UNIVERSITY OF PUERTO RICO SCHOOL OF MEDICINE DEPARTMENT OF MEDICINE

Transcription

1 UNIVERSITY OF PUERTO RICO SCHOOL OF MEDICINE DEPARTMENT OF MEDICINE INTERNAL MEDICINE TRAINING PROGRAM RESIDENTS MANUAL

2 Foreword Section 1 Program Personnel Program Leadership & Staff Clinical Faculty Department of Medicine Organizational Overview Important Phones & Pager Numbers Administrative Staff List of Residents & Fellows Chief Residents Duties Section 2 Program Overview ACGME Competencies Goals & Objectives The Yearly Rotation Schedule The Team System Schedules Conferences Table of Contents Section 3 Evaluation Process Residency Program Oversight & Evaluation Performance Criteria Evaluation Forms Section 4 Residency Policies Resident s Grievance Policy and Procedure Non-Teaching Patients Policy Policy on Order Writing Policy on ACGME Guidelines Ambulatory Assignments & Patient Loads Policy on Work Load Moonlighting Policy & Procedure Dress Code Policy Absences, Tardiness, Vacation, Illness & Parental Leave Policy on Fatigue and Resident Stress Section 5 Ambulatory Medicine General Clinic Special Interdisciplinary Clinical Experiences Continuity Clinic Assignments Section 6 Inpatient Medicine General Program Attendings & Residents Duties Floater Rotation Sign Out Rounds ICU Rotation Page Section 7 Medical Subspecialty Experiences 178 Section 8 Patient Management Conflict Decisions 209 Patient Without Adequate Decision-Making Capacity Improvements in End-of-Life Care 214 Practice Parameters for Determining Brain Death 218 Assessment & Management of Patient in Vegetative State 225 Section 9 Professionalism & Ethics

3 Foreword Welcome to the Internal Medicine Residency Training Program at the University of Puerto Rico School of Medicine! Our program is one of the oldest training programs in the island and it s located in the Puerto Rico Medical Center, which it is a large tertiary and supra-tertiary care facility. With affiliations with the University Hospital, UPR Hospital at Carolina and other community hospitals, the program combines the best of primary, secondary and tertiary care in a great educational experience. Actually we have a total of 80 residents, including fellows, in all the major subspecialties of Internal Medicine. We look forward to working with you as you continue your professional development and training. Residency training is an exciting, rewarding and busy time in your life; it will be one of your most formative experiences as you develop a personal practice style. We believe that the UPR Internal Medicine Residency Program will offer you the experiences you need to grow as a professional. We will work with you to enable you to excel in the diverse skills necessary to become an outstanding internist. We are privileged to guide your growth, and we thank you for joining us. We are committed to training residents who will constantly pursue excellence. We strive to provide a challenging yet supportive atmosphere, where autonomy and supervision are in dynamic balance. Our program is a truly energizing training site, fueled by a proactive team spirit. The energy, enthusiasm and aptitude you bring will help our program continue to grow and flourish. Together, we can create the highest quality experience possible, while forming friendships that will last a lifetime. This manual was created to serve both as an introduction to and also as a reference for the program. Keep it handy and refer to it as you embark on new rotations or have questions. It will be periodically updated and posted in electronic format on our web site and for download onto your handheld computer for easy searching. The written copy provided to you during PGY1 orientation is for initial introduction; updated policies will be posted electronically with new version dates therefore they will supersede the dated written version once posted. If you need any further information, do not hesitate to contact us. Welcome to our program! Carlos A. González-Oppenheimer, MD,FACP Carlos Fernández-Sifre, MD Elsie Cruz-Cuevas, MD, FACP Gladys Colón-Rivera, MS Program Director Associate Program Director Associate Program Director Program Administrator 3

4 SECTION 1 PROGRAM PERSONNEL Program Leadership & Staff Clinical Faculty Department of Medicine Organizational Overview Important Phones & Pager Numbers Administrative Staff List of Residents & Fellows Chief Residents Duties 4

5 SECTION 1: PROGRAM PERSONNEL RESIDENCY PROGRAM LEADERSHIP & STAFF PROGRAM DIRECTOR Carlos A. González-Oppenheimer, MD, FACP ASSOCIATE PROGRAM DIRECTORS Carlos Fernández-Sifre, MD Vice Chair of Medicine UPR Hospital-Carolina Elsie Cruz-Cuevas, MD, FACP Assistant Professor KEY CLINICAL FACULTY Rafael A. Calderón, MD David Martínez, MD, FACP Jesús Muñiz, MD, Vanessa Sepúlveda, MD, FACP PROGRAM ADMINISTRATOR Gladys Colón-Rivera, MS SECRETARY & COORDINATOR Vanessa Caraballo, BSS CHIEF RESIDENTS Eduardo González, MD José M. Pérez-Cardona, MD CHIEF RESIDENT SECRETARY Luz E. Torres 5

6 University of Puerto Rico School of Medicine Department of Medicine Internal Medicine Program Clinical Faculty NAME TITLE OR RANK CARDIOLOGY 1 MARIO R. GARCIA PALMIERI Emeritus & Distinguished Professor Division Chair & Program Director 2 HECTOR DELGADO OSORIO Profesor & Assistant Program Director 3 PABLO I. ALTIERI NIETO Professor 4 RAFAEL A. COX ROSARIO Professor 5 CHARLES D. JOHNSON FUGATE Professor 6 JOSE E. LOPEZ RODRIGUEZ Professor 7 ARTURO MEDINA RUIZ Professor 8 JORGE ORTEGA GIL Professor 9 HECTOR L. BANCHS PIERETTI Associate Professor 10 JOSE A. MARTINEZ TORO Associate Professor 11 MIGUEL E. ABREU GARCIA Assistant Professor 12 RAFAEL A. CALDERON RODRIGUEZ Assistant Professor ENDOCRINOLOGY 13 MYRIAM Z. ALLENDE VIGO Professor & Division Chair 14 MARGARITA RAMIREZ VICK Associate Professor & Program Director 15 VILMA RABELL VILCHES Associate Professor. 16 MARIELSA RABELO Assistant Professor GASTROENTEROLOGY 17 PABLO J. COSTAS CACERES Associate Professor & Division Chair 18 ESTHER A. TORRES RODRIGUEZ Professor, Chair of Medicine & Program Director 19 VICTOR L. CARLO CHEVERE Assistant Professor & Assistant Program Director 20 JUAN TOMASINI Professor 21 IVAN ANTUNEZ GONZALEZ Assistant Professor 22 HENRY GONZALEZ RIVERA Assistant Professor 23 HUMBERTO MUÑOZ RODRIGUEZ Assistant Professor 24 RAFAEL RODRIGUEZ LOPEZ Assistant Professor 25 JOHAM SENIOR MARINO Assistant Professor 26 MARCIA CRUZ CORREA Associate Professor 27 JORGE HERNANDEZ DENTON Associate Professor GERIATRICS 28 JUAN A. ROSADO MATOS Professor & Division Chair 29 IVONNE Z. JIMENEZ VELAZQUEZ Professor, Program Director & Department of Medicine Vice-Chair for Education 6

7 NAME TITLE OR RANK GENERAL INTERNAL MEDICINE 30 CARLOS GONZALEZ OPPENHEIMER Professor, Division Chair & IM Program Director 31 ELSIE CRUZ CUEVAS Assistant Professor & Associate Program Director 32 FERNANDO LOPEZ MALPICA Professor 33 MARIA T. CRUZ CARRERAS Assistant Professor 34 LILLIAM S. CHIQUES COLON Assistant Professor 35 INES M. HERNANDEZ RODRIGUEZ Assistant Professor 34 ADELAIDA T. ORTIZ GOMEZ Assistant Professor 36 ROBERTO RUIZ LOPEZ Assistant Professor 37 VANESSA SEPULVEDA RIVERA Assistant Professor 38 ISAAC VARGAS CESAR Assistant Professor 39 GONZALO GONZALEZ LIBOY Associate Professor 40 GILBERTO ALVAREZ Assistant Professor 41 JOSE COLON Assistant Professor HEMATOLOGY/ONCOLOGY 42 EILEEN PACHECO Associate Professor & Acting Division Chair 43 JUSTINIANO CASTRO MONTALVO Assistant Professor & Program Director 44 GENOVEVA MARTINEZ POVENTUD Associate Professor & Program Coordinator 45 ALBERTO LOPEZ ENRIQUEZ Professor 46 NORMAN MALDONADO SIMON Professor 47 JOSE J. CORCINO BLANCO Associate Professor 48 ADRY FERNANDEZ Assistant Professor 49 DEANA HALLMAN NAVARRO Assistant Professor 50 SIXTO PEREZ GARCIA Assistant Professor 51 EZEQUIEL RIVERA RODRIGUEZ Assistant Professor 52 MARIBEL TIRADO Assistant Professor INFECTIOUS DISEASES 53 CARLOS G. SANCHEZ SERGENTON Professor & Division Chair 54 JORGE BERTRAN PASARELL Assistant Professor & Program Director 55 MICHELLE GONZALEZ RAMOS Assistant Professor & Assistant Program Director 56 HUMBERTO GUIOT Assistant Professor 57 JORGE L. SANTANA BAGUR Assistant Professor & ACTU Director 58 RUTH SOTO MALAVE Assistant Professor NEPHROLOGY 59 RAFAEL BURGOS CALDERON Professor & Division Chair 60 CARLOS G. RIVERA BERMUDEZ Associate Professor & Associate Vice Chair for Clinical Affairs 61 ENRIQUE O. ORTIZ KIDD Associate Professor & Program Director 62 LILLIAN J. BORREGO CONDE Assistant Professor & Assistant Program Director 63 DENIZ GARCIA DE LA ROSA Assistant Professor 64 CLARYLEE OCTAVIANI Assistant Professor 7

8 NAME TITLE OR RANK PULMONARY MEDICINE 65 DONALD DEXTER COBIAN Professor, Division Chair & Program Director 66 YOHANA DE JESUS BERRIOS Professor 67 ANGEL F. LAUREANO CUADRADO Assistant Professor. 68 HYRZA VAZQUEZ RIVERA Assistant Professor. RHEUMATOLGY 69 LUIS M. VILA PEREZ Associate Professor, Division Chair & Program Director 70 GRISSEL RIOS SOLA Assistant Professor & Assistant Program Director 71 DAVID MARTINEZ MELENDEZ Professor 72 VANESSA E. RODRIGUEZ Associate Professor UPR HOSPITAL- CAROLINA 73 CARLOS FERNANDEZ SIFRE Associate Professor & Vice Chair of Medicine 74 MARINA ROMAN EYXARCH Assistant Professor & Medical Director 75 ORLANDO APONTE APONTE Associate Professor. 76 DAYSI BAEZ FRANCESCHI Associate Professor 77 ROBERTO FRED SANTANA Assistant Professor 78 MARITZA CABEZAS MIJUSTE Assistant Professor 79 ALFREDO CANINO VARGAS Assistant Professor 80 MARUQUEL CASTILLO VELEZ Assistant Professor 81 MANUEL GONZALEZ RODRIGUEZ Assistant Professor 82 MANUEL IMBERT GARRATON Assistant Professor 83 HECTOR S. MIRANDA DELGADO Assistant Professor 84 JESUS MUÑIZ GONZALEZ Assistant Professor 85 ROBERTO PEREZ GUTIERREZ Assistant Professor 86 WILLIAM TABOAS COLON Assistant Professor 87 ROLDAN CABRET RAMOS Instructor 88 JORGE L. MUÑIZ RIVERA Instructor OTHER COLLABORATING FACULTY 89 CARLOS E. GIROD MORALES Ad-Honorem Professor 90 ERNEST CUNNINGHAM Ad-Honorem Professor 91 JOSE MORALES Ad-Honorem Professor NEUROLOGY 92 JESUS VELEZ BORRAS Professor, Division Chair & Program Director 93 MARITZA ARROYO MUÑIZ Professor & Associate Program Director 94 ANA J. ROMAN GARCIA Professor 95 PETRA BURKE RAMIREZ Professor 96 RAUL CRUZ RODRIGUEZ Professor 97 VALERIE WOJNA MUÑIZ Professor 98 CARMEN SERRANO RAMOS Professor 99 GISHLAINE ALFONSO MENDEZ Associate Professor 100 CARLOS LUCIANO ROMAN Associate Professor 101 BRENDA DELIZ ROLDAN Assistant Professor 102 IGNACIO PITA Assistant Professor 8

9 Organizational Overview Esther A. Torres, MD, FACP CHAIR OFFICE OF THE CHAIR Associate Vice Chairman & Clinical Services Vice-Chair for Undergraduate Education Vice-Chair of Medicine UPR Hospital-Carolina Training Program Director Program Administrator & Executive Secretary Financial Administrator Carlos G. Rivera-Bermúdez, MD Ivonne Z. Jiménez-Velázquez, MD Carlos Fernández-Sifre, MD Carlos A. González-Oppenheimer, MD Gladys Colón-Rivera, MS Osvaldo Cajigas, MHSA DIVISION CHIEF OF DIVISION PROGRAM DIRECTOR Cardiology Mario R. García-Palmieri, MD Mario R. García-Palmieri, MD Endocrine/Metabolism Myriam Z. Allende-Vigo, MD Margarita Ramírez-Vick, MD Gastroenterology Pablo Costas-Cáceres, MD Esther A. Torres, MD General Internal Medicine Carlos A. González, MD Carlos A.González, MD Geriatrics Juan Rosado-Matos, MD Ivonne Z. Jiménez, MD Hematology/Medical Oncology Eileen Pacheco, MD Justiniano Castro, MD Infectious Diseases Carlos Sánchez-Sergentón, MD Jorge Bertrán, MD Pulmonary Donald Dexter, MD Donald Dexter, MD Nephrology Rafael Burgos-Calderón, MD Enrique Ortiz-Kidd, MD Neurology Jesús Vélez-Borrás, MD Maritza Arroyo, MD Rheumatology Luis M. Vilá-Pérez, MD Luis A. Vilá-Pérez, MD 9

10 TELEPHONE NUMBERS Medicine Intensive Care Unit (MICU)-University Hospital (787) Ext Coronary Care Unit (CCU)-Cardiovascular Center (787) Exts & 3024 Emergency Room (Internal Medicine Area)-ASEM (787) Exts & 3708 Women & Men (Internal Medicine Area) - University Hospital (787) Women: Exts. 3814, 3807 & 3849 Men: Exts & 3812 Floaters Beepers (787) Units: & Ward Beepers (787) Units: Orange Group Red Group Blue Group Green Group

11 UPR-MEDICAL SCIENCES CAMPU SCHOOL OF MEDICINE DEPARTMENT OF MEDICINA Tel. (787) ; (787) Fax (787) Tel. RCM (787) NAME POSITION EXTENSION Dr. Esther A. Torres Professor & Chair 1875 Dr. Carlos G. Rivera-Bermúdez Vice Chair for Clinical Affairs 1821 Dr. Carlos A. González Training Program Director 1826 Dr. Ivonne Z. Jiménez-Velázquez Vice Chair for Undergraduate Medical Education 1184 Mrs. Gladys Colón Executive Secretary & Program Administrator 1876 Mrs. Vanessa Caraballo-Picornell Training Program Secretary 1828 Mr. Osvaldo Cajigas Administrator 1824 Mrs. Karyleen Velázquez Administrative Secretary 1877 Mrs. Wanda Pizarro Undergraduate Medical Education Secretary 1844 Mrs. Lourdes Rivera Secretary of the Director 1822 Mrs. Neida Pizarro Receptionist 1821 Mr. Joaquín Ramírez Messenger

12 UPR- SCHOOL OF MEDICINE DEPARTMENT OF MEDICINE INTERNS & RESIDENTS Dr. José M. Pérez-Cardona, Chief Residents (PG-4) Dr. Eduardo J. González-Vélez, Chief Residents (PG-4) INTERNS (PG-1) 1. Barlucea Bajo, Ana M. 2. Borges Cancel, William 3. Cantres Fonseca, Onix J. 4. Febles Negrón, Arelis 5. Leavitt Caraballo, Jorge 6. Meza Venencia, Verónica 7. Morales Vásquez, Lilliana 8. Negrón Rodríguez, Amarie M. 9. Rivera Acostas, José E. 10. Rivera Rodríguez, Noridza 11. Rohena Santaella, Jorge A. RESIDENTS (PG-2) 1. Correa Millán, Yadira M. 2. Cruz Oliver, Dulce M. 3. De Varona Negrón, Miguel 4. González Rivera, Tania C. 5. González Rosario, Rafael 6. Iturrino Moreda, Johanna C. 7. López Mattei, Juan C. 8. Meléndez Hernández, Jorge 9. Nieves Rodríguez, Mariela 10. Ortiz Díaz, Enrique O. 11. Pardo Ruiz, Wandaly I. 12. Rodríguez Pérez, Noelia 13. Segarra Alonso, Omar 14. Sánchez Rivera, Carlos J. 15. Vázquez Roque, María I. 16. De Jesús Monje, Wilfredo E. (Research Resident) RESIDENTS (PG-3) 1. Abuomar Abuomar, Jumana 2. Annexy Márquez, Roberto A. 3. Canino Rodríguez, Alexis 4. Castro Santana, Lesliane E. 5. Colacciopo Saavedra, Ricardo G 6. Colón Santos, Eileen 7. Franqui Rivera, Hilton 8. Marrero McFaline, Yanira 9. Martínez Rodríguez, Meliza 10. Ortiz Lasanta, Grisell 11. Ortiz Santiago, Juan C. 12. Rodríguez Hernández, Ralph 13. Rodríguez Maldonado, Karen M. 14. Santiago Casas, Yesenia del C. 15. Vega Martínez, María T. 16. Vergara Gómez, Mark A. Off-cycle Residents 17. Hernández Vélez, Priscilla A. (end PG-3 on 02/2007) 18. Pérez Torres, Doris (end PG-3 on 10/2007) 19. Plá Pérez, Alejandro (end PG-3 on 02/2007) 20. Ramos Romey, Cristina J. (end PG-3 on 03/2007) 12

13 UPR- SCHOOL OF MEDICINE DEPARTMENT OF MEDICINE FELLOWS RESIDENTS (PG-4) Cardiology 1. Aguiar, Nelson E. 2. Figueroa, Yolanda 3. Pérez, Edwin I. 4. Nieves, Omar Endocrinology 5. Lúgaro Ana M. Gastroenterology 6. Cruz, Abdiel 7. Rivera, Michelle 8. Romero, Carlos 9. Vendrell, Roberto Gastro-Research 10. Ortiz, Zhamarie Geriatric 11. Carrillo, Felix Infectious 12. Conde, Ana M. Hema-Onco 13. Betancourt, Rafael Neprhology 14. Posada, Jorge L. Pulmonary 15. Montalvo, Francisco Rheumatology 16. Nadal, Anaida J. RESIDENTS (PG-5) Cardiology 1. Carro, Eric 2. Martínez, José 3. Ojeda, Willibaldo 4. Rodríguez, Miguel 5. Salgado, Víctor Endocrinology 6. Maldonado, Mirna 7. Santiago, Alejandra N. Gastroenterology 8. Mera, Roberto E. Hema-Onco 9. Jiménez, Gilberto Infectious 10. Amador, Rosana Neprhology 11. García, Rafael 12. Padilla, Samuel Pulmonary 13. Serrano, Jahaira Rheumatology 14. Font, Yvonne M. RESIDENTS (PG-6) Cardiology 1. Grovas, Damián 2. Rodríguez, José 3. Trinidad, Dionalis Gastroenterology 4. Gregory, Federico J. 5. Jiménez, Carlos E. Hema-Onco 6. Aponte, Emmalind 13

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17 CHIEF RESIDENTS DUTIES There will be one Chief Resident in charge of all activities in the University Hospital at the Puerto Rico Medical Center and another a the UPR Hospital- Carolina and all community and continuity clinics in outreach areas. The main duties of the Chief Residents will: 1. Works as primary liaison between the program director, site directors of medicine and the medical residents. 2. Creates and implements the master schedule and the monthly schedules. 3. Conducts daily morning and afternoon sign-in /sign-out rounds. 4. Evaluates all residents daily and once a month completes an evaluation. 5. Revise performance of all residents in the morning sign in-report. 6. Provides effective supervision of the residents at various levels in the care of patients. 7. Performs periodic chart reviews of each resident s work in the inpatient settings. 8. The chief medical resident will use the Medical Record Review Form for Inpatient Records to document his review of each resident s ability to maintain appropriate, timely, comprehensive, and legible records of inpatients. 9. Performs periodic chart reviews of each resident s work in the ambulatory setting. 10. The chief medical resident should schedule periodic visits at the continuity clinic sites to perform chart reviews and evaluate residents in the ambulatory setting. 18

18 11. The chief medical resident will use the Medical Records Review Form for Ambulatory Clinic to document his review of each resident s ability to maintain appropriate, timely, comprehensive, and legible records of patients seen in the ambulatory clinics. 12. Performs periodic rounds with each team to evaluate the R-1 and their supervising residents. 13. Critically evaluates the performance of the medical residents (punctuality, patient care, etc). 14. Assists presenters at lectures with projectors and other audiovisual materials. 15. Administers the monthly quizzes to the medical residents. 16. Helps to conduct periodic surveys to evaluate compliance with the rules and regulations regarding resident work hours. 17. Works as preceptors for medical students. 18. Attends departmental meetings such as quality improvement meeting and staff meetings. 19. Participates as a member of the Clinical Competence Committee and Graduate Medical Education Committee. 20. Participates in the orientation of new medical residents. 21. Assists in the investigation of alleged irregularities by the medical residents. 22. Provides effective leadership to achieve resolutions of conflicts. 23. Plays role of mentor for the medical residents. 24. Keeps abreast of policies and procedures; appropriately utilizes newly acquired information in daily activities. 25. Prepare schedules of vacations of the Housestaff and obtain consent for such schedule from the Head of the Department or Program Director. 19

19 26. Assign Housestaff seminars, journal clubs and other educational activities. 27. Attend the Program s Committee on Graduate Education and the Clinical Competence Committee meetings. 28. Participate in the residency recruitment process. 20

20 SECTION 2 PROGRAM OVERVIEW ACGME Competencies Goals & Objectives The Yearly Rotation Schedule The Team System Schedules Conferences 21

21 ACGME Competencies The goal of the UPR Internal Medicine Residency Program is to train residents possessing the diverse skills required of an internist in our ever-changing health care system. To achieve this goal, we endorse teaching and evaluating Competencies as described by the Accreditation Council for Graduate Medical Education (ACGME). The Competencies form the foundation for our longitudinal curriculum, defining objectives leading to our goal. The Competencies also form the foundation of our resident evaluation system. All residents must have a functional understanding of these Competencies in order to understand their educational goals and objectives, and to understand the standards by which they will be evaluated. A detailed Competency Curricula for longitudinal training with learning objectives for each training year is distributed to each resident in a CD format and also it may be found soon on the residency website, A print format may be requested to the Program Administrator. The following descriptions quote the full language ACGME text of the Competencies, as endorsed by the ACGME in September of This quoted text is publicly posted at: The 6 Competencies: 1. PATIENT CARE Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. 22

22 Residents are expected to: communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families gather essential and accurate information about their patients make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment develop and carry out patient management plans counsel and educate patients and their families use information technology to support patient care decisions and patient education perform competently all medical and invasive procedures considered essential for the area of practice provide health care services aimed at preventing health problems or maintaining health work with health care professionals, including those from other disciplines, to provide patient-focused care 2. MEDICAL KNOWLEDGE Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. 23

23 Residents are expected to: demonstrate an investigatory and analytic thinking approach to clinical situations know and apply the basic and clinically supportive sciences which are appropriate to their discipline 3. PRACTICE-BASED LEARNING AND IMPROVEMENT Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to: analyze practice experience and perform practice-based improvement activities using a systematic methodology locate, appraise, and assimilate evidence from scientific studies related to their patients health problems obtain and use information about their own population of patients and the larger population from which their patients are drawn apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness use information technology to manage information, access on-line medical information; and support their own education facilitate the learning of students and other health care professionals 24

24 4. INTERPERSONAL AND COMMUNICATION SKILLS Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Residents are expected to: create and sustain a therapeutic and ethically sound relationship with patients use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills work effectively with others as a member or leader of a health care team or other professional group 5. PROFESSIONALISM Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices demonstrate sensitivity and responsiveness to patients culture, age, gender, and disabilities 25

25 6. SYSTEMS-BASED PRACTICE Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to: understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources practice cost-effective health care and resource allocation that does not compromise quality of care advocate for quality patient care and assist patients in dealing with system complexities Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance 26

26 INTERNAL MEDICINE TRAINING PROGRAM INTRODUCTION The Internal Medicine Training Program aims to provide the knowledge and to develop the skills and attitudes that are necessary for the management of adult persons requiring a very broad range of general medical services and orientation. Training and education are aimed at a wide perspective of health and diseases, giving emphasis to General Internal Medicine. The residency training is of three years duration. After this, the physician may decide to go into practice or continue training in a great variety of medical subspecialties within the department of Medicine or other training programs, either in Puerto Rico or in the mainland United States. Currently, the Department of Medicine offers subspecialty training in: Cardiology, Endocrinology, Gastroenterology, Geriatrics, Hematology-Oncology, Infectious Diseases, Nephrology, Pneumology and Rheumatology. There are 45 residency positions in the Internal Medicine Training Program, usually 15 for each year of training. The clinical facilities utilized are the University Hospital, the central clinical facilities of the Puerto Rico Medical Center, the University of Puerto Rico Hospital in Carolina (UPRH-C), the San Juan Veterans Administration Center, the Puerto Rico Cardiovascular Center (CCV), and by special agreements, other hospitals, physicians offices and clinics in the metropolitan area and nearby towns. The University Hospital and the Puerto Rico Medical Center are the ultimate places of referrals for all medical services in the Island. Both also respond as the safety net of the Island s health care system. The UPR Hospital at Carolina offers a community based hospital experience. The San Juan Veterans Administration Center 27

27 offers additional experiences in General Internal Medicine and is also a setting for specialty rotations. The Puerto Rico Cardiovascular Center is used for rotations in cardiovascular diseases, acute coronary care and intensive post of care. GENERAL OBJECTIVES The general objectives of the Internal Medicine Training Program establish a balance between the development of general medical clinical skills and the progressive acquisition of skills in technical procedures. The experiences offered should influence the residents in such a way that they may eventually become physicians who will: - Provide comprehensive, high quality medical care to adults. - Serve effectively and appropriately as primary physicians for a very large share of the adult population in any community. - Be concerned with patients problems of whatever cause, severity or duration. - Accept particular responsibility for direct care of patients on continuity bases in various places of work, including the office, the health center, hospitals, nursing home, and health related facility or in the patient s own home. - Be able to coordinate care of patients, or be part of a health care delivery team in any place dedicated to collaborate effectively to medical - health services. - Advocate for improvement in quality care in any medical setting. - Have in depth knowledge and skills needed to provide optimal care for patients in any setting and to serve as consultants for physician in other disciplines. 28

28 - Acquire an understanding of patients as fellow human beings in need of medical advice and care. SPECIFIC GOALS The specific goals of the program are the following: - Evaluate, diagnose and manage hospitalized as well as ambulatory patients referred to the Department of Medicine services. - Develop the skills necessary to perform diagnostic procedures employed in the practice of Internal Medicine. - Participate in research projects. - Participate in the health team approach in the prevention of illness, and in the diagnosis, management and rehabilitation of the patient. - Become involve in the health problems of the different communities, which serve as points of referral of patients to the University Hospital and other affiliated institutions. - Expand the knowledge of Internal Medicine on the basis of programmed training activities in the subspecialties of Internal Medicine. - Participate in complementary General Internal Medicine and primary care experiences in various other medical fields, both in ambulatory and in hospital settings. - Become involved in the processes of self-teaching and teaching of medical students and paramedical staff as a method of enhancing personal continuing education and professional development. EXPECTED ATTITUDES OF RESIDENTS IN TRAINING As professionals, the residents must always be: present, presentable, punctual, prepared, positive, and proficient. In addition, residents must: 29

29 - Demonstrate interest in learning to become good clinicians and in continuing to improve personal knowledge and skills. Residents are expected to continuously refine and update their knowledge base. - Demonstrate awareness of their own psychological reactions, as well as their positive and negative attitudes in their interrelationship with patients. - Demonstrate concerns for the patients and their families. - Demonstrate understating and ability to deal with their own, as well as their patient s fears and anxieties concerning disease and death. - Assume responsibilities for the care and management of patients appropriate to their level of experience. - Accept patients as they are. - Demonstrate respect, sympathy, and compassion for the human being. - Maintain interest in the patient as a person and understand individual reactions to diseases. - Recognize the necessity of continuous health care throughout a patient s lifetime, rather than care limited to a specific illness or for a limited period of time. - Demonstrate to be patient oriented, rather than disease oriented. - Demonstrate effectiveness in teamwork approach to solve medical problems by adequate interrelationship with other health care personnel. - Demonstrate intellectual integrity. - Develop habits and motivation for perpetuation of their continuing educations. Residents are expected to participate in continuous quality improvements efforts. - Recognize their capacities, as well as their limitations. 30

30 - Recognize the importance of reviewing a textbook of medicine and the use of periodical literature and medical journals concerning their patient s problems or illness. - Work with a strong sense of personal commitment and responsibility for the welfare of the patient. - Demonstrate punctuality and reliability. - Be thorough, neat and orderly in their work habits. Residents are expected to develop effective relationships, and maintain comprehensive, timely and legible medical works. - Develop patient management plans based on clinical judgment, scientific evidence, and patient preferences ELECTIVE TIME Residents at PGY-2 and PGY-3 levels are offered at least one month in an elective of their own choosing. These vary widely depending on individual preferences. Some electives are taken in areas quite different from the medicine field and other are conducted in mainland at USA hospital or research institutes. 31

31 The Yearly Rotation Schedule Resident schedule limits: Per American Board of Internal Medicine eligibility rules 1, the 36 months calendar of full-time residency education training content: (1) Must include at least 30 months of training in general internal medicine, subspecialty internal medicine, critical care medicine, geriatric medicine, and emergency medicine. Up to four (4) months of the 30 months may include training in area related to primary care, such as neurology, dermatology, office gynecology, or orthopedics. (2) May include up to three (3) months of other electives approved by the Internal Medicine Program Director. (3) May include up to three (3) months of leave for vacation time, parental leave, or illness. Vacation or other leave cannot be forfeited to reduce training time. The rotation schedule is prepared each year after receiving resident schedule preferences. After the schedule is distributed, no rotations changes can be made unless the resident submits a complete change of rotation form at least 8 weeks prior to the rotation start date, and receive approval from the Chief Resident and Program Director. Residents should at all times strive to personally discuss any requested changes and reasons for the change request with the affected supervising faculty. Rotation changes impact other medical residents, and residency staff; therefore, changes will not be approved without a pressing and specific educational reason. 1 Policies and Procedures for Certification, American Board of Internal Medicine, July

32 An average resident schedule: PG- 1 PG General Inpatient Medicine 2 Critical Care Medicine 1 Psychosocial Medicine 1 Ambulatory Medicine Block 2-3 electives 3-4 General Inpatient Medicine 1 Critical Care Medicine 1 ½ Night Float Medicine ½ Anesthesia/procedures 1 Cardiology 1 Physical Medicine & Rehabilitation 1 Neurology 1 Emergency Medicine 2-3 Electives PG-3 2 General Inpatient Medicine 2 Critical Care Medicine 1 Night Float Medicine 1 Ambulatory Block [non-medicine specialties] 1 Medical Consultation 1 Hematology - Oncology 1 Geriatrics 4 Electives 33

33 The Team System The UPR Residency Program organizes general medicine inpatient and outpatient services into teams. A team refers to a group of residents and faculty that function as a cooperative group practice. This system enhances continuity of care for patients in and out of the hospital. There are four teams: Red, Blue, Green and Orange. Each resident clinic group works together as an ambulatory group practice. While assigned to the inpatient general medicine wards, residents work with their team colleagues to maintain continuity of patient care and to build strong collegial relationships. (Each team rounding group will care for a group of inpatients, not to exceed a patient total census of 24). The team rounding groups provide crosscoverage for each other at night and on weekends, and at times during the day if residents are in clinic. While continuity contributes to quality patient care, some variety in patient exposures, peer interaction, and faculty exposure is also desirable to optimize education. This occurs through assignment of various combinations of senior and junior residents on team rotations. In the Ambulatory Clinics each clinic has a group of residents with an assigned attending. This gives the opportunity to share patients in the event that the resident is assigned to floater rotation or a vacation. 34

34 SCHEDULES 35

35 INTERNAL MEDICINE RESIDENCY PROGRAM (PG-1) ROTATIONS 4 WEEKS ROTATIONS General Internal Medicine Ward (UPR-Carolina Hospital, UH, VAH) Hematology-Oncology Ward & Leukemia Unit 1 Cardiology Ward 1 Emergency Room Carolina Emergency Room Rotation 1 Floater 1.5 Special Interdisciplinary Clinical Experiences 1 Medicine Intensive Care Unit 1 Vacations 1 Pulmonary Diseases 1 TOTAL 4 ½ 13 TYPE OF ROTATION NUMBER OF WEEK ROTATION Inpatient 6 Outpatient (ambulatory medicine) 1 Intensive Care Medicine 1 Emergency Room 1.5 Floater 1.5 Vacations 1 Consultation 1 13 TOTAL 36

36 (PG-2) ROTATIONS 4 WEEKS ROTATIONS General Internal Medicine Ward (UPR-Carolina Hospital, UH, VAH) ICU Carolina 1 Nephrology Ward 1 Endocrinology Ward 1 Emergency Room Rotation 1 Floater 1.5 Special Interdisciplinary Clinical Experiences 1.5 Coronary Care Unit 1 Elective 1 Vacations 1 TOTAL 3 13 TYPE OF ROTATION NUMBER OF WEEK ROTATION Inpatient 5 Outpatient (ambulatory medicine) 1 Intensive Care Medicine 2 Emergency Room 1 Floater 2 Electives 1 Vacations 1 13 TOTAL 37

37 (PG-3) ROTATIONS 4 WEEKS ROTATIONS Internal Medicine Consultation & Preadmission Clinic 2 Hematology Oncology Ward & Leukemia Unit 1 Selective Rotation (Cardiology, Pneumology or Infectious Diseases) Nephrology Ward 1 Rheumatology Ward 1 Gastroenterology Ward 1 Elective 2 Special Interdisciplinary Clinical Experiences 1 Medicine Intensive Care Unit 1 Geriatric Ward 1 Vacations 1 TOTAL 1 13 TYPE OF ROTATION NUMBER OF WEEK ROTATION Inpatient 4 Outpatient (ambulatory medicine) 2 Intensive Care Medicine 1 Consultation 3 Electives 2 Vacations 1 13 TOTAL 38

38 WEEKLY ACTIVITY SCHEDULE Monday Tuesday Wednesday Thursday Friday 7:15 to 8:00 am 8:00 to 9:00 am Morning Report In-Training Review or Special Conference 7:15 to 8:00 am 8:00 to 9:00 am Morning Report GR or Mortality 7:15 to 8:00 am 8:00 to 9:00 am Morning Report CPC or Professionalism 7:15 to 8:00 am 12:00 m to 1:00 pm Morning Report LUNCH 7:15 to 8:00 am 8:00 to 9:00 am Morning Report Special Conference or Seminar EBM (Journal Club) 12:00 m to 1:00 pm LUNCH 11:30 am to 12:30 m Staff Meeting 11:00 am to 12:00 m Pathology Review (once a month) 4:00 to 5:00 pm Education al Activities 12:00 m to 1:00 pm LUNCH 4:00 to 5:00 pm 5:00 to 5:30 pm Senior IM Board Review Sign out Rounds 5:00 to 5:30 pm Sign out Rounds 4:00 to 5:00 pm 5:00 to 5:30 pm Senior IM Board Review Sign out Rounds 5:00 to 5:30 pm Sign out Rounds 5:00 to 5:30 pm Sign out Rounds 39

39 OUTPATIENT CLINIC ROTATION AM FIRST YEAR RESIDENTS (PGY-1) MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY Dermatology Dermatology Dermatology CLETS HIV CLETS HIV Neurology Infectious Diseases (VAH) CLETS HIV CLETS STD CLETS STD CLETS HIV CLETS HIV CLETS STD Neurology CLETS STD CLETS STD Neurology PM Dermatology CLETS HIV CLETS STD CLETS HIV CLETS STD CLETS HIV CLETS STD *Pending scheduling Gynecologic and Psychiatric Clinics CLETS HIV CLETS STD CLETS HIV CLETS STD AM SECOND YEAR RESIDENTS (PGY-2) MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY Dermatology Dermatology Dermatology CLETS HIV CLETS HIV Neurology Infectious Diseases (VAH) CLETS HIV CLETS STD CLETS STD CLETS HIV CLETS HIV CLETS STD Neurology CLETS STD CLETS STD Neurology Neurology PM Dermatology CLETS HIV CLETS STD CLETS HIV CLETS STD CLETS HIV CLETS STD CLETS HIV CLETS STD *Pending scheduling Urology, Ophthalmology and Urology Clinics CLETS HIV CLETS STD AM PM THIRD YEAR RESIDENTS (PGY-3) MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY Nephrology Dermatology Dermatology CLETS HIV Rheumatology Endocrinology Infectious Diseases (VAH) CLETS HIV CLETS STD Dermatology CLETS HIV CLETS STD Neurology Neurology CLETS STD Neurology CLETS HIV CLETS STD Neurology Dermatology CLETS HIV CLETS STD Hematology-Oncology Pacemaker Special Cardiology Liver Trans. Hema/ Onco. Endocrinology Pneumology Gastroenterology Anticoagulation *Third year resident will be assigned to PMR and Cardiac Rehabilitation Clinics for first two weeks of rotation 40

40 INTERNAL MEDICINE TRAINING PROGRAM INTENRS (PGY-1) SCHEDULE

41 INTERNAL MEDICINE TRAINING PROGRAM SCHEDULE FOR RESIDENTS-PGY FIRST SEMESTER RESIDENTS JULY 1 TO JULY 30 JULY 31 TO AUGUST 27 AUGUST 28 TO SEPTEMBER 24 SEPTEMBER 25 TO OCTOBER 22 OCTOBER 23 TO NOVEMBER 19 NOVEMBER 20 TO DECEMBER 17 Barlucea Bajo, Ana Ward Pneumology Floater Ward ER ASEM MICU Borges Cancel, William MICU ER Carolina Ward Clinics Ward Pneumology Cantres Fonseca, Onix H/O ER ASEM Clinics Ward Vacations Ward Febles, Arelis ER Carolina Ward H/O Cardio Ward ER ASEM Leavitt Caraballo, Jorge Ward Cardio Ward H/O Clinics Ward Meza Venencia, Veronica Clinics Ward Cardio ER ASEM Pneumology Floater Morales Vasquez, Lilliana Ward Clinics Ward MICU Floater Vacations Negron Rodriguez, Amarie M. ER Carolina Ward ER ASEM Vacations H/O Cardio Rivera Acostas, Jose E. Ward ER Carolina Pneumology Ward Cardio Ward Rivera Rodriguez, Noritza Ward Clinics Ward Pneumology MICU Ward Roman, Lurdemar Clinics/Ward Psychiatry PMR Floater Radio ER Carolina 42

42 INTERNAL MEDICINE TRAINING PROGRAM SCHEDULE FOR RESIDENTS-PGY SECOND SEMESTER RESIDENTS DECEMBER 18 TO JANUARY 14 JANUARY 15 TO FEBRUARY 11 FEBRUARY 12 TO MARCH 11 MARCH 12 TO APRIL 8 APRIL 9 TO MAY 6 MAY 7 TO JUNE 3 JUNE 4 TO JUNE 30 Barlucea Bajo, Ana Cardio Ward H/O Ward ER Carolina Clinics Vacations Borges Cancel, William Floater Cardio Ward Vacations ER ASEM H/O Ward Cantres Fonseca, Onix Pneumology Ward MICU ER Carolina Ward Cardio Floater Febles, Arelis Clinics Vacations Ward Pneumology Ward Floater MICU Leavitt Caraballo, Jorge MICU Floater Vacations ER ASEM Pneumology Ward ER Carolina Meza Venencia, Veronica Vacations Ward ER Carolina H/O MICU Ward Ward Morales Vasquez, Lilliana ER Carolina Pneumology ER ASEM Ward H/O Ward Cardio Negron Rodriguez, Amarie M. Ward MICU Floater Clinics Ward Pneumology Ward Rivera Acostas, Jose E. ER ASEM Clinics Ward MICU Floater Vacations H/O Rivera Rodriguez, Noritza H/O Ward Cardio Floater Vacations ER ASEM ER Carolina Roman, Lurdemar Vacations ER-ASEM Neurology Clinics/Ward Cardio MICU Ward Rotations: 1. WARD 6. Cardio 11. Half Floater/Half ER-Carolina 2. WARD 7. Hematology/Oncology 12. Clinics 3. WARD 8. Floater 13. Vacations 4. WARD 9. ER-ASEM 5. MICU 10. Pneumology 43

43 INTERNAL MEDICINE TRAINING PROGRAM SECOND YEAR RESIDENTS (PGY-2) SCHEDULE

44 INTERNAL MEDICINE TRAINING PROGRAM SCHEDULE FOR RESIDENTS-PGY FIRST SEMESTER RESIDENTS JULY 1 TO JULY 30 JULY 31 TO AUGUST 27 AUGUST 28 TO SEPTEMBER 24 SEPTEMBER 25 TO OCTOBER 22 OCTOBER 23 TO NOVEMBER 19 NOVEMBER 20 TO DECEMBER 17 Correa Millan, Yadira M. Nephrology Ward Clinics Ward CCU Floater Cruz Oliver, Dulce M. Vacations Elective ER ASEM CCU Floater Endo De Varona Negron, M. Floater Ward Clinics Ward ICU Carolina Ward Gonzalez Rivera, Tania C. Ward Endo Floater Nephrology Elective Clinics Gonzalez Rosario, Rafael CCU Ward Nephrology Floater Clinics ICU Carolina Iturrino Moreda, Johanna C. Clinics Nephrology Floater ICU Carolina Endo Ward Lopez Mattei, Juan C. ER ASEM Vacations ICU Carolina Endo Ward Floater Melendez Hernandez, Jorge Endo ER ASEM ICU Carolina Ward Floater CCU Nieves Rodriguez, Mariela Ward CCU Endo Elective Vacations Clinics Ortiz Diaz, Enrique O. ER ASEM Elective Ward Floater Ward Nephrology Pardo Ruiz, Wandaly I Clinics Floater Ward ICU Carolina ER ASEM Vacations Rodriguez Perez, Noelia Ward ICU Carolina Vacations ER ASEM Nephrology Ward Segarra Alonso, Omar Floater Nephrology Elective Vacations Clinics ER ASEM Sanchez Rivera, Carlos J. Elective Floater Ward Vacations Ward Clinics Vazquez Roque, Maria Endocrine Ward CCU Ward Clinics Ward De Jesus, Wilfredo Ward 45

45 RESIDENTS DECEMBER 18 TO JANUARY 14 INTERNAL MEDICINE TRAINING PROGRAM SCHEDULE FOR RESIDENTS-PGY SECOND SEMESTER JANUARY 15 TO FEBRUARY 11 FEBRUARY 12 TO MARCH 11 MARCH 12 TO APRIL 8 APRIL 9 TO MAY 6 MAY 7 TO JUNE 3 JUNE 4 TO JUNE 30 Correa Millan, Yadira M. Elective ER ASEM ER Carolina Vacations Endo ICU Carolina Ward Cruz Oliver, Dulce M. ER Carolina Clinics Ward ICU Carolina Ward Nephrology Ward De Varona Negron, M. CCU ER ASEM Endo Elective Vacations ER Carolina Nephrology Gonzalez Rivera, Tania C. ER ASEM Ward CCU Vacations ER Carolina Ward ICU Carolina Gonzalez Rosario, Rafael Vacations Ward Endo ER Carolina Ward Elective ER ASEM Iturrino Moreda, Johanna C. Vacations Ward CCU Elective Ward ER Carolina ER ASEM Lopez Mattei, Juan C. Nephrology ER Carolina Ward CCU Elective Ward Clinics Melendez Hernandez, Jorge Ward Nephrology Ward ER Carolina Elective Clinics Vacations Nieves Rodriguez, Mariela ICU Carolina Ward ER Carolina Nephrology ER ASEM Ward Floater Ortiz Diaz, Enrique O. Ward Endo ICU Carolina Clinics Vacations ER ASEM CCU Pardo Ruiz, Wandaly I Ward Elective Nephrology Ward CCU Endo ER Carolina Rodriguez Perez, Noelia Endo Floater Clinics Ward Elective ER Carolina CCU Segarra Alonso, Omar Ward CCU Ward Endo ER Carolina ICU Carolina Ward Sanchez Rivera, Carlos J. ER Carolina Nephrology ER ASEM Ward ICU Carolina CCU Endo Vazquez Roque, Maria Floater ICU Carolina Vacations ER ASEM Elective ER Carolina Nephrology De Jesus, Wilfredo Rotations: 1. WARD 6. Nephrology 11. Half Floater/Half ER-Carolina 2. WARD 7. Endocrinology 12. Clinics 3. WARD 8. Floater 13. Vacations 4. CCU 9. Emergency Room-ASEM 5. MICU-Carolina 10. Elective 46

46 INTERNAL MEDICINE TRAINING PROGRAM THIRD YEAR RESIDENTS (PGY-3) SCHEDULE

47 RESIDENTS JULY 1 TO JULY 30 INTERNAL MEDICINE TRAINING PROGRAM SCHEDULE FOR RESIDENTS-PGY JULY 31 TO AUGUST 27 FIRST SEMESTER AUGUST 28 TO SEPTEMBER 24 SEPTEMBER 25 TO OCTOBER 22 OCTOBER 23 TO NOVEMBER 19 NOVEMBER 20 TO DECEMBER 17 Abuomar, Jumana Ward Nephrology Ward Hema/Onco Research Clinics Annexy Marquez, Roberto A. MICU Carolina ID Nephrology Elective Hema/Onco Research Canino Rodriguez, Alexis Ward Ward MICU Elective Gastro Hema/Onco Castro Santana, Lesliane E. Rheuma Hema/Onco ID Ward Geriatric Clinics Colacciopo Saavedra, Ricardo Nephrology MICU Research Vacation Elective Gastro Colon Santos, Eileen Hema/Onco Elective Research Ward ID Geriatric Franqui Rivera, Hilton Gastro Research Elective MICU Vacation Clinics Marrero McFaline, Yanira Elective Ward Rheuma ID Nephrology Geriatric Martinez Rodriguez, Meliza MICU Research Gastro Elective Ward Rheuma Ortiz Lasanta, Grisell ID Geriatric Nephrology Gastro Elective Hema/Onco Ortiz Santiago, Juan C. Clinics Gastro Ward Rheuma Elective ID Rodriguez Hernandez, Ralph Clinics Rheuma Hema/Onco Geriatric Elective Ward Rodriguez Maldonado, Karen Rheuma Hema/Onco Research Elective MICU Ward Santiago Casas, Yesenia Nephrology MICU Research Vacation Clinics Rheuma Vega Martinez, Maria T. Research Nephrology Elective MICU Rheuma Ward Vergara Gomez, Mark A. Geriatric Elective MICU Gastro Ward Nephrology Pla, Alejandro Vacation Selective Geriatric Nephrology Research Clinics Ramos, Cristina Research Geriatric Ward Selective Ward Nephrology Hernandez Pricilla Gastro Clinics Geriatric Selective Elective MICU Perez, Doris Selective Elective Vacation 48

48 DECEMBER 18 TO JANUARY 14 INTERNAL MEDICINE TRAINING PROGRAM SCHEDULE FOR RESIDENTS-PGY SECOND SEMESTER JANUARY 15 TO FEBRUARY 11 FEBRUARY 12 TO MARCH 11 MARCH 12 TO APRIL 8 APRIL 9 TO MAY 6 MAY 7 TO JUNE 3 JUNE 4 TO JUNE 30 RESIDENTS Abuomar, Jumana MICU Geriatric Vacation Rheuma Gastro Elective ID Annexy Marquez, Roberto A. Clinics Vacation Gastro Ward MICU Rheuma Ward Canino Rodriguez, Alexis Clinics Rheuma Research Vacation Geriatric ID Nephrology Castro Santana, Lesliane E. Elective Gastro Nephrology MICU Ward Research Vacation Colacciopo Saavedra, Ricardo Clinics Rheuma Ward Geriatric ID Hema/Onco Ward Colon Santos, Eileen Clinics MICU Rheuma Nephrology Ward Vacation Gastro Franqui Rivera, Hilton Rheuma Ward Nephrology Geriatric ID Ward Hema/Onco Marrero McFaline, Yanira Research Hema/Onco Vacations Gastro Clinics Ward MICU Martinez Rodriguez, Meliza Clinics Geriatric Vacations Ward Hema/Onco Nephrology ID Ortiz Lasanta, Grisell Ward Vacation MICU Research Rheuma Ward Clinics Ortiz Santiago, Juan C. Nephrology Hema/Onco Ward Vacation Research MICU Geriatric Rodriguez Hernandez, Ralph ID MICU Ward Vacation Nephrology Gastro Research Rodriguez Maldonado, Karen Geriatric Nephrology ID Ward Clinics Gastro Vacation Santiago Casas, Yesenia Ward ID Hema/Onco Gastro Elective Geriatric Ward Vega Martinez, Maria T. Gastro Clinics Geriatric ID Ward Vacation Hema/Onco Vergara Gomez, Mark A. ID Ward Research Hema/Onco Clinics Vacation Rheuma Pla, Alejandro Hemi/Onco Research Ramos, Cristina Clinics Elective Vacation Hernandez Pricilla Vacation Research Perez, Doris Rotations: 1. Hematology/Oncology 6. WARD 11. Research 2. Gastroenterology 7. WARD 12. Clinics 3. Rheumatology 8. Geriatrics 13. Vacations 4. Renal 9. Infectious Disease 5. MICU 10. Elective 49

49 PROGRAMMED CONFERENCES AND OTHER LEARNING ACTIVITIES Orientation program for new interns Morning Reports General Internal Medicine Lectures Staff Meetings Conferences & Professionalism Grand Rounds Clinico-pathologic Conferences Medicine-Pathology case reviews Mortality Conferences Resident s Seminars Journal Clubs Emergency Medicine In-Training Exam Review Visiting Lectures Other special lectures & learning activities Floater Rounds Review of current MKSAP of the ACP ORIENTATION PROGRAM FOR NEW INTERNS An important series of lectures are given at the start of the residency for new residents. These include: 1. ACL s course 2. Emergency Medicine topics 3. Introduction to the interpretation of laboratory and other diagnostic tests 4. The Competencies Lectures 5. HIPPA Law 6. OSHA Regulations Safety 7. Institution Clinical Research 8. Medico-legal and medical ethics issues 9. Review of proper interviewing skills 10. Women s health topics 11. Social Violence & Domestic Violence 12. Orientation to the hospital setting and the local health care system 50

50 MORNING REPORTS Daily activities start with the Morning Report at 7:15 am. The Senior Resident (PG3) on duty the night before reviews the previous Signing Out Rounds conducted the day before with that night s on duty team. The Senior Resident discusses the problem cases presented that previous afternoon and summarizes their clinical evolution throughout that night. He/she also comments on any new problems that might have arisen during his/her night on duty. This is followed by a brief presentation of all admissions made to all services by the on duty or Floater team. The Chief Resident and faculty in attendance make sure that patients were admitted to the appropriate services or sections in the Department of Medicine and that proper immediate care was provided to these patients. Brief discussion of the essentials of each case from the standpoint of history, physical examination, differential diagnosis, immediate orders for treatment and initial clinical management, follows each presentation. The Morning Report ends at 8:00 am and the residents teams go on to their respective services and work areas. Attendance of all residents with in hospital rotations, as well as the senior resident on duty is mandatory in this activity. Faculty members in charge of the supervision of the particular residents teams are also present. 51

51 GENERAL INTERNAL MEDICINE CONFERENCES On Mondays and Thursday during the first half of the academic year a series of lectures are given on topics related to General Internal Medicine, particularly, those related to ambulatory medicine. Some of the topics discussed are: updates in the management of Diabetes Mellitus, Hypercholesterolemia, Hypertension, Asthma, COPD, Chronic Liver Disease, Irritable Bowel Syndrome, Spastic Colon, Degenerative Joint Disease, Nephrotic Syndrome, etc. Staff Meetings Staff Meetings are held every Tuesday at 11:30 am. All residents rotation in the various medical clinical services attends this meeting. All hospital statistic of the Department are reviewed; including admissions to the various services, transfers, allergic and blood reactions, mortality and morbility. Staff meeting is directed by the Chief Resident with the Department Chair, the Assistant Chief of the Department at the University Hospital and the Program Director in attendance. Grand Rounds Foremost among the teaching activities of the Department of Medicine are weekly Grand Rounds conducted on Tuesday from 8:00 am to 9:00 am. The Chief Resident programs the Grand Rounds in consultation with the Chief of Sections and the attending staff assigned to the wards and with the approval of the Chair of the Department. 52

52 Clinico-Pathologic Conferences (CPC) CPC s are held every other Wednesday from 8:00 to 9:00 am in cooperation with the Department of Pathology. Whenever possible the cases discussed are those of patients previously admitted to the University Hospital to the various services of the Department of Medicine. Most of the faculty and all residents rotating in the Department clinical services attend these conferences. Medicine Pathology case reviews: Once a month cases of patients admitted to medicine on which biopsies or autopsies were performance are discussed with the residents and autopsy or biopsy material is presented. These reviews are directed by the Chief Residents of Medicine and Pathology. Review of the Medical Knowledge Self Assessment Program (MSKAP) of the American College of Physicians On Wednesday, and Friday s for 1½ to 2 hours, the current MKSAP is discussed. This is done in a systematic manner, each service or section covering the topics that pertain to their particular field. Information to residents is pertinent and up to date and time is set out for the discussion of questions among the residents and the Chief Resident. Floater Rounds: Floater rounds are conducted immediately following the Morning Reports on Wednesday and Fridays. The Floater Team on duty the night before meets with the Chief Resident and the Program Director or one of the Key Faculty members and go over the cases admitted to the hospital by the Floater Team. Cases are discussed at bedside and the history is reviewed, as well as physical findings, admission orders and 53

53 the immediate management upon admission. On Mondays the Floater Rounds is due at 6:00 am with the Program Director to comply with ACGME continuous 24-hours working schedule. Mortality Conferences Mortality Conferences are done every month, the last Tuesday of each month. A case seen in the hospital who presents a particular management problem or concern is discussed, usually by the attending physician who had been in charge of the patient while in hospital. All cases have autopsy findings and these are discussed by the pathologists. Residents Seminars Review of applied basic medical sciences to the clinical aspects of patient s management is one o the objectives of this teaching exercise. A specific topic is assigned to each resident for presentation. A member of the attending staff supervises the activity and discusses any controversial points. The resident prepares a written report with appropriate references that is distributed at the presentation. Journal Club In order to maintain the resident staff abreast of the literature, a Journal Club is conducted every week. The residents participate on rotation basis. The Journal to be discussed is announced before each session in order to permit everyone to participate actively. One attending physician is assigned to each session and is responsible for overseeing the activity. Emergency Medicine Conferences These are directed mostly to the new PG1 as they start residency training. Conferences are given every day in July from 8:00 9:00 am to instruct these residents in the recognition and initial management of medical emergencies. 54

54 In-Training Exam Preview From late August to mid October a series of lectures are given to residents in preparation for the yearly In-Training Examination. The Chief Residents prepare a set of pertinent references on important topics in medicine and these serve as bases for general discussion for this review. Visiting Lectures Every year, particularly during winter and early spring, the Department receives a good number of visiting lectures. Various topics are covered in these conferences, which are frequently presented as Grand Rounds or as special topics in internal medicine. Special Lectures: Other topics relevant to internal medicine, but not necessarily part of it are discussed with the residents. These include the discussion of topics such as: -Clinical decision making -Issues on ethics -Pertinent topics in -Physical medicine -Pharmacokinetic ophthalmology, -Rehabilitation -Environmental medicine otorrhinolaryngology, -Clinical nutrition urology, orthopedics, adolescent medicine, etc. 55

55 CLINICAL INVESTIGATION AND OTHER SCHOLARLY ACTIVITIES All internal medicine residents are required to present a research work or a scholarly activity they have developed in their residency. This may be: 1. The critical review of current medical literature on a particular topic 2. The preparation of a clinical vignette 3. The preparation of a scholarly work, such as the revision of a series of cases with a particular problem or illness seen in the University Hospital or other affiliated hospital from the perspectives of: a. How the diagnosis is confirmed? b. What is the therapy of management? c. What is the outcome? d. What has been the long term evolution? e. How does the local experience compare with other in the literature? 4. The presentation of original research work Each resident recruits a faculty member who helps him/her conduct this work and provide adequate supervision. This activity helps residents: A. Use appropriate resources to complete a literature search B. Critically evaluate a research article C. Communicate effectively to different audiences D. Organize written material 56

56 E. Apply rules of proper language, usage, style and composition F. Formulate a research question G. Design a descriptive or explanatory study H. Collect and analyze dada In preparation for this requirement and throughout the year, residents have received lectures on statistics, design of research protocols, basic epidemiology and the use of computers for search of literature. They are also encouraged to seek faculty advice and support for the development of their clinical research project. Their work is presented to the faculty members and housestaff in Grand Rounds conferences schedules in June each year. 57

57 Conferences Attendance Policy Since educational quality and program accreditation are facilitated by resident attendance of at least 60% of all mandatory conferences, residents who fail to achieve the attendance requirements for two consecutive quarters, or as averaged out over an academic year, may be required to appear before the Clinical Competence Committee (CCC). The CCC will then decide upon a suitable remediation for the resident. Conferences take two forms, mandatory and elective. Residents are expected to attend a minimum of 60% of all conferences designated as mandatory by the Program Director. Residents must sign in to receive credit for attendance. Records of attendance are kept by the Chief Resident. Residents are excused from conferences during vacation and educational leave. While on Night Float, residents must participate in Morning Report, but Night Float residents are excused from daytime didactic conferences. Therefore, residents are excused from afternoon conferences during vacation/leave/night float. The remaining weeks are considered mandatory. NOTE: Residents should attempt to attend all required conferences. The 60% standard is intended to allow for times when a resident is post-call or otherwise unavailable. Mandatory conferences are Grand Rounds, Mortality Conferences, Clinicopathologic Correlations, Professional Formation, and Academic Afternoons on Thursdays. A conference calendar is available through the Chief Resident s office, program office or the residency website Most of the Grand Rounds lectures and other important conferences are available in handouts. It s accessible to the resident floater and to the residents assigned to clinics, when he/she needed. 58

58 University of Puerto Rico School of Medicine Department of Medicine Resident Research Requirements REQUIREMENT STRUCTURE Participation in a clinical or basic science research project, either as principal investigator or co-investigator with appropriate dissemination of the results through submission of a research abstract (to a regional, national or international scientific meeting) or a manuscript for peer-review publication with appropriate write-up deemed suitable by the Program Director or Chair of the Department of Medicine PY-1 year: Begin gathering ideas for research project & methodology Consider potential mentors Consider scheduling research rotation during PG-2 year or early PG-3 year PG-2 year: Narrow down the idea list Contact potential faculty mentor to discuss project & arrange supervision Develop the proposal with mentor & submit to the Program Director Compile data PG-3 year: Complete data gathering and analysis Write up findings in consultation with mentor Submit research abstract to scientific meeting Submit report to Program Director which reviews the report and notifies resident of successful satisfaction of research requirement Submit full manuscript for peer-journal review Present research project to the faculty and residents of the Department Adapted from Residents as Researchers: Expectation, Requirements, and Productivity. Potti, A, Mariani, P, Saeed, M. Smego, R. The American Journal of Medicine, Volume 115, Association of Professors of Medicine, Oct July 1,

59 SECTION 3 EVALUATION PROCESS Residency Program Oversight and Evaluation Evaluation Forms 60

60 Residency Program Oversight and Evaluation Residency Program goals and objectives, as well as program effectiveness are reviewed on a regular basis. The program has several mechanisms in place to ensure that the educational effectiveness is evaluated and improved in an ongoing and systematic fashion. Program evaluation consists of the following several major aspects: 1. Faculty evaluation of resident performance 2. Resident evaluation of faculty and rotations 3. Resident evaluation of the residency program 4. Results of national In-Training Examinations (ITE) 5. Passing rate and board scores 6. Success of graduates in achieving fellowship positions 7. Achievements post graduation Resident evaluation focuses on progress in the achievement of Core Competencies. For descriptions of the competencies, see Section 2. The American Board of Internal Medicine (ABIM) requires each program to evaluate each resident's competence by conducting longitudinal evaluations, as well as by a final review by the Program Director and the Clinical Competence Committee (CCC). Consistent demonstration of and progress in the Accreditation Council on Graduate Medical Education (ACGME) competencies are important to this determination. The ABIM has noted that residents perceived as having little chance of passing the ABIM certifying examination should not be allowed to sit for the examination. Our goal is to ensure that residents demonstrate knowledge, skills, attitudes and behaviors that meet criteria for board eligibility as defined by the ABIM. 61

61 Faculty Evaluation of Residents The program ensures periodic evaluation of the resident during the training process by attending physicians and faculty responsible for the educational growth of the resident and to ensure that residents obtain competencies in the six required areas outlined in the General Core Competencies of the program and specific competencies for each rotation. At the conclusion of each rotation, each resident will be evaluated as to medical competence and attitudes by written evaluation forms submitted by faculty. These evaluations forms are filed in the permanent file of each resident. The Program Director will review each resident s performance monthly as to progress and problems identified. Resident Evaluations: Resident evaluations are completed by faculty following the completion by the resident of an assigned rotation. Resident performance is evaluated by the faculty to whom they are assigned for rotation, following each rotation. Faculty members receive electronic evaluation forms following each rotation through E-Value System. Once completed, the forms are included in the resident s training file. Faculty may give a written examination at the end of each rotation Faculty determines competency levels for each of the rotation s specific objectives at the end of the rotation. Resident evaluations by faculty will be used, in part, by the Program Director to formulate the semi-annual and annual performance evaluations of the residents. Resident evaluations by faculty are available for the resident s review, sign-off and comments in E-Value as soon as completed. 62

62 Semi-Annual Evaluations Twice yearly, residents discuss their overall performance with the Program Director or a designated Key Clinical Faculty (KCF) member. During this semiannual evaluation, the year-to-date evaluations, progress, plans, and any problems or concerns are discussed with a review of all performance information available to the evaluator. The designated faculty will provide the resident with guidance on their progress in the achievement of Competency objectives for their stage of training, and will also provide general professional guidance. Residents who are not satisfactorily progressing in achievement of competency will be reviewed by the Clinical Competence Committee (CCC) for appropriateness of promotion. See Promotion Criteria for Performance guidelines. Review of the Resident Evaluation File A resident may review his/her confidential evaluation file during usual office hours. Twice annually the resident will review his/her file with the Program Director or one of the Program Key Faculty. The purpose of the meeting is to identify academic strengths and weaknesses, plan and individualize curriculum, develop study plans, and plan for the post-residency period. Resident Procedure Logs Procedure Logs will be maintained by residents to document and track all procedures performed. Each resident should utilize the supplied form to document all procedures performed. After completion of each academic year, a copy of the procedure documentation should be turned into the Residency Coordinator for review by the Program Director. Patient identifying information will be protected. A copy of the log books containing confidential information will be placed in the resident s personal file, which is kept by the Program Administrator, and stored in 63

63 locked cabinets. The Housestaff office will be given a copy of the procedure log upon written request. Residents are advised and encouraged to patient identifying information from their records as soon as it is no longer needed. Annual Evaluations The annual evaluation of the resident physician is completed in accordance with program policies and procedures, regulatory agencies (ABIM) and accreditation (ACGME) standards and consists of a summary of evaluations received throughout the performance period as well as personal interaction and observation by the Program Director, Associate Program Directors, Attendings, Chief Residents and Key Clinical Faculty. This takes place at the end of the academic year. Resident evaluations are used to determine appointment renewal status, board eligibility and to summarize the resident s performance each year. Final evaluation will include a review of the resident s performance during the final period of education and verify that the resident has demonstrated sufficient professional ability to practice competently and independently. Resident Evaluation of Faculty After the rotation, the resident fill an electronic evaluation of his/her assigned attending and the rotation. All of these evaluations are revised by the Program Director. 64

64 Residents will have the opportunity to evaluate the faculty and education curriculum. Evaluations completed by residents, including any descriptive comments, are not released to involved faculty until a sufficient number of evaluations have been submitted to ensure resident confidentiality. Following the completion of a clinical rotation, the resident will complete both an electronic rotation evaluation form and a faculty evaluation form for the rotation. Residents will evaluate the teaching received during the rotation and the effectiveness of the rotation s contribution toward their educational experiences and goals. The Program Director will review the summary reports annually with each Subspecialty Program Director and will discuss the summary evaluations as well as other aspects of their faculty and program performance. The Program Director will meet annually with all subspecialty fellows to discuss general aspects of their training. Program Annual Evaluation Residents will complete confidential, comprehensive, annual evaluations surveys of the training program to provide valuable feedback regarding rotations and ways to improve the clinical and educational experience. The Program Administrator will be in charge of the process, analysis of the gathered data, and submission of a summary report to the Program Director. Resident names will be withheld from the summary reports. An annual meeting is held to discuss al aspects of the Residency Program with the participation of the faculty and housestaff. 65

65 Resident Examinations The Department of Medicine funds annual participation of its residents in the In- Training Examination (ITE) co-sponsored by the American College of Physicians- American Society of Internal Medicine. Residents of all levels will also take an annual Clinical Competence Examination and 3 to 4 Mini-Clinical Evaluation Exercises (Mini- CEX) per year. The ITE is offered as an external measure of medical knowledge to assess resident progress toward ABIM certification. All residents must take the ITE during each year of residency training. The results of the exam will not be used to determine status in the program. Results will be used to inform decisions regarding rotation assignments, directed study programs, other educational interventions, and program improvements. Individual ITE results are confidential and are only shared with the residency administrative leadership (Department Chair, Program Director, Key Clinical Faculty and Program Administrator), unless the resident grants specific permission. Residents, who perform poorly, as judged by the Program Director, may be required to participate in remediation activities. The USMLE Step 3 examination is intended to verify an adequate knowledge base for the independent practice of medicine as a general practitioner (after one year of residency training). The program encourages passing this exam in the first two years of training. ABIM Certification The program encourages senior residents to take the certification examination. Review courses and practice are given for the better performance in the examination. Annual graduate performance on the ABIM certification exam in Internal Medicine is closely reviewed by the Program Director. 66

66 Reappointment Process Reappointment for an additional year of residency will be accomplished by May 1. Failure to be re-appointed is a decision made by the Clinical Competence Committee of the Residency Program after careful consideration of all aspects of the resident s performance. See Due Process Guidelines. All contracts are for a one-year period. Contracts are considered legal documents and are binding. Residents are not free to sign contracts with other programs while under contract with the UPR Internal Medicine Residency Program. Release from such contractual obligations will be granted on a case by case basis after discussion with the Program Director. Curriculum Revisions: The curriculum is fully reviewed and revised at least every 3 years. As a part of this process, a resident participate to ensure that it accurately describes the educational process and to enhance the total description. The curriculum is assessed for strengths and weaknesses, and weaknesses are targeted for improvement during the continuing curriculum revision process. GME Committee Internal Review The Program completes a full administrative Internal Review according to ACGME policies, assessing compliance with administrative and educational goals. Internal Review committees include external guests and resident representatives. 67

67 Performance Criteria Performance Review: The Clinical Competence Committee (CCC) will review all resident evaluation files. The CCC shall deliberate and decide when additional action is necessary. Such action may include a requirement for resident appearance before the Clinical Competence Committee (CCC) a specific required remediation program for the resident, or a possible delay or denial of promotion or renewal of contract. Performance Requiring Resident Appearance Before the CCC A resident shall have his/her evaluation file reviewed by the CCC when faculty evaluations reflect one or more of the following during a single year of training: During the first half of the academic year (ie, July through December): Two (2) or more performance evaluations rated 4 (marginal) for the same single competency. During the second half of the academic year (ie, January through June): One (1) performance evaluation of rated 4 (marginal) for a single competency. An overall performance evaluation of rated 4 (marginal) in the end-of-year semiannual evaluation. Other triggers: One (1) notation of significant deficits for a single competency on a semiannual review. The CCC shall deliberate and decide whether further action is necessary. Such action may include a specific required remediation program for the resident, formal probation, possible delay or denial of promotion or renewal of contract, a 68

68 denial of recommendation to sit for the American Board of Internal Medicine Certifying Examination. If the CCC determines the resident is not appropriate for remediation, probation, or training delay, the CCC may consider resident dismissal. Performance Scores Requiring Resident Appearance Before the CCC Possible Immediate Dismissal: A resident shall have his/her evaluation file reviewed and is required to appear before the CCC for immediate dismissal consideration when faculty evaluations reflect one or more of the following during a single training year: Three (3) evaluations of significant deficits (rated 3) on the same single competency by more than one observer. One (1) overall performance evaluation of significant deficits (rated 3) on a semiannual evaluation. A critical incident involving patient safety, unprofessional behavior or other event suggesting unsuitability for continuing training. Other action may include, at the CCC s discretion, a specific continued remediation program or a possible delay or denial of promotion of that resident, nonrenewal of the resident's contract, or a denial for the resident to sit for the American Board of Internal Medicine Certifying Examination Resident Rebuttal of Marginal and Unsatisfactory Faculty Performance Score Ratings: Any resident who disagrees with or wishes to comment on any overall evaluation of minor deficits or significant deficits, or an evaluation of significant deficits on any single competency is invited to submit a Resident Rebuttal for CCC review. Registration of this disagreement at the time of electronic sign off is acceptable as compliance. The comments of the CCC about resident rebuttals will be entered in the 69

69 resident's file in addition to the rebuttal. The opinion of the CCC at such time shall take precedence. Furthermore, a resident may request to appear before the CCC to review any aspect of his/her training or evaluation. Any resident who appears before the CCC, regardless of the circumstance, is encouraged to identify and bring a faculty and/or resident advocate of their choice to the CCC meeting. Incident Reports: Any incident report that is received by the Program Director will be shared with the resident and possibly with the CCC. Depending upon the nature of the problem, the resident may be asked to appear before the CCC to explain his/her behavior. A large number of unfavorable behavioral reports or any report that is of severe enough consequence, in the opinion of the CCC, may prompt action from the CCC. This action may include a specific required remediation program, probation, delay or denial of promotion, or dismissal from the residency program. 70

70 EVALUATION FORMS 71

71 University of Puerto Rico Internal Medicine Subject: Evaluator: Site: Period: Dates of Activity: Activity: Evaluation Type: Clinical Educator Evaluation information entered here will be made available to the evaluated person in anonymous and aggregated form only. Is motivated/interested while carrying out his/her duties (Question 1 of 17 - Mandatory) Cannot Evaluate Poor Fair Good Very Good Excellent Emphasizes problem solving approach (Question 2 of 17 - Mandatory) Cannot Evaluate Poor Fair Good Very Good Excellent Is sensitive to the students and residents as individuals (Question 3 of 17 - Mandatory) Cannot Evaluate Poor Fair Good Very Good Excellent Emphasizes pathophysiology in discussing patients (Question 4 of 17 - Mandatory) Cannot Evaluate Poor Fair Good Very Good Excellent Compares divergent views and/or approaches (Question 5 of 17 - Mandatory) Cannot Evaluate Poor Fair Good Very Good Excellent Answers questions directly and explains reasons for decisions (Question 6 of 17 - Mandatory) Cannot Evaluate Poor Fair Good Very Good Excellent Recognizes and corrects students' and residents' difficulties (Question 7 of 17 - Mandatory) Recognizes and aims at correcting students' and residents' difficulties Cannot Evaluate Poor Fair Good Very Good Excellent Provides constructive feedback on ward work and write-ups (Question 8 of 17 - Mandatory) Cannot Evaluate Poor Fair Good Very Good Excellent Reviews patient's history and physical to provide feedback (Question 9 of 17 - Mandatory) Performs teaching rounds; review patient's history and physical to provide prompt feedback. Cannot Evaluate Poor Fair Good Very Good Excellent 72

72 Corrects constructively without undue criticism (Question 10 of 17 - Mandatory) Corrects students and residents constructively without undue criticism Cannot Evaluate Poor Fair Good Very Good Excellent Encourages students/residents to function as primary physicians (Question 11 of 17 - Mandatory) Cannot Evaluate Poor Fair Good Very Good Excellent Is accessible when requested and is prompt for appointments (Question 12 of 17 - Mandatory) Cannot Evaluate Poor Fair Good Very Good Excellent Is courteous to patients, staff, residents, and students (Question 13 of 17 - Mandatory) Cannot Evaluate Poor Fair Good Very Good Excellent Was this proctor a positive role model? (Question 14 of 17 - Mandatory) Yes No Experience with proctor was positive (Question 15 of 17 - Mandatory) Would you want this faculty member to be your proctor for another rotation? Yes No Proctor: Suggestions or improvement (Question 16 of 17) If you answered 'no' to the proctor being a positive role model or had a negative experience with him/her during the rotation please explain why. 73

73 Subject: Evaluator: Site: Period: Dates of Activity: Activity: University of Puerto Rico Internal Medicine Evaluation Type: Concern Card About A Trainee Information entered on this form is considered confidential. Access to this information is available only to the program director(s) and to the E*Value system administrator(s). During this time I personally interacted with or observed the resident and base this evaluation on: (Question 1 of 6 - Mandatory) Minimal time (0-5 hours, or less than 3 operations) Moderate time (6-10 hours or 4-8 operations) Extensive time (>10 hours, more than 9 operations) Reason for Concern (Question 2 of 6 - Mandatory) My concerns about the performance and/or professional behavior of this physician are based on: (please check) Critical Incident Gut level reaction Series of "red flags" Concern Comments (Question 3 of 6) Comments: Discussed With Physician (Question 4 of 6 - Mandatory) I have discussed my concerns with the physician. Yes No Discomfort with discussion of concern (Question 5 of 6 - Mandatory) I feel uncomfortable discussing my concerns with the physician. Yes No Call about concern (Question 6 of 6 - Mandatory) Please call me about these concerns. Yes No 74

74 University of Puerto Rico Internal Medicine Subject: Evaluator: Site: Period: Dates of Activity: Activity: Evaluation Type: Praise Card About A Trainee Information entered on this form is considered confidential. Access to this information is available only to the program director(s) and to the E*Value system administrator(s). Reason for Praise (Question 1 of 2 - Mandatory) My praise about the performance of this physician is based on his/her demonstration of exceptional ability in the following: (please check) Clinical Judgment Clinical Skills Medical Knowledge Communication Skills Teaching Professionalism Team management and leadership Critique of medical/scientific literature Conduct of research Praise Comments (Question 2 of 2) Comments: 75

75 Subject: Evaluator: Site: Period: Dates of Activity: Activity: Evaluation Type: Resident University of Puerto Rico Internal Medicine Patient Care (Question 1 of 8 - Mandatory) Incomplete, inaccurate medical interviews, physical examinations, and review of other data; incompetent performance of essential procedures; fails to analyze clinical data and consider patient preferences when making medical decisions. Superb, accurate, comprehensive medical interviews, physical examinations, review of other data, and procedural skills; always makes diagnostic and therapeutic decisions based on available evidence, sound judgment, and patient preferences. N/A Unsatisfactory Satisfactory Superior Medical Knowledge (Question 2 of 8 - Mandatory) Limited knowledge of basic and clinical sciences; minimal interest in learning; does not understand complex relations, mechanisms of disease Exceptional knowledge of basic and clinical sciences; highly resourceful development of knowledge; comprehensive understanding of complex relationships, mechanisms of disease. N/A Unsatisfactory Satisfactory Superior Practice-Based Learning Improvement (Question 3 of 8 - Mandatory) Fails to perform self-evaluation; lacks insight, initiative; resists or ignores feedback; fails to use information technology to enhance patient care or pursue self-improvement. Constantly evaluates own performance, incorporates feedback into improvement activities; effectively uses technology to manage information for patient care and selfimprovement. N/A Unsatisfactory Satisfactory Superior Interpersonal and Communication Skills (Question 4 of 8 - Mandatory) Does not establish even minimally effective therapeutic relationships with patients and families; does not demonstrate ability to build relationships through listening, narrative or nonverbal skills; does not provide education or counseling to patients, families, or colleagues. Establishes a highly effective therapeutic relationship with patients and families; demonstrated excellent relationships through listening, narrative or nonverbal skills; excellent education and counseling of patients, families, and colleagues; always interpersonally engaged. N/A Unsatisfactory Satisfactory Superior Professionalism (Question 5 of 8 - Mandatory) Lacks respect, compassion, integrity, honesty; disregards need for self-assessment; fails to acknowledge errors; does not consider needs of patients, families, colleagues; does not display responsible behavior. Always demonstrates respect, compassion, integrity, honesty; teaches/role models responsible behavior; total commitment to self-assessment; willingly acknowledges errors; always considers needs of patients, families, colleagues. N/A Unsatisfactory Satisfactory Superior

76 System-Based Learning (Question 6 of 8 - Mandatory) Unable to access/mobilize outside resources; actively resists efforts to improve systems of care; does not use systematic approaches to reduce error and improve patient care. Effectively accesses/utilizes outside resources; effectively uses systematic approaches to reduce errors and improve patient care; enthusiastically assists in developing systems improvement N/A Unsatisfactory Satisfactory Superior Resident's Overall Clinical Competence in Internal Medicine on Rotation (Question 7 of 8 - Mandatory) N/A Unsatisfactory Satisfactory Superior Attending's Comments (Question 8 of 8) 77

77 University of Puerto Rico Internal Medicine Subject: Evaluator: Site: Period: Dates of Activity: Activity: Evaluation Type: Rotation Curriculum and.or Description of Rotation was Given (Question 1 of 29 - Mandatory) Was the curriculum or description of this rotation distributed and reviewal with you at the start of this rotation? Not Applicable No Partially Yes Admission Note for Patients ( >60% ) (Question 2 of 29 - Mandatory) Did you write the admission note of most of the patients under your care? Not Applicable No Partially Yes Your work load was: (Question 3 of 29 - Mandatory) Too Little About Right Too Much Quality of Teaching and Supervision (Question 4 of 29 - Mandatory) Rate the overall quality of teaching and supervision during this rotation. Not Applicable Poor Fair Good Very Good Excellent Demonstrated Balance of Education Training & Patients' Services (Question 5 of 29 - Mandatory) Did you feel that there was an adequate balance between education training and patients' services expected from you in this rotation? Not Applicable No Partially Yes 78

78 Balance of Education Training & Patients' Services (Question 6 of 29 - Mandatory) Not Applicable Too Much Teaching Too Much Service Adequate Balance Between Teaching and Service Rotation Areas of Improvement (Question 7 of 29 - Mandatory) In what areas do you think this rotation needs improvement or attention? Number of Patients Under My Care Physical Environment Faculty Supervsion Nursing, Technical or Other Allied Health Professionals Ancillary Support Back Up from Consultation Services Availability of Laboratory Results Overall Training and Education Experience Other Obtain an ECG (Question 8 of 29 - Mandatory) Did you have the opportunity to perform any of the following procedures or develop any of the following skills in this rotation? No Yes Interpret ECG (Question 9 of 29 - Mandatory) Did you have the opportunity to perform any of the following procedures or develop any of the following skills in this rotation? No Yes Draw ABG's (Question 10 of 29 - Mandatory) Did you have the opportunity to perform any of the following procedures or develop any of the following skills in this rotation? No Yes Interpret ABG's (Question 11 of 29 - Mandatory) Did you have the opportunity to perform any of the following procedures or develop any of the following skills in this rotation? No Yes Interpret ph and Electrolyte Disturbances (Question 12 of 29 - Mandatory) 79

79 Did you have the opportunity to perform any of the following procedures or develop any of the following skills in this rotation? No Yes Place NG Tube (Question 13 of 29 - Mandatory) Did you have the opportunity to perform any of the following procedures or develop any of the following skills in this rotation? No Yes Place Foley Cath (Question 14 of 29 - Mandatory) Did you have the opportunity to perform any of the following procedures or develop any of the following skills in this rotation? No Yes Do Lumbar Puncture (Question 15 of 29 - Mandatory) Did you have the opportunity to perform any of the following procedures or develop any of the following skills in this rotation? No Yes Do Thoracentesis (Question 16 of 29 - Mandatory) Did you have the opportunity to perform any of the following procedures or develop any of the following skills in this rotation? No Yes Do Paracentesis (Question 17 of 29 - Mandatory) Did you have the opportunity to perform any of the following procedures or develop any of the following skills in this rotation? No Yes 80

80 Place CVP Line (Question 18 of 29 - Mandatory) Did you have the opportunity to perform any of the following procedures or develop any of the following skills in this rotation? No Yes Do Arthrocentesis (Question 19 of 29 - Mandatory) Did you have the opportunity to perform any of the following procedures or develop any of the following skills in this rotation? No Yes Do Endo Trach. Entub. (Question 20 of 29 - Mandatory) Did you have the opportunity to perform any of the following procedures or develop any of the following skills in this rotation? No Yes CPR or ACLS (Question 21 of 29 - Mandatory) Did you have the opportunity to perform any of the following procedures or develop any of the following skills in this rotation? No Yes Interpretation of Chest Roenlgenograms (Question 22 of 29 - Mandatory) No Yes Interpret Samples of Urinary Sediment (Question 23 of 29 - Mandatory) No Yes Interpret Renal Function Laboratory Parameters (Question 24 of 29 - Mandatory) No Yes Performs a Flexible Sigmoidoscopy (Question 25 of 29 - Mandatory) No Yes Obtain a Rectal Biopsy (Question 26 of 29 - Mandatory) No Yes 81

81 Other (Question 27 of 29 - Mandatory) No Yes Objectives and Training Goal were Accomplished (Question 28 of 29 - Mandatory) Did you feel that the objectives or training goals of this rotation were accomplished? Not Applicable Not At All Slightly Somewhat Mostly Completely Comments (Question 29 of 29) Please provide additional comments. 82

82 Subject: Evaluator: Site: Period: Dates of Activity: Activity: Evaluation Type: Mini-CEX University of Puerto Rico Internal Medicine Patient Problem/Diagnosis (Question 1 of 15 - Mandatory) Patient Problem/Diagnosis Patient Complexity (Question 2 of 15 - Mandatory) Low Moderate High Mini-CEX focus (Question 3 of 15 - Mandatory) What area(s) of patient care did this mini-cex focus upon? (select all that apply.) Data Gathering Diagnosis Therapy Counseling Medical Interviewing Skills (Question 4 of 15 - Mandatory) Facilitates patient s telling of story; effectively uses questions/directions to obtain accurate, adequate information needed; responds appropriately to effect, non-verbal cues. Unable to Unsatisfactory Satisfactory Superior assess Physical Examination Skills (Question 5 of 15 - Mandatory) Follows efficient, logical sequence; balances screening/diagnostic steps for problem; informs patient; sensitive to patient s comfort, modesty Unable to Unsatisfactory Satisfactory Superior assess Humanistic Qualities/Professionalism (Question 6 of 15 - Mandatory) Shows respect, compassion, empathy, establishes trust; attends to patient s needs of comfort, modesty, confidentiality, information Unable to assess Unsatisfactory Satisfactory Superior

83 Clinical Judgment (Question 7 of 15 - Mandatory) Selectively orders/performs appropriate diagnostic studies; considers risks, benefits. Unable to Unsatisfactory Satisfactory Superior assess Counseling Skills (Question 8 of 15 - Mandatory) Explains rationale for test/treatment, obtains patient s consent, educates/counsels regarding management. Unable to Unsatisfactory Satisfactory Superior assess Organization/Efficiency (Question 9 of 15 - Mandatory) Prioritizes; is timely; succinct. Unable to Unsatisfactory Satisfactory Superior assess Overall clinical competence. (Question 10 of 15 - Mandatory) Demonstrates judgment, synthesis, caring, effectiveness, efficiency. Unable to Unsatisfactory Satisfactory Superior assess Comments (Question 11 of 15) 84

84 Observation Time (Question 12 of 15 - Mandatory) Mini-CEX Observation Time (minutes) >25 Feedback Time (Question 13 of 15 - Mandatory) Mini-CEX Feedback Time (minutes) >25 Evaluator Satisfaction with Mini-CEX (Question 14 of 15 - Mandatory) Low High Resident Satisfaction with Mini-CEX (Question 15 of 15) Low High

85 UNIVERSITY OF PUERTO RICO SCHOOL OF MEDICINE UNIVERSITY HOSPITAL DEPARTMENT OF MEDICINE GUIDELINES FOR THE EXAMINERS INVOLVED IN THE CLINICAL COMPETENCE EXERCISES OF THE HOUSESTAFF 1. The purpose of the Clinical Competence Exercise is to evaluate the intern's/resident's performance regarding: history taking, physical examination, clinical judgment and synthesis, medical care and humanistic attributes, as defined in the Clinical Evaluation Exercise Form (CEX form). This evaluation will be recorded in the aforementioned form. 2. The patient selected for the examination should be able to give an adequate history. The case must be unknown to both examiner and housestaff member. 3. The time to be allowed for history and physical examination will be one hour. During this hour, the evaluator should remain inconspicuous and shall not interrupt so that the patient relates primarily to the resident. However, when necessary, the evaluator should go to the patient to demonstrate proper techniques to the resident or elicit findings which the resident omitted. 4. After leaving the patient, about thirty to forty-five minutes should be designated for the resident's presentation of the history and physical examination, initial diagnostic impression and initial plans for diagnostic studies and medical care. 5. At the conclusion of the exercise, the evaluator should discuss in detail with the resident the strengths and weaknesses observed in his/her clinical performance. These observations should be stated clearly in the CEX form. 6. A complete write-up of the case, including: the differential diagnosis, laboratory and other studies needed to evaluate the particular case, and the appropriate therapeutic plan must be handed in to the evaluator not later than 24 hours after the date of examination. This information should be included with the CEX form and placed in the resident's file. 7. This write-up should be sent to the Office of the Department of Medicine as soon as possible. a:clincomp.exa 86

86 UNIVERSITY OF PUERTO RICO - DEPARTMENT OF HEALTH SCHOOL OF MEDICINE UNIVERSITY HOSPITAL DEPARTMENT OF MEDICINE C L I N I C A L E V A L U A T I O N E X E R C I S E This form is recommended for use in reporting on a single exercise where a resident is observed while interviewing and examining a patient. Resident's Name: Evaluator's Name: Date: To the examiner: please review the guidelines for the Clinical Competence Exercise enclosed with this form. I. CLINICAL SKILLS - HISTORY Demonstrates consideration for the patient during the interview. Recognizes and interprets nonverbal clues. Allows the patient adequate time to tell about the illness in his/her own words, yet directs questions effectively to obtain the necessary information. Develops in chronological sequence an accurate description of the pertinent symptoms and events in the present illness. Obtains appropriately complete information in the past history, family history and social history. Comments: Describe major strengths and Rate: Superior weaknesses observed (i.e., give Satisfactory positive and negative critical Unsatisfactory incidents). II. CLINICAL SKILLS - PHYSICAL EXAMINATION Demonstrates concern for the patient's comfort and modesty. Enlists the patient's cooperation. Positions patient properly, applies skillfully the fundamental techniques of examination to each region. Follows a logical sequence of examination from one region to another, emphasizing those areas of importance suggested by the interview. Applies special techniques to help gather complete information about an abnormality. Modifies the examination to adapt to patient limitations imposed by illness. Records the physical examination in the patient's chart in a well-organized, thorough manner. Comments: Describe major strengths and Rate: Superior weaknesses observed (i.e., give Satisfactory positive and negative critical Unsatisfactory incidents). 87

87 III. CLINICAL JUDGMENT AND SYNTHESIS (as elicited by Case Presentation) Spends appropriate time for the complexity of the problem. Uses terminology that is meaningful and unambiguous. Presents information concisely in logical sequence. Reports accurately the information related by the patient and the observations made during the physical examination. Relates information about major problems in adequate detail without significant omissions or digressions, selectively highlighting less important problems. Comments: Describe major strengths and Rate: Superior weaknesses observed (i.e., give Satisfactory positive and negative critical Unsatisfactory incidents). IV. MEDICAL CARE (including utilization of Laboratory Tests and Procedures) Understands in physiologic terms, the meaning of the patient's abnormal findings and interrelates them to explain logically the patient's illness. Is able to develop a differential diagnosis with an appreciation for priorities in each of the diagnoses considered. Identifies all of the patient's major problems. Uses a logical sequence in planning diagnostic tests and procedures. Integrates diagnostic studies with the diagnostic impression, proceeding from simpler tests to more complex ones. Demonstrates clinical judgment in selecting the most effective care with the least risk to the patient. Plans treatment to deal with all of the patient's major problems. Comments: Describe major strengths and Rate: Superior weaknesses observed (i.e., give Satisfactory positive and negative critical Unsatisfactory incidents). V. HUMANISTIC ATTRIBUTES Demonstrates the necessary human qualities and interpersonal skills which will allow the development of appropriate patient-physician relationships. Demonstrates integrity, empathy, compassion and respect for the patient; exemplifies that the primary concern is for the patient's welfare. Appreciates the patient's perception of his/her illness. Is careful to place the patients' problems in the context of the patient's life and history. Display sensitivity to the patient's needs for comfort and encouragement. Comments: Describe major strengths and Rate: Superior weaknesses observed (i.e., give Satisfactory positive and negative critical Unsatisfactory incidents). Overall Clinical Competence 88

88 Circle the number which best describes overall clinical competence (as demonstrated in this exercise). Superior Satisfactory Unsatisfactory Signature of Evaluator Note: The Clinical Competence Committee of the Department of Medicine has approved the guidelines stated below, in order to help each evaluator (or examiner) to define more sharply what each number really means. 9 - Should be reserved for the exceptional resident such as the best resident you can see. This could represent the top 5% of the residents that can be encountered. 8 - Could be assigned to residents among the top 6% to 15% of the residents that can be encountered. 7 - Describes a definitely above average resident, but below the top residents deserving 9 and Most competent residents deserve this rating; 4 imply the lowest of acceptable performance Denotes unsatisfactory work. No credit can be given for this type of work. a:clincomp.exa 89

89 UNIVERSITY OF PUERTO RICO DEPARTMENT OF MEDICINE DIAGNOSTIC & THERAPEUTIC PROCEDURES Resident s Name: Date: Year of Training PGY- To this date, Dr. has performed the following procedures: NUMBER PERFORMED COMPETENT TO PERFORM HAS PERFORMED BUT NOT ENTIRELY COMPETENT NOT PERFORMED OBSERVED PROCEDURES Abdominal paracentesis ACLS Adult ventilator management Arterial line placement Arterial puncture Arthrocentesis Bone marrow aspiration Bone marrow biopsy Central venous line placement DC Cardioversion ECG interpretation Endotracheal entubation Flexible sigmoidoscopy with biopsy Foley cath female Foley cath male Lumbar Puncture Nasogastric intubation Pelvic Exam - Pap smear and endocervical culture Pleural Biopsy Skin biopsy (punch) Swan-Ganz catheter placement Temporary pacemaker Thoracentesis Total Parenteral nutrition management Treadmill stress testing Other: Name of the Faculty reviewer: Faculty Signature: Resident Signature: SENIOR S RESEARCH EVALUATION FORM 90

90 RATING: Unacceptable (1) Poor (2) Average (3) Good (4) Excellent (5) Name: Title: GRADING PER ITEM: N/A Experimental Design Originality Methods Used Quality of Work Literature Review Discussion Quality of Presentation COMMENTS: Evaluator s Signature Date 91

91 UPR-SCHOOL OF MEDICINE DEPARTMENT OF MEDICINE RESIDENTS INTERVIEW Residents Name: Year of Training: PGY- Today I met with Dr. who will finish (her/his) year of training next June 30, 200. We went over (her/his) evaluations in (her/his) record and discussed the program strong areas as well as those that need strengthening. Among strong areas, she/he mentioned The areas that need improvement: With a rating from 1 to 5 (5 being superior and 1, poor) she/he gave a ranking of: to the program: to the overall faculty supervision to the supervision or assistance received from residents her/his senior. We also reviewed the list of procedures she/he has done during training. Overall, Dr. is: performing and progressing well in his/her residency having minor difficulties in. However, these are being corrected. having some difficulties that have been brought up to the attention of the Program Director and the Clinical Competence Committee. Please check: USMLE status (1 & 2) Is resident doing moonlighting? USMLE Step 3 Is resident aware of rules Licensure status regulating moonlighting? Continuity clinics Complaint 80-hours work duty Research Activity Name of Faculty Resident Signature Date Date 92

92 University of Puerto Rico School of Medicine Department of Medicine Internal Medicine Residency Program End of Training Resident Final Evaluation Internal Medicine NAME SOCIAL SECURITY # DATE OF BIRTH DATES OF TRAINING: FROM: TO: Did the resident/fellow receive full credit for this training? Please check: YES NO If no, please complete the following: fellowship. Successfully completed yrs/months of a year residency/ Please explain if the resident/fellow did not receive full credit THE PROFESSIONAL SKILLS OF THIS PHYSICIAN ARE EVALUATED AS FOLLOWS: COMPETENCIES POOR FAIR GOOD SUPERIOR 1 ESSENTIAL COMPONENTS OF CLINICAL COMPETENCE Accurate, comprehensive medical interviews, physical examination, review of other data, and procedural skills; always makes diagnostic and therapeutic decisions based on available evidence, sound judgment, and patient preference 2 PATIENT CARE Logical, thorough, complete, accurate, and efficient 3 MEDICAL KNOWLEDGE Knowledge of basic and clinical sciences, resourceful development of knowledge; comprehensive understanding of complex relationships, mechanisms of disease 4 PRACTICE-BASED LEARNING & IMPROVEMENT Evaluates own performance, incorporates feedback into improvement activities; effectively uses technology to manage information for patient care and self-improvement 5 INTERPERSONAL & COMMUNICATION SKILLS Establishes highly effective humanistic and therapeutic relationships with patients and families; demonstrates excellent listening, narrative and nonverbal skills; successful in educating and counseling patients, families, and colleagues; always interpersonally engaged 6 PROFESSIONALISM Demonstrates respect, compassion, integrity, honest, teaches/role models responsible behavior; total commitment to self-assessment; willingly acknowledges errors; consistently considers needs of patients, families, and colleagues 7 SYSTEM-BASED PRACTICE Accesses/utilizes outside resources; uses systematic approaches to reduce errors and improve patient care; enthusiastically assists in developing systems improvement 93

93 NAME AT THE CONCLUSION OF THIS PHYSICIAN RESIDENCY TRAINING, HE/SHE WAS JUDGED CAPABLE OF PERFORMING THE FOLLOWING PROCEDURES INDEPENDENTLY PROCEDURES IN INTERNAL MEDICINE YES NO Arthrocentesis of the knee Lumbar puncture Paracentesis Insertion of subclavian central line Insertion of femoral central line Insertion of internal jugular central line Insertion of arterial line Flexible sigmoidoscopy Bone marrow aspiration and biopsy Insertion of Swan Ganz catheter Punch skin biopsy Thoracentesis Other: As the Program Director, can you verify that this resident has demonstrated sufficient professional ability to practice competently and independently? Please check one: YES NO Name of Program Director Program Director Signature Date I have reviewed this evaluation with the Program Director or designee. I understand that this form will, in most cases, be utilized as the confidential verification and reference form in lieu of other forms when requests for verification of resident/fellowship training and/or reference are received by the Department of Medicine of the UPR School of Medicine Resident Signature Date Resident refused to sign. Approved by Dr. C. González Oppenheimer, IM Program Director May 2006 Dr. Esther A. Torres, Chair of Medicine Dr. Yolanda Gómez, DIO Prepared by Gladys Colón, Program Administrator 94

94 UNIVERSITY OF PUERTO RICO SCHOOL OF MEDICINE INTERNAL MEDICINE PROGRAM RESIDENT SURVEY-CONTINUITY CLINIC EXPERIENCES Date: Clinical Site: PGY Level: DESCRIPTION 1. Faculty is available for consult 2. Faculty evaluates my work 3. The patient volume is adequate 4. The variety of diagnosis is ample 5. Laboratory services are adequate 6. Specialty consulting services are adequate 7. Auxiliary consulting services are adequate 8. I can control the scheduling of patients 9. I have my own notebook of patients schedules 10. I feel this is my clinic and these are my patients 11. My clinic resembles an internal medicine office practice 12. When in my clinic, I m excused from other activities 13. I have gained knowledge & skills about the natural course of disease 14. I m not interrupted by other duties while in clinic 15. I enjoy my clinic time STRONGLY AGREE 4 AGREE 3 DISAGREE 2 STRONGLY DISAGREE Percent of patients in my clinic I m giving follow up: 75% 70%-60% 60%-50% 40%-30 % < 25% 17. What aspect of the continuity clinic you like most? 18. What aspect of the continuity clinic you like less? 19. What aspect of the continuity clinic you will change? clr.may.04 95

95 UNIVERSITY OF PUERTO RICO SCHOOL OF MEDICINE UNIVERSITY HOSPITAL DEPARTMENT OF MEDICINE PG-1 PG-2 PG-3 EVALUATION OF CLINICAL COMPETENCE This is to certify that I met with the Program Director or his designee to review my record and discuss my evaluations of Clinical Competence for the previously stated academic year. I acknowledge the fact that I have read the comments made by my supervisors and that I have received adequate counseling regarding areas that need improvement. I am aware that this form will be kept on my record as documentation required by the accreditation agencies. Resident Name Signature Evaluator Name Signature clr.may 04 Date 96

96 UNIVERSITY OF PUERTO RICO SCHOOL OF MEDICINE UNIVERSITY HOSPITAL DEPARTMENT OF MEDICINE HEALTH CARE TEAM EVALUATION HOUSESTAFF OFFICER NAME: EVALUATOR S NAME: EVALUATIO DATE: POSITION: UNSATISFACTORY SATISFACTORY SUPERIOR NEEDS ATTENTION Observations: 98

97 UNIVERSITY OF PUERTO RICO DEPARTMENT OF MEDICINE SAN JUAN, PUERTO RICO OVERALL RESIDENT EVALUATION Intern (PG-1) Resident (PG-2) Resident (PG-3) Resident s Name: Evaluation of Period of: COMMENTS: UNSATISFACTORY SATISFACTORY SUPERIOR NEED ATTENTION 1. PATIENT CARE G 2. MEDICAL KNOWLEDGE G 3. PRACTICE BASED LEARNING IMPROVEMENT G 4. INTERPERSONAL AND COMMUNICATIONS SKILLS G 5. SYSTEM BASED LEARNING G 6. PROFESSIONALISM G 7. OVERALL CLINICAL G COMPETENCE Evaluator s Name (Print) Evaluator s Signature Date 99

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100 SECTION 4 Policies 1. Resident s Grievance Policy and Procedure 2. Non-Teaching Patients Policy 3. Policy on Order Writing 4. Policy on ACGME Guidelines Ambulatory Assignments & Patient Loads 5. Policy on Work Load 6. Moonlighting Policy & Procedure 7. Dress Code Policy 8. Absences, Tardiness, Vacation, Illness & Parental Leave 9. Policy on Fatigue and Resident Stress 102

101 GRIEVANCE PROCEDURE Any grievance or misunderstanding presented by a house officer should normally be resolved by and within the Department of Medicine. If the problem relates to the residents academic activities, they should first look to their Senior Resident (s) and subsequently to his Chief Resident for resolution. Whenever the nature of the problem involves other hospital departments and/or the administration, it should be discussed with the Chief Resident and with the Assistant Chief of Medicine for Clinical Services. Finally, house officers may consult the Program Director the evaluation of the situation, if the house staff member feels that no satisfactory agreement has been reached. The house staff member has recourse to the Department s Grievances and Complaints Committee for presentation of the matter. The Department s Grievances Committee Members is as follows: Dr. Carlos Fernández -Sifre Dr. Carlos G. Rivera-Bermúdez Dr. Vanessa Sepúlveda Dr. Adelaida Ortiz Ultimately, if need, the resident (s) can present their claims to the Postgraduate Education Committee of the School of Medicine and petitions or attention to specific matters will follow the procedures established by this Committee. 103

102 University of Puerto Rico School of Medicine Department of Medicine Internal Medicine Residency Program Resident s Grievance Policy and Procedure I. POLICY STATEMENT The Internal Medicine Residency Program of the University of Puerto Rico School of Medicine Resident s Grievance Policy and Procedure provides a mechanism for resolving disputes and complaints that may arise between residents or fellows and their program director or other faculty member. Residents and fellows may appeal grievable disagreements, disputes, or conflicts with their program using the procedure outlined below. II. PROCEDURAL GUIDELINES A. Purpose The purpose of the Resident s Grievance Policy and Procedure is two-fold: 1. to provide a means of resolving disagreements or misunderstandings at the lowest possible administrative level, achieving equitable solutions to individual grievances which may arise about the interpretation or application of the policies and procedures of the residency training program or any unresolved dispute or complaint with the program director or other faculty member; and 2. to provide an impartial decision and a remedy in those cases which cannot be resolved by mutual agreement. B. Definition A grievance shall mean any dispute or controversy about the interpretation or application of the policies and procedures of the residency training program or any unresolved dispute with his/her program director or other faculty member. The non-renewal of a resident s appointment upon expiration of the one year term is not grievable under these procedures nor is questions about the teaching hospital(s) or University of Puerto Rico policies, quality of patient care, adequacy of facilities, operations of ancillary and support services, etc. Concerns about such matters must be pursued by other means. The due process for a resident to be terminated or suspended without pay for cause is provided for 104

103 separately and does not come under the provisions of the Grievance Procedure. Complaints of illegal discrimination, including failure to provide reasonable accommodations and sexual harassment, are processed in accordance with the University of Puerto Rico Medical Sciences Campus policies and procedures. Grievable matters are those relating to disputes or complaints related to application, interpretation, or compliance with the provisions of the of the policies, procedures, rules or regulations of the residency training program, the policies and procedures governing graduate medical education and the general policies and procedures of the University of Puerto Rico School of Medicine. Questions of capricious, arbitrary, punitive or retaliatory actions or interpretations of the policies governing graduate medical education on the part of any faculty member or officer of the Internal Medicine Residency Program are subject to the grievance process. C. Preliminary Procedure In the event a resident or fellow in the Department of Medicine of the University of Puerto Rico School of Medicine has a grievance or is dissatisfied with any aspect of the program, he/she is encouraged to initially discuss the issue with his/her attending physician, key faculty or the chief residents. If this fails to provide adequate closure to the grievance, then he/she is directed to speak with the Program Director or Chair of Medicine. No matter shall be submitted for the Grievance Procedure unless it has first been discussed personally with the Program Director. If the Program Director is personally involved in the matter, then the Director of the Department of Medicine shall substitute the Program Director. Both parties shall make a good faith effort to resolve the grievance and to achieve a mutually agreeable solution. If the grievance is not resolved, the resident may proceed to Step One of the Grievance Procedure. D. Formal Procedure Step 1 If the grievance is not resolved to the satisfaction of the resident after discussion with the Program Director, the resident has the option to present the grievance, in writing, to the Program Director within ten (10) working days following the grievable event. This notification should include the nature a statement of the grievance, the facts upon which it is based, and the remedy sought. Within seven (7) calendar days after written notice of the grievance is given to the Program Director, the resident and the Program Director will set a mutually convenient time to discuss the complaint and attempt to reach a solution. Step 1 of the informal resolution process will be deemed complete when the Program Director (PD) informs the aggrieved resident, in 105

104 writing, of the final decision following such discussion. This written response should address the issues and the relief requested. A copy of the Program Director s final decision will be sent to the Department Chair and to the Assistant Dean of Graduate Medical Education. Step 2 If the resident is dissatisfied with the decision resulting from the procedure in Step 1, the resident may choose to proceed to notify the Department Chair of the grievance in writing. Such notification must occur within ten (10) working days of receipt of the Program Director s final decision. This notification should include all pertinent information, including a copy of the PD s final written decision, evidence that supports the grievance, and the relief requested. Within seven (7) calendar days of receipt of the grievance, the resident and the Department Chair will set a mutually convenient time to discuss the complaint and attempt to reach a solution. The resident and the Department Chair may each be accompanied at such meeting by one person, other than legal counsel. Legal counsel shall not be permitted to participate in Step 1 or Step 2 discussions. Step 2 of the grievance process will be deemed complete when the Department Chair provides the aggrieved resident with a written response to the issues and relief requested. Copies of this decision will be kept on file in the main office of the Department of Medicine and sent to the Assistant Dean of Graduate Medical Education. Step 3 If the resident disagrees with the final decision of the Department Chair, he/she may appeal the case to the Departmental Grievance Committee and petitions or attention to specific matters will follow the procedures established by this Committee. The notice of appeal to the Committee shall be submitted in writing within fifteen (15) working days following receipt of the decision in Step 2. The notification should describe the nature and the basis for the grievance and include copies of the final written decisions from the Program Director and Department Chair and any other pertinent information. Failure to submit the grievance in the fifteen-day period will result in the resident waiving his/her right to proceed further with this procedure. In this situation, the decision of the Department Chair will be final. 106

105 A. Composition of the Grievance Committee This Committee will consists of three (3) uninvolved attending physicians, the Vice Chair for Clinical Affairs, one (1) member appointed by the Assistant Dean of Graduate Medical Education, and one (1) person from the housestaff nominated by the Chief Resident. The Vice Chair for Clinical Affairs shall be the President of the Committee, shall attend to the administrative matters and may participate in the deliberations, but shall not have a vote. B. Grievance Committee Procedures The Grievance Committee shall be formed within fourteen (14) working days of filing grievance. The Committee shall hear the case as promptly as is practicable with due notice to all parties and in any event within ten (10) working days after constitution of the Committee unless delay is mutually agreed upon by all parties. Evidence and argument may be submitted in writing or personally or both. The President may call for further evidence or argument at his/her discretion. Either party or both may be assisted by counsel or other advisor of choice. The attorney or counsel will not actively participate in the proceedings unless authorized by the Committee President. A record of the hearing shall be kept. The Committee shall decide whether the subject is grievable or not. Should the Committee decide that the matter is not grievable, the proceeding shall be stopped. The decision of the Committee in this regard is final. If the Committee finds the matter grievable, they are to recommend a remedy or procedure acceptable to settle the dispute. The Committee may affirm, reverse, or modify the decisions taken by the Chair of Medicine or the Program Director. All Committee decisions and recommendations shall be decided by a majority vote of the voting members of the Committee and are final. The decision and the recommended action shall be in writing and shall be delivered to the parties involved in the dispute and to the Assistant Dean of Graduate Medical Education. Step 4 If the resident does not agree with the Departmental Grievance Committee decision, he/she will appeal in writing to the Dean of Medicine. The Dean will refer the appeal to the Graduate Medical Education Committee (GMEC) who will name an ad-hoc committee. There cannot be a member of the Department of Medicine involved in this committee. The ad hoc committee will submit a written report with recommendations to the Dean of Medicine. If the decision is adverse, the resident can further appeal to the Medical Sciences Campus Chancellor. In situations where the grievance relates to the Chair or Program Director, or where the resident believes that a fair resolution cannot be attained by presenting the grievance to those individuals, he/she may present the grievance in writing directly to the Dean of Medicine. The 107

106 Dean will refer the appeal to the Assistant Dean for Graduate Medical Education who will meet with the resident, the Program Director, the Chair and one or more of the program s Chief Residents to determine the cause and validity of the complaint and to determine the means of redress. Should the meeting with the Assistant Dean fail to resolve the grievance to the satisfaction of the resident, the resident may request that he/she be heard by the Dean of Medicine. Any action(s) taken in good faith by the Dean addressing the grievance will be final. III. CONFIDENTIALITY All participants in the grievance process are expected to maintain confidentiality by not discussing the matter under review with any third party, except as may be required for purposes of the grievance procedure. lv. AMENDMENTS This grievance procedure may be revised and amended any time, or from time to time, in writing, by the Graduate Medical Education Committee of the Department of Medicine of the UPR School of Medicine. Original Date Approved: August 10, 2005 Next Review Date: August 2006 Revised & Approved by: Director Dr. Esther A. Torres, Professor and Chair of Medicine Dr. Carlos A. González-Oppenheimer, Internal Medicine Program Dr. Yolanda Gómez, Assistant Dean Graduate Medical Education, UPR School of Medicine Edited by: Mrs. Gladys Colón, Program Administrator References: Internal Medicine Training Manual , UPR- School of Medicine Housestaff Manual , Graduate Medical Education Division, UPR School of Medicine. Grievance Procedures in Higher Education Contracts, Volume 1, Number 4, October Graduate Trainee and Grievance Policy & Procedure, Beth Israel Deaconess Medical Center, BIDMC Manual, May 17,

107 University of Puerto Rico School of Medicine Department of Medicine Internal Medicine Program NON-TEACHING PATIENTS POLICY AT CARDIOVASCULAR CENTER OF PUERTO RICO & THE CARIBBEAN (H-4) 1. Internal Medicine residents, while on duty under our supervision at the Puerto Rico Cardiovascular Center may be called to attend private patients not under the care of our faculty. 2. If the patient s situation is not critical or emergent, the resident will instruct the ward nurse to notify the patient s personal physician (s). 3. In an emergency requiring immediate action, the resident must contact the patient s personal physician. Only immediately needed emergent measures to stabilize the patient are to be taken by the resident. In these cases, the resident on duty should seek the Cardiology Fellows assistance, if needed. 4. The Internal Medicine resident must make sure that the patient s clinical condition is stable or that the patient is under the proper care of his personal physician before discontinuing his participation in the immediate care of the patient. The resident must write a progress note documenting his/her work. 5. In the event that the patient s personal physician cannot be reached, the resident must report this situation to the Cardiology attending-physician on call for the University Hospital Cardiology Service. Approved: May 12,

108 University of Puerto Rico School of Medicine Department of Medicine Internal Medicine Program POLICY ON ORDER WRITING I. PURPOSE The UPR Internal Medicine Training Program requires that residents write all orders for patients on the teaching services. The purpose of this policy is to assure that housestaff are kept aware of any and all management and therapeutic decisions regarding the patients which they are assigned. II. POLICY Residents must write all orders for patients under their care with appropriate supervision by the attending physician. Medical student orders must be counter-signed by a supervising resident. It is recognized that there are some circumstances where attendings or fellows will write orders on a resident s patient (i.e. DNR/DNI, dialysis, post procedure and chemotherapy orders); the attending or subspecialty resident must communicate his/her action to the resident in a timely manner. III. SCOPE The Department of Medicine training programs comply with the ACGME program requirements for residency education in Internal Medicine. This policy applies to all residents during their rotations at any of the four (4) teaching sites (University Hospital, UPR-Hospital at Carolina, San Juan VA Hospital and Cardiovascular Center). 110

109 IV. PROCEDURE 1. Orders for patients admitted to medicine service are to be written by the Internal Medicine (IM) resident. 2. Orders for patients consulted to the medicine service are to be written by the primary team taking care of the patient, i.e. the house staff and/or attending physician. The subspecialty team has the responsibility to indicate recommendations in the written consult of contact the patient s physician to discuss the need for the order. 3. Orders should be written during morning rounds. 4. Emergency and new admissions orders are written as the situation may arise. 5. All orders must be clear and legible using only the abbreviators approved by the Medical Record Committee. 6. The patient s name, medical record number and room number should be clearly stated in each order sheet. 7. Orders that are to be executed on the same day and/or stat orders are to be called to the nurse s attention. 8. The attending physician will review the resident s order and will ensure that they are adequately written, legible, and updated as necessary. V. IMPLEMENTATION Implementation of this policy is the responsibility of the Department Chair, Program Director, Division Chiefs and Subspecialties Program Directors. Housestaff are oriented with respect to this policy at the beginning of each academic year. Faculty should obtain a copy of the education handbook, which is available on hard copy in the main office of the Department of Medicine, which details the roles and responsibilities of faculty members during their inpatient service months. Any issues regarding compliance with this policy should be brought directly to the Program Director for feedback to the individual faculty member. VI. REFERENCES ACGME Program Requirements for Residency Education in Internal Medicine, V.E.3 111

110 University of Puerto Rico School of Medicine Department of Medicine Internal Medicine Program Policy on ACGME Guidelines Ambulatory Assignments & Patient Loads All trainees are required to follow the Accreditation Council on Graduate Medical Education (ACGME) program requirements for residency education. The following is a complete listing of the guidelines as set forth by ACGME and has been adopted for the Department of Medicine residency training program. 1. Ambulatory Medicine a. At least one-third of the residency training is in the ambulatory care setting. (NOTE: In assessing the contribution of various clinical experiences with ambulatory patients to the 33% minimum, the following guidelines can be used: ½ day per week assigned to an ambulatory setting throughout all 3 years of training is equivalent to 10%; a 1-month block rotation is equivalent to 3%; 1 full day per week throughout a single year of training is equivalent to 7%. Examples of settings that may be counted toward this requirement are general medicine continuity clinics, subspecialty clinics, ambulatory block rotations, physicians' offices, managed health-care systems, emergency medicine, walk-in clinics, neighborhood health clinics, and home-care visits.) (1) In an ambulatory setting, one faculty member is responsible for no more than five residents or other learners. (2) On-site faculty members' primary responsibilities include the supervision and teaching of residents. On-site supervision as well as the quality of the educational experience must be documented. (3) Residents are able to obtain appropriate and timely consultation from other specialties for their ambulatory patients. (4) There are services available from other health-care professionals such as nurses, social workers, and dietitians. 112

111 b. Ambulatory Medicine - Continuity Clinic (1) At the Program Director s (PD) discretion, residents may be excused from attending their continuity clinic when they are assigned to an intensive care unit, to emergency medicine, to an away-elective, or to night float. (2) Residents attend a minimum of 108 weekly continuity clinic sessions during the 36 months of training. (3) The continuing patient-care experience is not interrupted by more than 1 month, excluding a resident's vacation. (4) The number of patients seen by a first-year resident, when averaged over the year is not less than 3 or greater than 5 per scheduled 1/2-day session. (5) The number of patients seen by a second-year resident, when averaged over the year is not less than 4 or greater than 6 per scheduled 1/2-day session. (6) The number of patients seen by a third-year resident, when averaged over the year is not less than 4 per scheduled 1/2-day session. (7) During the continuity experience, arrangements are made to minimize interruptions of the experience by residents' duties on inpatient and consultation services. (8) Each resident follows patients with chronic diseases on a long-term basis. (9) It is desirable that residents be informed of the status of their continuity patients when they are hospitalized so the resident can make appropriate arrangements to maintain continuity of care. c. Ambulatory Medicine - Emergency Medicine (1) Internal medicine residents assigned to emergency medicine have first contact responsibility for a sufficient number of unselected patients to meet the educational needs of internal medicine residents. Triage by other physicians prior to this contact is not tolerated. (2) Internal medicine residents are assigned to emergency medicine for at least 4 weeks of direct experience in blocks of not less than 2 weeks. (3) Total required emergency medicine experience does not exceed 3 months in 3 years of training. (4) During emergency medicine assignments, continuous duty does not exceed 12 hours. 113

112 (5) Residents have direct patient responsibility, including participation in diagnosis, management, and admission decisions across the broad spectrum of medical, surgical, and psychiatric illnesses, such that the residents learn how to determine which patients require hospitalization. (6) Internal medicine residents assigned to rotations on emergency medicine have on-site, 24-hour, supervision by qualified faculty members. (7) Timely, on-site consultations from other specialties are available. 2. Inpatient Medicine a. On Inpatient Rotations: (1) A first-year resident is not assigned more than five new patients per admitting day; an additional 2 patients may be assigned if they are in-house transfers from the medical services. (2) A first-year resident is not assigned more than eight new patients in a 48-hour period. (3) A first-year resident is not responsible for the ongoing care of more than 9-10 patients. (4) When supervising more than one first-year resident, the supervising resident is not responsible for the supervision or admission of more than 10 new patients and 4 transfer patients per admitting day or more than 16 new patients in a 48- hour period. (This does not apply to Night Float residents.) (5) When supervising one first-year resident, the supervising resident is not responsible for the ongoing care of more than 14 patients. (6) When supervising more than one first-year resident, the supervising resident is not responsible for the ongoing care of more than 24 patients. (7) First-year residents should interact with second or third-year internal medicine residents in the care of patients. (8) Second or third-year internal medicine residents or other appropriate supervisory physicians (e.g., subspecialty residents or attendings) with documented experience appropriate to the acuity, complexity, and severity of patient illness are available at all times on-site to supervise first-year residents. (9) On inpatient rotations, residents have continuing responsibility for most of the patients they admit (unless they are on Night Float or the ED rotation.) (10) Residents from other specialties do not supervise internal medicine residents on any internal medicine inpatient rotation. 114

113 (11) Residents write all orders for patients under their care, with appropriate supervision by the attending physician. In those unusual circumstances when an attending physician or subspecialty resident writes an order on a resident's patient, the attending or subspecialty resident communicate his or her action to the resident in a timely manner. (12) There is a resident on-call schedule and a detailed checkout procedure, so residents learn to work in teams and effectively transmit necessary clinical information to ensure safe and proper care of patients. (13) The on-call system includes a plan for backup to ensure that patient care is not jeopardized during or following assigned periods of duty. (14) There is a minimum of 6 months of inpatient internal medicine teaching service assignments in the first year (15) There is a minimum of 6 months of inpatient internal medicine teaching service assignments over the second and third years of training combined. (16) The required 12 months of inpatient internal medicine include a minimum of 3 months of inpatient general internal medicine teaching service assignments over the 3 years of training. (17) Geographic concentration of inpatients assigned to a given resident is desirable because such concentration promotes effective teaching and fosters interaction with other health-care personnel. b. Inpatient Medicine - Critical Care (1) Residents are assigned to critical care rotations (e.g., medical or respiratory intensive care units, cardiac care units) no fewer than 3 months in 3 years of training. (2) Total required critical care experience does not exceed 6 months in 3 years of training. (NOTE: When elective experience occurs in the critical care unit, it must not result in more than a total of 8 months of critical care in 3 years of training for any resident.) (3) All critical care training occurs in critical care units that are directed by ABMScertified critical care specialists. (4) All coronary intensive care unit training occurs in critical care units that are directed by ABIM-certified cardiologists. (5) Timely and appropriate consultations are available from other internal medicine sub specialists and specialists from other disciplines. 115

114 3. Subspecialty Experience a. Clinical experience in each of the subspecialties of internal medicine is included in the training program and may occur in either inpatient or ambulatory settings. b. Although it is not necessary that each resident be assigned to a dedicated rotation in every subspecialty, the curriculum is designed to ensure that each resident has sufficient clinical exposure to the diagnostic and therapeutic methods of each of the recognized internal medicine subspecialties. c. Residents have formal instruction and assigned clinical experience in geriatric medicine. The curriculum and clinical experience is directed by an ABIM 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. 116

115 University of Puerto Rico School of Medicine Department of Medicine Internal Medicine Program Policy on Work Load 1. PG-Is on all ward services are limited to five (5) admissions per long call day. 2. PG-I on all services should not have more than 12 patients under their care at one time, including the immediate post-call day. The Chief Resident will take steps to limit the number of admissions or take patients off the teaching service if/when the number of patients an intern follows exceeds PG-2 residents in all services will not have more than 24 patients to supervise. 4. Short-call admissions will be limited based on the number of patients carried by an intern. 5. Residents with an excessive number of complex patients may have their patient load reduced at the discretion of the Program Director, Associate Program Director or Chief Resident. Residents are encouraged to notify the Chief Resident if the patient load on a team is suboptimal for education or patient care. 6. Residents will not be responsible for the ongoing care of more than 24 patients. 7. Admissions will be limited if the intern or resident feel that the work load might compromise the 80-hour rule. Revised 1/24/06 117

116 University of Puerto Rico School of Medicine Department of Medicine Internal Medicine Program Moonlighting Policy & Procedure I. Policy statement The special nature of residency programs requires extensive clinical activity and availability to patients at times other than the regular working day. In addition, residency programs have a continuing academic component that requires continual personal effort. The general policy of the UPR School of Medicine is not to encourage any type of outside clinical employment. Each program director (PD) has the authority to develop and adopt a definitive policy applicable to the residency program with respect to outside moonlighting. Such policy may allow or prohibit moonlighting of housestaff. Because residency education is a full time endeavor, the resident must ensure that moonlighting does not interfere with their ability to achieve the goals and objectives of the educational program. All moonlighting hours must be counted toward the 80-hour weekly limit on duty hours. Residents are responsible for ensuring that the addition of moonlighting hours does not result in a work week in excess of the 80-hour maximum, or result in fatigue which might affect patient care or learning. II. Definition Moonlighting is defined as any patient care activities external to the educational program in which the resident is enrolled. Moonlighting is a voluntary and optional experience. No resident may be required to engage in moonlighting. III. Moonlighting procedural guidelines 1. It is the responsibility of the program director (PD) to decide whether or not moonlighting will be allowed. 2. Moonlighting will be permitted only to third-year residents (PG-3) within the home institution or in sites that are used by the educational program (in-house moonlighting). 3. It is the responsibility of senior residents to notify the PD if they wish to moonlight. 118

117 4. If the PD allows a resident to moonlight, he will provide written statement permission prior to any moonlighting activity. The PD s statement will be retained in the resident s file. 5. Residents who are permitted this privilege must be in good standing in the program. If a resident has academic difficulties, this privilege will be forfeited. 6. The time used in moonlighting will be counted toward the 80-hour per week duty hours limit. 7. No resident may be engaged in moonlighting unless he/she is licensed for unsupervised medical practice in Puerto Rico. 8. No resident may engage in moonlighting without obtaining his own liability insurance for the moonlighting activities. Moonlighting is not covered by the institution malpractice coverage. 9. The PD will monitor resident performance to ensure that moonlighting activities are not adversely affecting patient care or learning. 10. The PD may require detailed information on the timing and level or activity to assure it does not cause fatigue or interfere with patient care and the goals and objectives of the program. This information will be kept by the program director. 11. If the PD determines that the resident performance is deficient, the resident may be subject to withdrawal of permission or disciplinary actions. 12. Residents on J-1 visas may never moonlight. 13. Any violation of the moonlighting policy is subject to disciplinary action. 14. Subspecialty residents must follow the directives of their training program directors, which should be in compliance with the aforementioned procedure. Approved by the GMEC: May 2004 Revised: February

118 University of Puerto Rico School of Medicine Department of Medicine Internal Medicine Program Dress Code Policy All Internal Medicine residents and medical students rotating through the Department of Medicine shall maintain a professional appearance and dress appropriately whenever they are representing the Department of Medicine of the School of Medicine of the University of Puerto Rico in any on or off-campus setting. This includes academic and clinical sites, meetings, and special events. Being neatly dressed and well groomed exemplifies a professional appearance and shows respect for patients and colleagues. EACH RESIDENT AND MEDICAL STUDENT IS REQUIRED TO FOLLOW THE DRESS CODE AS OUTLINED BELOW: CLOTHING CLOTHING SHOULD ALLOW FOR ADEQUATE MOVEMENT DURING PATIENT CARE, AND SHOULD NOT BE TIGHT, LOW CUT, OR EXPOSE THE TRUNK WITH MOVEMENT. o Residents and medical students are not to wear such items as tennis shoes, shorts, cut-off, T-shirts, hats, or clothing with rips/tears, bare midriff o Men are to wear shirts with collars. o Female residents and medical students are not to wear short skirts or plunging necklines. o White coats will be worn at all times. o When attending clinics, it is strongly recommended that male residents and medical students wear a dress shirt with necktie. 120

119 NAILS o During on-duty & ER rotations a relaxed clothing may be permitted, such as scrubs, classical relaxed-fit jeans, tennis shoes with professional appearance o Fingernails should be kept trimmed. o Any nail polish should be discreet. JEWELRY o Watches, wedding bands and/or engagement rings are permissible as appropriate. o No excessive bracelets or necklaces. o Earrings are permitted for female residents and medical students only. o No more than two earrings per ear. No dangling or oversized earrings are allowed. o No other visible body piercing is permitted. TATTOOS o Residents and medical students may not exhibit tattoos. PERFUMES o No excessive or heavy perfumes or after shave lotion. HAIR o Hair and facial hair should be clean and arranged so as not to interfere with provision patient care. ID CARDS o The ID card identifies you as an Internal Medicine resident or medical student and is MANDATORY at all times. ID cards must be worn on either your coat or clothes while at the clinical or academic site. NO GUM CHEWING OR USE OF TOBACCO PRODUCTS WILL BE ALLOWED IN THE CLINICAL SETTING. 121

120 CLINICAL SUPERVISORS, PRECEPTORS, DEPARTMENT FACULTY OR CHIEF RESIDENTS HAVE THE RIGHT TO ASK ANY RESIDENT OR MEDICAL STUDENT WHO IS NOT APPROPRIATELY DRESSED TO LEAVE THE CLINICAL OR ACADEMIC SITE AND INFORM THE INTERNAL MEDICINE PROGRAM DIRECTOR OR CHAIR OF MEDICINE. *If the clinical site has established policies and practices regarding the dress code, the site s policies supersede those of the Department of Medicine of the UPR. Effective Date: July 1, 2005 Revised and approved by: Esther A. Torres, MD Carlos A. González-Oppenheimer, MD Prepared by: Gladys Colón-Rivera, MS 122

121 Absences, Tardiness, Vacation, Illness & Parental Leave ABSENCES & TARDINESS POLICY Attendance and punctuality to all academic and clinical activities (Morning Reports, Night Duties, Outpatient Clinics, Journal Clubs, Staff Meetings, Resident Seminars, Case Presentations and mandatory conferences) are mandatory for all residents. After three (3) absences or lateness without any reasonable excuse, the resident will be referred to the Program Director. Residents MUST notify the residency office as well as their attending when are unavailable for expected work duties, whatever the reason. We frequently get calls for residents and need to be able to locate the residents. Failure to do so may result in disciplinary action. Absences during working hours including vacations, illness, out of town conferences, etc., impact patient care. Therefore, the Program Director and the Chief Resident must be notified of the exact dates requested for an absence at least eight weeks prior to the time off. Failure to notify the office of an absence prior to departure will result in time-off without pay that may affect training schedule, and may also result in disciplinary action. VACATIONS Residents are granted 30 calendar days of paid vacation, which cannot be accumulated from year to year. Any additional days that could be authorized on a contractual basis will be cleared and assigned at the discretion of the Program Director. The vacations period may be distributed through the academic year provided that is not in conflict with the policies stated by the Training Program, the resident contract, the American Board of Internal Medicine (ABIM) and the Accreditation Council on Graduate Medical Education (ACGME). ILLNESS Residents are granted 18 days of sick leave per academic year, which cannot be transferred to future contracts. When a resident is unable to perform usual duties due to significant illness or disability, he/she must inform their supervising attending physician, the Chief Resident and the program office ASAP. The office will then assist the resident in arranging needed coverage for their duties. All days of absence from assigned duty, including illness days, count toward the allowed total time off for the resident s training year. Sick days are therefore charged to the total vacation available to the resident. PARENTAL LEAVE Female residents will be granted up to 8-paid calendar weeks of maternity leave. This leave must be coordinated with the GME office and a physician certification must be submitted indicating the approximate due date. Two-paid calendar weeks will be granted for paternity leave following the birth of the child. Birth certificate must be presented to grant this leave. The Program Director or his/her designee will determine how much of the time will be needed to made up to fulfill the 36-months of residency training requirement in order to be admitted to the certification examination of the American Board of Internal Medicine (ABIM) 123

122 EDUCATIONAL LEAVE Each resident s assigned vacation time, paid holidays, and educational leave are specified in their yearly contract. A resident may in rare circumstances be granted increased educational leave days, but not increased vacation time, at the discretion of the Program Director or his/her designee. Such leave dates would be approved only for attendance at special conferences that arise occasionally and are deemed in the best interests of the program. (e.g.: ACP, APDIM rising Chief Resident conference.) EFFECT OF ABSENCES ON LENGTH OF TRAINING The ABIM stipulates that board-eligibility requires that a resident's training program must be extended beyond 36 months if the total time away from the residency program for any reason (vacation, sickness, leave of absence, parental leave, etc.), exceeds 3 months out of the 36 month total, or an average of one month per year. It is important to be aware of this rule as it may delay graduation date from the residency program and affect resident availability to begin practice or fellowship training on July 1 of a given year. A yellow contract will be issued and will not entitle to institutional health insurance coverage or stipend. 124

123 May 17, 2004 INTERN AND RESIDENTS-INTERNAL MEDICINE RESIDENT ABSENTEEISM AND TARDINESS POLICY Attendance and punctuality to all academic and clinical activities, including Morning Reports, Night Duties, Outpatient Clinics, Grand Rounds, Journal Clubs, Staff Meetings, Resident Seminars, Case Presentations and Conferences, are mandatory for all residents. If for any reason a resident will be late or absent, he/she must notify the Chief Residents immediately and notify them about the specific problem. If personal health is involved, the resident must bring a proper medical excuse from the employee or students physicians within a reasonable time. After 3 absences or lateness, the resident will be referred to the Chief Resident and Program Director. If after proper orientation his/her absenteeism or lateness continues, a letter will be placed on his personal file that will state that either he/she abandoned patient care or abandoned academic activities. Unsatisfactory rating and/or negative incidents denoting inadequate professional attitudes will jeopardize completion of training. In case of personal unforeseen difficulties that present you from fulfilling any of your responsibilities, including your on duty assignments, you must contact the Chief Residents to find ways to solve the particular problem. Carlos González-Oppenheimer, MD Training Program Director Rev..May

124 Policy on Fatigue and Resident Stress PURPOSE This policy is to assist the UPR Internal Medicine Residency Program in its support of high quality education and safe/effective patient care. The Residency Program is committed to meeting the requirements of patient safety and resident wellbeing. Excessive sleep loss, fatigue and resident stress are serious matters. In the event that any resident experiences fatigue and/or stress that is interfering with his/her ability to safely perform his/her duties, they are strongly encouraged and obligated to report this to his/her senior resident and/or supervising attending physician on service. Fatigue among residents may increase the possibility of error, compromise decisionmaking, and therefore jeopardize safety in patient care. Faculty and residents are instructed to closely observe other residents for any signs of undue stress and/or fatigue. They are encouraged to report such concerns of sleepiness, tardiness, resident absences, inattentiveness, or other indicators of possible fatigue and/or excessive stress to the supervising attending Chief Residents and/or Program Director. The resident will be relieved of his/her duties until the effects of fatigue and/or stress are no longer present. POLICY Faculty and residents should be alert for signs of fatigue among housestaff. These signs include falling asleep, irritability, apathy, and careless medical errors. When faculty and residents observe these signs, the houseofficer should be questioned about sleep loss, fatigue and/or stress. Brief counseling should be provided if a sleep deficit is identified. This counseling may include information about naps, use of caffeine, and good sleep hygiene. If the symptoms continue, referral to the Chief Residents or Program Director should occur. If the houseofficer's fatigue or stress symptoms at any point are sufficient to jeopardize patient care, the houseofficer or attending physician discovering the problem should consult immediately with other members of the team or with the Chief Residents or Program Director so that the houseofficer may be immediately relieved of duty. Patient care should then be delivered by other members of the team or by another houseofficer. There will be no academic repercussions for taking time out due to fatigue or stress situations. 126

125 SECTION 5 Ambulatory Medicine General Clinics Special Interdisciplinary Clinical Experiences Continuity Clinic Assignments 127

126 GENERAL CLINICS Residents will go to their continuous ambulatory care experience (half-day per week) to allow for continuity of care to their own group of patients. This assignment takes priority overall other responsibilities except for vacations and Floater Rotation. AMBULATORY CARE EXPERIENCES (ACE) Ambulatory Care Experiences (ACE) constitutes at least 33% of the residents regularly scheduled work-training time. An ACE is divided into block rotations in ambulatory clinics (usually while the residents are in subspecialty rotations or emergency service duties) and continued ambulatory care experiences (CACE). All residents (PG1 to PG3) are assigned during 1 1/2 day each week to their CACE through their three years of training. The CACEs settings are organized so that residents continue to see a panel of patients throughout their 3-years of training on continuity bases. Residents add on to their assigned panel of patients, those whom they have seen before in the hospital and have discharged to be followed in these clinics, as well as patients they have seen on consultations and in the Emergency Room. The CACEs in the Carolina Hospital and others participating institutions conducted in a managed care setting. Residents are supervised by attending physicians whose primary responsibilities are to supervise and teach them. Their CACE activities are planned and conducted in such a way so as to make this activity as similar as possible to what their office practices as general internists will be in the future. The principles of continuity of care and the recognition of the various psychosocial factors that affect patients with organic diseases are stressed. Residents have opportunity to have consultation services with almost all medical and allied health professionals for their patients. 128

127 Meaningful ambulatory care experiences occur in each of the three years of residency training. Arrangements are made to minimize interruptions of the residents time in CACEs. Residents are excused from these clinics only when on vacations and while in floater duties. Activities are oriented so as to provide residents with experiences that will help them to: - Learn the natural history of diseases - Master techniques of interview and physical examinations - Develop skills in psychological assessment of patients - Develop skills in counseling and education of patients and promoting patients health and well being - Specifically, ambulatory care experiences are appropriate for the residents to demonstrate: - Skill in verbal communication - Employment of appropriate nonverbal behavior to convey active listening - Knowledge of important concepts and variables in doctor-patient relationships - Skills in developing and maintaining therapeutic relationships with patients - Knowledge of family structure and dysfunctions and how these modify organic illness - Teaching skills for patient education - Ability in applying principles of decision analysis to their practice - Knowledge in processes for requiring effective consultations - Familiarity with ways in which medical practices are organized 129

128 - Skills in organizing information about life-situational stimuli and psychological and behavioral elements in illness - Meaningful responsibility for patients, including participation in the diagnosis and management across the broad range of adult patients with medical and surgical illnesses. They are provided with the opportunity to learn how to discriminate which patients required hospitalization. The residents are assigned 1 1/2 day per week for evaluation and long term follow up of patients who were discharge from their service or from the Emergency Room. Also, they follow-up patients who were in the continuity clinics of PG-3 residents after they finish training to insure continued coverage of patients. Besides the experience of managing patients with the most common diagnoses in internal medicine, residents have the opportunity to deal with problems and situation concerning preventive medicine, periodic health examination, environmental health family dynamics, etc. There are a primary out patient clinical experiences at the Primary Care Health Center in the PR Medical Center, the UPR Hospital-Carolina, Hospital del Maestro in the morning and La Fondita de Jesús. Clinics are supervised by general internists. Also there is the interaction with the rest health care team. CACE permits the thoughtful and cautions use of time in the diagnosis and management of illnesses. It establishes a balance between the physician oriented in-hospital activity with a less controlled situation, in which it is the patients who establish the therapeutic tempo, as they as free to decide to follow the physicians advises or not. It is in ambulatory care experiences where the skills of establishing a fruitful and balanced doctor-patient relationship are mastered. Hence, the importance of personal involvement in this task and the continuity of experiences in the ambulatory setting. With these experiences, residents 130

129 must realize that observation of the evolution or resolution of illnesses can only be possible when they are able to follow up their own group of patients throughout their three years of training. SPECIAL INTERDISCIPLINARY CLINICAL EXPERIENCES (SICE or CLINICS) Opportunities are given to expand on the knowledge and skills of the general internist by assigning time in various other learning experiences that go beyond the classical area of internal medicine. The activities are oriented towards expanding the role of the internist as a primary care provider by increasing the general internists field of expertise in patients management. Increasing the general internist s armamentarium and increasing the experiences in ambulatory medicine. These additional experiences vary depending on resources available and the scheduling of the resident s rotations. They usually include: psychiatry, dermatology, medical ophthalmology, office gynecology, rehabilitation medicine, and other clinical experiences. These help they become familiar with those aspects of care in each specialty area that are appropriately diagnosed and managed by general internists, and with those that should be referred to, or managed jointly with other specialists. Additional SICE experiences are organized and carried out during specialty rotations. SICE generally include: Dermatology Geriatric Medicine & Acute Geriatric Care Unit Medical Consultation Services Pre-admission Clinics HIV Diseases Clinics Office Ophthalmology Community Based Medicine Physical Medicine & Rehabilitation Experiences Sexually Transmitted Diseases Clinic Office ENT Elective Time 131

130 A. DERMATOLOGY Skin aliments, are a frequent reason for clinic visits. The general internist must become proficient in the diagnosis and management of the usual skin disorders, particularly those in systemic diseases, those with infectious etiologies, those related to environmental and occupational factors and those which are malignant and require early identification. Other areas stressed are those related to skin manifestations of sexually transmitted diseases, normal aging skin processes, common skin problems in the elderly and skin allergic reactions. In their rotation, residents are exposed to diagnostic procedures such as skin biopsies and become aware of indications for photo therapy. In addition, the experience gives them insight as to the symptoms and clinical presentations of some of those dermatological conditions which require referral to the dermatologist. B. GERIATRIC MEDICINE: The principal programmed and scheduled Geriatric experience for residents in internal medicine is a one month rotation during their third year of training in the Acute Geriatric Unit (AGU) at the UPRH-Carolina. ACUTE GERIATRIC CARE UNIT (AGU) The inpatient ward is a 10 bed unit established to develop models of care for the elderly and provide education in problems of aging and the aged. Education training, clinical research and development of patient care models are primary goals. The general approach in evaluating and managing patients on the unit is to use and interdisciplinary (and multidisciplinary) team of health care. All aspects of the patient s care is assessed, planned, supervised, and developed by the geriatric health care team. 132

131 AGU Director (or designated attending physician) role descriptions: 1. Assumes overall administrative responsibility for the AGU. 2. Assumes supervisory medical responsibility for patients in the AGU. 3. Oversees admission and discharge decisions. 4. Rounds on all AGU patients with the team three times weekly. 5. Participates in weekly conferences. 6. Helps organize the weekly seminars and presents some lectures. 7. Develops and conducts patient care audits. In this setting, the PG3 resident will: 1. Performs a complete history, physical examination and writes orders on each assigned AGU patient. His/her work-up is reviewed by the Fellow and attending physician. 2. Evaluates acute problems on the ward and carries out routine ward tasks on assigned patients. 3. Participates in all team conferences and provides information to other team members on patient s medical status. 4. Participates in all resident and fellow education activities of the Geriatrics Division (e.g., Clinical Lecture Series, Journal Club, Basic Science Lecture Series, Geriatric Core Lectures, nursing home assessment rounds and rehabilitation hospital rounds.) 5. Provides medical educational supervision for the medical student, and other team members. 6. Prepares one presentation for the Geriatric Grand Rounds program. 133

132 7. Participates in other special AGU activities (e.g., patient home visits, field visits to community senior centers, quality assurance visits to VA contract nursing homes. Following the completion of the rotation in Geriatric Medicine, both the house staff and medical students will be asked to complete evaluation forms. This will assist in assessing the quality of the trainee s experiences in terms of patient care and teaching. C. OFFICE GYNECOLOGY: While in their block rotation in ambulatory medicine clinics, residents will spend one afternoon each week in the general gynecology clinic. Trainees in general medicine are closely supervised by the faculty of the Department of Obstetrics and Gynecology. The experience is oriented and organized for the residents in order that they may develop knowledge and skills in: 1. The performance of the adult gynecology examination. 2. The differential diagnosis of abnormal uterine bleeding. 3. The identification and treatment of common infections of the female reproductive tract. 4. The approach to the patient who has suffered sexual assault and trauma and the performance of the general and gynecologic evolution in these cases. 5. Identification of common benign and malignant lesions of the female reproductive tract. 6. Understanding of physiologic and endocrinologic alterations seen in menopause and in the elderly gynecologic patient. 7. Assessing need for surgical intervention in cases of uterine prolepses, urinary incontinence, etc. 134

133 8. Recommendations to patients and indications of management of abnormal cervical cytology findings. 9. Understanding the orientation and requirements of family planning. 10. Gathering and adequate gynecologic and obstetric history; including the sexual history. 11. Obtaining vaginal and cervical cytology. 12. Offering oral and IUD contraceptive counseling. 13. Offering humane counseling to those seeking abortion. D. MEDICAL CONSULTATION SERVICES: Third year residents (PG3 s) have at least one month rotation exclusively assigned to consultation services. These include serving as in hospital consultants in medicine for other services, such as, general surgery, orthopedics, gynecology, etc., both for ambulatory as well as for in hospital patients. Residents are under the supervision of a full-time faculty member in charge of this service. In addition, besides this consultation service as general internists, residents participate in other medical subspecialty consultation activities when they rotate in the medical specialty experiences. Here they see consults specifically involving patients with endocrinologic, cardiac, pulmonary, problems, etc. Residents may see these patients initially and then discuss their findings, diagnoses and recommendations with the attending physician of these services or may see patients on consultation together with a fellow in these subspecialties. In these cases, resident s supervision is more direct and feedback about his/her performance as consultant is more prompt and direct. These activities help orient the resident to: 135

134 1. Thoughtfully integrate and apply previously learned skills to new situations. 2. Become more proficient and discriminating as they realize that other physicians need a complete assessment of the consulted patient s situation and clear recommendations as to how to proceed. 3. Develop integrative skills, as direct practical response of their consults is expected by other physicians. 4. Feel adept and comfortable with the dynamics between him/herself as the consultant, the patient and the primary physician requesting the consult. 5. Find him/her in a position to orchestrate and enlist others in a coordinated team effort for the benefit of a particular patient, often with a difficult diagnosis or with a life threatening disease. 6. Understand the validity and need for continued follow up and care even in this consultant role. 7. Define clearly what is the specific question raised by the consultation, what is expected of him/her, and understand the importance of a clearly specified and written consultation. 8. Become aware of the importance to clearly document findings and state specific recommendations as a consultant, based upon known data, cost effectiveness and common sense. E. PRE-ADMISSION CLINICS: PG-3 residents spend an extra month in pre-admission clinics. In these clinics their role as consultants is expanded to included specific functions such as: preoperative evaluations of patients to undergo same day surgery or invasive diagnosis procedures, the initial evaluation of patients in whom no urgent hospitalization has been 136

135 suggested. In these last cases, the residents determine if patients need hospitalization within the next few days or if work up for diagnosis and treatment can be continued on ambulatory bases. Learning goals are similar to those previously presented for the consultation services; but in pre-admission consults, special attention is given to the assessment of need for: antibiotic prophylaxis, anticoagulation, surgical risk considerations, pulmonary therapy immediately post operation, recommendations for physical therapy, etc. F. HIV DISEASE CLINICS: Residents are assigned to special HIV Diseases Clinics where they learn about the diagnostic and management approaches to patients with HIV infection. Experiences include patients with early HIV infection who have few or no symptoms and also patients with advanced HIV infection who manifest the Acquired Immuno Deficiency Syndrome (AIDS). Besides developing new knowledge skills, residents practice counseling tactics in alternative health practice, HIV risk assessment, post-diagnosis counseling and substance abuse. G. OFFICE OPHTHALMOLOGY: The general internist must be able to evaluate many ophthalmologic complaints, including pain, redness, itching and visual changes. Residents should be able to identify and treat frequently encountered problems such as conjunctivitis and identify problems requiring referral to the ophthalmologist. Residents must develop competency in the office examination of vision and the eye, an appreciation of the critical elements in the patients histories, and an understanding of the indications for routine and emergency referral. Residents must also be able to recognize the funduscopic changes secondary to systemic illnesses, including hypertension, arteriosclerosis, and diabetes mellitus, and realize that ocular complaints may herald other illnesses. 137

136 H. COMMUNITY BASED MEDICINE During one of their months in block clinic rotations, residents have at least 4 whole days in which they work under the supervision of general internist in their own office practices. These internists have been selected to serve as supervisors because of their motivation to teach and their potential as role models. In fact, the practitioners chosen for this activity are graduates of our residency program. They are well grounded in the goals and objectives of these experiences and will select those patients that will help the residents meet these goals. This experience is oriented as a career-shaping one, so that residents may experience the like of the community physician, which is often quite different that that of the academic internist. Besides reviewing some previous medical experiences and practicing professional acumen in real life situations, this experience will begin to orient the residents towards their future practices. Residents begin to understand the economic aspects of medical practice and understand the negotiations needed to work within groups and with third party payers. They should also understand that they need to develop the necessary attitudes and skills that will permit their maintenance of the highest level of medical care regardless of the medical system in which they may work. K. PHYSICAL MEDICINE AND REHABILITATION EXPERIENCES: The general internist will be responsible for the care of many patients who may have suffered impairments of the neuro-musculoskeletal system that have resulted in residual disability. As a primary care provider, the general internist will need to be aware o the effects of such disabilities on other body systems and on the patient s ability to perform the routine activities of daily living and to fulfill 138

137 various societal roles. The general internist will have the crucial role of ensuring continuity of care when the patient with medical problems requires intervention from many health care professionals. Experiences in physical medicine and rehabilitation will orient GIM resident to: - Know the different between impediment, disability, and handicap. - Know how to diagnose and manage the common musculoskeketal disorders, including fibromyalgia, myofascial pain, repetitive motion disorders, and overuse syndromes. - Know how to recognize the complications of prolonged bed rest (contractures, pressure sore, deep venous thrombosis, osteoporosis, muscular deconditiong, and others). - Be able to describe various physical medicine treatment modalities, including diathermy, ultrasound, electrical stimulation, and others. - Know the physiologic effects of aerobic exercise. - Know the various types of therapeutic exercises. - Be able to describe the health care team for rehabilitative medicine and the roles of allied health professionals (for example, physical therapist, occupational therapist, psychologist, speech and language pathologist, prosthetist, orthotist, and others). - Know when to use the various assertive devices that may reduce disability, including wheelchairs, prosthetics, orthotics, and others. - Know the principles of evaluation and management of chronic pain, particularly low back pain. 139

138 - Know the methods for minimizing long-term disability from acute illnesses (e.g., prophylaxis against venous thrombosis, bed sores, and contractures). - Be able to assess the effects of impairment on a patient s daily function. L. SEXUALLY TRANSMITTED DISEASES CLINICS Residents are assigned to the principal clinics of the Latin American Center for Sexually Transmitted Diseases, which is located in the Puerto Rico Medical Center. Here, residents see new patients coming in for evaluation to the intake-screening clinics are held on daily bases. Residents are supervised by physicians with extensive training and experiences in this field. The residents have experience in: 1. Reviewing their skills in obtaining a sexual history. 2. Reviewing their skills in performing pelvic examinations and the examination of male genitalia. 3. Dealing with reckless sexual behavior. 4. Identifying various STDs, including HIV and AIDS. 5. Counseling patients with acute depression, agitation, etc. (crisis management) due to the knowledge of having STDs. 6. Ordering and interpreting specific diagnostic tests. M. OFFICE ENT The residents in internal medicine should be able to evaluate and manage common disorders such as pharyngitis, otitis and sinusitis, and recognized more complicated conditions that require subspecialty consultation. Residents must understand that in their future internal medicine practice they will play a key role in screening for, and in the prevention of respiratory tract and esophageal malignancies, particularly for patients who smoke. The general internist should also be competent in 140

139 evaluating specific symptoms, such as hoarseness, hearing loss, and facial pain. Experiences in the ENT rotation will orient GIM s residents to identify and participate in the management of patients with common clinical problems, such as: - discharge from ears - tennitus - ear pain - vertigo - hearing loss - epist axis - airway obstruction - facial or sinus pain - nasal congestion or discharge - snoring - sneezing - hoarseness - nocturnal airway obstruction - sore throat and sleep apnea - oral lesion -Acquire skills, such as: -insertion of wicks in auditory canal -removal of cerumen (observe) -anterior nasal packing -speculum shinoscopy -transillumination of maxillary sinuses -indirect laryngoscope (observe) -Be able to either interpret or understand the need of the following tasks: -Water s radiograph view of sinuses -Audiometry -CT of sinuses -Rapid streptococcal antigentes -Radiography of sinuses -Throat culture Be able to identify the following conditions: -Otitis -Sensorineurual hearing loss -Acute epiglotitis -Laryngitis 141

140 -Benign positional vertigo -Acute labyrinthitis -Cerumen impaction -Eustachian tube dysfunction -Rhinitis, various syndromes -Masses or lesions of the oral cavity -Epistaxis -Peritonsillar abscess -Pharyngitis -Sleep apnea -Nasal polyps -Septal deviation -Sinusitis 142

141 UNIVERSIDAD DE PUERTO RICO-RECINTO DE CIENCIAS MÉDICAS ESCUELA DE MEDICINA DEPARTAMENTO DE MEDICINA REGLAS Y GUIAS GENERALES PARA LAS EXPERIENCIAS DE CLINICAS DE CONTINUIDAD EN MEDICINA INTERNA Las experiencias en clínicas de continuidad se han organizado con la intención de que los redientes de medicina interna tengan la oportunidad de practicar medicina ambulatoria en un ambiente que se asemeje a la futura práctica de un internista general en su oficina. Existen unas características muy importantes en este tipo de práctica. La más obvia es precisamente la continuidad de atención médica a los pacientes. La relación médico-paciente se establece a largo plazo y se trata de desarrollar una relación más personal. Esto conlleva una responsabilidad particular del médico al hacerse cargo de sus pacientes. Requiere disponibilidad y cumplimiento con su horario o programación de sus clínicas. Se hace necesaria una orientación de trabajo en equipo para asegurarnos que en caso de situaciones imprevistas en las cuales el médico no pueda cumplir con su clínica, sus compañeros puedan atender sus pacientes citados y conseguirles una futura cita con su médico para asegurar la continuidad de trabajo. Con el interés de que se puedan organizar y desarrollar estas clínicas se elaboraron las siguientes reglas y guías: 1. La responsabilidad final de las clínicas de continuidad corresponde a la facultad asignada a las mismas. Las responsabilidades incluyen la supervisión, evaluación y organización de los trabajos. También están a cargo del cumplimiento de las normas administrativas y de garantías de calidad que exige la institución. Responsables de la asignación de pacientes a los estudiantes de medicina y de la supervisión y evaluación de éstos. La facultad será también responsable de los procesos de transición, cuando así fuese necesario de una clínica que anteriormente no era de continuidad. Para esto es necesario la asignación de pacientes que antes no tenían médico fijo a los residentes que se encargarán de su seguimiento a largo plazo. Mediante este proceso esperamos que a corto plazo todos los residentes tengan un panel de pacientes que atenderán en la clínica durante sus años de residencia. 143

142 Otra labor crucial de la facultad es la de asegurarse que los pacientes que citen los residentes a sus clínicas, reciban finalmente sus citas en la fecha solicitada por los residentes. Esto implica incluir el nombre del paciente con su médico correspondiente en la libreta de citas y darle al paciente la orden para recibir su cita en el sistema mecanizado de citas. 2. Los residentes serán los responsables de solicitar citas para sus pacientes en las fechas en que están asignados a sus clínicas de continuidad. Estos pacientes serán usualmente aquellos que son dados de alta del hospital y aquellos que han atendido anteriormente y que necesitan seguimiento. 3. Todos estos procesos conllevan un esfuerzo de comunicación entre todos los residentes a cargo del paciente. 4. Una vez un residente tiene su asignación de clínica de continuidad, continuará con esta programación durante toda la duración de su residencia. 5. Los residentes se nutrirán de pacientes en sus clínicas de varias formas: a. De pacientes de Sala de Emergencia y otros lugares. b. De pacientes asignados por la facultad del pool general de pacientes de las clínicas. c. Casos nuevos que llegan a las clínicas. d. Walk-ins o pacientes que se presentan a las clínicas para resolver problemas urgentes fuera de cita. e. Pacientes de otro(a) compañero residente que por alguna razón no pudo venir a su clínica. Ocurrirán ocasiones en que tendrán asignados a sus clínicas, pacientes adicionales a los citados por ustedes. La facultad de la clínica se asegurará que la asignación de pacientes sea una equitativa y que el número de pacientes que atienden los residentes por clínica sea uno razonable y manejable, según los requisitos para estas experiencias. 144

143 6. Los residentes que comparten una mañana o tarde de clínica deben integrarse como un grupo de práctica clínica. Esto facilitará el trabajo y garantizará que el paciente no pierda la continuidad con su médico, pues si algún residente se ve imposibilitado de ver su paciente ese día, un compañero suyo podrá atenderlo y solicitarle luego otra cita con su médico. 7. Los residentes están excusados de sus respectivas clínicas únicamente durante sus vacaciones y en rotaciones de Floater. El compromiso de su clínica es ineludible y sobrepasa a cualquier otro que pueda tener, incluyendo otras clínicas de subespecialidades. 8. Es conveniente que cada residente tenga una libreta para que pueda anotar los nombres de pacientes que cita a sus clínicas para así distribuir mejor su trabajo. 9. Las dudas o dificultades que puedan surgir con relación a estas reglas y guías deben ser traídas a la atención del Director del Programa. 145

144 SECTION 6 Inpatient Medicine General Program Attendings & Residents Duties Floaters Rounds Sign Out Rounds ICU Rotation 146

145 GENERAL PROGRAM All the educational activities are organized with the intention of providing a coherent, integrated and progressive academic program in the broad field of Internal Medicine throughout the three years of training. The program offers the residents with an exposure to a rather broad patient population with a wide spectrum of diseases in various stages of acuity. Residents gain experience in the management of patients with an ample range of clinical problems. The etiology, pathogenesis, clinical presentation, and natural history of various diseases are presented and residents have the opportunity to develop and advance their level of skill in diagnosis, as well as their judgment and resourcefulness in therapy. The team approach and the sharing of responsibilities are emphasized throughout all clinical experiences, particularly in the ambulatory care clinics. Residents have the opportunity to function in harmony with their peers, faculty and with other members of the health care team. In most of the clinical rotations, the PG-I and PG-II residents form a working team and share the care of the patients in their services. Residents are given the responsibility for decision-making and for direct patient care in all settings under direct supervision of the faculty and the senior house staff. Residents write all medical orders for the patients under their care and residents responsibilities increase progressively during the three years of training. Residents with more training help with the supervision of more junior ones and that of medical students. It is also expected that with all the teaching activities, residents may become proficient as leaders in the organization and management of patient care. The training program in General Internal Medicine (GIM) is divided in eight main areas, such as: 147

146 I II III IV V VI VII VIII General Internal Medicine (GIM) Experiences Medical Specialty Experiences Continued Ambulatory Care Experiences (CACE) Special Interdisciplinary Clinical Experiences (Clinics) Emergency and Critical Care Medicine Professional Development Programmed conferences and other formal learning experiences Clinical investigation and other scholarly activities I GENERAL INTERNAL MEDICINE (GIM) EXPERIENCES (University Hospital) First (PG-I) and second year (PG-II) residents have between four to six months rotations each year in the general medicine services of the University Hospital, the UPR-Carolina Hospital and the San Juan VA Medical Center. They participate in daily hospital rounds and are usually in charge of no more than 15 patients per team. A team is composed of a PG-II, one or two PG-I, medical students, usually one senior and two juniors, and an attending-faculty physician. The work responsibilities are distributed in such a way that the PG-II resident assumes responsibility of being the personal physician of all the patients of the team, while supervised by the attending physician assigned to the service. The PG-I share the responsibilities of the PG-II, taking direct care of a particular fraction of the team s patients; from five (5) to eight (8) patients each, depending on the number of PG-I in the team. Faculty attending go on rounds with the residents in the morning and the residents continue work rounds during the rest of the day. The general medicine team takes care of all hospital medical admissions except (protocol patients admitted to the Leukemia Unit, acute leukemia and lymphoma, and other special hematology patients), those admitted to the following subspecialty 148

147 services: oncology and hematology, cardiology, pneumology, nephrology, neurology, gastroenterology, rheumatology and endocrinology. The general medicine teams also admit patients with neurologic diagnoses such as: complicated cerebral thrombosis, and bleeds, embolism and bacterial meningitis. The GIM service also admits patients with common infections diseases, including AIDS patients. In general terms, the following cases are admitted to the general medicine groups (Each case is evaluated individually to assure the bed assignment most appropriate to facilitate optimum patient care): - All infectious diseases cases (as primary diagnoses); including AIDS and HIV+ patients - Common neurology cases (not primary neurologic cases) - Non-complicated, common hematology cases - Referred dermatology cases - All allergy and immunology cases - Acute (previously undiagnosed) renal failure - First episode of GI bleeding - First episode of decompensate chronic liver disease - First episode of hepatitis - Acute pancreatitis and undiagnosed jaundice - Exacerbations of bronchial asthma - Deep venous thromboses - Patients with fever of unknown origin - Suspected hidden malignancy for work up - Terminal oncology patients who are not candidates for chemo or radiotherapy (Palliative care) 149

148 - Patients with common cardiovascular problems not admitted at the PR Cardiovascular Center Orientations and Aims Rounds in the general medicine services and learning activities are conducted with the following considerations: 1. To assure that the patient gets the best medical and humane care that can be given by our medical faculty and housestaff with the resources at hand. 2. To maintain and elevate the quality of teaching at all professional levels: students, residents, attending staff and the rest of the health care team. 3. To maintain a close supervision of the care of patients by the house and attending staff. 4. To assure proper consultations from other subspecialties as needs arise. 5. To develop concern among the trainees of individual patient s needs and to be able to assess them within the context of the perceived need, the complexity of a particular problem and the accountability for a cost-effective practice. 6. To improve avenues of communications with members of other health care disciplines by utilizing a team approach in teaching, learning and in health care delivery. Responsibilities of the Attending Faculty while on the General Medicine Service 1. The attending physicians are responsible for the supervision of the team s residents and the overall care of the patients assigned to their groups. 2. They make rounds with residents in the morning. The attending physician must make sure that for and equivalent of 4 ½ hours per week, teaching 150

149 rounds are conducted. These teaching rounds include the evaluation of the patients at bed-side, and such points as interpretation of clinical data, pathophysiology, differential diagnosis, and appropriate use of technology. Although, the discussion is patient centered, the issues discussed go beyond the specific management of a single patient. The attending physician must go over the pertinent parts of history and physical examination with the residents. At all times, the importance of the dignity of the patient-physician relationship is presented and emphasized. 3. Attend Morning Report while on GIM rotation or on call schedule. 4. Will see and review with their housestaff and medical students all new patients admitted to their team and follow-up patients. They will make sure that the patients are seen daily by the housestaff and that comprehensive, intelligent notes are written in the records as required by each individual patient. 5. Be available at any time on call bases for any consultation that residents may need with regards to the patients under their care. 6. Supervise whenever possible (if not a senior resident will be at patients bedside) and give follow up of all special procedures done by the residents. They will assist or performed the procedures when residents are unable to proceed accordingly. 7. Be responsible for the completion of the record within 5 days of the discharge of the patient. 8. Ensure that electrocardiograms in their services are officially interpreted and that the interpretation is included in the medical record. 151

150 9. Share with the Division Chiefs and with the Program Director a commitment to the goals and objectives of the teaching program, including development in the residents of medical knowledge, clinical, technical and management skills, and clinical judgment. The faculty must be able to nurture the attributes of the scholar, scientist, teacher and humanist. 10. They review and countersign the admission note of the PG-II and the history, physical examination, admission diagnostic impressions and initial assessment of PG-I residents and fourth-year medical students. They countersign the residents progress notes after reviewing them, and write their own notes about patients progress and comments on management plans. 11. Prepare resident evaluation forms at the end of a rotation and provide performance feedback to the residents. 12. Be aware of the other responsibilities residents have with other programmed academic activities, particularly their continuity clinics and excuse them from rounds in order to meet these other responsibilities. 13. Be flexible with regards to timing on rounds. 14. Write their own progress notes, summarizing their impression of the diagnoses, management and clinical evolution of their patients. General Rules concerning all Residents in the GIM Services 1. All residents are required to arrive at 7:15 am in order to meet with the Chief Resident and of duty the night before to go over the admissions of new patients to their various services. Once a week, at 11:00 am, they meet the Chief Resident for the Staff Meeting with the Head of the Department, Program Director and Associate Chief of the Department in order to report 152

151 the admissions, discharges, deaths and pathology findings of patients during the preceding week are brought up in this meeting. Any irregularities that need to be mentioned are brought up in this meeting. 2. Rounds with the attending physician begin promptly after the morning programmed educational activities. Specialty rounds should not interfere with GIM ones. On Sundays, the Senior Resident on duty will conduct ward rounds at 10:00 am, and all new admission, seriously ill patients, and problem cases will be reviewed. 3. The type of teaching ward round may vary according to the preference of the Senior Attending in charge, however, provisions will be made that every patient is seen by the residents every day in rounds. Teaching rounds must be conducted at least for 4 ½ hours each week. 4. The nurse may be present at the regular morning rounds every day to supply any information regarding the patients, note any new orders for management as they are given and generally contribute to facilitate and expedite the conduct of rounds. All nurses supervisors attend the weekly Staff Meetings. 5. All orders will be written by the residents of each GIM group during morning rounds. Emergency and new admissions orders are written as the situation may dictate. The orders written after rounds are to be called to the attention of the nurse. The attending physician will review the resident s orders and will ensure that they are updated as necessary. 6. The interns and residents on each GIM team will make rounds on those patients not seen in the teaching rounds. 153

152 7. All special procedures (spinal punctures, bone marrow aspirations, thoracentesis, etc.) will be done by residents under the supervision of residents their senior or faculty. The nurses shall be informed before hand, so that they may have the appropriate materials available and furnish any help needed. 8. Every time, a patient is admitted, the proper service must be notified as soon as possible. The trainees on a given subspecialty should see the patients after they have been seen and worked up by the residents assigned to the admitting service. Elective admissions will take place in the morning. 9. Discharge of patients should be arranged for the morning rounds. Every time a patient is discharged, complete discharge orders must be written, as well as the discharge summary, which includes the order to discharge, activity at home, diet, medications, special treatment, laboratory tests required for follow up, prognosis and clinical appointments. 10. Smoking is prohibited in the hospital. 11. All residents must wear coats and proper visible identification. In addition to the above, the following rules are applicable to the residents level indicated. Duties for the First Year Residents (PG-I) While in the General Internal Medicine (GIM) services, the duties of the PG-I residents will be: Start their work with Morning Rounds (7:15-8:00 am), where they will share the presentations of patient admitted the night before with the PG-II residents. 154

153 - Be ready to do admissions their teams from 8:00 am to 5:00 pm from Monday to Fridays. They will not leave the hospital until all work is completed on their patients. - Be responsible for the admission work up; diagnosis, writing of orders and initial management plan, with assistant resident (PG-II) on every patient admitted to their service. This should include and Intern Admission Note (IAN) with a complete written review of the history, physical examination, and admission diagnoses. They are also responsible to outline a plan of laboratory confirmation of the diagnosis, write admission orders with the supervision of the PG-II, and to consult their attending physicians and the residents assigned to their group. - See all emergency admissions immediately and work up all patients admitted to the GIM services during their on duty hours. - Write a progress note on daily all their patients and describe all special procedures done, such as: paracentesis, spinal taps, blood transfusions, etc., in the progress notes sheets. Progress notes should follow a SOAP format. - Be responsible for presenting all the information concerning a patient at any time during ward rounds. Therefore, all histories and physical examinations of patients admitted on the preceding day must be completed for next morning rounds. Interns are expected to present their findings at rounds without making reference to the chart. - Be ready and able to start some intravenous medications, such as IVs to restore vascular volume, Hypertonic Glucose, and other IV emergency medications. Specifically, infusions that will modify hemodynamic 155

154 parameters will be monitored and maintained by a physician, who will keep a close watch at the bedside and who has the duty to take blood pressure recording every 15 minutes or more often, as needed until patients are stabilized. The results must be charted in the record. - Stay in the hospital while on duty. In case of absolute need for temporary absence from the hospital while on duty, the intern must, in the interest of his patients, notify and arrange with the assistant resident in charge or with the Senior Resident to find a replacement who will be available for all emergencies and continue in follow up of their patients until their return. - Understand that no patient is to remain in the hospital overnight without an admission note. This rule will be enforced at all time. All patients admitted to the GIM service need a IAN. - In case of hospital death, certify this event by recording pertinent information on progress sheet, write a Death Summary. This information should be complete. - Make all the necessary attempts to secure permission for autopsy. A statement is to be written in each record whether the autopsy was requested or not. The resident will be available to go to the autopsy room to see the autopsy or otherwise communicate with the pathologist to receive information on findings and transmit these in the next Staff Meeting. - Write and fill a discharge note and summary of Diagnosis and Management Form on their assigned patient the same day the patient leaves the hospital. Under no circumstances, should they leave the hospital before writing this discharge note and handing a copy of the 156

155 Discharge Form to the patient. The purpose of this is to have information readily available to the physicians outside the hospital and to the Outpatient Department of the patient s diagnosis and medications. - Develop competency in the interpretation of electrocardiograms, basic roentgenogram images, and interpretation of gram stains of body fluids, microscopic examination of urine and results of basic laboratory tests. - Evaluate the faculty and the training experience itself, at the end of each rotation. - Develop competency in the performance of diagnostic procedures expected of residents at their level of training (venipunctures, starting IVs, ACLS measurers, paracentesis, thoracentesis LPs, NG entubations, etc.) Intern s Teaching Duties The interns will: - Assist all medical students on proper methods of history taking and physical examination. - Notify students in advance of autopsies and before doing special diagnostic and therapeutic procedures such as paracentesis, thoracentesis, spinal tap, blood transfusions, etc. - PG-I residents attendance to the following educational activities is compulsory while in hospital duties in the General Internal Medicine service: Morning Report, Grand Rounds, Mortality Conferences, CPC, Staff Meetings, Resident Seminars, Journal Clubs, Special and Programmed Conferences (see Curriculum Manual). 157

156 Continued Ambulatory Medicine Experience - PG-I residents will go to their continuous ambulatory care experience (half-day a week) to allow for continuity of care to their own group of patients. This assignment takes priority overall other responsibilities except for vacations and floater rotation. Emergency and Admission Room Duties for Interns - PG-I residents rotating for 5 to 8 months in the Department and categorical residents will have one month assigned to the Emergency Room at ASEM. While in the Emergency Room, they will be under the direct supervision of the residents and attending staff of the Department. - They will be responsible for receiving, interviewing questioning and examining all medical emergencies. After a tentative diagnosis is reached, the PG-I resident will proceed according to the instructions or recommendations received. - No patient is to be sent home without the approval of the resident or attending staff. - No patient is to be left overnight or receive prolonged treatment in the Emergency Room, except when no beds are available in the hospital. - As soon as a patient is admitted, the resident of the appropriate service ward will be notified. - The resident staff at the Emergency Room will provide continuous follow up of the Departments patients at the Emergency Room until patients are taken to their respective rooms in hospital or otherwise decided. 158

157 Duties for the Second Year Residents (PG-II) While the (GIM) Services, the PG-II will: - Be the principal member of the GIM team. They will always be responsible for all the patients admitted to the team. If there are two interns in the team, each one will be in charge of approximately half of the teams patients. - They have no more than fifteen (15) patients under their care, while PG-I residents will have generally between 6 to 12, depending on the number of PG-Is in each team and the nature and severity of illness. - Will distribute work among the PG-Is and seniors medical students in the team and supervise their works. - Will develop additional technical skills in diagnostic and therapeutic procedures. These procedures may include, but are not limited to, arterial line placement, bone marrow aspiration, elective cardioversion, endotracheal intubation, flexible sigmoidoscopy, pulmonary artery balloon flotation catheter placement, skin biopsy (punch), temporary pacemaker placement, ambulatory electrocardiographic interpretation, treadmill exercise testing, supervision and interpretation and any other procedures depending on their particular rotations. - Evaluate the PG-I during the rotation utilizing the evaluation form provided by the Department of Medicine. - Transfer or discharge patients after discussing plans for such actions with the team attending physician. 159

158 - Be present in the ward during visiting hour to see relatives. This is an important factor in promoting good patient-physician relations. The patients are entitled to information regarding their condition. Residents should be available at the visiting hours should relatives express their desire to see the ward physician. - Be responsible for the work up, diagnosis and management of every patient admitted to their teams. This should include a Resident Admission Note (RAN) with a complete written review of the history, physical examination, and admission. PG-II residents will write admission orders directly or will review modify or add to the intern s admission orders. They are also responsible to outline a plan of laboratory confirmation of the diagnosis and to consult their attending physician and Senior Residents when they feel they should do so. They will write a comprehensive, intelligent note of what has been discussed in the attending and subspecialty rounds. - Be expected to see all emergency admissions immediately. - Be responsible for supervision of all activities, including diagnostic and therapeutic procedures other residents assigned to them. - Ensure that a progress note is written every day on routine cases, a complete progress note following any procedures done on any patient, and progress notes as required during emergency situations. They will add their own progress notes to report on particular, conclusive laboratory results, diagnostic studies or changes in patients condition. In other routine situations, they will countersign the PG-I residents progress notes if they feel the adequately reflect the patients evolution and situation. 160

159 - Be responsible with the PG-I in obtaining autopsy permissions and blood donation. It must be emphasized that both autopsy permits and blood donations are responsibilities of the resident (PG-II). Final summaries of records of patients dying in the medical ward should be prepared with special attention to all details, history, physical examination on admission clinical course of patient, treatments and special procedures performed and a final complete diagnosis. This summary is to be written after the last progress note before the chart is given to the pathologist or sent to the record room. - Attend and participate in residents work rounds and chart reviews. - Provide adequate follow up of patients in their continuity clinics upon patients discharge from hospital. - Make sure that all advice and instructions given to patients upon discharge are written. - Participate with their interns in sign out rounds with the house staff assigned to the ward duty that night and the residents on call in order to see the new admissions and to notify the incoming group of any seriously ill patient or any important information related to any of their patients. - Do periodic chart rounds and working rounds. - Consult at once with the attending physician or residents their senior any seriously ill patient. - Be responsible to check all laboratory reports and see that these should be placed on the chart as soon as possible. - Help in the supervision and orientation of medical students in their clerkships in medicine. 161

160 - Share with the interns or supervise their writing of the discharge summary on all records of their patients. These shall include important findings of history, physical examination, laboratory, final diagnosis, condition of patients on discharge, recommendations for continued treatment and disposition on the day of discharge and before the patient leaves the hospital. All diagnoses must conform to the official list as it appears in the book A Standard Nomenclature of Diseases and Operations. The medical records must be fully completed within five (5) days of the discharge of the patient. - Evaluate the PG-Is under their supervision, the faculty and the training experience itself at the end of each rotation. - Participate actively in getting consultations from other services promptly and making sure recommendations are carefully considered by all. Emergency and Admission Room Duties for PG-II Residents - Assistant Residents will serve in the Emergency and Admission Room as team leaders. They will be the physician in charge of admitting patients to the medicine wards. No admissions will take place except through their control, as delegated by the Chief Resident. - They will supervise the PG-I resident assigned to the service. They will be responsible of a medical patients referred to them for final disposition. They must be kept informed of ward conditions regarding empty beds, etc., so that they will be able to determine the review the cases left on the admission room with the residents on duty. 162

161 Assistant Residents Teaching Duties PG-II residents will: - Be responsible and as team leaders supervise all teaching activities of the GIM group. - Assign duties to the members of the group. - Check on all PG-II and medical students work and activities with patients. - Serve as a good professional example. - Review everything written in the charts and make the necessary corrections. - Teach proper techniques for diagnostic studies. - Guide PG-1 and medical students in their respective tasks. Duties for the Third Year Residents (PG-III) The third-year residents (PG-III) program also includes rotations through various required internal medicine subspecialties: Hematology/Oncology, Cardiology, Endocrinology, Geriatrics, Nephrology, Gastroenterology, Pneumology, ICU, in addition to elective rotations, in General Internal Medicine and other (see Curriculum Manual for detailed information). While on the GIM Service, senior residents will: -- Be the team leader on the duty schedule after regular working hours. - Supervise all residents in the GIM teams. - Attend the Morning Report. - Participate in the Sign Out Rounds at the end of the day. - Be available to answer consultations from other medical services. - Be senior medical officer in the ICU. 163

162 - Be the contact between GIM residents on duty and the Fellows of other services and the faculty on call. - Be available to assist the assistant residents and interns in any situation that may arise. - Follow those patients they have seen in consultation before and write progress notes as required by the condition of patient. - Go to their continuity GIM clinics. - Attend a formal educational experience in preparation for taking the ABIM exam soon after finishing their residency program. Floater Rotations at the University Hospital The floater system assigns several PG-I and PG-II residents to assume most of all night-time residents duties, while allowing the rest of the housestaff to go home and rest several nights during the week and maintain an on-duty schedule longer than every fifth night. Floater rotations are done from Sundays through Thursdays for 4 consecutive weeks. Basically, floater teams replace the rest of the residents teams in the hospital through the night. Night floaters do not cover during holidays nor on Fridays or Saturdays. Floater teams consist usually of 2 residents and 3 interns. Residents on the floater teams have the following responsibilities: 1. Do admission work ups of patients admitted to the in-hospital medical services, usually from 5:00 pm to 7:00 am the following day. 2. See patients in Emergency Room on consultation for admission or other dispositions between 8:00 pm to 7:00 am the following day. 3. Cross cover with residents in the in-hospital services for the follow up of patients in the hospital. 164

163 4. Present the admitted patients during morning report between 7:15 to 8:00 am. 5. Go on morning floater rounds with the Chief Resident, Key Faculty or Program Director between 8:00 to 8:45 am, except on Mondays when floaters rounds will be done at 6:00 am. 6. Give follow up to the patients they have admitted during their floater duties. 7. Write floater follow up notes in patients presenting important changes in their status and write progress notes in all the patients they see during their on duty service. Experience over the past several years with the floater systems reveals that it has: - Improved housestaff attitudes towards the residency program. - Decreased fatigue. - Improved housestaff morale and satisfaction. - Reduce cross-coverage problems and volume of work for the non-float housestaff. - Improved working hours, the team spirit and the sharing of responsibilities. - Improved communications during signing-out rounds at the end of the day and has not shown to be deleterious to the continued follow up of patients in hospital. Half of the team starts at 5:00 pm with sign out rounds and the other half starts at 8:00 pm. The teams are supplemented by a senior resident (PG-III), who is the on-duty team leader and is assigned to the Intensive Care Unit (ICU) in the University Hospital. 165

164 Floaters Morning Rounds Every morning, immediately after the morning report and from Monday through Fridays, there are floater morning rounds. All patients admitted during the night are seen at the bedside with the residents on duty that previous night and who were responsible for the patients admissions. In essence, these are teaching rounds in which the Chief Residents, the Program Director or the faculty assigned go over the patients histories and physical examinations; pointing out the pertinent positive and negative issues in the history and findings in the physical examination that help establish the principal admitting diagnoses. The admission orders are reviewed and such points as: the interpretation of clinical data, the pathophysiology and the differential diagnoses in each case are discussed. Also, the specific management of the patients and the appropriate use of technology to confirm the diagnoses are discussed. Sign Out Rounds Sign out rounds are conducted at the end of the day in order to preserve continuity of care and transfer the responsibility of the care of patients to the new on duty teams. Residents must recognize that their obligation to their patients is not automatically discharged at any given hour of the day or any particular day of the week. In no case should residents go off duty until the proper care and welfare of patients have been ensured. Signing out rounds is directed by the senior resident (PG-III), who will be on duty after regular working hours. All critically ill patients are presented and clear and specific directions are given to the new on duty teams for the care and follow up of these patients. The senior resident makes a list of all these 166

165 specific situations, gives follow up during the on duty period and reports on patients developments during the following Morning Report. A similar process is followed during weekdays at 8:00 pm with the residents finishing their duty at the Emergency Room services. Each weekend days and/or holidays, a sign out meeting takes place in the conference room of the Internal Medicine Department at University Hospital. In this meeting, all the admissions of previous days are discussed with the assigned group and the attending. Difficult or rare cases are evaluated with the presence of the attending. Guidelines for staffhouse during ICU rotation The medical intensive care unit rotation a performed of the medical surgical critical care unit. The unit is under the medical directorship of the Pulmonary Critical Care Section. Surgical and medical patients have assigned separate beds. The surgical patients and housestaff follow the guidelines of the surgical department. The medical patients and housestaff are under the supervision of a Pulmonary Section attending and fellows the guidelines of the Pulmonary Critical Care Section. Interaction members both faculties and housestaff is encouraged. Conferences and Lectures Required attendance for all personnel in ICU: - Daily rounds - Ethic discussion once a month - Critical care pharmacology discussion during daily rounds with the unit s clinical pharmacist and staff physicians 167

166 Admission to the ICU team The decision regarding admission to the ICU from the medical ER is made by the ER staff physician in consultation with the ICU housestaff. The decision for admission from the ward to the ICU about its appropriates, then ICU attending must be made by the senior ward residents or attending in consultation. If an admission presents questions about its appropriates, then ICU attending must be notified. All transfers from other institutions must be coordinated by the clinical coordination and attending physician. 168

167 UPR-RECINTO DE CIENCIAS MÉDICAS DEPARTAMENTO DE MEDICINA PROGRAMA DE RESIDENCIA EN MEDICINA INTERNA BREVE GUÍA DE TRABAJO ROTACIÓN MEDICINA INTERNA GENERAL HOSPITAL UNIVERSITARIO DE ADULTOS Bienvenidos a su rotación por piso de Medicina Interna del Hospital Universitario de Adultos (UH). A continuación, les menciono algunas guías básicas y sencillas de trabajo, que espero sean provechosas para ustedes y sus pacientes. Las mismas son las siguientes: El facultativo asignado a su grupo de trabajo será el médico primario del paciente y el que tomará las dediciones de manejo conjuntamente con los consultores. Por lo tanto, deberá tener la información más completa y al actualizada de todos los pacientes. Es importante presentarse diariamente a sus pacientes y familiares, y debe ponerse a la disposición de éstos. Además, acláreles que no podremos estar físicamente 24 horas al día, pero que hay un grupo de médicos de guardia (24/7) accesibles en todo momento de haber algún problema serio. Sin embargo, estos médicos pueden que no conozcan todos los detalles del paciente, por lo tanto, se deberán comunicar con nosotros en horario regular de trabajo para la información del progreso diario del mismo. Se evaluarán los pacientes todos los días. Se pasará visita con el facultativo a todos los pacientes admitidos, por lo menos tres veces a la semana working/teaching rounds, y el resto de los días se evaluarán las admisiones de la noche anterior, a los pacientes más críticos y con los que se tengan dificultades en su manejo. Aunque siempre habrá un facultativo de guardia (incluyendo sábados, domingo y días feriados), el facultativo de su grupo estará disponible 24 horas al día 7 días a la semana para atender cualquier duda o problema. Es obligatorio asistir a TODAS las actividades educativas del Departamento y a las reuniones administrativas (Staff Meeting, ect.) excepto cuando ocurra alguna emergencia. Al menos, una vez a la semana, su grupo discutirá un artículo o tema referente a algún paciente. 169

168 Al principio de la rotación, se aclarará todo lo referente a su evaluación final; y durante el mes, se discutirá su progreso en cuanto a los aspectos que debe mejorar y/o cambiar. Al final de la rotación, tendrá una pequeña reunión con el facultativo para discutir las evaluaciones. Éstas serán tanto individual como grupal. Además, el facultativo deberá recibir retroalimentación de los residentes y estudiantes. Es importante que al principio de las rotaciones intercambien los números telefónicos con su facultativo asignado. De tener alguna duda durante su rotación, deberá llamarlo su celular, beepers y/o residencia. Además estos números están siempre disponibles en Sala, en el Departamento de Medicina y en la Oficina del Jefe de Residentes. Esperamos tener TODOS una rotación rica en experiencias educativas nuevas y de crecimiento profesional. Calos A. González Oppenheimer, MD, FACP Director Programa de Residencia y Director Sección Medicina Interna 170

169 RESIDENTS (PG1 & PG2) ACCEPTANCE NOTES In all situations in which patients are admitted by residents who will not be their primary physicians while in the hospital, (admissions done by Floaters on other On-duty Teams), the PG 1 and PG 2 residents who will be taking care of the patients in the hospital will write. Acceptance Note. These will summarize the patients histories and physical examination, will review patients orders, will describe patients evolution from the time of their admission to the moment in which the primary physicians took over care, and will add any other additional pertinent information concerning these patients. Rev..May

170 FLOATER (OR ON-DUTY) FOLLOW- UP NOTES Residents on the Floater Teams will identify their follow-up notes on the following patients during their on-duty assignment. A. Patients they were asked to follow up during Signing Out Rounds. B. Patients they were asked to see by other physicians or nurses in the hospital. C. Patients they were asked to follow up during Floaters Morning Emergency Room Rounds. There will not be Week End or Holiday Notes. Rev..May

171 ADMISSION WORK UPS By now you have done a good number of patients work ups as a medical student. Now, you are faced with the situation of needing to complete several admission work ups in a relatively short period of time. Therefore, you need to be precise, succinct and to the point. Things to take into consideration in your work ups: 1. Improve on the skills you bring from medical school. 2. Follow up a chronological sequence of events in the history of present illness. Many of your patients have chronic, complex medical problems. Pay more attention on your HPI on the recent events that brought your patient to the hospital. Describe these events in their proper sequence. 3. Elicit your data trying to come up in your mind with a principal diagnosis. 4. Shape your interview according to the patients illness or symptoms. Let these keep the flow of your interview. 5. Avoid barriers of communication. 6. Write your history in an understandable and legible narrative of events. 7. Do not be a mere recorder of events; show you re deductive or detective skills. 8. If you finish your history and you do not have in your mind a possible or working diagnosis, you and the patient are in trouble. Get more information. 9. Perform your physical exam in the context of the clinical data base you obtained from the history. You will find and see only what you are looking for. 173

172 10. Come up with a diagnosis with your history and physical, even before you have your laboratory analysis or special studies reports. These will usually confirm your initial impression; if not, they will be a surprise; but this is all right, they happen infrequently. 11. Write your overall assessment of the patients clinical condition(s), but do write your final impression(s) or diagnosis (es). All this will document your medical decision making. 12. Use progress notes during the same day of admission of your patients to add pertinent information and describe the patients evolution and response to your initial treatment. Describe your plan of care. 13. All patients admitted to the hospital will have both an intern (PG1) and resident s (PG2) work up. In patients with admission to our hospital within the previous two weeks and having complications of, or the similar problem that required that previous admission, it its permissible to have Interval Notes, but these will be written both by interns and residents that admit the patients. Rev. May

173 UNIVERSIDAD DE PUERTO RICO ESCUELA DE MEDICINA DEPARTAMENTO DE MEDICINA ENTREGAS DE GUARDIAS Y DISTRIBUCIÓN DE TAREAS Las entregas de guardias comenzarán a las 5:00 p.m. en Sala de Hombres, en el cuarto piso del Hospital Universitario, excepto los viernes que serán a las 4:00 de la tarde. Se ofrecerá la información necesaria sobre los pacientes con condiciones o situaciones que ameriten vigilancia o atención especial durante la guardia. Es necesario entender que la responsabilidad de la atención del residente a cargo de pacientes hospitalizados en los distintos servicios no cesa automáticamente al entregarse los pacientes a los residentes a cargo de la guardia. El hecho de que un nuevo grupo de médicos residentes se hagan cargo de la guardia, no revela de su responsabilidad a los residentes que tenga a su cargo pacientes inestables. Asistirán a las entregas de guardias los cuatros grupos asignados a Medicina Interna General: los residentes rotando por sub-especialidades que tengan pacientes para cuidado durante la guardia; los residentes de tercer año asignados a Salas de Medicina; el residente de tercer año de guardia; los residentes rotando por Sala de Emergencia y el grupo de residentes Floaters. Luego de finalizada la entrega en el cuarto piso, el PG-3 de guardia se trasladará a la Unidad de Intensivo Medicina (ICU) para recibir los pacientes de cuidado crítico y cardiovascular que tendrá a su cargo durante la guardia. El P-3 a cargo de la guardia permanecerá en ICU. La entrega del fin de semana se conducirá de manera similar comenzando a las 8:30 a.m. El residente de tercer nivel Senior es la autoridad máxima durante las guardias. Está asignado a la Unidad de Cuidado Intensivo de Medicina donde tendrá la responsabilidad del cuidado directo y manejo de estos pacientes críticamente enfermos. Supervisará directamente a los residentes de segundo y primer año durante este periodo y asistirá en el manejo y toma de decisiones cuando sea requerido. Además, tiene a cargo la evaluación de consultas que surjan tanto en el área de Recovery y otras áreas del Hospital Universitario. El PG-1 asignado a la Unidad de Coronaria tendrá el cuidado y responsabilidad directa de los pacientes admitidos a ésta área. Todos los documentos de admisión a la Unidad son responsabilidad de éste intern admisión note, resident admission note, órdenes. Se trasladará a la Sala de Emergencias de ASEM únicamente cuando haya 175

174 algún paciente que vaya a ser admitido a la Unidad de Coronaria. Contestará las consultas que surjan en el Centro Cardiovascular bajo supervisión del Senior de la guardia. Además, atenderá situaciones que ocurran en el piso de pacientes hospitalizados bajo el Grupo Universitario de Cardiología y pacientes bajo el cuidado de miembros de la facultad. Los PG-2 asignados a la Sala de Emergencia son los que tienen la autoridad de admitir pacientes al Servicio de Medicina y subespecialidades. Atenderán todos los pacientes que requieran atención por el servicio de Medicina Interna, sean referidos de otras instituciones, walk in patients y consultados por otros servicios, incluyendo la Unidad de Trauma. Darán seguimiento a los pacientes admitidos a nuestros servicios que permanezcan en Sala de Emergencia. Además, supervisarán directamente a los residentes de primer año y los asistirán en decisiones de manejo sobre los pacientes hospitalizados. Los PG-1 tienen la responsabilidad directa de atender los pacientes hospitalizados en nuestras salas (Medicina Hombres, Medicina Mujeres, Unidad de Leucemia, Unidad de Diálisis Peritoneal). Ellos darán continuidad a los pacientes entregados en la guardia y resolverán situaciones agudas que surjan durante este periodo. El PG-1 irá a Sala de Emergencia cuando sea requerido una evaluación de admisión de interno y en situaciones donde las salas de hospitalizados esté controlada y se requiera su ayuda por los residentes. Bajo estas circunstancias un residente asistirá en la Sala de Emergencia y el otro se quedará cubriendo las salas. Además, toda decisión tomada sobre manejo, deberá ser notificada al PG-2. Todo paciente admitido durante la guardia debe tener al día siguiente una nota de seguimiento del grupo Floater que lo admitió. Además los pacientes presentados en el pase de visita por la mañana, debe tener una nota documentando la discusión de los casos entre el grupo de guardia, el attending y el Jefe de Residentes durante el Round en Sala de Emergencia. Rev. Mayo

175 SECTION 7 Medical Subspecialty Experiences 177

176 MEDICAL SPECIALTIES EXPERIENCES All the PG-I and PG-II residents have at least 2 months rotations in internal medicine specialties every year. All PG-III residents have an additional month rotations during their last year of training, either as direct assignments or through electives. Each subspecialty Program Director is responsible for the rotation and the Internal Medicine Program Director will meet with him/her in the event of any difficulty of concern. Subspecialties programs where PG-I and PG-II residents have one month rotations are: Cardiology, Pulmonary Medicine, Nephrology, Endocrinology, Medical Oncology and Hematologic Malignancies (Leukemia Unit), Neurology, and Rheumatology. The following patients are admitted directly to these six subspecialties groups: - Patients with serious complications or primary diagnoses related to the respective subspecialties. - Patients previously admitted with the same or related diagnosis to these subspecialties. - Referrals from other hospitals and accepted for admission to these subspecialties. - Patients referred from the respective subspecialty clinics. - Patients referred by the respective subspecialties. PG-I and PG-II are in charge of the admission and management of patients admitted to these services under the supervision of the PG-III rotating in this specialty and the faculty team with its fellows. During these monthly rotations they are in charge of anywhere between four (4) to fifteen (15) patients depending on the number of admissions and the number of other residents and fellows assigned to that particular 178

177 service. The purpose of these specialties rotations is to familiarize the PG-I and PG-II residents with the basic knowledge of this specialty so that they may themselves apply it to the management of patients they will see in the general medicine services. Also, they will become aware of the need and best timing to consult with these specialty services. While in these specialty rotations, the PG-I and PG-II resident go to specialty ambulatory clinics. Here they see patient with problems of increasing complexity from their first to their third year of training. PG-III residents rotating in the subspecialty experiences share with fellows the consulting responsibilities to other services. They also perform special diagnostic procedures in patients under close supervising of the fellows and the corresponding specialty faculty. The description of each specific medical specialty rotations for each level of training follows: 1. Cardiology PG-II and PG-III residents rotate through the Cardiology Section as follows: Puerto Rico Cardiovascular Center Residents in Internal Medicine Program are responsible for the initial evaluation of the patients at the Emergency Room located at the Puerto Rico Medical Center. If the patient needs hospitalization, the resident who sees the patient calls the first year cardiology fellow to evaluate the patient with him/her for admission. The PG-II assigned to the CCU is responsible to write the initial evaluation of the patient. This includes history, a physical examination, and assessment of the laboratories, EKG s, and results of procedures. He/she is responsible, with the fellow assigned to the CCU, to write the admission orders, give daily follow up and participate in the final disposition of the patient, including discharge instructions and future follow up arrangements. These same processes apply for the admission of patients to the Cardiology Ward. The Cardiology Fellows assigned to these services also write a brief 179

178 admission note and review the admission orders with the residents. If an invasive or non-invasive cardiovascular procedure is needed, the fellow proceeds with it with the assistance of the residents. The Cardiology Fellows and faculty supervise the work performed by the internal medicine residents during their rotations in Cardiology (CCU and General Cardiology Service). The residents and the fellows are responsible for the follow up of the patients previously evaluated in consultation and of those admitted to their services. Clinic Services PG-III residents rotate through the different Cardiology clinics. They are assigned about 4-6 cases per resident in each clinic. The distribution of patients to residents is done taking into consideration the complexity of the cases and trying to maintain continuity of care by the same physician in each visit. If -re-evaluation and or special cardiovascular ambulatory procedures are needed, the residents and the fellow see the patient at the cardiovascular laboratory facilities where the special procedure is performed. The attending physician assigned to the clinics is available to answer questions or to clarify doubts of the residents, as well as to examine the patients, to corroborate physical findings and discuss the patients management plan with the residents. Residents clinic records are reviewed periodically using a standard form. During their rotations, the residents participate in lectures related to the principles of cardiac diagnosis and evaluation, and on core subjects. They also participate in the cardiac pathology conference, journal clubs and seminars that are conducted every Thursday. At the beginning of their rotation, a list or a copy of recent update core publications in Cardiology are given to them. They are expected to read them during their rotations. 180

179 2. Nephrology PG-II residents in Internal Medicine rotating through the Nephrology Service will: - Admit all patients to the Renal Service and write admission orders under the supervision of senior residents and Nephrology Fellows. - Act as the primary physician of all patients admitted to the Renal Service under the direct supervision of the rotating PG-III resident, Nephrology Fellow, and attending physician. - Do a complete initial evaluation including a complete history and physical examination, as well as a complete urine analysis when indicated. - Make individual daily rounds and write progress notes on their assigned patients. On the day when no official rounds are schedule, they will report any change in the status of any of their patients to the renal fellow or attending staff in the service. - PG-II will have one day off by arrangement with on-call fellow. - Make rounds with attending staff and discuss all patients during these rounds with staff, informing them of current follow-up and writing notes in the chart. During such rounds, documenting staff recommendations for a given patient rounds and outpatient clinic take the highest priority among the activities scheduled for the residents rotating through the Nephrology Program. Absence from rounds is not permitted, except for the residents continuity clinics. - Participate in the General Internal Medicine on duty rounds to discuss and inform of renal patients who need close follow-up and attention during the night duty. 181

180 - Assist the medical students in their elective rotations in Nephrology. - Attend renal clinics. - Check patients who are scheduled for kidney biopsies to make sure they can undergo the procedure; assist staff in performing such biopsies and give follow-up of these patients post-biopsy. - Present a seminar on a Nephrology topic chosen by on attending physician at least once during the rotation. - Attend the academic activity every Thursday afternoons. - Participate and attend the weekly staff meeting as part of general internal medicine program. PG-III residents in internal medicine rotating through the Nephrology Service will: - Be responsible for the initial admission orders and resident admission note (RAN) in each patient admitted to the renal service. - Answer all consultations and suggest initial patient work up for presentation to Nephrology staff during formal rounds. A consultation form should be accompanied by a full PG-III resident evaluation, which should include a complete urine analysis done by the resident. - Make individual rounds and write progress notes on their assigned patients. On the day when no official rounds are scheduled, they will report any change in status from any of these patients to the renal fellow or attending staff in the service. PG-III is expected to visit patient once in a weekend during their rotation. - Make rounds with attending staff. - Assist in all hemodialysis and peritoneal dialysis procedures on acute patients. 182

181 - Check patients who are scheduled for kidney biopsies to make sure they may undergo the procedure; assist staff in performing such biopsies and give follow up of these patients post-biopsy - Attend renal clinics. - Check with one of the Nephrology Fellows or attending staff regarding potential of expected calls, as well as of the procedures that may take place during day. During this time, residents will also check to see if they are needed at the dialysis area. - Assist medical students rotating in their electives in Nephrology. - The PG-III resident is responsible to present a seminar base in any topic related to Nephrology field at least once during their rotation. The faculty member in charge of the academic activity will assign this topic. - Attend the programmed academic activities of the Nephrology Section. 3. Gastroenterology Duties of the PG-III residents assigned to the Gastroenterology Service will be: - PG-III residents will be the primary physicians of the patients admitted to the Gastroenterology Service beds. He will be responsible for writing the admission notes and orders, and will be directly supervised by the junior fellow. All patients will be seen by both trainees, and all admissions will be presented and discussed daily with the junior fellow. He will be responsible for attending the internal medicine weekly Staff Meeting and informing on the GI service. - He will also be responsible for the change of duty rounds in the afternoon to inform the duty officers of any patient that requires special attention during the call. He/she will attend the general clinic on Friday and 183

182 academic activities on Monday. The senior medical resident will report to the GI unit at 7:30 am, unless he is assigned to other teaching activities in the Internal Medicine Program; in which case he will report immediately upon completion of them. All admissions must be discussed with him/her on a daily basis, and a brief comprehensive note must be written on the chart. - He/she will be responsible for answering consultations from IM and other services, as assigned by the GI fellow. - Under the instructions of the junior fellow, the resident should proceed to do a history and physical exam on the patient and present the case to the junior fellow before writing a note on the patient s chart. All pertinent information will be recorded in a consultation form with a copy. - All procedures to be done on hospitalized or OPD patients should be cleared first with the junior fellow, who will schedule the patient for the procedures. The resident is encouraged to schedule and perform flexible sigmoidoscopies under supervision. He/she can obtain enough experience to be able to perform them on his own (30). - Under NO CIRCUMSTANCES will the resident perform a procedure on a patient without first presenting the case to the junior fellow and obtain his consent for scheduling and arranging proper supervision. - Ward working rounds with the junior fellow should be programmed in advance at the convenience of both. - A written progress note should appear in the patient s record at least daily if the patient is admitted to the GI service or is acutely ill or 3 times a week to assess the patient s course in the hospital. 184

183 - Presentation of a case at any conference or round is the responsibility of the resident who worked up the case if still rotating through the service. - After a patient is discharge, the resident will hand to the secretary the copy of patient s consult with all the patient information, specifically, the final diagnosis should be very clear. - The resident is expected to participate actively in the Journal Club and case presentations. He will also present a core topic in gastroenterology during his rotation (Senior Seminars).At the end of a rotation, a resident should have had an equal distribution of male and female patients. He can learn how to perform sigmoidoscopies and should be familiar with other gastrointestinal special procedures. - The resident will be evaluated at the end of the rotation and receive appropriate feedback. The resident will evaluate the attending and the rotation at the end of it. - The resident will be excused of the GI service while attending his/her weekly continuity clinic. Additional Guidelines Admissions made by on call residents to the GI service after regular hours that are seriously ill, or in which there is any doubt on the management, should be consulted to the GI fellow on call. The fellow will use his judgment regarding the need to evaluate the patient immediately or the need for consulting the second call or attending on duty. All doubtful cases should be consulted. As flexible sigmoidoscopy is a primary care procedure, the rotating resident is encouraged to perform flexible sigmoidoscopies, during their rotations through Gastroenterology. These must be documented in his Log Book and signed by the 185

184 supervisor. Patients in whom this procedure is indicated, include those complaining of change in bowel habits, abdominal pain suggestive of colonic origin, chronic diarrhea, those in whom a barium enema is indicated (to evaluate the rectum before the X Rays), and patients over 50 years of age as a screening procedure for colon cancer. All procedures must be discussed with a supervisor prior to scheduling. 4. Pulmonary Medicine The general principles for all levels residents in the Pulmonary Medicine rotation will be: - Exposure to the most common pulmonary disorders, diagnostic and therapeutic modalities. - Interaction in theme discussions about pulmonary physiology and pathology. - Basic knowledge in the interpretation of chest radiology. - Basic skills in assisted ventilatory support and different modalities of ventilation. - Pulmonary function test interpretation. - Knowledge about indication of fiberoptic bronchoscopy (FOB), thoracentesis and pleural biopsy. - Be in contact with interstitial lung disease (ILD), obstructive airway disease (OAD), pleural, and mediastinal diseases. - Attendance to pulmonary clinics. Students and PG-I Role - Active participation in diagnostic modalities and therapeutic approaches in pulmonary problems. 186

185 - Exposure to invasive procedures such as fine needle aspiration thoracentesis, pleural biopsy, percutaneos transthoracic fine needle aspirations (FNA) and FOB. - Responsible for reading assignments and the discussion of articles about most common pulmonary disorders. - Attendance at pneumology staff meetings and participation in case discussions and articles review and other educational activities. - Attendance to pulmonary clinics. PG-II Role - Responsible for the direct care of pulmonary patients, under the direct supervision of the pneumology fellow and/or attending physician. - Active participation in pneumology staff rounds. - Discussion of themes and articles review about pulmonary physiology and diseases. - Attendance at pneumology staff meetings and participate in case discussion, article review, and other educational activities. - Participation in invasive procedures such as FOB pleural biopsy, thoracentesis and FNA. - Direct supervision by the pneumology fellow and attending physician. - Attendance at pulmonary clinics. PG-III Role - Active participation in working and staff rounds in the ICU pulmonary consultations, and pulmonary service. - Attendance and participation in FOB, pleural thoracentesis, pleural biopsy and FNA. 187

186 - Acquire skills in mechanical ventilation. - Basic skill in post-surgical cardiothoracic patient care and weaning modalities. - Attendance at the pneumology clinics. - Assistance and participation in pneumology staff meetings and educational activities. - Reading assignments and article reviews of most common pulmonary disorders. Purpose To ascertain a basic knowledge and skills in chest radiology indication and interpretation, diagnostic approach and therapeutic modalities of ILD, OAD, pleural pathology, acute and chronic pulmonary infectious process, and respiratory malignancy. 5. Emergency and Critical Care Medicine Residents in the three levels of training are assigned to emergency services and intensive care units for various periods of time. Here, residents become proficient in the various steps that need to be taken before reaching a specific diagnosis and to establish a specific therapy or follow up a proper course of action. Residents learn to: a. Acquire data from patients, relatives, nurses or fellow physicians. b. Interpret information gathered in a logical and integrated manner. c. Identify reliable findings. d. Approach the differential diagnosis of each problem. e. Establish the probabilities of each diagnostic possibility putting in practice the dictum: common things occur commonly. 188

187 f. Determine whether sufficient evidence exists to establish any of probable diagnoses, which are being considered and determine what further data are necessary or potentially available. g. Arrive to a therapeutic decision or reassess the whole situation again. Because of their urgent nature, these experiences place in perspective and integrate many skills which the resident has been developing throughout his/her training: a. interviewing skills and skills in physical examination b. procedural skills c. clinical observation abilities d. judicious use and intelligent evaluation of laboratory and other diagnostic data e. assessment of the reliability of data and information f. grouping of recognizable complexes of signs and symptoms into a meaningful pattern, pointing perhaps to a specific organ involvement g. reasoning of the pathophysiologic process from the general to the specific h. assessing response to treatment i. development of clinical acumen The following activities are structured to enhance the previously mentioned skills: 1. Emergency medicine rotation, one month each in PG1 and PG2 level at the Puerto Rico Medical Center. Additional emergency services screening experiences are scheduled while in the UPR-Hospital at Carolina rotations. There, and for 1/2 day a week they go to the hospital s emergency department 189

188 where they have first contact responsibility of adult patients coming directly to the emergency room or from neighboring primary care physicians office. Residents see adult patients with a variety of symptoms, from medical gynecologic and surgical standpoint. They do the initial evaluation and make determinations as to admission of patients or ambulatory follow up. They have the opportunity to polish their diagnostic acumen and procedural skills. 2. Critical Care Unit rotations at the Intensive Care Unit of the University Hospital. This is a one-month rotation under the supervision of the Pulmonary Diseases Section. 3. Intensive Cardiac Care Unit. A one month at the Puerto Rico Cardiovascular Center under the supervision of the Cardiology Division. 4. PG-3 year on call duty at the hospital as senior medical officer every tenth night throughout the year. This places the senior resident in the position of senior consultant intervening with all critical situations that may develop in the Department of Medicine. The senior resident on night duty is assigned to the departments medical Intensive Care Unit. In all these settings residents deal with patients who are critically ill with life threatening situations of systems or organ failures. Taking care of these patients require a multidisciplinary approach and a high level of expertise in the acquisition and interpretation of laboratory data and advanced skills in the use of sophisticated monitoring systems and techniques of intervention to stabilize and treat such cases as respiratory and cardiovascular failure, shock, sepsis, bleeding and major metabolic derangements. With these activities residents: 1. Acquire skills in performing invasive diagnostic and therapeutic procedures. 190

189 2. Assess information gathered by invasive monitoring processes. 3. Improve cognitive skills in performing triage. 4. Become familiar with and apply knowledge and skills in medical ethics problems and situations. 5. Become familiar with applicable living will statutes, as well as the ethical issues surrounding termination of life support, do-not-resuscitate orders, and informed consent. 6. Acquire knowledge of current criteria for the clinical diagnosis of brain death. 7. Perform basic and advanced life support measures. 8. Know the incidence of both acute and chronic underlying organ dysfunction and incidence and causes of multi organ failure and their effect on outcome. 9. Become aware of needs and methods of consults and transportation procedures for critical ill patients. 10. Understand alteration in pharmacokinetics and pharmaco-dynamics that may modify therapeutic regimens in dealing with patients with specific organ dysfunction or multiorgan failure. Guidelines For During ICU Rotation The Intensive Care Unit (ICU) at University Hospital is a multidisciplinary critical care unit operated by the Pulmonary Critical Care Service primarily for the care of critically patients on the medicine service. However, obstetric, neurosurgical, orthopedic and other postoperative patients from some of the surgical subspecialties may also be cared for in the ICU. The Critical Care Service and the ICU provide 191

190 training in critical care medicine for housestaff in internal medicine, anesthesia and family medicine, and for fellows in Pulmonary/Critical Care. The Critical Care Service consists of teams responsible for the care of patients in the medical ICU. Each team typically consists of one PG-1 resident or acting intern and one PG2 or PG3 resident. A Pulmonary/Critical Care faculty attending heads the team. The Critical Care Service provides direct care for all patients admitted to the service, whether admitted form the Emergency Room or the ward. The ICU may board patients as overflow from other units. These are cared for by the primary team initially responsible for the patients transferred to the Unit. The ICU team approves all admissions to the ICU. Rounds Rounds are scheduled daily with an attending physician, housestaff and nurse team members. This constitutes the major work and teaching rounds for the unit. All patients have been seen prior to the start of rounds with lab recorded on the lab flowsheets. Orders for changes in therapy decided during rounds are written on rounds, so as the reduce the time required to implement changes. Afternoon rounds start at 4:00 pm and are intended to review the plan for patient management for the evening, including bed prioritization. The senior resident in medicine conducts these rounds. Team takes all call every day in rotation. The team on call the previous night is dismissed after morning rounds have been completed. The fellow assigned to the unit takes night call from home by beeper. The Critical Care attending takes call as assigned by Pulmonary Section call schedule. Students take call with a housestaff team. 192

191 The Nurse Director of his/her designates acts as critical care coordinator. The Nurse coordinators for Critical Care are responsible for arrangement of interhospital transfer, assistance in special procedures, housestaff instruction in policies and procedures, monitoring of clinical research protocols, and coordination of the Extracorporeal Life Support (ECLS) services. House and attending staff should familiarize themselves and follow ICU policies guidelines required attendance for all personnel in ICU: 1. Daily rounds 2. Ethic discussion every third Thursday 3. Critical Care pharmacology discussion on every second Thursday. Housestaff Responsibilities Residents are the primary care physicians of ICU patients under the supervision of the attending physician. The fellow (or faculty) is notified in the following circumstances: 1. Admission of any patient 2. Death of any patient 3. Before any invasive procedures are performed 4. Any significant complication of a procedure 5. Major changes in patients conditions requiring changes in therapy 6. Any situation with legal complications The Pulmonary fellow is involved in all patients with major respiratory dysfunction. The ICU resident or intern is available to nurses in the ICU at all times to manage, patients immediately when unstable. If any patient is unstable, the resident and intern rotate their absences for meals, etc., so that they may be allowed to watch. 193

192 Admission orders are written by residents on admission to the ICU. All previous orders are cancelled at admission, so the orders must be new and complete. Patients with any hemodynamic derangements should have a least IV lines, with a large bore IV catheter. All patients must be on continuous electrocardiographic monitoring. Physicians must write patient care orders during or immediately after rounds so that the nursing staff may implement them early. This will be done preferably in the morning. Verbal orders are accepted only in emergencies, and must be signed within 24 hours. Verbal orders are not permitted for narcotics. Orders written by medical students required a physician countersignature before they can be carried out. All orders must be completely renewed (rewritten every 7 days). All narcotic orders must be rewritten every 3 days. All orders must be timed as well as dated. Orders must be legible and signatures must be identifiable. Record Notes: An Admission History and Physical is written on each patient admitted from the ER, which includes events up to the ICU admission. All unstable or potentially unstable patients must also have a separate critical care note which documents interventions during initial encounter with the patient in the ICU and progressive care of the patient so that all procedure and actions taken to stabilize the patient are clearly outlined. These notes should be dated and timed with the inclusive time interval spent stabilizing the patient. A daily critical care note which documents interventions during initial encounter with the patient in the ICU and progressive care of the patient so that all procedures and actions taken to stabilize the patient are clearly outlined. These notes should be dated and timed with the inclusive time interval spent stabilizing the patient. 194

193 A daily critical care note is to be written on each patient. The note should be concise and deal with pertinent issues only. It is important that brief entries be entered (with the time) throughout the day to document procedures, major changes in condition or therapeutic goals, and results of special diagnostic tests, etc. Any order written alters therapy, excepting minor orders, should have an associated entry in the progress notes documenting the reason for the change in therapy. All progress notes be timed as well as dated. Medical Student Responsibilities at ICU Medical students may be assigned to each ICU team. Medical students function as acting interns, and carry the same responsibility, except that orders need a countersignature before they can be carried out. Students histories, physicals, and progress note must be consigned by housestaff. Admission and Discharge Policy The ICU is intended for critically ill patients who require either specialized or intensive level of care, or the use of specialized medical equipment not available elsewhere in the hospital. The decision regarding admission to the ICU from the ER is made by the ER staff physician in consultation with the Critical Care Medicine (CCM) fellow of staff and not the ICU housestaff. The decision for admission from the ward to the ICU may be made by the senior ward resident or attending in consultation with the CCM fellow or staff. If an admission appears to be inappropriate, then the ICU attending physician must be notified. All transfers from other institutions must be coordinated by the clinical coordinator (or attending physician after hours). 195

194 When a bed is readily available, all admissions to the ICU must be made promptly, even if admission papers have not been processed. Do not work-up patients in the Emergency Room, as this will only delay transfer to the ICU and cause you to be out of the ICU. Patients in the ER who may need admission to the ICU, but who have not a bed available there, are managed by the ER and medical service staff fellow, not the ICU Team. Consultations on ICU Patients Consultations to the medicine subspecialty service for specific problems are encouraged, since the care of the critically ill often involves the resources of multiple disciplines, such consults should be judiciously obtained to receive the most benefit. Most ICU problems and procedures are handled by the team. Except in the emergency, the ICU resident should discuss the issue of a consultation with the pulmonary fellow or staff before the consultation is obtained. 6. Hematology-Medical Oncology Duties of the PG-I residents During the rotation at the Hematology-Medical Oncology Section, PG-Is are assigned to the Leukemia/BMT Unit where they become the bedside physicians of the patients admitted to this twelve (12) bed unit. PG-Is responsible of the primary care of all the patients admitted to the Unit. They perform the usual basic procedures of internal medicine, including bedside interviews, physical examinations, routine diagnostic studies and bedside rounds. In addition, they supervise the administration of all the chemotherapy infusions administered in the unit. They also assist the PG-IIIs in 196

195 the performance of other procedures, such as bone marrow aspirations and biopsies, lumbar punctures and catheterization of central lines. During this rotation, they are under the direct supervision of an attending physician, the PG-III resident and the assigned fellow (PG-IV, V or VI). PG-I are required to attend most of the educational activities offered as part of the academic program of the Hematology-Medical Oncology Program. These include: in-patient rounds, radiotherapy treatment planning conferences and combined Hematology/Oncology-Pathology conferences and case discussions. They also attend both the Hematology and Medical Oncology clinics held weekly on Tuesday and Thursday afternoons, respectively. The PG-III duties will be: The third year residents supervise the PG-Is assigned to the Leukemia/BMT Unit. They answer the consultations assigned to them with the supervision of a fellow and the attending physician assigned to them. They are responsible of performing bone marrow aspirations and biopsies in all their patients, supervised by the fellow in charge of the team. PG-III also learns the basic concepts of bone marrow interpretation under the supervision and guidance of the assigned fellow and the staff morphologist in charge of this endeavor at the Hematology-Medical Oncology Section. PG-III is required to attend all the educational activities offered as part of the academic program of the Hematology-Medical Oncology Program. These include: inpatient rounds, seminars, Journal Clubs, radiotherapy treatment planning conferences, blood morphology sessions, combined Hematology/Pathology conferences and case discussions. They also attend both the Hematology and Medical Oncology clinics held weekly on Tuesday and Thursday afternoons, respectively. 197

196 7. Neurology The Neurology Section of the Department of Medicine has organized and developed the in-hospital Neurology service assuming direct patient care responsibilities in the hospital. The Neurology Department of the University Hospital will function in a way similar to other sections of the Department of Medicine in the hospital, which also has a number of patients admitted to the hospital under their direct care. The admissions of neurology patients are carried out the same way as those of the other patients admitted to other medical specialties. The following agreements apply: - Admissions to the Neurology Services in the hospital will originate: a) As an elective admission through the hospital s admission office. b) As a transfer from another medical unit or another department in the hospital. c) As an admission from the Emergency Room. These admissions will occur either during regular working hours or during on duty hours. d) As an admission from our neurology clinics or from the neurology faculty. (Both a and b will naturally required the prior consent of the senior neurology residents or the neurology faculty member who will accept the admission to transfer to his/her service). During regular working hours, the Internal Medicine s (IM) residents evaluate the patient in the Emergency Room. They order the basic necessary tests, establish an initial (working or tentative) diagnosis, stabilize the patient, start proper initial general care and consult or notify admission. According to the diagnosis guidelines, the Internal Medicine s resident call the neurology resident assigned to the Emergency Room when the admission of the patient to neurology is deemed necessary. The neurology resident 198

197 then continues with the care of this patient and proceeds with the admission to the neurology service. In these situations, it is the responsibility of the neurology resident to write the admission note, which will be a RAN. Should discrepancy develop with regards to the decision if the patient is to be admitted to the Internal Medicine or to the neurology service, the attending physician assigned to the hospital s neurology service will make a final decision. During on-call (on duty) hours, at night or during weekends and holidays, the Internal Medicine s residents assigned to the Emergency Room evaluate and handle the patient as previously described. If the IM resident determines that the patient should be admitted to neurology, he/she will proceed with the admission. In these situations, it is the responsibility of the IM residents rotating in the Emergency Services to write both an IAN (the PG-I) and the RAN (the PG-II). A short admission is not acceptable, except known MS patients admitted for treatment. The IM residents will call the neurology resident on call in cases of doubt about the diagnosis or when they need the neurology resident s advice or direct assistance with the initial management of the patient. Any discrepancies regarding the admission of patient to neurology will be solved between the senior resident on duty of the medicine and neurology services. Once admitted, the patient will continue under the direct care of the IM on-duty teams until the end of their on-call duties and the regular working arrangements are resumed. The neurology resident will write an admission note on the patient as soon as he/she becomes the principal physician following the patient in the hospital. 199

198 - Admitted neurology patients that remaining the Emergency Room because no beds are available in hospital, will be followed by the neurology service during the regular working hours. IM residents on duty during the night will follow these patients still remaining in the Emergency Room. They will call the neurology resident on call, as need may arise. - Neurology patients already admitted in-hospital or in Emergency Room will be seen by the neurology service staff on daily bases. Progress notes will be written by the neurology staff on daily bases. - The neurology staff will also write a complete admission note on each patient admitted to this service. - Emergencies that may arise off regular working hours will be handled by the IM residents in call in the hospital. They will assess the clinical situation, will take immediate necessary actions and will call the neurology resident to notify the changes in patient s condition and request or receive the necessary back up from the neurology resident on call. - On-call rosters of residents and faculty is to be provided in advance and on monthly bases to the Chief Resident of Medicine, the Emergency Room, ICU, the Department of Medicine s office and to the Resident s Secretary office in the hospital. - The Neurology Department will not have a specific number of beds in the hospital. The number of patients under its responsibility will vary depending on the number of admissions and the patterns of referrals to their service. 200

199 - Other clinical and consulting neurology services will continue without change after the start of this in-hospital service. - The Department of Medicine will provide all the necessary support of consultant services to this new neurology service in the hospital. - The neurology in-hospital staff and faculty team will cover Emergency Room consultation service during regular hours in order to insure prompt service to patients with neurology problems consultation or for admission. - The Department of Neurology will not have need for additional office or room space in the IM services (or wards) in the hospital. The usual administrative matters and quality assurance and control patient s services in neurology will continue to be the responsibility of the neurology service. - A member of hospital s Neurology Department will be designated to report to the Department of Medicine s faculty meetings all necessary information with regards to the in-hospital neurology service. - The evaluation of neurology residents will continue unaltered. The Neurology Department will continue to bill for their services to hospitalized patient and will contribute 10% of the income derived from this group of patients to the Department of Medicine s general practice plan fund. In general terms, patients with primary neurologic diagnoses will be admitted to the neurology service in the University Hospital. Specifically, these include patients with the following primary diagnoses, situations or with clinical presentation related to the following diagnoses: - All patients referred from neurologic clinic services for admission for further neurologic diagnostic work up or treatment. 201

200 - Patients accepted by neurology faculty form outside clinics or referring physicians for admission to the hospital. - Patients with primary neurology diagnoses in need of in-hospital neurologic diagnostic studies. - Non-traumatic sub-arachnoid s hemorrhages, stages I and II. - Cerebrovasculars diseases in patients without other severe metabolic derangements (DKAs, hyperosmolar states, renal failure, hepatic failure, hyponotremia, hypernatremia, etc.), hypertensive crisis with CNS as target organ, suspected cerebral embolization from cardiac source, collagen vasculities, etc. - Transient cerebral ischemic attacks. - Movement disorders for diagnostic studies and/or treatment optimization. - Neuromuscular disorders (not related to known primaries medical illnesses; i.e. paraneoplastic syndromes, HIV, etc.) Including: neuropathies, nyasthenia gravis (also in myasthenic or cholinergic crisis), Guillain-Barre. - Myelitis (non traumatic), acute paralysis (non traumatic). - MS, ALS and similar or other myelin diseases. - Pseudo tumor cerebri. - Nom metabolic, toxic, or traumatic (acute) seizures the novo or known history of seizures, in recurrence. - Brain tumors, pre surgical evaluation and treatment. - Neuroleptic malignant syndrome. 202

201 - Patients with altered state of consciousness in which traumatic, toxic metabolic hypoxic etiologies have been ruled out. Stuporuous and comatose patients will be admitted to the Internal Medicine Services. - Primary CNS degenerative disorders, including dementia. These guidelines substitute all previous ones dealing with admissions of patients with neurologic diagnoses or arrangements for neurology consulting services in the hospital or Emergency Room. 8. Rheumatology PG-III residents will have a one-month compulsory rotation in the rheumatology service. This rotation is described in detail in the Internal Medicine Resident s Curriculum. The resident will work in the in-patient rheumatology ward, the in-patient consultation service and the ambulatory service of the Rheumatology Program. The residents will attend the General Arthritis Clinic, the Lupus Clinic and the Pediatric Rheumatology Clinic. All these activities will be supervised by the Rheumatology Fellows and at least one attending physician. The resident will also participate in the didactic activities of the program. At the end of the month, a written examination will be administered to the resident. In order to successfully complete the rotation, the resident will have to pass this examination. The residents will be trained in diagnosing and treating rheumatic conditions, performing intra-articular injections and interpreting laboratory tests, including special tests, such as: serologic tests, synovial fluid analyses and bone densitometries. The Rheumatology Program also offers a one-month elective to second-year Internal Medicine residents. In addition, Internal Medicine residents will have the opportunity to attend the out-patient rheumatology clinics while at their ambulatory clinic rotation. 203

202 9. Endocrinology PG-I Level During one month, PG-I residents level of training rotate through the Endocrine/Diabetes/Metabolic Clinics, where they have the opportunity to get familiarized with the most common disease entities. This is accomplished by means of prior patient record screening by an attending physician who assigns patients on the basis of their relative complexity to the residents. New cases are preferentially assigned to them, in order to give them unbiased exposure of this rich patient population. Their histories, physical findings, differential diagnoses, diagnostic tests and plans of therapy are briefly reviewed. Their strengths and weaknesses are pointed out, and they are urged to study the written OPD Guidelines for Patient Follow-up, which stresses an approach to the patient as a person rather than an entity. These guidelines are distributed to all residents together with other pertinent information before their start of rotation in the endocrinology service. The various aspects of history-taking and physical findings are enforced, in an attempt to have them come back to bed-side diagnoses whenever possible. The in-patient experience is provided through the consultations that they ask from the Endocrinology Division and their joint follow-up with fellows. During weekly rounds, PG-I and PG-II residents have the opportunity to join the staff to become knowledgeable about the condition (s) at hand by means of the feed-back obtained. Again, the various endocrine and metabolic disturbances are mostly addressed, for which written guidelines and tables are also available. Patients with endocrinology clinical problems are admitted to the general medicine services under the care of PG-I and PG-II residents. 204

203 PG-II Level During the one month rotation, PG-II resident are called upon to participate in 3 weekly clinics. A booklet on patho-physiology is provided, and their fund of knowledge is probed both pre and post-rotation tests. They are given feedback as to their weaker areas in order for them to strengthen them. It is emphasized that, as they are supposed to take the ABIM during the next fall season, they are to make every effort to cover all of Endo/Diab/Metab as they spend this month at our division. During their one month rotation, they are assigned about one third of the consultations arising from the medical wards or from other departments. Their consultations are revised during case presentations and ward rounds and an interactive method is employed in arriving at the pertinent answers to actual or theoretical problems a propose of the patient being consulted. 10. Infectious Disease Rotation The Internal Medicine Resident (PGY-II or III) as an elective have a 4-week rotation in Infectious Diseases. The Resident is part of the ID Consult Team consisting of an ID Fellow and Faculty. The ID Consult Service sees patients from all hospital areas, including Medicine, Surgery, Ob-Gyn, Cardiovascular Center, Trauma Unit, Hema-Onco unit as well as transplant cases if consulted. During the Infectious Disease rotation is expected that each resident will acquire the knowledge of Infectious Diseases, as related to a systematic approach to the patient who may have an infectious problem by taking a thorough problem directed history, performing a careful physical examination, and generating a differential diagnosis related to infectious problem. The resident will acquire the clinical, management and interpersonal skills related to recognizing broad clinical syndromes and initiating proper 205

204 empirical therapy based on working knowledge of likely pathogens. The resident will develop the professional attitudes and behavior necessary to treat patients with Infectious Diseases including HIV infection and the experience required to become a proficient general internist, with knowledge of HIV. Internal Medicine residents rotating in Infectious Diseases will have the following responsibilities: - Attend Morning Reports, IM Core Lecture Series, Grand Rounds and M&M - Evaluation of Infectious Disease Consult under the supervision of ID Fellow and faculty - Oral presentation of an ID Topic of at least 30 minutes duration - Attend ID Conferences on Mondays - Attend Teaching Rounds on Tuesdays at UDH, Thursdays at VA, and - Children s Hospital last Friday of the month - Attend ID Journal Club and ID Case presentations (Thursday/Friday) - Attend ID Ambulatory Clinics once a week - Daily rounds with ID Fellow and Faculty In this rotation the Internal Medicine residents are expected to attain competencies in the following areas: Patient Care Medical Knowledge Practice Base Learning and Improvement Interpersonal and Communication Skills Professionalism System Base Practice 206

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206 SECTION 8 Patient Management 1. Conflict Decisions 2. Patient Without Adequate Decision-making Capacity Improvement in End of Life Care 4. Brain Death 5. Assessment & Management of Patient in Vegetative State 208

207 RESOLVING CONFLICTS IN PATIENT MANAGEMENT In case of conflicts regarding decisions about patients management including their treatment or disposition, remember to follow the chain of command. If you do not agree with another team member with regards to the management, bring concerns to your attending physician. The faculty member assigned to your group is the physician ultimately responsible for the patients under the care of your team. During duty hours you will always have a senior resident at the ICU or a faculty member in the Emergency Room, or you can always call your attending physicians or the Chief Residents; or reach the attending physician on call. You should always be guided by your patients needs and welfare. Rev..May

208 UNIVERSITY HOSPITAL MEDICAL ETHICS POLICY DECISION FOR WITHHOLDING AND WITHDRAWING LIFE-SUSTAINING THERAPY PATIENT WITHOUT ADEQUATE DECISION-MAKING CAPACITY When a patient lacks decision-making capacity, a surrogate decision maker should be identified to help make decisions on the patient s behalf regarding life-sustaining therapy. 1. An adult patient, who no longer has decision-making capacity, should continue to have the right to refuse all forms of medical therapy. 2. However, this right must be exercise on the patient s behalf by an appropriate surrogate decision maker. 3. Under these circumstances, the surrogate decision maker and the patient s physician should jointly deliberate decision regarding withholding or withdrawing life-sustaining therapy with the physician providing help and advice to the surrogate in making the decision. 4. The surrogate decision maker may be a court-appointed representative, an individual previously designated by a capable patient in a oral or written advance directive or a specific family member as stipulated by state law. 5. If no such person exists, the physician should help to identify one or more close family members or close friends of the patient to be the surrogate decision maker, primarily on the basis of their knowledge of the patient s preferences, values, and goals and their commitment to supporting the patient s rights and best interest. 6. Whenever possible, out of respect for the patient s autonomy, the surrogate decision maker should make the same decision as the patient would have made if capable of doing so, based on the patient s prior written or oral statements concerning use of life-sustaining therapy. 7. If the patient made no known prior oral or written statements or if these statements are not applicable to a peculiar decision, then the surrogate should use his or her best judgment of what the patient would have preferred under the circumstances, based on an understanding of the patient s values and goals in life. 210

209 8. If circumstances arise in which the surrogate decision maker cannot make a decision based on knowledge either of the patient s prior statements of the patient s values and goals, he or she should collaborate with the patient s physician to make decision for the patient based on what is determined to be in the patient s best interests. 9. This process should be made as reasonable and objective as possible by weighting the benefits for the patient s of starting or continuing a certain lifesustaining therapy against its burden on the patient. 10. If the benefits of the therapy exceed the burdens, the therapy should be administered, if the burdens exceed the benefits, the therapy should be forgone. 11. This same basis of decision making on the patient s behalf that weighting versus burdens should also be used when advance treatment directive by the patient is available and when no surrogate decision maker who has known the patient can be found. 12. In this latter circumstance, when no one who has known the patient can be located the patient s health care institution should have a mechanism for identifying an appropriate person or persons to serve as surrogate decision maker for the patient. Excerpt from: Withholding and Withdrawing Life-Sustaining Therapy Position Paper, American Thoracic Society Ann. Intern Med. Vol. 115, No: 6, 1991 Rev..May

210 DECLARACION DE VOLUNTAD EN CASO DE NO PODER EXPRESAR MI CONSENTIMIENTO O RECHAZO DE TRATAMIENTO MEDICO Hago esta declaración encontrándome en buen estado de salud física y con capacidad para ejercitar mi mejor juicio. Si llegara el momento en que sufriera una enfermedad incurable e irreversible, que en opinión de mi médico de cabecera va a causar mi muerte en un tiempo relativamente corto si no se aplica tratamiento para el sostén de la vida (no curativo) y yo no estuviere en condiciones de poder ejercitar mi autonomía y expresar mi decisión sobre mi tratamiento, por este medio le manifiesto a mi médico de cabecera que mi voluntad es que no utilice o que retire, si ya lo ha comenzado, cualquier tratamiento que sólo sirva para prolongar el proceso de morir y no sea necesario para mi bienestar o para aliviar dolor. La misma disposición aplica, si mi condición de incapacidad para ejercer mi voluntad es debida a una enfermedad o un traumatismo que en opinión de mi médico de cabecera haya producido un estado vegetativo persistente o una muerte cerebral. Con fines de hacer más claro el alcance de mis directrices, expreso que rechazo los siguientes tratamientos, de encontrarme en las situaciones mencionadas anteriormente: 1. Resucitación cardiopulmonar (compresión cardiaca externa, respiración artificial de boca a boca, shock electrónico, medicinas o cardiogénicas). 2. El uso de máquinas de entubación para respiración artificial 3. Transfusiones de sangre. 4. Nutrición e hidratación artificial, (líquidos intravenosos, tubos en el estómago por la vía oral o por cirugía). 5. Diálisis 6. Antibióticos 7. Cualquier tratamiento innovador posterior a esta declaración que tampoco logre curar la enfermedad o traumatismo y sólo sirva para mantener la vida y prolongar la muerte. Deseo expresar, que de encontrarme en las situaciones arriba especificadas, le ruego a mis médicos que se me provea medicinas para el dolor, en caso de que mi condición lo requiera y que se me provea el tratamiento y atención médica y de enfermería que respete mi dignidad humana y sirva de alivio y paz mental a mis familiares. Firmado este día de en, Puerto Rico. Firma Testigo Testigo Dirección Dirección Dirección Rev..Mayo

211 HOSPITAL UNIVERSITARIO FORMULARIO DE ORDEN DE NO REANIMACIÓN (ONR) O NO RESUCITACIÓN Yo,, solicito que se me aplique la orden de No (el/ella suscribiente) Reanimación o No Resucitación. Mi condición médica y pronóstico para recuperación ha sido explicada en detalles. El/ La Dr./Dra., me explicó todos los factores médicos, riesgos, alternativas y procedimientos envueltos en reanimar a un paciente y al aplicar la orden de No Reanimación o No Resucitación. Se me explicaron las consecuencias de la aplicación de la orden de No Reanimación o No Resucitación, entre los que se encuentra la posibilidad de morir. Todas mis dudas han sido satisfactoriamente aclaradas. Firmemente creo tener la suficiente información para tomar mi decisión. Por lo tanto, autorizo que la orden de No Reanimación o No Resucitación se documente en mi expediente médico y que a menos que yo revoque esta petición, ningún esfuerzo se realice para reanimarme. Estoy de acuerdo en que el Hospital Universitario, sus médicos, agentes y empleados sean exonerados de responsabilidad alguna en relación a la aplicación de la orden de No Reanimación o No Resucitación. Fecha: Hora: am/pm Firma del Médico Firma del Paciente 213

212 20 IMPROVEMENTS IN END OF LIFE CARE Changes Internists Could Do Next Week! Don Berwick, MD, Institute for healthcare Improvement at the ACP-ASIM Annual Meeting, April 22, 1999 Prepared by Americans for Better Care of the Dying 1. Ask yourself as you see patients, Would I be surprised if this patient died in the next week few months? For those sick enough to die, prioritize the patient s concerns often symptom relief, family support, continuity, advance planning or spirituality. 2. To eliminate anxiety and fear, chronically ill patients must understand what is likely to happen. When you see a patient who is sick enough to die tell the patient, and start counseling and planning around that possibility. 3. To understand your patients, ask: (1) What do you hope for, as you live with this condition. (2) What do you fear? (3) It is usually hard to know when death is close. If you were to die soon, what would be left undone in your life? (4) How are things going for your family? Document and arrange care to meet each patient s priorities. 4. Comprehensive and coordinated care often breaks when providers don t have all the facts and pains. The next time you transfer a patient or colleague covers for you, ask for feedback on how patient information could be more useful or more readily available next time. 5. Unsure how to ask a patient about advance directives? Try: If sometime you can t speak for yourself, who should speak for you about health care matters? Follow with: (1) Does this person know about this responsibility (2) Does he or she know what you want? (3) What would you want? and (4) Have you written this down? 6. To identify opportunities to share information with patients and care givers, ask each patient who is sick enough to die : Tell me what you know about (their diseases). Then: Tell me what you know about what other people go through with this disease. 7. Most internists practices have educational handouts on heart failure, COPD, cancer and other fatal chronic illnesses to give to patients. Read them-if your handouts do not mention prognosis, symptoms, and death, exchange them for ones that do. Perhaps make The Handbook for Mortals and other resources available to your patients. 214

213 8. Some patients and their families are getting most of their information form the Internet. Log onto a patient-centered Internet site about an eventually fatal chronic illness to learn what is of interest to patients and families. 9. Is coordinating the care of your chronically ill patients taking up too much of your time? Call a local advocacy group (American Heart Association, American Cancer Society, etc.) for help, or consult with a care management service. 10. Discussing and recording advance directives with your entire patient may take a while. How many patients over the age of 85 do you have? Start making plans with them. Expand to all who are sick enough to die. 11. Use each episode in the ICU or ER as a rehearsal. Ask the patient what should happen the next time. Be sure the patient has all necessary drugs at home and knows how to use them. Can you promise relief from dyspnea near death? Tell the patient and family what s possible, and make plans together. 12. As your next patient who is sick enough to die whether anything happened recently regarding their medical situation for which they were unprepared. Work to anticipate the expectable complications and to have plans in place. 13. Since meperidine (Demerol) is almost the only opioid which has toxic metabolites and thus is contraindicated to chronic pain, banish meperidine form your prescribing and from the formularies where you work. 14. Very sick people will often be most comfortable at home or in nursing homes. Identify programs that are good at home care, send patients to those quality services, and work with them to fill the gaps your patients encounter. 15. Feedback on performance guides improvement. Find the routine surveys, administrative data, and electronic records those records symptoms, location of death, unplanned hospital or ER use, family satisfaction after the death, and other outcomes. Set up routines to get feedback on performance and improvement every month. 16. Except in hospice, most families never hear from their internist after a death. Change that! Make a follow-up phone call or set a visit to console, answer questions, support family care givers, and affirm the value of the life just recently ended. At least, send a card! 17. Working with very sick patients who die is hard on care givers. Next week-and every week-praise a professional or family care giver who is doing a good job. 18. We can t really change the routine care without changing Medicare. Contact your Congressional representatives to ask for hearings, demonstration programs, research and innovation to improve the Medicare program. 19. Some of language really does not serve us well. Never say, There s nothing more to be done or Do you want everything done. Talk instead about the life yet to be lived and what CAN be done to make it better (or worse). 20. Patients and families need to be able to rely upon their car system. Consider what you can PROMISE on behalf of your care system-pain relief, family support, honest prognosis, enduring commitment in all settings over time, planning for complications and death and so on. Pick a promise that your patients need to hear and start working with others to make possible to make that promise! Quality improvement strategies work! 215

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