer than 5 to 10 minutes to complete.
ANY PATIENT WITH A CONDITION WHICH MAY DETERIORATE PRECIPITOUSLY MUST BE
CALLED TO THE ATTENTION OF THE ED ATTENDING IMMEDIATELY, EVEN IF THE INITIAL
EVALUATION IS NOT COMPLETED. A list of such conditions is listed in this handout.
After formulating a differential diagnosis and treatment plan, but before writing orders, the intern
is to present the patient to the ED attending. At that time, an evaluation and treatment plan can
be formulated and orders written.
No verbal orders are acceptable.
After all ancillary studies have been completed, the houseofficer is to present the case to the ED
attending again, this time noting the results of laboratory values, X-rays, etc. At this time a
disposition will be made and the patient will be either discharged, admitted or transferred to a
different institution.
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TYPES OF PATIENTS SEEN
Adult patients with a wide variety of complaints are seen in the Acute Care area of the ED. In
addition to evaluating and treating patients with general medical and surgical problems, you will
gain experience with patients whose complaints include the following:
Psychiatric - Our responsibility is medical clearance; be especially careful with elderly
patients or those with confounding medical problems; some psychiatric patients will be seen
directly by the Psychiatric consultants.
OB-Gyn - Women at 20 weeks or greater gestation are transferred directly to Labor and
Delivery. The exceptions to this are if they have any type of trauma or a complaint totally
unrelated to pregnancy. All women between 10-60 should be assumed to be pregnant until
proven otherwise by a negative urine or serum pregnancy test.
Trauma - Major trauma patients, as determined by criteria, are seen by the Trauma
team, EM Attending and Senior Emergency Medicine Residents. Patients with lesser trauma are
evaluated and treated by the general ED staff.
Pediatrics (ages 15 and below) - These patients are seen directly by a Pediatric resident,
either in Pediatric Acute Care (9a-11p) or in the Acute Care ED at other times.
ANCILLARY SERVICES
Laboratory Studies
1.
Laboratory studies are ordered in writing on the order sheet.
2.
Laboratory reports results can be obtained on the computer. Be sure to check the
computer frequently
for results so the patient can receive disposition in a timely manner.
3.
All laboratory studies must be documented on the chart, including those that
are pending at the time
of disposition.
Radiologic Studies
1.
If a patient needs an X-ray or other imaging study, write the order on the order
sheet and give the order sheet to the clerk. You need to write a reason for the X-ray
study, i.e. chest pain or SOB. The X-ray orders are entered into the computer by
the nursing staff.
2.
Look at the patient’s X-rays even though the radiologist’s interpretation is available.
Remember that you have the advantage of knowing the patient’s clinical presentation
and thus may notice something the radiologist might have misses.
3.
If you have any questions regarding the interpretation of a particular radiograph,
you may consult the radiology attending or resident by dialing 68850.
4.
All radiologic studies must be documented on the chart!
MEALS
Housestaff are encouraged to briefly leave the ED for nutrition breaks as patient flow permits, but
only after notifying the attending that they are leaving.
DOCUMENTATION STANDARDS
It is your responsibility to see that these standards are met on every chart. Charts will be
returned to you for completion if documentation standards are not met.
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DISCHARGE INSTRUCTIONS AND FOLLOW-UP
All patients are to receive a discharge instruction sheet prior to leaving the Emergency
Department. There are specific items that must be included on the discharge form.
PATIENTS LEAVING THE EMERGENCY DEPARTMENT AGAINST MEDICAL ADVICE (AMA)
All patients who threaten to leave the Emergency Department against medical advice (AMA) must
be seen by the ED attending immediately. The patient is required to sign an AMA form on the
back of the chart and must be properly informed of the risks of departing AMA.
SECURITY AND PARKING
Escorts to the parking decks are available 24 hours a day. USE THEM!! Use the Point to Point
Service (962-7867) or have hospital security accompany you! You cannot park in the ED patient
parking lot.
DRESS CODE AND IDENTIFICATION
Name badges must be worn at all times. Housestaff are expected to look and act like
professionals at all times. Scrubsuits are acceptable for wear in the Emergency Department
provided they are clean and in good condition. Jeans, shorts, sweats and T-shirts are not
permitted.
WHEN YOUR SHIFT ENDS
You must turn your patients over to an intern or resident on duty in the ED. If your patient is
nearing completion of their evaluation – please fill out the chart completely including the
discharge form if appropriate. If the evaluation is in progress, please have a clear plan to pass on
to the next doctor.
Medical Conditions Requiring
Immediate Attending Physician Notification
The following is a list of conditions that require immediate notification of the Emergency Department
attending physician, regardless of your level of training. This list does not cover all possible
situations, and you should feel free to notify the attending immediately if you have a patient you
feel may deteriorate precipitously or if you are uncomfortable given your present level of training.
1. Any patient who presents with or develops acute cardiopulmonary arrest.
2. Any patient with a complete or partially obstructed airway.
3. Any patient who presents with or develops a significant cardiac arrhythmia, whether stable or
not.
4. Any patient with acute onset Alteration of Mental Status (AOMS). This includes any patient
presenting with this as the chief complaint or any patient whose mental status deteriorates
while in the ED.
5. Any patient with significant hypotension or hypertension. For these purposes, significant
hypotension will be defined as blood pressure of less than 100 mmHg systolic and significant
hypertension will be defined as a blood pressure of greater than or equal to 180 mmHg
systolic or hypertension associated with acute alteration of mental status.
6. Any patient with severe respiratory distress. For these purposes, significant respiratory
distress will be defined as a respiratory rate greater than 30 breaths/minute, any patient
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with a pulse oximeter reading of less than or equal to 90 mmHg, any patient with an acute
elevation of pCO2 greater than or equal to 60 mm Hg, any patient with a complaint of
shortness of breath accompanied by diaphoresis, use of accessory muscles of respiration,
cyanosis, alteration of mental status, bradycardia, or any other signs consistent with
imminent respiratory failure.
7. Any patient with significant tachycardia or bradycardia. For these purposes, significant
tachycardia is defined as a heart rate greater than or equal to 150 beats/minute and
significant bradycardia is defined as a heart rate less than or equal to 60 beats/minute.
8. Any patient with a significant cardiac arrhythmia.
9. Any patient with either clinical or EKG evidence of acute myocardial infarction.
10. Any patient with a fever greater than 105 degrees Fahrenheit, any patient with significant
alteration of mental status associated with a fever, or any patient with a fever and a
potentially immunocompromised state (e.g. HIV disease, cancer patients, transplant
patients, etc.)
11.
11. Any patient with significant hypothermia. For these purposes, significant hypothermia is
defined as a rectal temperature less than or equal to 95 degrees Fahrenheit.
12. Any patient with severe abdominal pain or abdominal pain associated with peritoneal signs.
13. Any female with abdominal pain and a positive pregnancy test.
14. Any patient with significant upper or lower GI bleeding (whether hypotensive or not).
15. Any patient who develops seizure activity while in the Emergency Department.
16. Any patient with significant abnormality of any laboratory value (e.g. hypo/hypernatremia,
hypo/hyperkalemia, symptomatic hypercalcemia, hematocrit less than 28, etc.).
17. Any patient with a history of significant trauma.
18. Any patient with a pregnancy and sign/symptoms of a precipitous delivery.
19. Any patient with an overdose of prescription or over-the-counter medications.
20. Any patient or visitor who gives evidence of becoming significantly agitated, violent, or
suicidal.
21. Any patient with a blood sugar of less than 70 mg/dL.
22. Any patient with a snakebite.
23. Any patient with significant bleeding, or bleeding associated with hemophilia (blood
dyscrasias).
24. Any patient with a significant allergic reaction.
25. ANY PATIENT WHO YOU FEEL IS BEYOND YOUR PRESENT CAPABILITIES AS A
RESIDENT, OR WHO YOU THINK MAY DETERIORATE SUDDENLY.
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Documentation Standards
The following information is required on all charts for all Emergency Department patients for legal
and billing purposes. Please review this in conjunction with the copy of the chart included in this
packet.
1. The Emergency Department uses the T System for charting. Please complete the T System
training module
before starting your first shift.
2. For all patient charts, documentation should reach a “level 5” by the standards of the T
System
Documentation System. Please confirm this before signing your chart.
3. It is important to write a short summary of your assessment and plan in each chart..
Based on the differential problem list that you have established, it should be obvious by reviewing
the chart how you distinguished among the possibilities and came to your final diagnosis. Some
examples: GI cocktail given, patient with complete relief; Phenergan 25mg IV given, nausea relieved
and patient tolerating PO well.
If you make a clinical diagnosis without any work-up, you need to explain that. For example: 20
year old white female with reproducible chest wall pain, no risk factors for CAD and no associated
symptoms, likelihood of cardiopulmonary disease as the underlying etiology is very low. We will
treat her with NSAID’s. Patient knows to return if symptoms change or worsen.
4. You need to list the medications the patient is taking and any drug allergies the patient has.
5. If the patient is in the Emergency Room for a significant length of time waiting for disposition
or a bed, you need to make note that you reevaluated the patient during this time. For example:
2:45 pm Patient now afebrile and tolerating oral fluids well. Many conditions such as respiratory
distress, chest pain and abdominal pain require frequent reevaluation, and you need to
document it.
6. If you call a consultant to see the patient, record the time and who you talked with. For
example: 6 pm Discussed case with Dr. Smith(General Surgery) who will evaluate patient.
“Curbside” consultations are not official. If there is really a question, the patient must be seen by
the consultant.
7. Record a procedure note for all procedures done on the patient including laceration repairs,
lumbar
punctures, central lines, etc.
8. Please select a disposition and diagnosis (often more than 1diagnosis) for each patient.
DISCHARGE INSTRUCTIONS
The T system has standard discharge instructions for many different diagnoses as well as
medications Every discharged patient should receive 1 or more of these instruction sets.
All patients should receive Follow-Up. Follow-up options include but are not limited to:
1.
Follow-up with their own doctor (MUST BE NAMED) for a specific period of time. If the
patient is unable to identify an MD, a referral should be given.
2.
UNC Clinic Appointment:
Options for obtaining this are:
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* You can call and get an appointment for the patient (Mon-Fri 8a-5p)
* Fill out a clinic referral sheet available in the ED, these are faxed to a central office
where appointments are made,
* You can give the patient the phone number for a specific clinic (listed in the T system
discharge instructions) BUT, keep in mind, it may be several months before a patient can
get an appointment.
Welcome!
From the Nurses in the Emergency Department
The following handout details survival skills for your emergency department rotation. We hope that
it may be helpful to you.
The ED is divided into several sections:
Triage
Acute Area
Team C
Pediatric Acute Care
The nursing staff is assigned by “team.” One or two nurses are assigned to the triage area.
These nurses are responsible for screening all patients and prioritizing their care. The Acute Area
is divided into Team A and Team B. Two or more nurses are assigned to cover each of these
teams.
There are three trauma bays, including a pediatric resuscitation bay. There are two cardiac
resuscitation rooms. The Acute Area is divided into the A and B teams which are each
responsible for ½ the acute area of the department. Team C is a separate area that usually
evaluates ESI score 4 and 5 patients (see above).
A charge nurse is assigned to coordinate the care of the ED patients. At various times, the
charge nurse will also have a patient care assignment. Two nurses are assigned to the trauma
team. If there is a trauma in progress and the nurse assigned to a certain area becomes
unavailable, refer all questions to the charge nurse.
 Remember, if you are busy, so is the nursing staff!
This is a team-oriented department. Help us and each other!
General Information
 It is mandatory that you wear your name tag!
Familiarize yourself with the clean and dirty utility rooms on your first day. You will find this
invaluable. Most of the equipment you need is located in these areas. Equipment is secured in
the PYXIS.
Tidy up after yourself after completing an exam or procedure. There are trash cans located at
each patient care bedside. (This includes the lounge!)
The ED staff is a lifeform in itself. The nursing assistants, clerks, nurses, and social worker can
be great resources for the inside scoop on usual routines, community resources, etc.
 Clerks can help you with phone calls and paging. Clerks answer the phones, even if you have
paged someone. Listen to the intercom for your name or the person you have paged. The key
staff in the ED have assigned intercom cell phones.
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Nursing Assistants can perform the following:
simple wound preps
crutch set-up
lab transport
patient transport (excluding monitored patients)
room set-up
assist with procedures
Remove all needles and sharps from trays and dispose of them in the sharps box!
If a laceration needs sutures, anesthetize the wound prior to wound prep. The department’s
infection rate has been consistently 0% because the NA’s do an excellent job.
RN’s
1. Unless the patient is acutely ill, please allow the RN to triage the patient prior to beginning
your exam or
gathering information.
2. ED nurses will assess the acuity of patients and institute treatment and diagnostic procedures
prior to
your seeing the patient. For example: monitoring, IV access. Orders still need to be written for
the patient.
Educational Conferences
Emergency Medicine conferences are held Wednesday from 7:00 am to noon. All PGY1 residents
assigned to the Emergency Department each month will be expected to attend.
Scheduling in the Emergency Department
PGY-1 Medicine Interns will work 12 hour shifts beginning at 7 am, 10 am, or 7pm. These times
will rotate throughout the month.
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Same-Day Clinic CURRICULUM
Low Back Pain
Monoarticular Arthritis
Approach to Arthritis
Musculoskeletal Syndromes of the Neck and Arm
Depression
Initial Diagnosis and Management of Hypertension
Initial Diagnosis and Management of Type II Diabetes
Bronchitis
Rhinitis/Sinusitis
Headache
Pharyngitis/Mononucleosis
PID
Chest Pain
STD’s
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CARDIOLOGY AMBULATORY CURRICULUM
Consultations including preoperative evaluations will be handled by internal medicine
residents, cardiology fellows and faculty. When the residents is not involved with patient workups, he or she can see patients in faculty clinics, participate in exercise stress testing, read EKG’s
from teaching files and/or ACC patients. The following subjects will be reviewed on the month
rotation
1.Evaluation of arrythmias in the post-operative patient
2.Pre-operative risk assessment for the patient with known cardiac disease
3.Evaluation and management of malignant hypertension
4.Use of thrombolytic therapy
5.Evaluation and management of shock in the post-operative patient
6.Endocarditis prophylaxis
7.Evaluation and management of lipid abnormalities
8.Evaluation and management of peripheral vascular insufficiency
9.Recognize common EKG abnormalities
10.Recognize common echocardiographic abnormalities
11.Evaluation and management of patients with left ventricular dysfunction
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ORIENTATION FOR ROTATION IN ENDOCRINOLOGY AND METABOLISM
Dear Residents and Students,
The Endocrine Division is delighted that you will be taking our
Endocrinology and Metabolism Elective. Our clinic is located in Durham near
Southpoints Mall off of Hwy 54 (Highgate Specialty Center, 5316 Highgate Dr,
Suite 125, Durham NC, 27713. 919-484-1015). The majority of your time will be
spent in the clinic working with various attendings and seeing a variety of
Endocrine patients. On rare occasions, when too many residents/students are
assigned to Endocrinology, you may be asked to spend a few days with the
inpatient team.
Clinic Operations
Highgate Specialty Center opens at 7:30am and closes by 5:30pm. Please arrive
by 8:30 each morning and look for Dr. O’Connell who will help coordinate the attending
with whom you will work (usually Dr. O’Connell the first day and any day that other
attendings are not available). We will try to have you work with almost every attending
during your two weeks so you can see a wide variety of patients and styles. Dr.
O’Connell is never at Highgate on Thursdays so if your first day is Thursday, simply
come and introduce yourself to another attending who is present that day. Dr. Ontjes is
usually there on Thursdays and is always amenable to working with residents and
students.
The clinic is closed most Thursday afternoons to allow everyone to attend Thursday
afternoon Endocrine Conferences.
Conferences
Thursday afternoon Endocrine conferences as described below are from 3 pm to
5:30 pm. You are expected to attend these while on your Endocrine rotation. They are
located in the GCRC conference room, 3rd floor bedtower.
3pm: Fellows conference: a faculty member will give a didactic lecture to the
fellows/residents
4pm: Endocrine Journal Club:
5pm: 30 minute case presentation and discussion by one of the fellows
Evaluations
Please give your evaluation form (students) to the Elective Director, who will
then distribute it to the fellows and faculty in the division. Evaluations (students and
residents) are compiled by the Elective Director after input from other members of the
division.
We appreciate your attention to these matters and hope that you find your
rotation with us to be educational and enjoyable. Please bring any concerns to our
immediate attention.
Sincerely,
Tom O’Connell, MD (pager 216-6359)
Resident Elective Director
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Endocrinology and Metabolism
Thomas_oconnell@med.unc.edu
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Hematology/Oncology Consults
Curriculum
Updated 6/9/2008
Outpatient Electives for Medical Residents.
Out Patient block, Medical Residents
Overview:
This is a 1month block of time designed to expose medical residents to some of the
breadth of outpatient oncology or hematology patients. We suggest that the resident
choose either the Oncology block or the Hematology Block and not make a combined
block of the various clinics. This will enable the resident to get a good spectrum of one
part of this broad field. The resident will see patients along with the attending
physician and will be responsible for obtaining histories and examinations, dictate or
type consult notes and progress notes, follow up on calls and tests. In many cases
there will be a reading list to master. This can be discussed with the attending for each
clinic. Residents are also encouraged to participate in the Division conferences and
when possible, present at the Case of the month program. Participation at Case of the
month should occur if this is offered during the resident’s rotation (The division can let
the resident know ahead of time.).
Outpatient Rotation. Oncology
Monday
7:30 GI
Tumor
Board.
Gravely Gd
Floor
Breast
Cancer
Clinic with
Dr Carey**
12:30
Monday
Lectures
Divison
lectures.*
Breast
Cancer
Clinic with
Dr Carey
Tuesday
Wednesday
7:30 am Fellows’
Conference***
Room 3004 old
clinic (check
calendar)
Thoracic Oncology
Multidisciplinary
Thoracic
Oncology
conference.
Gravely Gd floor.
Thoracic Oncology
Thursday
7:30 am
Fellows’
Conference
Room 3004
old clinic
(check
calendar)
Friday
7:30 am Head
and Neck
Conference**.
GI Clinic with
Dr O’Neil and
Dr Bernard
GU Clinic
Check
Breast
Conference
10:30 to 12
Gravely Gd
Floor
Breast Oncology
1:15 GU
tumor
board.
Gravely Gd
Floor
GU clinic
** If Dr Carey’s clinic does not take place go to head and neck clinic.
Head and Neck Conference on Friday is optional but encouraged if you
have seen these patients.
***Beginning in 1/2008, Fellows’ Conference is switching to Tuesdays.
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Outpatient Rotation Hematology
Monday
Tuesday
7:30 am
Fellows’
Conference
Room 3004
old clinic
(check
calendar) **
Hemophilia Sickle Cell
Clinic with Clinic
Dr Key and
Ma
12:30
Monday
Division
Lectures *
Coagulation Sickle Cell
Clinic with Clinic
Dr Moll



Wednesday
Thursday
7:30 am
Fellows’
Conference
Room
3004 old
clinic
(check
calendar)
**
Heme
Parker
Malignancy conference
Clinic with at 11am if
Drs
time.
VanDeventer Gravely Gd
and
Floor
Voorhees
Friday
7:30 am
Fellows’
Conference.
Room 3004
Old clinic
Heme clinic,
Dr Ma
1PM Heme
conference
Heme clinic,
Dr Ma
Check with the Division re the Conference on Mondays for titles
and place
**Beginning in 1/2008, Fellows’ Conference is switching to
Tuesdays.
Check with Dr Ma. She may be moving her clinic to Thursdays.
When that happens the clinic will be off site and you will not need
to go to Parker Conferences.
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PULMONARY DISEASES AMBULATORY CURRICULUM
In overview, the medical resident’s activities will mirror the responsibilities of the
Pulmonary consult Fellow, i.e., evaluation of inpatient and outpatient referrals and interpretation
of standard pulmonary function tests. The resident will interact closely with the Pulmonary
consult Fellow and Attending.
The overall educational goals will be accomplished through several formats:
1.
Daily inpatient consults on all non—ICU pulmonary referrals (we average -1.5 consults per
day).
2.
Interpretation of pulmonary function tests and review of tests with the Attending
physician. We perform about 600 individual pulmonary function tests per month. Specific
attention will be focused on interpretation of blood gases and spirometric parameters.
Understanding the indication for lung volume and DI.ICO tests will be a goal for the
resident’s experience.
2.
Work—up of a new pulmonary outpatient referral and follow—up of selected patients in
each Wednesday’s day—long clinic. In conjunction with the consult fellow and clinic
attending, this will involve selecting and interpreting appropriate pulmonary function
tests.
4.
Evaluation of sleep—clinic outpatient referrals on Friday mornings and review of sleep
apnea studies in conjunction with a senior Fellow and the Attending. The goal will be to
better define for the resident indications for obstructive sleep apnea studies.
5.
Evaluation of outpatient “walk—in” referrals or outpatient consults who need to be
“added—on” and seen on days other than Wednesday. We see 2—4 new patients per week
by this route.
6.
Presentation and discussion of cases at the weekly medicine— radiology—chest surgery—
oncology conference (1 hour).
7.
Three didactic conferences (1 hour each) per week related to critical care medicine, clinical
topics, and review of research papers. These presentations draw on faculty and fellows
from Pulmonary, Infectious Disease, Radiology, Critical Care Surgery, Anesthesiology, &
etc.
8.
The weekly pulmonary division clinico—pathologic “work” conference (2 hours) that
involves presentation of difficult, complex, and/or interesting cases. Pathophysiologic
concepts are emphasized.
Although the consult service performs a number of procedures, we will not emphasize the
technical aspects of those studies except for aspects of the thoracentesis and/or pleural
biopsy. The opportunity to observe decision—making about bronchoscopic procedures,
and to visualize endobronchial anatomy during bronchoscopy, will contribute to the
resident’s appreciation for the role of this procedure in the evaluation of pulmonary
disease.
9.
In summary, the medical resident will enjoy an integrated experience of inpatient and
outpatient evaluations, learn the indications and interpretation of pulmonary functions tests,
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have exposure to patients referred for sleep—apena studies (and perhaps learn some indications
for these referrals), better appreciate the role of fiberoptic bronchoscopy in evaluation of
pulmonary disease, and expand their pulmonary physiologic concepts. Overall, this resident
rotation complements the resident’s ICU and inpatient exposure to pulmonary diseases. It
provides an experience that will be useful for most internal medicine physicians because
pulmonary disease is a common cause for clinic visits to the internists.
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DIGESTIVE DISEASES AMBULATORY CURRICULUM
On the Digestive Diseases Consultation Service, residents have the opportunity to see
patients with gastroenterology as well as hepatology disorders. The following subjects will be
reviewed on the month rotation.
1.
Evaluation and treatment of diarrhea
2.
Evaluation and treatment of jaundice
3.
Inflammatory bowel diseases
4.
Hepatitis - viral and non-viral
5.
Diagnosis and management of peptic ulcer disease
6.
Nutritional support - enteral and intravenous
7.
Colonoscopy - indication and screening
8.
Diagnosis and management of pancreatitis
9.
Diagnosis of esophageal motility disorders
10. Evaluation and treatment of abdominal pain
11. Diagnosis and management of cirrhosis
12. Liver transplantation - indicators and outcomes
13. Diagnosis and management of GI bleeding
14. Appropriate use of radiologic studies of the gastrointestinal system
15. Evaluation and management of gallstones/gallbladder diseases
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INFECTIOUS DISEASE AMBULATORY CURRICULUM
Role:
Residents play an important role on the consult service and in the clinic, where they help to manage
outpatients with AIDS, chronic fatigue syndrome, and a variety of different infections including
endocarditis and osteomyelitis. Residents are supervised by an attending physician.
Teaching Conferences:
Teaching conferences include a Wednesday clinical case conference at 8:30 a.m. and a Friday 8:30
a.m.conference which is didactic and/or research oriented.
Topics:
Topics covered through these conferences can be organized according to an organ system approach in
Infectious Disease. These include 1) central nervous system infections, including meningitis and
encephalitis; 2) infections of the eyes, ears, nose and throat; 3) infections of the upper and lower
respiratory tracts; 4) infections of the cardiovascular system including endocarditis; 5) infections of the
intestinal tract including infectious diarrhea and intra-abdominal catastrophe; 6) infections of the urinary
tract, including sexually transmitted diseases; 7) systemic infections, including HIV; 8) infectious disease
syndromes, including chronic fatigue syndrome. General lectures also include a) antibiotics, b) host
defenses, c) microbial pathogenesis. Pathogenesis includes discussion of worms, protozoans, fungi,
viruses and bacteria.
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Resident’s Responsibilities
for Consults and Ward Service
Rounds will begin at 1:30 PM in the Clinical Microbiology lab with discussion of sterile fluid infection,
review of new micro data and “unknown” case presentations from Microbiology faculty.
Consultations & Rounds:
Residents are responsible for full evaluations of patients seen in
consultation. Residents are responsible for following in-patients daily,
presenting patients during rounds, discussing differential diagnoses with
the attending, and writing appropriate notes in the medical record. The
on-call schedule and sequence of assignments will be discussed by the
Attending or the Fellow at the beginning of the rotation.
Conferences
The following conferences are held weekly by either the Division of Infectious Diseases or the
Department of Medicine. All listed conferences are required.
Day/Conference
Time
Place
Wednesday:
Case Presentation
8:30am
Orthopedic Conference Room
Dept. of Medicine Grand Rounds
12:00pm
Clinic Auditorium
Friday:
ID Didactic/Research Conference
8:30am
Clinic B Conference Room
Thursday:
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RHEUMATOLOGY / ORTHOPAEDICS AMBULATORY CURRICULUM
Welcome to the Division of Rheumatology and Immunology. Although rheumatologic and autoimmune
disease are, in the aggregate, extremely common, physicians who miss this special opportunity for a rotation
on a rheumatology service may never acquire the knowledge and skills required for caring for patients with
these disorders. For this reason, emphasis during your rotation will be on learning “nuts and bolts”
rheumatology:
a)
b)
C)
d)
e)
f)
signs and symptoms of the different arthritides
performance of a musculoskeletal history and exam
construction of common differential diagnoses
choice and interpretation of laboratory tests and x-rays
arthrocentesis and soft-tissue injection techniques
choice of therapy for commonly encountered conditions.
In addition, you will learn the basic elements of the pathogenesis and disease expression in rheumatologic
disease. These educational objectives will be accomplished by seeing disease. These educational objectives
will be accomplished by seeing patients, clinical discussions with faculty and fellows, literature searches and
reviews, various lectures and conferences, and Bob Berger’s “tool-kit.”
Rheumatology is largely an out-patient specialty, and the major block of your time will be spent in the
Musculoskeletal Module in the ACC. This module houses rheumatology and orthopaedic examining and
consult rooms, facilities for physical therapy, occupational therapy, patient education, a library, and a
special bone and joint x-ray suite. You will also see in-patient consults at UNCH. Scheduling of consult
rounds, on-call responsibilities, your time in clinic, etc., will vary from month-to-month. Schedules and
responsibilities will be discussed with you by the Attending and/or Fellow at the beginning of your
rotation.
There are only four rules: 1) Be in clinic on time. Medicine residents and students should report to clinic at
9:00am. 2) If you are not called to see an urgent consult, be in the clinic. 3) Formal consult rounds
will not be held until 3:30pm in order to minimize conflicts with your ambulatory care experience in the
clinic. 4) Turn in the evaluation sheet and list of patients seen to me at the end of your rotation.
Resident’s Responsibilities for Clinics and Consults
Report to the musculoskeletal module, 1st floor, Ambulatory Care Center at 9:00 am following Morning Report.
Meet for Consult Rounds at the film assembly desk (“cage “) in Radiology at the times designated by the
Attending or Fellow.
Clinic Responsibilities:
Residents will perform complete evaluations of new patients and return patients, as assigned by the
Attending. The nursing staff may also direct residents to do initial work-ups on patients. Residents will be
responsible for presenting patients to the Attending, developing a therapeutic plan, discussing differential
diagnoses with the attending, and completing a write-up for the medical record.
Consultations & Rounds:
Residents are responsible for full evaluations of patients seen in consultation. Residents are responsible for
following in-patients daily, presenting patients during rounds, discussing differential diagnoses with the
attending, and writing appropriate notes in the medical record. The on-call schedule and sequence of
assignments will be discussed by the Attending or the Fellow at the beginning of the rotation.
Schedule
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The following schedule is subject to some change. Please check with your attending
on the first day of the rotation to confirm the following schedule.
Monday
8:30 - 3:30
Clinic
Tuesday
8:30 - 12:00
Clinic
10:00-11:00
Rheumatology
Grand Rounds
3:30-5:00
Clinic or
Consult
Rounds
12:00-1:00
Immunology
Journal Club
2:00-3:00
Research-inProgress
3:30-5:00
Clinic or
Consult
Wednesday
8:30- 3:30
Clinic
1:OO 3:30
Clinic
Thursday
9:00-3:30
Clinic
3:30 - 5:00
Clinic or
Consult
Rounds’
Friday
8:30 - 3:30
Clinic
3:30-5:00
Clinic or
Consult
Rounds
3:30- 4:30
Clinic or
Consult
Rounds
Sounds’
Please note that this schedule only includes required events. Optional conferences, etc. are listed separately.
• NOTE: Consult rounds are held 2-3 days per week. Days of week may vary in different months. Formal consult rounds
will not be held earlier than 3:30. Scheduling of consult rounds far the month will be defined by me Attending at Fellow at
the beginning of each rotation.
Conferences
The following conferences are held weekly by either the Division of Rheumatology and Immunology or
the Department of Medicine. Please note that several are required for medical students and others
are optional. For more in formation regarding speakers and titles, contact the Rheumatology
Division Office in 3330 Thurston Building, (919) 966-4191.
Day/Conference
Required/Optional
Time
Place
Monday
Immunology Journal Club
10:00am
3280 Thurston
Optional
Rheumatology Grand Rounds
Research-I n-Progress
12:00noon
2:00pm
3280 Thurston
3280 Thurston
Required
Optional
Wednesday
Lecture:Program On Aging
12:00 Noon
Clinic Auditorium
Optional
Thursday
Dept. of Medicine Grand Rounds
12:00 pm
Clinic Auditorium
Required
Friday
Ambulatory Care Conference
12:00 Noon
Clinic Auditorium
Optional
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Nephrology Ambulatory Curriculum
Nephrology Consultation Service Resident Curriculum
Role of Resident
Evaluation and discussion of patients with kidney disease, hypertension, and disorders
of fluid, and electrolyte and acid-base balance disorders in the consultative
setting under the supervision of Nephrology faculty.
Consults
Residents will see both hospitalized and ambulatory patients in consultation on a daily
basis, unless assigned to their continuity clinic. Patients with a wide range of nephrologic
diagnoses will be seen and discussed with the Nephrology Attending and fellow. Residents are
expected to communicate consultative recommendations with the referring physicians, and to
provide ongoing follow up while on the rotation.
Curriculum
Topics to be discussed during rounds as well as during formal didactic sessions will
include the following:

Evaluation of kidney structure and function
o
o
o
o
o
Urinalysis
Measurement of GFR
Evaluation of proteinuria
Measurement of urinary electrolytes
Renal imaging techniques

Chronic kidney disease

Acute kidney injury

General principles of dialysis
o
o
o
Hemodialysis
Peritoneal dialysis
Continuous renal replacement therapies

Critical care nephrology

Metabolic acidosis

Metabolic alkalosis

Disorders of water metabolism (hyponatremia and hypernatremia)

Disorders of potassium and magnesium metabolism

Disorders of calcium, phosphorus and bone metabolism

Overview of evaluation and treatment of hypertension
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
Glomerular syndromes
o
o
nephritic syndrome
nephrotic syndrome

Diabetic nephropathy

Principles of kidney transplantation
Clinics
Participation in several Nephrology Subspecialty Clinics is available to residents interested in
seeing patients with specific diagnoses and is optional. Residents will see patients under
the direction of one of the Nephrology Attendings.

Monday PM
Hypertension Clinic

Tuesday AM and PM
Transplant Clinic

Thursday AM and PM
Vasculitis Clinic
Renal Conferences
Residents are encouraged to attend the following Divisional Educational Conferences during
the rotation:
Conference
Time
Leader/Organizer
Topic
Hypertension
2nd and 4th
Review of literature related to
Drs. Romulo
Journal Club
Mondays
hypertension
Colindres and Steven
4-5 pm
Transplant
Journal Club
Grossman
1st and 3rd
Review of literature related to
Mondays
kidney transplantation
Dr. Randy Detwiler
4-5 PM
Fellows
Tuesday
Review of topics in
conference
4-5 pm
clinical nephrology and
Drs. Romulo
Colindres and Gerald
Renal physiology
Nephrology
Wednesday
Review of nephrology
Journal Club
8:30-9:30 am
literature; study of issues
Hladik
Nephrology Division
related to design and analysis
of clinical studies
Nephrology
Wednesday
Conference
4-5 pm
Clinical nephrology
Nephrology Division
ADOLESCENT MEDICINE AMBULATORY CURRICULUM
1) Knowledge of the epidemiology of adolescent health issues
•
Describe the major causes of adolescent morbidity and mortality.
•
Describe the ways that these issues are addressed in routine adolescent care.
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•
Understand that the rationale for guidelines for preventive adolescent health care is
based on the major causes of adolescent morbidity and mortality.
•
Describe guidelines for routine health screening, including laboratory tests.
2) Skill in communicating with adolescents
•
Recognize that adolescents should be interviewed privately as a routine part of
physician visits.
•
Describe how the issues of consent and confidentiality are managed with minor
adolescents.
•
Perform a thorough history, including an adolescent risk assessment.
3) Understanding of normal adolescent development
•
Describe normal psychosocial and co2nitive development.
•
Recognize that the timing of psychosocial and cognitive development is independent
of pubertal development.
•
Accurate assessment of Tanner staging.
•
Describe the range of normal variation in timing of pubertal changes.
•
Recognize and manage common concerns of puberty (e.g. Am I normal?
Gynecomastia in males, Acne, etc.).
4) Sexuality
•
Perform a complete sexual history in a sensitive and age-appropriate manner.
•
Demonstrate appropriate anticipatory guidance and risk-reduction counseling.
•
Perform a complete pelvic exam including collection of cervical cytology and tests for
STDs.
•
Perform a male genital examination including tests for STDs.
•
Teach self-breast examination and self-testicular examination.
•
Provide contraception.
•
Instruct and demonstrate how to use condoms.
5) Common acute and chronic medical problems of adolescence
•
Recognize, evaluate, and manage common medical problems of adolescence (e.g.
acne, dysmenorrhea, STDs, pregnancy diagnosis, scoliosis, Osgood- Schlatter
disease, headaches, etc.).
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•
Describe a strategy for evaluation and management of chronic somatic symptoms,
including recognition that mental health problems may present as somatic
symptoms.
•
Understand the influence of puberty and adolescent development on chronic illness.
•
Describe the issues regarding the transition of adolescent patients with chronic
illness to adult care.
6) Identification and management of mental health problems
• Recognize abnormal psychosocial development.
•
Recognize that significant psychiatric disease can present in adolescence.
•
Perform an assessment for depression and suicide, and describe appropriate
management of patients with varying risk of suicide.
•
Understand that mental health issues are often associated with multiple risktaking behaviors.
•
Describe strategies to persuade adolescents and parents of the need for
psychological evaluation and treatment.
7) Substance use
• Perform an assessment of substance use, including tobacco, alcohol, illicit
drugs, and steroids.
•
Describe risk factors for substance abuse.
•
Describe physical symptoms or signs associated with substance use.
•
Describe management plans for adolescents with varying risk of substance
abuse.
•
Understand that mental health problems may be associated with substance use.
8) Nutrition eating disorders
•
Perform a nutrition history.
•
Demonstrate ability to accurately assess growth using height, weight, and BMI.
•
Describe counseling regarding healthy foods and eating patterns.
•
Describe management for mild to moderate obesity.
•
Recognize symptoms and signs of eating disorders, and describe strategy for
appropriate evaluation and management.
9) Sports Medicine
• Perform a pre- participation sports examination.
•
Describe the indications for limiting/requiring protective devices for sports
activities.
•
Describe the initial management of common sports injuries.
•
Understand the importance of screening for abnormal eating patterns and steroid use
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GERIATRIC MEDICINE CURRICULUM
Outpatient Geriatric Curriculum:
Residents in Internal Medicine who complete the Outpatient Geriatric Rotation will be expected to
meet the above goals in knowledge, attitude, and skill sets. Residents will work at all times with
a Faculty member from the Division of Geriatric Medicine and will rotate through the following
sites of care:
1.
Long Term Care Communities: Residents will work with faculty and Geriatric Fellows
and will see and evaluate patients who are in the outpatient clinic setting as well as the
health center/skilled nursing care area in these communities. They will see patients who
are older and completely independent who are followed for continuing care at the clinics
on site, as well as patients with dementia and other functional limitations who reside in
the nursing care area.
2.
Hospice: Residents will evaluate patients with the hospice team by doing home
visitations. Residents will also meet regularly with the hospice team and director to
discuss patient management issues.
3.
Geriatric Evaluation Clinic: Residents will work with faculty and Geriatric Fellows in
the Evaluation Clinic by seeing and evaluating older patients with complicated issues
who have been referred for complete geriatric assessments. Residents will work with an
interdisciplinary team to develop a plan of care for patients.
4.
Senior Center: Residents will work with one of our Faculty members and a trained
Physical Therapist to conduct screenings and assessments of older adults.
5. Residents will also spend time with the Geriatric Psychiatry inpatient unit,
Rehabilitation clinic, and memory disorders clinic. Residents may also chose to
have additional time with faculty who work with incontinence, urogynecology,
dementia, movement disorders, sleep disorders, or other specific interests.
6. Residents with interests in subspecialty training may chose to do additional work
with faculty in congestive heart failure, nephrology, intensive care, or other areas
of interest.
7. Residents will meet weekly with the division and the fellows for educational
conferences.
Based upon:
2004 The American Geriatrics Society: Curriculum Guidelines for Geriatrics Training in
Internal Medicine Residency Programs. The AGS Education Committee. Updated Jan
2004.
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PGY -1 Continuity Elective
Enhanced Intern Outpatient Education Rotation and Ambulatory Medicine
Tract & Chief Residency Restructuring
Learners: Interns interested in careers in outpatient internal medicine. The
emphasis will be acquiring outpatient skills in a diverse primary care setting.
The acquired skills and experience will be generalizable to other outpatient
internal medicine specialties.
Objectives:
1. Fulfill the traditional core residency competencies of patient care,
medical knowledge, professionalism, and interpersonal skills and
communication in the outpatient setting. The resident will acquire
intensive disease and condition specific outpatient training in the
following domains:
a. Diabetes mellitus
b. Anticoagulation
c. Chronic pain and comorbid psychiatric conditions
d. Acute care medicine through the Same Day Clinic
e. Continuity clinics
f. Travel medicine through existing Internal Medicine Travel Clinic
g. Women’s health
h. (Possibly dermatology. Dean Morrell open to this but department
has had faculty shortage.)
2. Acquire first-hand experience with new competencies of practice-based
learning and systems-based practice within Internal Medicine Clinic
Enhanced Care Program
a. Learn quality improvement methodology
b. Learn the importance of patient tracking through patient
registries/databases
c. Work in multidisciplinary teams consisting of physicians, clinical
pharmacists, nurse practitioners, physicians assistants,
dieticians, nurses, care assistants, lab personnel
3. Provide intensive continuity with a panel of patients early in residency
Curriculum:
Existing curriculum for residents on Continuity Elective with selective
adaptations.
Infrastructure and Template:
1. Capitalize on existing UNC Internal Medicine and Enhanced Care
Programs that already provide an educational environment for medical
students, residents in continuity clinic, residents on continuity elective,
and pharmacy students and residents.
2. Rotation would last one month
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Sample Schedule
Mon
Tues
Am
CC
Pain
Noon
Pm
Coag
Precept/Mento
r
Wed
DM
Ambulator
y
Conference
SDC
Thurs
Conferences, QI Project,
Reading
Grand Rounds
Fri
WH
CC
SDC
Legend: DM=Diabetes program; Pain=Chronic pain management; Coag=Anticoagulation
management; SDC=Continuity Clinic; TC=Travel Clinic; CC=Continuity Clinic;
Preceptor/Mentor=One-on-one preceptorship and mentorship in attending clinic
WH=Women’s health
Features:
1. Two continuity clinics per week.
2. Dedicated continuing education time on Thursday
3. Balanced outpatient experience consisting of acute, continuity, women’s
health, travel clinic, and disease specific care.
4. Preceptorship with mentoring and role-modeling by experienced internal
medicine faculty
Resources:
1. Money: None requested
2. Faculty: Sufficient
3. Increased intern time
4. Increased administrative support needed (see below).
Proposals for Securing More Intern Time
Options:
1. Add Outpatient Internal Medicine (OIM) month as third non-inpatient,
non-ER month for selected interns interested in pursuing outpatient
internal medicine. This would constitute an ambulatory medicine
tract.
2. Invite incoming interns to request OIM month as a rotation.
Commentary: Would be a good recruiting tool. Could compensate for lost
intern capacity by also offering hospitalist tract to upper levels who might
want to pursue hospital medicine.
Capacity: One intern per month=One intern FTE. (Would prefer incremental
approach with fewer intern months for first year or two to establish program.)
Practice-Based Learning Deliverable:
QI project
Other Responsibilities
Consider recruiting motivated and interested residents in participating in the
decision-making structure of the UNC Internal Medicine Clinic a la the
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University of Nebraska model that has cultivated ownership of clinic experience
through substantive input of residents who sit on “board of directors” of clinic.
This will be an enhance systems-based practice experience (i.e. cultivating
ownership of patients through cultivation of ownership of the work
environment. How can you foster learning of systems-based practice if
residents feel they have no ability to influence the system?).
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Administrative Support for Expansion of Outpatient Education Experience
Review of Accomplishments to date:
1. Established continuity elective (COE) as novel, diverse outpatient
experience for residents.
2. Established SDC as venue for acute outpatient medicine care after
Urgent Care was decommissioned by hospital
3. Initiated QI project for improvement of HTN.
Administrative Resources:
1. ½ FTE for QI project (Annie Whitney, MS)
2. Considerable burden of administrative work for COE and SDC currently
being performed by Dr. Chelminski and other general medicine staff.
Proposals for Augmenting Administrative Support:
1. Hire purely administrative person (less desirable as this person will
probably not have ownership and show initiative.
2. Designate ambulatory chief resident. Two options:
a. ?Third chief (expensive; chief residents paid for by department)
b. Retain current complement of two chief residents but designate
one as ambulatory chief.
c. Ambulatory chief would be expected to continue her or his
continuity clinic (analogous to chief residents attending on
wards).
Division of General Medicine Commitments:
1. Office space for administrative chief.
2. Official and substantive role in the decision-making processes of the
clinic.
3. Sponsor attendance at annual SGIM meeting.
4. Provide certificate of advanced ambulatory competency to outpatient
chief
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PGY -2/3 Continuity Elective
Resident Continuity Elective
Rationale
Chronic disease has replaced acute disease as the principle consumer of
health care resources; more than 75% of resources are expended on
chronic illness care. Most chronic disease management occurs in
ambulatory settings. Internal medicine residencies, however, have
historically trained physicians in managing acute medical problems and
have not provided structured, continuous training in ambulatory and
chronic illness care. Chronic illness care poses a different set of
challenges than acute illness care where patients are symptomatic and
understand the imperative for intensive, structured medical care.
Chronic illness often produces no symptoms, and prevention is the focus
of management. Both providers and patients need to be aware that the
absence or stability of symptoms does not preclude intensive patient care
that is informed by data from clinical trials. This challenge requires a
new set of skills that traditionally have not been imparted in internal
medicine residencies.
Objectives
1. To improve resident training in ambulatory medicine through
exposure to chronic disease management programs in the
ambulatory care setting.
2. To develop skills that will prepare residents to provide high quality
chronic illness care, regardless of which specialty of internal
medicine they pursue. Residents will gain knowledge and
expertise in the following areas:
 Knowledge base for effectively managing chronic illness.
 Systems for tracking patient outcomes that improve the quality of
care. These systems rely on ancillary medical professionals,
electronic medical records, databases and information technology.
 Continuous quality improvement. This elective addresses a core
competency emphasized by the ABIM for Improving Performance in
Practice. The UNC model has been presented at national meetings
and is being adopted at other institutions, though it has not yet
directly been applied to resident education at our institution.
 Collaboration with mid-level providers such as clinical
pharmacists, physician assistants and nurse practitioners involved
in chronic disease management
Structure
1. Combine Urgent Care months with structured ambulatory care
time over a two month period. Total Urgent Care time will remain
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2.
3.
4.
5.
6.
neutral at one month. By coupling acute and chronic medical
care, this elective does not seek to de-emphasize the importance of
acute care; rather, it will prepare residents for the realities of
independent practice where both acute and chronic issues are
addressed continuously.
The elective will be offered to residents at all levels of training. It
will be an alternative to other electives and provide an additional
outpatient option.
The resident will rotate through the existing disease management
modules: anti-coagulation, chronic pain, diabetes mellitus.
The resident will manage patients independently using approved
protocols. The resident will receive guidance from attending
physicians and clinical pharmacists experienced with systematic
disease management.
The resident will spend one half day a week seeing patients
independently with an attending physician (team leader) who will
provide direct teaching related to ambulatory internal medicine on
a one-on-one basis. (Recall that the usual precepting and
continuity clinic experience diffuses an attending’s attention over
up to four residents at a time.) The resident and attending
physician will be templated for 12 to 14 patients in this half day.
Billing will therefore not need to adhere to the Primary Care
Exception.
The resident will spend one half day per week in her or his own
continuity clinic. The resident will have the option to schedule her
or his patients for close follow up during other half days at the
ACC when clinically indicated. This will provide an experience of
close continuity that is currently lacking in resident continuity
clinics.
Sample Elective
Monday
Am DSM:
Anticoag
Pm CC with
team
leader
Template
Tuesday
Wednesday Thursday
Friday
CC
UCC
Grand
UCC
Rounds/Conferences
DSM: DM UCC
DSM: Pain
UCC
Legend
DSM= Disease state management
Anticoag= Anticoagulation management
DM= Diabetes mellitus management
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Pain=Chronic pain management
Logistics
1. The new elective will have a capacity for 12 residents in the first
year.
2. This will mean that two residents will be accommodated
simultaneously.
Team Leaders for Disease Management Precepting
1. Michael Pignone, MD, MPH
2. Darren DeWalt, MD, MPH
3. Paul Chelminski, MD, MPH
4. Second full time ACC clinician (?Cristin Colford)
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Enhanced Care Elective Rotation
UNC General Internal Medicine Clinic
Ambulatory Care Preceptorship
Ambulatory Care Center, UNC Hospitals
Primary Preceptor
Paul Chelminski, MD, MPH
Assistant Professor of Medicine
Pager: (919) 216-6163
Office: (919) 966-0471
Email: paul_chelminski@med.unc.edu
Disease Management Preceptors
Betsy Bryant Shilliday, Pharm.D., CDE, CPP
Clinical Pharmacist Practitioner
Assistant Professor of Medicine
Assistant Clinical Professor of Pharmacy
Pager: (919) 216-5723
Office: (919) 843-0391
Email: betsy_bryant@med.unc.edu
Robb Malone, Pharm.D., CDE, CPP
Clinical Pharmacist Practitioner
Assistant Professor of Medicine
Assistant Clinical Professor of Pharmacy
Pager: (919) 216-5736
Office: (919) 843-0391
Email: rmalone@med.unc.edu
Timothy Ives, Pharm.D., MPH, CDE, CPP
Clinical Pharmacist Practitioner
Associate Professor of Pharmacy and Medicine
Pager: (919) 216-0193
Office: (919) 843-0391
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Email: tjives@med.unc.edu
Goal
The Enhanced Care elective incorporates various components of
outpatient medicine including disease management clinics, continuity
clinic, urgent care clinic, and one-on-one preceptorship with an
attending physician. This elective will provide the opportunity for the
learner to build upon information acquired in his/her didactic education
and to apply the knowledge and skills in direct patient care activities in
the primary care setting and specialty outpatient clinics. This experience
will be gained primarily under the Preceptorships of Drs. Betsy Bryant
Shilliday, Robb Malone, Tim Ives, and Paul Chelminski.
Practice Site Description
The Enhanced Care team is an interdisciplinary team that
provides disease state management services to patients who have
established care with a primary care physician in the UNC
General Internal Medicine (GIM) clinic. The patient population
consists of adults, ages 18 and older with a variety of medical
conditions. Patients can be referred to any of three existing
programs: 1) Anticoagulation 2) Diabetes and/or 3) Chronic Pain.
Clinical experiences afforded to the learner include, but are not
limited to: anticoagulation, hypertension, hyperlipidemia, diabetes
mellitus, depression, arthritis, congestive heart failure,
cardiovascular risk reduction, chronic pain and osteoporosis. The
clinic is located on the 3rd floor of the Ambulatory Care Center
(ACC) on Mason Farm Road, Chapel Hill, North Carolina.
Hours & Clinic Descriptions
Hours of the rotation are typically Monday through Friday 8am to 5pm.
However, afternoon hours may vary depending on patient workload and
issues that arise during clinic hours.
Clinic Template
Monday Tuesday
Am UCC
DSM:
Anticoag
Pm UCC
Wednesday Thursday
Friday
DSM: Pain
Grand
UCC
Rounds/Div.Meeting
DSM Meeting
Preceptorship DSM: DM
CC
UCC
with
attending
UCC: Urgent Care Clinic; DSM: Disease Management; CC: Continuity Clinic
The Urgent Care Clinic will be Mondays and Fridays 8am to 5pm. This
clinic will familiarize the learner with a variety of acute medical issues.
The evaluation of this component of the rotation will occur through the
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normal evaluation process through supervising attending physicians and
not separated out to this rotation.
The Continuity Clinic will be on Thursday afternoons and will allow the
resident learner to increase clinic time for this 2 month block of time.
The afternoon clinic slots will begin at 1:30pm. The evaluation of this
component will be under the normal evaluation process of supervising
attending physicians and not separated out to this rotation.
The one-on-one physician preceptorship will allow the resident learner
to work in tandem with an attending physician in his or her outpatient
clinic to improve outpatient management skills.
The Anticoagulation Clinic consists of a Clinical Pharmacist
Practitioner, Physician Assistant, Nurse Practitioner, and Registered
Nurse who see patients for warfarin initiation/education, INR
monitoring, warfarin dosage adjustment and enoxaparin (Lovenox®)
bridging. Patients are scheduled for 15-minute appointments as often as
necessary but return to clinic at least once every four weeks while on
warfarin therapy.
The Diabetes Clinic is a multidisciplinary clinic, consisting of Clinical
Pharmacist Practitioners, Nurse Practitioner, Registered Dietician and
Research Assistants, designed to medically manage and educate patients
with uncontrolled diabetes. Patients are followed until their A1c reaches
goal < 7%. Though emphasis is placed on diabetes management, clinical
care encompasses cardiovascular risk reduction, hypertension,
hyperlipidemia, congestive heart failure, depression and arthritis.
The Chronic Pain Clinic consists of a Clinical Pharmacist Practitioner,
Nurse Practitioner, and Research Assistant specializing in disease
management of chronic pain syndromes and associated psychiatric
disorders (depression and anxiety). Patients are assessed using
screening tools such as the Brief Pain Inventory (BPI) and Center for
Evaluation Studies of Depression (CES-D), and use of physical
assessment at every visit. Learners will be exposed to the prescribing
and use of chronic controlled substances and adjunct analgesics. They
will also become proficient in the outpatient monitoring of this patient
population, including the potential for medication diversion.
Global Program Objectives
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3. To improve resident training in ambulatory medicine through
exposure to chronic disease management programs in the UNC
Internal Medicine Clinic.
4. To develop skills that will prepare residents to provide high quality
chronic illness care, regardless of which specialty of internal
medicine they pursue. Residents will gain knowledge and
expertise in the following areas:
 Knowledge base for effectively managing chronic illness.
 Systems for tracking patient outcomes. These systems rely on
ancillary medical professionals, electronic medical records,
databases and information technology.
 Continuous quality improvement and systems-based practice
which is a core competency required by the ABIM for Improving
Performance in Practice. The resident will have opportunities
to performing chart audits of their clinic patients with diabetes.
After completion of the self-audit the resident will be able to
consider how their performance can improve with their
individual practice or with the system as a whole.
 Collaboration with mid-level providers such as clinical
pharmacists, physician assistants and nurse practitioners
involved in chronic disease management
Specific Program Objectives
General:
1. Develop a better understanding of the roles and functions of
disease management programs.
2. Assess potential barriers to care including literacy, psychosocial
issues, finances, transportation, etc. and assist patients with those
obstacles.
3. Focus clinic visit time on the specific chronic disease versus the
patient’s acute problems or entire problem list.
4. Adopt a better understanding of the UNC pharmacy benefit
program and disease management contracts.
Anticoagulation:
1. The learner should familiarize himself/herself with CHEST
guidelines. The Seventh ACCP Conference on Antithrombotic and
Thrombolytic Therapy. Chest 2004 Sept; 126(3) supp.
2. Understand how to better manage warfarin therapy and bridging
with low molecular weight heparin, while taking into account
patient specific bleeding and thromboembolic risk factors.
3. Determine an appropriate INR goal for specific patient indications
based on CHEST guidelines, learn how to properly adjust warfarin
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dose to target the goal INR and how to dose low molecular weight
heparin for various bridging procedures.
4. Assess signs/symptoms of bleeding/bruising.
5. Review current medication list, update in medical record and
address any drug-drug interactions, including over-the-counter
(OTC) medications such as aspirin and NSAIDs.
6. Educate patient on vitamin K content of diet and importance of
consistency while on warfarin therapy.
7. Educate patient on role of warfarin therapy in relation to their
indication for therapy, discussing duration of therapy.
8. Educate patient on proper use of OTC items such as pain relievers,
herbals, vitamins, supplements, etc.
9. Adjust weekly warfarin dose to target goal INR for patient’s
indication using nomograms and patient history.
10.
Assess past medical history (PMH) for factors which put the
patient at an increased risk for thromboembolic events.
11.
Assess PMH for factors which may increase the patient’s risk
for bleeding complications from warfarin therapy.
Diabetes:
1. The learner should familiarize himself/herself with ADA Guidelines
2005, JNC VII, and NCEP guidelines.
2. Obtain a focused CV and DM history and ROS.
3. Perform foot exams.
4. Assess vaccination status.
5. Assess tobacco use, determine stage of change, and recommend
appropriate intervention.
6. Make appropriate referrals to ophthalmology and/or nutrition.
7. Assess current DM, HTN, and lipid therapy for appropriateness.
Determine goal blood pressure and lipids based on patient’s comorbid conditions and recommend additional therapy with
evidence-based reason, if needed and according to protocols.
8. Assess current level of diabetes control, develop a medication
regimen and
monitoring plan and properly adjust and/or add medications to
obtain glycemic
goals.
Pain:
1. Assess the type and level of pain, develop a medication regimen
and monitoring plan to manage any combination of pain (e.g.,
nociceptive, neuropathic, inflammation)
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2. Assess and manage co-morbid conditions associated with pain
(e.g., depression, anxiety, sleep disorders, hypertension).
3. Learn how to more effectively control the prescribing of controlled
substances in patients with chronic pain to protect oneself, the
patient and the community from potential drug abuse and
diversion (e.g., use of urine toxicology screening).
Responsibilities and Activities

Take an active role in patient care.

Collect pertinent information from each patient’s medical record in
preparation for clinic visits.
Familiarize oneself with disease management protocols for each
program.
Formulate a comprehensive, evidence-based, patient-centered
therapeutic plan for each patient.
Work collaboratively with preceptors during clinic visits.
Educate and collaborate with patients and their families/caregivers
at their respective literacy level to ensure a patient-centered model
of care.
Document patient care activities for each visit as directed by
preceptor
Provide timely patient follow-up via telephone when necessary.
Attend grand rounds Thursday mornings at 7:30am, when
applicable in the 4th Floor Old Clinic Auditorium.
Attend General Medicine Division meeting every Thursday morning
at 8:30am in the 5th Floor Conference Room of Old Clinic Building.
Attend Disease Management meeting every Thursday morning at
9:30am in room 3004 (Hematology/Oncology Conference Room),
3rd Floor Old Clinic Building.
Present at least one journal club of current literature related to
pertinent chronic disease topics, with one being presented at
General Medicine Division meeting at designated time.
Actively participate in ongoing disease management projects and
Continuous Quality Improvement (CQI) initiatives pertinent to the
disease management programs.











Required Readings
All required readings can be found in hard copy format as well as
full text on a CD kept in the Learner’s Notebook.
Disease Management:
1. Ofman J, Badamgarav E, Henning J et al. Does Disease
Management Improve Clinical and Economic Outcomes in Patients
with Chronic Diseases? A Systematic Review. Am J Med.
2004;117:182-192.
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2. Bodenheimer, T.; Wagner, E. H., and Grumbach, K. Improving
primary care for patients with chronic illness. JAMA. 2002 Oct 9;
288(14):1775-9.
Anticoagulation:
1. The Pharmacology and Management of the Vitamin K Antagonists:
The Seventh
ACCP Conference on Antithrombotic and Thrombolytic Therapy.
Chest 2004;126:204S-233S.
2. Harrison L, Johnston M, Massicotte P et al. Comparison of 5 mg
and 10 mg Loading Doses in Initiation of Warfarin Therapy.
Annals of Internal Medicine. 1997;126:133-136.
3. Kovacs M, Rodger M, Anderson D et al. Comparison of 10 mg and
5 mg Warfarin Initiation Nomograms Together with Low-MolecularWeight Heparin for Outpatient Treatment of Acute Venous
Thromboembolism. Ann Intern Med. 2003;138:714-719.
4. Ridker P, Goldhaber S, Danielson E et al. Long-Term, LowIntensity Warfarin Therapy for the Prevention of Recurrent Venous
Thromboembolism. NEJM. 2003;348:1425-1434.
5. Kearon C, Ginsberg J, Kovacs M et al. Comparison of LowIntensity Warfarin Therapy with Conventional-Intensity Warfarin
Therapy for Long-Term Prevention of Recurrent Venous
Thromboembolism. NEJM. 2003;349:631-639.
Supplemental Readings:
6. Antithrombotic Therapy for Venous Thromboembolic Disease: The
Seventh ACCP Conference on Antithrombotic and Thrombolytic
Therapy. Chest 2004;126:401S-428S.
7. Antithrombotic Therapy in Atrial Fibrillation: The Seventh ACCP
Conference
on Antithrombotic and Thrombolytic Therapy. Chest
2004;126:429S-456S.
8. Antithrombotic Therapy in Valvular Heart Disease--Native and
Prosthetic:
The Seventh ACCP Conference on Antithrombotic and
Thrombolytic Therapy.
Chest 2004;126:457S-482S.
Diabetes:
1. Krentz A, Bailey C. Oral Antidiabetic Agents: Current Role in Type
2 Diabetes Mellitus. Drugs. 2005;65(3):385-411.
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2. MRC/BHF Heart Protection Study of cholesterol-lowering with
simvastatin in 5963 people with diabetes: a randomized placebocontrolled trial. Lancet. 2003;361:2005-2016.
3. Gaede P, et al. Intensified multifactorial intervention in patients
with type 2 diabetes mellitus and microalbuminuria: the Steno
type 2 randomised study. Lancet. 1999;353: 617-622.
4. Intensive blood-glucose control with sulphonylureas or insulin
compared with conventional treatment and reisk of complications
in patients with type 2 dieabetes (UKPDS 33). Lancet.
1998;352:837-853.
5. Effect of intensive blood-glucose control with metformin on
complications in overweight patients with type 2 diabetes (UKPDS
34). Lancet. 1998;352:854-865.
Supplemental Readings:
6. Rothman R, Malone R, Bryant B et al. A randomized trial of a
primary care-based disease management program to improve
cardiovascular risk factors and glycated hemoglobin levels in
patients with diabetes. American Journal of Medicine.
2005;118:276-284.
7. Rothman R, DeWalt D, Malone R et al. Influence of Patient
Literacy on the Effectiveness of a Primary Care-Based Diabetes
Disease Management Program. JAMA. 2004;292:1711-1716.
8. Rothman R, Malone R, Bryant B et al. The Spoken Knowledge in
Low Literacy in Diabetes Scale: A Diabetes Knowledge Scale for
Vulnerable Patients. Diabetes Educator. 2005;31(2)215-224.
9. Rothman R, et al. Pharmacist-led, primary care-based disease
management improves hemoglobin A1c in high-risk patients with
diabetes. Am J Med Qual. 2003 Mar-Apr;18(2):51-8.
10.
Clark PM, Gray AM, Briggs A, et al. Cost-utility analyses of
intensive blood glucose and tight blood pressure control in type 2
diabetes (UKPDS 72). Diabetologia. 2005;48:868-877.
Pain:
1. Holdcroft A, Power I. Management of Pain: Recent Developments.
BMJ.
2003;326:635-639.
2. Ballantyne J, Mao J. Opioid Therapy for Chronic Pain. NEJM.
2003;349:19431953.
3. Strasser F, Driver L, Burton A. Update on Adjuvant Medications
for Chronic
Nonmalignant Pain. Pain Practice. 2003;3(4):282-297.
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4. Hammett-Stabler C, Pesce A, Cannon D. Urine Drug Screening in
the
Medical Setting. Clinica Chimica Acta. 2002;315:125-135.
5. Goldenberg D, Burckhardt C, Crofford L. Management of
Fibromyalgia
Syndrome. JAMA. 2004;292:2388-2395.
Supplemental Readings:
11.
Chelminski, P. R.; Ives, T. J.; Felix, K. M.; Prakken, S. D.;
Miller, T. M.; Perhac,
J. S.; Malone, R. M.; Bryant, M. E.; DeWalt, D. A., and Pignone, M.
P. A primary
care, multi-disciplinary disease management program for opioidtreated patients
with chronic non-cancer pain and a high burden of psychiatric
comorbidity. BMC
Health Serv Res. 2005 Jan 13; 5(1):3.
12.
Gardner-Nix J. Principles of opioid use in chronic noncancer
pain. CMAJ.
2003;169(1):38-43.
8. Moulin, D. E.; lezzi, A.; Amireh, R.; Sharpe, W. K.; Boyd, D., and
Merskey, H.
Randomised trial of oral morphine for chronic non-cancer pain.
Lancet. 1996; 347(8995):143-7.
Assessment and Feedback


Self Assessment: A verbal self-assessment will be completed by all
preceptors at the end of the fourth week of the rotation. A written
self-assessment will be completed the last week of the rotation and
reviewed/discussed with the learner upon completion of the
rotation. You are welcome at any time to request an informal
evaluation of your progress.
Preceptor Assessment: A written assessment of the disease
management elective should be completed at the end of the
rotation. Formative verbal assessment is appreciated throughout
the month.
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SECTION 4
TEACHING CURRICULUM
Interns’ Conference
Ambulatory Care Conference
Internal Medicine Update Conference
Board Review
Occupational and Environmental Diseases
Bioethics and the Legal Principles of Medicine
Physician Impairment
Laboratory Medicine
Medical Informatics
Evaluation
Violence
Gender-Specific Health Care
Palliation Care & Pain Management
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Section 4
Teaching Curriculum
General
The Department of Medicine has daily teaching conferences that supplement teaching
done on individual rotations. As previously mentioned in Section 1, these conferences are held at
times that do not conflict with the activities of the respective services. The formats of these
conferences have also been described in Section 1.
Content is planned so that each resident is exposed to the breath of information
necessary to become a well-trained general internist. Specific curricula are also incorporated into
these conferences. These curricula are described in this section.
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INTERNS’ CONFERENCE
All PGY-1 residents are excused from clinical dates each Wednesday from noon to 1:00
pm. At the beginning of the academic year, each conference is led by a member of the faculty
who discusses a topic pertinent to PGY-1 management of patients. Topics included are outlines
below. Following this series of conferences, the format for this conference changes to case-based
teaching of 1-2 topics per session. This format continues throughout the year.
Topics for Conferences
EMERGENCIES
Anaphylaxis / PE
Hematology/Oncology Emergency
SVC Syndrome
Tumor Lysis
Hypercalcemia
Cord Compression
Pneumothorax / Aortic Dissection
CARDIOLOGY
Hypertension
Atrial Fibrillation
Myocardial Infarction
Congestive Heart Failure
EKG Interpretation
NEUROLOGY
Seizures
CVA
Altered Mental Status
PULMONOLOGY
Chronic Obstructive Pulmonary Disease
Lung Cancer
Asthma
Pneumonia
NEPHROLOGY
Acute Renal Failure
Chronic Renal Failure
ENDOCRINOLOGY
Thyroid Disease
Adrenal Disease
DIGESTIVE DISEASES
PUD
Pancreatitis
Liver Failure / ETOH Liver Disease
Hepatitis
Diarrhea
HEMATOLOGY/ONCOLOGY
Anemia
Breast Cancer
Prostate Cancer
Colon Cancer
RHEUMATOLOGY
Rheumatoid Arthritis/Osteoarthritis
Lupus
Sarcoidosis
INTRO TO EVIDENCE BASED MEDICINE
INFECTIOUS DISEASES
Human Immunodeficiency Virus
Tuberculosis
Meningitis
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AMBULATORY CARE CONFERENCE
This conference occurs each Friday from noon to 1 pm and is attended by PGY-1, -2, and
-3 residents. Each conference is led by a PGY-2 or PGY-3 resident. The resident researches the
topic, presents a key article, and critically appraises the article and the literature. The focus of
this conference is evidence-based medicine.
Topics for Conference
HEENT
Sinusitis/Rhinitis/Otitis/Laryngitis
Hearing Loss
Pharyngitis
Blinding Eye Diseases
Respiratory
Cough/Bronchitis
Pulmonary Nodule
Outpatient Management of Asthma
Cardiovascular
Evaluation and Treatment of Hypertension
Testing strategies for Suspected Coronary Artery Disease
Peripheral Vascular Disease (arterial)
Chronic Venous Disorders
Carotid Bruits and TIA’s
GI
Irritable Bowel Syndrome
Diverticular Disease
Dyspepsia
Constipation
Diarrhea
Avitaminoses
Endocrine
Outpatient Management of Type I DM
Outpatient Management of Type II DM
Osteoporosis
Goiter and Thyroid Nodules
Hyper- and Hypothyroidism
Musculoskeletal
Low Back Pain
Common Foot Problems in Primary Care
Evaluation of Musculoskeletal Complaints
-1- Neck and UE
-2- Hip and LE
Gout/CPPD
Gynecologic/Genitourinary
Prescribing Oral Contraceptives
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Menopause/Hormone Replacement Therapy
STD’s/Vaginitis/ Safe Sex Counseling
Pelvis Inflammatory Disease
Sexual Dysfunction
BPH/Prostatitis
UTI/Asymptomatic Bacteriuria
Nephrolothiasis
Dysfunctional Uterine Bleeding
Hematurias/Proteinuria
Incontinence
Neurologic
Dizziness
Syncope
Headache
Peripheral Neuropathy
Psychiatric
Anxiety/Panic Disorder
Management of Chronic Benzodiazepine Use
Narcotic Addiction/Narcotic-seeking Behavior
Recognition of Abuse in the outpatient setting (Domestic violence/Incest/Rape)
Depression in Primary Care
Insomnia
Recognition of Personality Disorders in the Outpatient Screening
Dermatology
Outpatient Dermatology
Screening/Prevention
Smoking: Counseling and Cessation
Tuberculosis Screening and Prophylaxis
Immunizations and Post-Exposure Prophylaxis
General Principles of Screening and Prevention Care
Cholesterol Screening
Breast Cancer Screening
Cervical Cancer Screening
Traveler’s Recommendations
Colorectal Cancer Screening
Prophylaxis for Procedures
Miscellaneous
Outpatient Management of HIV infection
Preoperative Medical Evaluation in the clinic setting
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INTERNAL MEDICINE UPDATE CONFERENCE
This conference occurs each Monday from noon to 1 pm. A series of topics is selected,
each one reviewed by a faculty member of the Department of Medicine. The subjects are chosen
based upon resident performance on the ACP sponsored In-Training Examination. All residents
attend this conference. The following subjects are reviewed in this conference.
CARDIOLOGY
MI diagnosis
MI Management
Arrhythmias
Diagnostic Testing
EKG & Physical Exam
CHF Management
Chest pain evaluation
HTN etiology
HTN Management
Endocarditis diagnosis
Endocarditis Management
CAD interventions
ICU
Aortic Aneurysm
Shock
Respiratory Failure
ARDS
Pulmonary Embolism
Pneumonias
Ionotropic Meds
DKA
Overdoses
NEPHROLOGY
Hyponatremia
Acidosis
Alkalosis
Electrolytes
Urine Electrolytes
Hypernatremic
Hematuria/Proteinuria
Lupus/Vasculitis
Transplants
Urinalysis
Dialysis / ARF
DIGESTIVE DISEASE
Nutrition
Upper GI bleed
Lower GI bleed
Liver Failure
Pancreatitis
Diarrhea
Cholecystitis/Cholangitis
Diverticulitis
Inflammatory Bowel Disease
Peptic Ulcer Disease
Cirrhosis
HEMATOLOGY
Sickle cell disease
DIC
Coagulopathies
Hemolysis
Anemia
Thrombocytopenia
Anticoagulation - How to
INFECTIOUS DISEASES
Meningitis
HIV 1 - Opportunistic Infect.
HIV 2 - Anti retroviral
Hepatitis
Antibiotics I
Antibiotics II
Fever of unknown origin
Sepsis
Urinary Tract Infections
Rare infections
PULMONARY
Asthma
Pulmonary nodule
Tuberculosis
Interstitial lung disease
Pleural effusions
Pulmonary Function Tests
GENERAL MEDICINE
Venous stasis ulcer
Depression
Stroke
Back pain
Dementia
Neuropathy
Screening
Occupational Health &
Exposure
Occupational Health - Toxins
ONCOLOGY
Lung Cancer I
Lung Cancer II
Leukemia I
Leukemia II
Hem/Onc emergencies
Lymphoma
Breast cancer
Colon cancer
Prostate cancer
Myelophthystic disorders
Multiple myeloma
Bone marrow transplantation
ETHICS
DNR
Apache Score/ Prognosis
Legal
RHEUMATOLOGY
Crystal disease
Inflammatory arthritis
Autoimmune
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INTERNAL MEDICINE BOARD REVIEW
At the conclusion of each academic year, a review of Internal Medicine is given to prepare
PGY-3 residents for the certification examination in Internal Medicine. The core of this review is a
series of lectures given by faculty members. All PGY-3 residents are excused from clinical duties
to attend.
The goal of each lecture is to give a broad overview of the subjects. Each lecture has an
accompanying handout. These are collected so that each participant receives a syllabus for the
course.
OCCUPATIONAL AND ENVIRONMENTAL DISEASES
Internists must always consider that certain symptoms and disease processes are related
to exposures in the occupational setting or particular environmental settings. At the completion
of training, residents should have a working knowledge and sufficient patient experience to
satisfy the following goals:
Incorporate in a history occupational and environmental exposures.
Identify physical and laboratory findings suggestive of occupational/environmental exposure alopecia, wheezing, hearing loss, chest x-ray abnormalities of silicosis, asbestosis, CO poisoning,
lead exposure.
Understand appropriate reporting to monitoring agencies
Know the procedure and how to assess disability
Know how to counsel patients about exposure risks
The information necessary to meet these goals is the subject of several teaching
conferences. It is also part of the Curriculum of the Pulmonary service as well as Allergy Clinic,
and part of Rheumatology rotation.
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BIOETHICS AND THE LEGAL PRINCIPLES OF MEDICINE
On a day-to-day basis, residents face ethical issues. Residents must gain expertise in the
following subjects and be familiar with their societal and legal boundaries.
Understand living wills and power of attorney and incorporate this into a history
Be able to define criteria for withdrawal of support
Be able to counsel a patient when the patient refuses treatment or is ambivalent about treatment.
Understand the legal aspects of confidentiality
Understand what constitutes malpractice and steps to prevent litigation.
Develop expertise with the dying patient and family.
Understand the role of hospice and be familiar with referral criteria
Be familiar with surrogate decision-making and permission for treatment.
Understand the legal aspects of “Do not resuscitate” orders.
Understand the legal aspects of confidentiality of medical records.
These subjects are reviewed in several teaching conferences in the Department of
Medicine. Some of these issues are part of the curriculum in the ICU and the general medicine
inpatient service. Finally, at least three Grand Rounds per year are devoted to these subjects.
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PHYSICIAN IMPAIRMENT
A significant number of physicians are impaired by alcohol, chemical dependency,
and/or psychiatric dysfunction. The recognition of such physicians, how they can be referred for
help, and their outcome should be appreciated by residents. Specifically, the following aspects of
physician impairment should be part of the knowledge base in internal medicine.
What constitutes physician impairment and how to identify it.
What is appropriate treatment for impaired physicians?
Recognition of the disease of addiction.
The utility of a contract for an impaired physician.
This subject and its components will be reviewed in a series of ’ conferences conducted by
members of the North Carolina Physicians Health Program, a group of experts in the field of
physician impairment. Educational reading materials will be provided at the conferences.
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LABORATORY MEDICINE
As part of a diagnostic evaluation, internists often order and subsequently interpret a
variety of laboratory tests. Internists should demonstrate competency in these areas for the tests
listed. This information is reviewed in the subspecialty and general medicine curricula.
Allergy and Immunology - levels of complement, C1 esterase, eosinophil count
Cardiology - cardiac enzymes, nuclear heart scan
Dermatology - Tzanck smear, microscopic exam for scabies
Endocrinology - bone mineral densitometry, serum glucose, gylcosylated hemoglobin, serum
gonadotropins, serum lipids, serum prolactin, thyroid function tests, thyroid scanning,
urine metanephrines, serum calcium, serum phosphate
Gastroenterology - assays for H. pylori, serum tests for liver diseases, colonoscopy, stool for O&P,
ercp, fecal electrolytes and osmolality, gall bladder scan, serum gastrin, viral hepatitis
serology, liver biopsy, stool fat, endoscopy
Hematology - bone marrow aspirate and biopsy, cytogenetics, clotting assays, iron studies, lymph
node biopsy, electrophoresis, B12 levels
Infectious Disease - CD4 counts, csf analysis, ELISA, PCR, serology for common infections,
syphilis serology
Nephrology - 24-hour urine electrolytes, fractional excretion of sodium, creatinine clearance,
renal biopsy, serology for glomerulornephritis, renal angiography
Neurology - anticonvulsant drug levels, carotid Dopplers, imaging of CNS, sleep study
Oncology - cytology, estrogen/progesterone receptors, serologic tumor markers
Pulmonary - bronchoscopy, pleural fluid analysis, and lung scans
Rheumatology - antinuclear antibodies, ESR, complement levels, rheumatoid factor, synovial
analysis for crystals.
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MEDICAL INFORMATICS
The extent of medical information, both educational as well as related to patient care, is vast.
Organization of this information is critical for an internist to function effectively. To this end, an
internist must have certain knowledge of computer systems to design an information system that
is reliable and accessible. The following curricular goals should be achieved.
Be able to use basic word processing
Be able to use CD-ROM’s and the Internet for education and literature searching
Be able to use computer systems for patient care
Know essential aspects of information storage.
To emphasize these goals, each resident attends a course to develop skills in using the
clinical workstations at the UNC Hospitals. Furthermore, there are instructional conferences on
CD-ROM for educational use.
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Violence
An internist must be able to recognize signs and symptoms of abuse as well as know how to manage
or refer patients who are victims of abuse. The following objectives will be addressed in didactic sessions.
1.
to learn the signs and symptoms of domestic abuse
2.
to learn the signs and symptoms of sexual abuse
3.
to learn the signs and symptoms of elder abuse
4.
to learn about the hospital & community resources to deal with these problems
5.
to learn the legal issues involved in abuse
These subjects are discussed at the departmental level, usually at Grand Rounds, by experts in
abuse. These experts work under the Beacon Program at the UNC Hospitals, which includes faculty members
from the Department of Medicine, the Department of Social Services, & the Legal Department.
Gender-Specific Health Care
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Women’s Health
The general internist will be called upon to perform health maintenance, recognize and treat common
disorders, and refer appropriately for complex diseases of women.
In preparation for these functions, the following objectives should be met in the residency:
1.
be able to perform bimanual pelvis examination, including preparing pap smears
2.
be able to perform a breast examination and instruct patients in self-examination
3.
know health maintenance guidelines for these examination (1, 2)
4.
be able to prescribe common contraceptives
5.
understand the evaluation of galactorrhea
6.
be able to diagnose and treat common STD’s-syphillis, gonorrhea, herpes
7.
be familiar with rape protocol
8.
understand the presenting signs of sexual abuse
9.
be familiar with the evaluation of pelvic pain
10. know the physical signs of cystocele, rectocele, uterine prolapse
11. be familiar with the presenting signs of pregnancy
12. be able to prescribe and understand the risks and benefits of hormone replacement
Physical examination skills for these objectives will be met in the continuity clinic, urgent care, general
medical rotations, as well as the Emergency Room. Didactics on these subjects are covered in these different
rotations as well as in Department conferences including Grand Rounds, ACC conferences, update
conferences, and resident’s report.
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Men’s Health
The general internist also will be involved in health maintenance, referral, diagnosing and
treating disorders specific to men. The following objectives should be met:
1.
be able to perform a genital examination, including examination of the prostate.
2.
know the health maintenance guidelines for the genital examination, including PSA
screening
3.
recognize presenting symptoms of prostate cancer
4.
be able to diagnose and treat prostatitis
5.
be able to diagnose and treat common STD’s-syphillis, gonorrhea, and herpes
6.
be familiar with the evaluation of impotence
7.
be able to recognize and diagnose common hernias
8.
be able to recognize and treat epididymitis
9.
be familiar with the evaluation of a testicular mass
10. understand the pathophysiology of gynecomastia
The appropriate skills and didatics will be covered in the same manner as described for women’s
health issues.
Palliative Care and Pain Management
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A number of diseases that the general internist faces have no effective treatment. For these
diseases once a diagnosis is made, the internist may have to focus all efforts on palliation and terminal care.
The following objectives should be met to prepare residents for these patient care situations:
1.
to develop an understanding of palliation care as perceived by the patient & family
2.
to learn the role of the health care team in the delivery of palliation care
3.
to learn the role of the hospice in the care of terminally ill patients
4.
to learn the principles of symptoms management including pain, nausea, vomiting, & dyspnea
5.
to understand about the financial aspects of palliation care, particularly in the home
These subjects will be covered in a series of lectures by expert faculty. Dr. Stephen Bernard,
Division of Hematology/Oncology, will give several of these. He has specific training & conducts an elective
course in the School of Medicine in palliation care. Members of the Department of Anesthesiology who serve
on the pain consultation service will also participate. Regarding specific experience, the Geriatrics rotation
includes time at a hospice.
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SECTION 5
EVALUATION
Resident performance must be evaluated on every rotation. The categories of evaluation as
defined by the Residency Review Committee (RRC) for Internal Medicine are as follows:
1.
2.
3.
4.
5.
6.
Patient Care
Medical Knowledge
Practice-Based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Systems-based Learning
The resident evaluation form asks faculty to evaluate residents in each of the competencies. A
copy is enclosed. The competencies have been reviewed with the Attendings in departmental
conferences.
Separate evaluation forms have been developed for Continuity Clinic and Same-day clinic. The
form will be filled out by the clinic preceptor for each clinic session for residents and the data will
be aggregated twice a year by the director of the clinic. Copies of the forms are included.
All residents are required to complete a clinical evaluation exercise in the first 6 months of the
PGY 1 year. A copy of this form is included.
All residents are evaluated semi- annually by the Program Director. At the end of each year a
global evaluation is submitted to the American Board of Internal Medicine. It is reviewed with the
resident and a copy is provided for each resident.
Residents are asked to evaluate the faculty on each rotation and to evaluate the curriculum
annually. Faculty are also asked to evaluate the curriculum Copies of these forms are provided.
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Procedure Competency
The American Board of Internal Medicine requires that residents
perform safely and competently the following procedures:
1.
2.
3.
4.
5.
ACLS
Drawing venous blood
Drawing arterial blood
Pap smear and endocervical culture
Placing a peripheral venous line
For other procedures the Board requires that residents know the
indications, contraindications, management of complications, and
interpretation of results. Performing these procedures is not required for
Board certification. These include:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Paracentesis
Arterial line placement
Arthrocentesis
Central venous line placement
Incision and drainage of an abscess
Lumbar puncture
Nasogastric intubation
Pulmonary artery catheter placement
Thoracentesis
The Department of Medicine has responded to this initiative by
developing a comprehensive procedure curriculum. This is given to all
PGY 1 residents. First residents are required to watch videos and read
selected articles about the procedures. The next step is a half-day
workshop in our simulation lab where residents practice central venous
line placement, peripheral venous line placement, and lumbar puncture.
Clinical instructors are present for each procedure. A post –workshop is
given to each resident.
All residents are given a procedure log to use throughout the residency
to record all procedures done. The information includes any
complications and the supervisor for the procedure. The log becomes
part of the resident’s permanent folder.
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Curriculum Evaluation
2008
PGY 1 ___
Scale:
PGY 2 ___
Strongly Agree
1
Agree
2
PGY 3 ___
Neutral
3
(Please designate your year.)
Disagree
4
Strongly Disagree
5
1.
Grand Rounds topics were clinically relevant and contributed to my knowledge base.
2.
CPC’s presented a wide array of diseased processes and contributed to my knowledge base.
_____
3.
Noon Conferences were clinically relevant and contributed to my knowledge base.
_____
4.
Teaching conferences placed an appropriate emphasis on Evidence-Based Medicine
_____
5.
Teaching conferences placed too much emphasis on Evidence-Based medicine.
_____
6.
The In-Training Examination adequately assessed my fund of information.
_____
7.
Residents Report presentation’s contributed to my knowledge base.
_____
8.
The case-based format of Residents Report was an effective learning environment.
_____
9.
The housestaff website was an effective tool for literature searching.
_____
10. My schedule allowed me adequate time to read.
_____
_____
Please feel free to add individual comments:
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Curriculum Evaluation
2008
Instructor/Assistant Prof ___ Associate/Full Professor ___
Scale:
Strongly Agree
1
Agree
2
Neutral
3
Division ___ ________
Disagree
4
Strongly Disagree
5
1.Grand Rounds topics were clinically relevant and contributed to my knowledge base.
_____
2.Morbidity/Mortality conferences were clinically relevant and contributed to my knowledge base.
_____
3.Textbooks are a main source of reference to prepare resident lectures
_____
4.Journal articles are a main source of reference to prepare resident lectures
_____
5.Electronic references are a main source to prepare resident lectures
_____
6.When I am attending, I hold teaching rounds at least 3 times a week
_____
7.When I am attending, I do bedside teaching at least 3 times a week
_____
8.The current call schedule for residents facilitates teaching
_____
9.The electronic record facilitates teaching
_____
10.The Department values my teaching efforts
_____
Please feel free to add individual comments:
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