Goals and Objectives. Neurocritical Care Fellowship

Transcription

1 Neurcritical Care Fellwship Type f Fellwship: 2year Neurcritical Care Name f the Fellwship Supervisr: Jeanne Teitelbaum MD FRCP Fellwship Infrmatin: Number f fellwship psitins requested: 2 Name f hspitals invlved in training Mntreal Neurlgical Institute Descriptin f Fellwship: Intrductin Many critically ill patients suffer primary r secndary neurlgic dysfunctin. Thrugh residency training, critical care and emergency neurlgy fellwships and cntinuing medical educatin, the neurlgical cmmunity will need t master a bdy f knwledge cncerning the special care f the critically ill patients with neurlgical disrders and incrprate this infrmatin int clinical practice, educatin and research. T this end, the members f the Critical Care and Emergency Neurlgy Sectin f the American Academy f Neurlgy have develped a cre curriculum fr critical care and emergency neurlgy. This curriculum is intended t serve principally as a tl fr prgrams develping fellwships in Neur Critical Care and Emergency Neurlgy. It als can serve as a guideline fr the integratin f the critical care and emergency neurlgy knwledge base and related skills in t the educatin f medical students, residents, fellws, and ther medical and allied health care prviders desiring educatin in this area. Definitin Critical care and emergency neurlgy is a special area f neurlgy that fcuses n the neurlgical disrders that affect critically ill patients. These can be primary neurlgic disrders, r secndary t ther systemic diseases that can affect the central nervus system, the peripheral nervus system r bth. It includes understanding the effects f critical illness n the nervus system and the special vulnerabilities f the nervus system f patients in intensive care units and ther emergency settings. It requires knwledge f the disrders that frequently ccur in these settingsas well as the methds f diagnsis, assessment, treatment, management and preventin f further injury. Critical care and emergency neurlgy als invlves bridges int many medical and allied health specialties, including critical care medicine, emergency medicine, neursurgery, nursing and scial wrk. Develpment f the specialty f critical care and emergency neurlgy recgnizes the special health needs f the ppulatin f critically ill patients with neurlgic dysfunctin, the characteristics f the nervus system in critically ill patients and the need fr interdisciplinary cllabratin in this field. Gals and Objectives The primary gal f the cre curriculum in critical care and emergency neurlgy is t prvide a training prgram that will prepare neurlgists, anesthetists, neusurgens and medical intensivists t cmpetently care fr critically ill patients with neurlgic Y:\PGME\PGME-CmmnShare\6a - FELLOWSHIPS\Fellwships by Prgram\Neurlgy\Neurcritical Fellwship\Neurcritical Care Fellwship 2 years.dc

2 disrders. This training must be based n supervised clinical wrk with increasing respnsibility fr inpatients. It shuld include nt nly the specific diseases f the nervus system f different age grups but als the neurlgical cmplicatins f medical and surgical cnditins. Critical care and emergency neurlgy is particularly a prcedure-riented specialty and basic training in prcedures used in neurcritical care must be included. In the 2 year prgram, there is an additinal, equally imprtant gal, and it is here that the tw prgrams differ mst. In this prgram the resident is expected t spend 50% f his r her time in research. There will be instructin in basic and/r clinical neurscience research and the applicant is expected t cmplete at least n prject leading t presentatin and, hpefully, publicatin. The verall bjective fr specialty training in critical care and emergency neurlgy is t prvide the skills and knwledge necessary t: 1. Prvide high quality clinical care and assessments f critically ill patients with neurlgical disrders, including diagnstic evaluatin, treatment, management, cunseling and scial interventin; 2. Wrk effectively with multidisciplinary teams riented t the care f these patients; and 3. Develp the capacity t pursue an academic/research career fcusing n neurlgical dysfunctin in critically ill patients. 4. Develp the capacity t teach thers in the methds and cncepts used in the care f critically ill patients with neurlgical disrders. 5. Cntinue elabrating and cmpleting research prjects in Neurcritical Care. Tpics in Critical Care and Emergency Neurlgy The tpics listed belw prvide an utline f a cre curriculum, in Critical Care and Emergency Neurlgy, fr fellwship training. Many f the tpics included can be used fr educatinal prgrams in Critical Care and Emergency Neurlgy fr medical students, neurlgy residents, Academic neurlgists and neurlgists in practice. All educatinal cmpnents f a fellwship prgram shuld relate t the prgram gals listed abve. Brain Death Cma Encephalpathies and Delirium Herniatin Syndrmes Hydrcephalus Intracranial hemrrhages: Epidural Subdural Subarachnid Parenchymal (supratentrial, cerebellar, brainstem) Intraventricular Cerebral Venus Thrmbsis Acute Anterir Cerebral Artery Occlusin Acute Cartid Artery Occlusin Y:\PGME\PGME-CmmnShare\6a - FELLOWSHIPS\Fellwships by Prgram\Neurlgy\Neurcritical Fellwship\Neurcritical Care Fellwship 2 years.dc

3 Acute Middle Cerebral Artery Occlusin Acute Basilar Artery Occlusin Brainstem Infarctin Cerebellar Infarctin Hemispheric Infarctin Critical Care & Emergency Neurlgy Sectin Cre Curriculum Page 3 Acute Spinal Crd Syndrmes Cerebral Bld Flw and Hypperfusin Cerebral Metablism and Oxygen Demand Cerebral Edema Syncpe Brain Abscess Encephalitis: Bacterial and Viral Meningitis: Bacterial and Viral Traumatic Brain Injury Traumatic Spinal Crd Injury Status Epilepticus Guillain-Barre Syndrme Myasthenia Gravis Equipment and Technlgies: Knwledge f the basic physilgy and underlying technical principles. Cardivascular and Pulmnary Mnitring Devices Intracranial Pressure Mnitrs: Fiberptic, Intraventricular, and Epidural Nninvasive Intracranial and Extracranial Vascular Study, Including Transcranial Dppler Bld pressure management in the cntext f severe neurlgic disease General Principles f Management f critically ill Neurlgic Patients General Perspectives f Care in critically ill Neurlgic Patients General principles in the assessment f sedatin, agitatin, delirium and pain using bjective criteria. Management f Agitatin delirium and Pain Management f Airway and Mechanical Ventilatin Management f Nutritin Management f Intravascular Vlume Status and Bld Pressure Management f Anticagulatin and Thrmblytic Therapy Management f Intracranial Pressure Management f Neurlgic Cmplicatins in Critically Ill Patients Management f Pst-perative Neursurgical Patients Management f Systemic Cmplicatins in Critically Ill Neurlgic Patients Management f Pulmnary Cmplicatins Management f Cardiac Cmplicatins Management f Acid-Base Disrders and Hypertnic and Hyptnic States Management f Gastrintestinal Cmplicatins Management f Nscmial Infectins Intensive Care Unit Organizatin and Management Psychscial Issues in the Intensive Care Unit Y:\PGME\PGME-CmmnShare\6a - FELLOWSHIPS\Fellwships by Prgram\Neurlgy\Neurcritical Fellwship\Neurcritical Care Fellwship 2 years.dc

4 End f Life Decisin Making Transplant and Organ Dnatin Management Descriptin f activities and respnsibilities: Research activity and publicatins related t fellwship Please refer t the supervisr s CV, appended t this submissin There are many prjects that will begin in The supervisr (J Teitelbaum) in cnjunctin with Dr Jean-Paul Sucy f the Neur-imaging center, have btained a $100, grant that will allw the funding f a quantitative SPECT scan. Several research prtcls using the SPECT have been elabrated, ntably fr research in sub-arachnid and intracerebral hemrrhage. As well, we hpe t d sme wrk n prgnsis in cma pst cardiac arrest using PET and functinal MRI. Cllabrative wrk is rganized with Dr Yanna Skrbik lking at bjective methds f delirium, pain and sedatin assessment in the Neurcritical Care ppulatin. Literature reviews are presently underway and grant applicatins will be submitted by September Prjects are being elabrated in the dmain f severe meningitis. The tw year prgram places particular emphasis n this aspect f the fellwship. The Fellw can participate in a previusly elabrated r nging prject. Alternatively, they can design their wn research prject. If this prject is acceptable after analysis by the staff, tls and guidance will be prvided t ensure its cmpletin. Missin statement fr fellwship The missin is t prmte: Quality Patient Care by identifying and implementing best medical practices fr acute neurlgical disrders that are cnsistent with current scientific knwledge, and that prmte cmpassinate care and respect fr patient-centered values. Prfessinal Cllabratin by prviding a frum fr cmmunicatin, cllabratin, and exchange f ideas between physicians and allied health-care prfessinals within different specialties wh care fr critically-ill neurlgical patients. Research by fstering clinical, experimental and utcmes research fcused n develping innvative and cst-effective medical and surgical interventins fr acute neurlgical disrders. Training and Educatin by develping standards fr advanced fellwship training, prgram accreditatin, and physician certificatin in the subspecialty f neurlgical intensive care. Advcacy by making the case t patients, the public, plicy makers and ther healthcare prfessinals that cmplex, life-threatening neurlgical diseases are best cared fr by a multidisciplinary team with special expertise in neurcritical care. Names f the Teaching Faculty Jeanne Teitelbaum MD FRCP Directr f the prgram Y:\PGME\PGME-CmmnShare\6a - FELLOWSHIPS\Fellwships by Prgram\Neurlgy\Neurcritical Fellwship\Neurcritical Care Fellwship 2 years.dc

5 Direct supervisin in the NICU C-directr f a research prject Summary f clinical practice: full-time accredited Neurlgist Neurintensivist with 18 years f neurcritical care practice as well as previus intensive care, internal medicine and family medicine practice. Mark Angle MD FRCP Rles: chief f Neuranesthesia as well as chief f the Neur ICU Direct teaching and supervisin in the NICU Direct teaching and supervisin in the perating rm C-directrship f research prjects Summary f clinical practice: full-time accredited inensivist in medical, surgical and neurlgical critical care as well as an accredited neuranesthetist. Full time clinical practice Majr Strengths: superb clinician in neur-anaesthesia and critical care Marcell Lannes MD FRCP Rles: Full time in Neuranesthesia as well as Neur ICU Direct teaching and supervisin in the NICU Direct teaching and supervisin in the perating rm C-directrship f research prjects Summary f clinical practice: full-time accredited inensivist in medical, surgical and neurlgical critical care as well as an accredited neuranesthetist. Full time clinical practice Majr Strengths: Masters in educatin as well as superb clinical skills in neur-anaesthesia and critical care Academic Facilities The fellw will be using the facilities f the Neurlgical Intensive Care fr his clinical and academic pursuits. The unit has a cnference rm and access t internet as well as Up-t-date n it s 3 cmputers. The fellw will be able t share an ffice and have his wn desk n the 3 rd flr. Library access is available at bth the MNI and the Ryal Victria Hspital. Materials relevant t fellwship training are kept in the cnference rm and the ffice f the assistant head nurse in the NICU. Multimedia learning materials available n CD and internet. These allw learning in Neuranatmy, neurphysilgy, strke, multiple sclersis and neurcritical care. There is als access t Up T Date. Fellw Duties and Respnsibilities Call respnsibilities t cver service: the fellw is n call ne in 4 week days as well as ne week-end per mnth. He is n first call frm hme and replaces the NICU attending. He r she des nt replace the neurlgy r neursurgery resident whse jb it is t assess and admit the patient. The resident ges ver admissins with the fellw. The attending is n as secnd call t supervise the fellw. The fellw is expected t supervise residents rtating thrugh the ICU with the help and instructin f the attending. Y:\PGME\PGME-CmmnShare\6a - FELLOWSHIPS\Fellwships by Prgram\Neurlgy\Neurcritical Fellwship\Neurcritical Care Fellwship 2 years.dc

6 The fellw with a backgrund in Critical Care will rtate nly at the Mntreal Neurlgical Institute and hspital. The fellw with a backgrund in Neurlgy will rtate at the Ryal Victria, in the medical/surgical intensive care. Rtatins are nt fixed in advance and will vary accrding t the needs f the candidate. What are the utpatient clinic respnsibilities: there are n utpatient clinic respnsibilaties. What are the teaching respnsibilities twards residents: the fellw is expected t present ne subject a week at 2PM teaching runds. Outline participatin in academic activities invlving the residents: the resident will participate in service runds. The fellw will either present r assist the 2PM teaching runds. Describe any supprt staff available t the fellw: the fellw will have access t the strke nurse clinician and the secretary. Prpsed meetings t be attended by the fellw: the fellw will be expected t attend the American Neurcritical Care cnference, this year in Miami, as well as the Trnt Critical Care cnference. What is the research prductivity/publicatins expected by the Fellw: ne prject, hpefully with a subsequent publicatin. Curriculum In rder t create an envirnment cnductive t academic activity, the intensivist may invlve residents whse time is dedicated t the unit, in the active care f patients. This will be cmplimentary t the respnsibilities f the referring services wh will maintain their primary rle. The resident in training will actively invlve himself / herself in the mnitring f all admitted patients. The resident shuld be present in the ICU frm 8AM t 5PM. Chart ntes n a daily basis are required. Bedside runds ccur each mrning and the resident is expected t attend, alng with the nurse respnsible fr the patient and the NICU attending. The resident will actively participate in teaching runds within and utside the ICU cntext. Call in the NICU is taken frm hme. Frequency is never mre than 1 in fur, with ne weekend per mnth, and can vary accrding t individual requirements. Intended case lad fr the Fellw: there are a ttal f 14 beds in the NICU. The Fellw is respnsible fr the care f these patients under the supervisin f the attending. He will als crdinate the activities f the residents rtating thrugh the NICU. Intended percentages f the varieties f cases: there is a large variety f cases, 60% surgical pathlgy, 40% neurlgical pathlgy as the primary prblem. All the pathlgies listed in the sectin called tpics are mre than likely t be encuntered. Y:\PGME\PGME-CmmnShare\6a - FELLOWSHIPS\Fellwships by Prgram\Neurlgy\Neurcritical Fellwship\Neurcritical Care Fellwship 2 years.dc

7 What regular reading materials are t be prvided (if any): There is a small library in the NICU that cntains the latest textbks in Neurcritical Care. These are available t the resident n a cnsultative basis. There are als textbks n cma, Neurlgy, and the Neurlgical exam. Unlike the US, mst f ur fellws are likely t be internal medicine and critical care residents rather than Neurlgy residents. In these cases, teaching f basic Neurlgy becmes ne f the gals f the fellwship and the textbks reflect this. Outline the weekly / mnthly cnference schedule Afternn curse frm 2 t 3 PM 3 days per week, 3 ut f 4 weeks Neurlgy service runds: nce per week Grand Runds in Neurlgy: nce per week Grand runds in Neursurgery: nce per week Strke runds: nce per mnth What rle will the Fellw play in attending, rganizing, and presenting runds/cnferences The fellw will present ne afternn curse per week Evaluatin: The fellw will be evaluated every mnth using CANMEDS criteria. They will als be able t write a practice exam based n the American Neurcritical Care subspecialty exam. Y:\PGME\PGME-CmmnShare\6a - FELLOWSHIPS\Fellwships by Prgram\Neurlgy\Neurcritical Fellwship\Neurcritical Care Fellwship 2 years.dc

8 Neurlgy Residency Prgram Department f Neurlgy & Neursurgery Pstal address: Mntreal Neurlgical Institute 3801 University Street Mntreal, PQ, Canada H3A 2B4 Tel.: (514) Fax: (514) Department f Neurlgy and Neursurgery Neurcritical Care Fellwship (General and Specific Objectives) 1. Medical Expert/Clinical Decisin-Maker General Requirements Demnstrate diagnstic and therapeutic skills fr ethical and effective patient care. Access and apply relevant infrmatin t clinical practice. Demnstrate effective cnsultatin services with respect t patient care, educatin and legal pinins. Acquire skills necessary t elabrate and carry ut clinical and basic science research in Neurcritical Care. Be able t successfully apply fr research grants. Specific Requirements Prvide scientifically based, cmprehensive and effective diagnsis and management fr patients with: Brain Death Cma Encephalpathies and Delirium Herniatin Syndrmes Hydrcephalus Intracranial hemrrhages: Epidural Subdural Subarachnid Parenchymal (supratentrial, cerebellar, brainstem) Intraventricular Cerebral Venus Thrmbsis Acute Anterir Cerebral Artery Occlusin Acute Cartid Artery Occlusin Acute Middle Cerebral Artery Occlusin Acute Basilar Artery Occlusin Brainstem Infarctin Cerebellar Infarctin Hemispheric Infarctin 1

9 Acute Spinal Crd Syndrmes Cerebral Bld Flw and Hypperfusin Cerebral Metablism and Oxygen Demand Cerebral Edema Syncpe Brain Abscess Encephalitis: Bacterial and Viral Meningitis: Bacterial and Viral Traumatic Brain Injury Traumatic Spinal Crd Injury Status Epilepticus Guillain-Barre Syndrme Myasthenia Gravis Clinical: Fr a patient with an acute life-threatening neurlgical illness, the neurlgical cmplicatins f severe medical illness r allied disrder (see previus list), the resident will be able t: Obtain a cmplete neurlgical histry frm adults and children btaining a cllateral histry where necessary Perfrm an apprpriate physical examinatin. Determine whether a patient's symptms and signs are the result f a disrder related t the field f neurcritical care Frmulate an apprpriate lcalizatin, differential and prvisinal diagnsis f the life-threatiening illness in questin. Outline an apprpriate plan f labratry investigatin. Outline an apprpriate therapeutic plan. Exhibit apprpriate clinical judgment in utlining a differential diagnsis and an investigative and therapeutic plan, taking int accunt matters such as the patient's age, general health, risk and cst f investigative prcedures, risk and cst f therapeutic interventins, and epidemilgy f the disease. General Principles f Management f Critically III Neurlgic Patients General Perspectives f Care in Critically III Neurlgic Patients Management f Agitatin and Pain Management f Airway and Mechanical Ventilatin Management f Nutritin Management f Intravascular Vlume Status and Bld Pressure Management f Anticagulatin and Thrmblytic Therapy Management f Intracranial Pressure Management f Neurlgic Cmplicatins in Critically Ill Patients Management f Pst-perative Neursurgical Patients Management f Systemic Cmplicatins in Critically Ill Neurlgic Patients Management f Pulmnary Cmplicatins Management f Cardiac Cmplicatins 2

10 . Management f Acid-Base Disrders and Hypertnic and Hyptnic States Management f Gastrintestinal Cmplicatins Management f Nscmial Infectins Intensive Care Unit Organizatin and Management Psychscial Issues in the Intensive Care Unit End f Life Decisin Making Transplant and Organ Dnatin Management Technical Skills T learn/review detailed, practical anatmy f the central nervus system, the ventricular system and the spinal crd. Other technical skills related t fellwship: Knwledge f the basic physilgy and underlying technical principles f equipment and technlgies such as Knwledge Cardivascular and Pulmnary Mnitring Devices Intracranial Pressure Mnitrs: Fiberptic, Intraventricular, and Epidural Nninvasive intracranial and extracranial vascular study, including Transcranial Dppler and ther future methds 2. Cmmunicatr Acquire and understand the neuranatmic principles and pathlgical substrates f the diseases listed abve Becme familiar with the neurphysilgical principles, the basic mechanisms related t the diseases listed abve. Learn the majr categries r classificatins related t acute severe neurlgic illness. Learn clinical neurpharmaclgy related t neurcritical care Acquire expertise in the decisin making related t the diseases listed abve General Requirements Establish therapeutic relatinships with patients/families. Obtain and synthesize relevant histry frm patients/families/cmmunities. Listen effectively. Discuss apprpriate infrmatin with patients/families and the health care team. Specific Requirements Cmmunicate effectively with patients, their families and medical clleagues (particularly referring physicians), and ther health care prfessinals in bth the inpatient and utpatient settings. The resident will: 3

11 Cmmunicate effectively and regularly with patients and their families. Be cnsiderate and cmpassinate in cmmunicating with patients and families, willingly prvide accurate infrmatin apprpriate t the clinical situatin, with a reasnable attempt at prgnsis. Learn t write cncise reprts f the clinical findings with cnclusins and recmmendatins cmprehensible t the nn-specialist. Cmmunicate effectively and apprpriately with the nurses and paramedical persnnel. When rdering investigative prcedures, ensure there has been adequate cmmunicatin abut the patient with the persn wh will actually be ding and/r reprting the diagnstic study. 3. Cllabratr General Requirements Cnsult effectively with ther physicians and health care prfessinals. Cntribute effectively t ther interdisciplinary team activities. Specific Requirements Be an effective teacher f ther physicians (including medical students and huse fficers), ther health care persnnel, and patients. The resident will: Prvide instructin t medical students and mre junir physicians at a level apprpriate t their clinical educatin and prfessinal cmpetence. Willingly share knwledge with thers with whm they are assciated, thus ensuring the mst effective delivery f health care t patients. 4. Manager General Requirements Utilize resurces effectively t balance patient care, learning needs, and utside activities. Allcate finite health care resurces wisely. Wrk effectively and efficiently in a health care rganizatin. Utilize infrmatin technlgy t ptimize patient care, life-lng learning and ther activities. Specific Requirements Be prficient in prfessinal skills related t the diagnsis and treatment f acute severe neurlgic illness and the neurlgic cmplicatins f severe medical illness. Demnstrate the fllwing prfessinal skills in time management: 4

12 Recgnize that effective use f time depends upn punctuality. Recgnize that effective use f time requires planning. Develp speed as well as accuracy in clinical skills. Reserve time fr reading and keeping current with the neurlgical literature. Establish rutines fr carrying ut regular activities and adhere t them. Maintain cmplete and accurate medical recrds: Recrd and maintain a cmplete and accurate medical recrd fr every patient seen; this recrd will include the patient's histry and the findings n physical examinatin (including the neurlgical examinatin), a differential diagnsis, a prvisinal diagnsis, Effectively crdinate the wrk f the health care team:. Indicate, by the treatment plan, that fr the ptimal treatment f many patients with neurlgical disrder, a team apprach is necessary -- members f the team may include nurses, rehabilitatin persnnel (physitherapists, ccupatinal therapists, speech therapists, etc.), psychlgists, scial wrkers, etc. Identify where an imprtant rle(s) can be played by disease fcused lay grups with regard t helping the patient and/r family and t facilitate its happening. 5. Health Advcate General Requirements Identify the imprtant determinants f health affecting patients. Cntribute effectively t imprved health f patients and cmmunities. Recgnize and respnd t thse issues where advcacy is apprpriate. Specific Requirements Learn abut cmmunity resurces and related patient supprt grups; prvide assistance t access prgrams (e.g. hme care, ccupatinal and physitherapy, drug plans, applicatin fr nursing hmes etc) and participate in their activities. Educate, be able t generate and access infrmatin (e.g. printed material, vide tapes web sites) and be available as a resurce persn t cunsel patients effectively n neurlgical disrders. Cunsel patients n the imprtance f taking respnsibility fr their wn well-being and recgnize the imprtant determinants predispsing t wrsening f neurlgical status Understand the rle f natinal and internatinal bdies (e.g. Canadian Neurcritical Care Grup, the Neurcritical Care Sciety) in the prmtin f neurlgical health, and the preventin, detectin, and treatment f acute severe neurlgical disrders. 5

13 6. Schlar General Requirements Develp, implement and mnitr a persnal cntinuing educatin strategy. Critically appraise surces f medical infrmatin. Facilitate learning f patients, huse staff/students and ther health prfessinals. Cntribute t develpment f new knwledge. Specific Requirements Be able t critically assess the neurlgical literature as it relates t patient diagnsis, investigatin and treatment: Develp criteria fr evaluating neurlgical literature. Critically assess the neurlgical literature using these criteria. Be familiar with the design f experimental and bservatinal studies, especially randmized cntrlled trials. Be able t calculate abslute risk reductins, relative risk reductins and numbers needed t treat r harm. Be able t participate in clinical r basic science studies as a member f a research team: Be able t describe principles f gd research. Use the abve principles, and be able t judge whether a research prject is prperly designed. Be prepared t present research findings t peers at lcal, natinal r internatinal cnferences. Be able t elabrate and participate in clinical r basic science studies as a member f a research team: Be able t describe principles f gd research. Use the abve principles, and be able t prperly design a research prject. Be prepared t present research findings t peers at lcal, natinal r internatinal cnferences. 7. Prfessinal General Requirements Deliver highest quality care with integrity, hnesty and cmpassin. Exhibit apprpriate persnal and interpersnal prfessinal behaviurs with patients/families, peer residents and ther health care prfessinals. 6

14 Practice medicine ethically cnsistent with bligatins f a physician. Specific Requirements Demnstrate persnal and prfessinal attitudes cnsistent with a cnsulting physician rle: Peridically review his/her wn persnal and prfessinal perfrmance against natinal standards set fr the specialty. Be willing t include the patient in discussins cncerning apprpriate diagnstic and management prcedures. Shw apprpriate respect fr the pinins f fellw cnsultants and referring physicians in the management f patient prblems and be willing t prvide means whereby differences f pinin can be discussed and reslved. Be willing and able t appraise accurately his/her wn prfessinal perfrmances and shw that he/she recgnizes his/her wn limitatins with regard t skill and knwledge by apprpriately cnsulting ther physicians and paramedical persnnel when caring fr the patient. Be willing and able t keep his/her practice current thrugh reading and ther mdes f cntinuing medical educatin and develp a habit f maintaining current his/her clinical skill and knwledge base thrugh cntinuing medical educatin. 7