DEPARTMENT OF MEDICINE

DEPARTMENT OF MEDICINE Internal Medicine Residency Husestaff Manual Prgram Directr: Lee Merchen, MD ACADEMIC YEAR 2015-2016 Updated 06/23/15

Table f Cntents Intrductin... 7 Missin... 7 Educatinal Gals... 7 Patient Care... 7 Medical Knwledge... 7 Practice Based Learning/Imprvement... 8 Interpersnal and Cmmunicatin Skills... 8 Prfessinalism... 8 Systems-Based Learning... 8 Medicine Quality Aim... 8 Respnsibility... 9 Methds Used t Achieve Prgram Missin, Gals, and Objectives... 9 Educatin... 10 General InPatient Rtatins... 10 EDUCATIONAL PURPOSE... 10 GOAL... 10 Rle f the ward attending... 11 Definitin f level f resident supervisin by faculty in all patient-care activies... 14 ACGME Milestnes... 15 Teaching Methds... 16 Bedside instructin... 16 Small grup discussin... 16 Persnal feedback... 16 Evaluatin and review f write ups... 17 Didactic lectures... 17 Assigned readings... 17 Educatinal Resurces t be used Check requirement... 17 Harrisn s Curriculum Plan... 17 Expectatins f Residents and Attendings as Teachers... 23 Rle f the PGY-1... 23 Rle f the PGY-2/PGY-3... 23 Lines f Cmmunicatin... 23 Prgressive Patient Care Respnsibility f Residents... 24 PGY-1 (Categrical and Preliminary)... 24 PGY-2... 25 3

PGY-3... 25 Attending Supervisin Plicy... 25 DEFINITIONS... 25 POLICY... 26 SCOPE... 26 POLICY STANDARDS... 27 PROCEDURE... 28 Ambulatry and Cnsultative Rtatins (Required and Elective)... 30 Cre rtatins... 30 Electives Rtatins... 30 Supervised care f limited numbers f hspitalized patients and cncurrent educatinal activities... 31 Supervised care f limited numbers f ambulatry patients... 33 Prgram Requirements... 36 Didactic Curriculum... 36 Special educatinal experience... 38 Schlastic Requirements... 38 Resident evaluatin and prmtin... 39 Resident Cmpetency... 39 Advisr Prgram... 39 Cmpetency evaluatin tls... 39 Criteria fr advancement f residents... 40 Academic Remediatin, Prbatin, and Dismissal frm the Prgram... 41 Prgram Evaluatin... 41 ADVISOR MEETING WITH ADVISEE... 42 Resident Wrk Hurs and Wrk Hur Mnitring... 43 Prcedure... 44 Resident Supervisin... 44 resident Administrative requirements... 45 General Administrative Requirements... 45 Perfrmance f Duty... 45 Dictatin f Charts... 45 Incmplete and Delinquent Recrds... 45 USMLE 3 Examinatin... 45 Required Prcedures... 46 Cnference/lectures Attendance Plicy... 46 4

Dictatins and Medical Recrds... 47 Prcedure... 47 Discharge/Death Narrative Summary Outline Example... 49 Clinic Plicy... 50 FOR ALL RESIDENTS WITH CLINICS AT GRU... 51 Walk-In Clinic (VA) and Faculty Acute Care Clinic (GRU)... Errr! Bkmark nt defined. Inpatient expectatins... 52 Night Medicine... 52 Intern Night Flat... 52 Night Flat Team... 53 GRU and VA Night Flat Resident (Night Flat Team)... 53 GRU Night Flat Resident specifics... 54 Medicine Call Days... 55 Hspitalist Call Days... 55 Overnight Cnsults... 56 VA Night Flat Resident specifics... 56 VA Utility Flat Resident... 56 GRU Utility Flat... 57 GRU Medicine Ward/Unit Days ff plicy... 57 Special circumstances... 58 Readmissins... 59 Cde 99... 59 Checkut... 59 Transfers frm the micu... 59 GRU - Wards/MICU/CCU... 60 WARDS... 60 MICU... 61 CARDIOLOGY/CCU... 62 CONSULTS... 63 Team Reprt... 64 VAMC - Wards/MICU/CCU... 64 WARDS... 64 MICU... 66 CARDIOLOGY/CCU... 66 CONSULTS... 66 TRANSFERS... 66 DAYS OFF... 67 Discharge Plicy... 67 Purpse... 67 Applicability... 67 Plicies... 67 5

Prcedures... 68 Quality Imprvement... 69 Back-up Plicy... 69 Cnsult Resident... 70 General Plicies... 71 Resident Stress and Fatigue Plicy... 71 Pager Plicy... 71 Overall... 71 Inpatient interns... 71 Inpatient residents... 72 Outpatient interns/residents... 72 Vacatin interns/residents... 72 On Call/Cde Pagers... 72 Prfessinalism in Medicine... 73 Definitin... 73 Expectatins f prfessinalism... 73 Examples f Unprfessinal Attitudes... 74 Examples f Unprfessinal Behavir... 74 What are the cnsequences f unprfessinal attitude and behavir fr residents?... 74 Dcumentatin and Due Prcess fr alleged unprfessinal attitude and behavir... 75 Dress Cde... 76 Leave Plicy... 77 Vacatin Leave... 77 Sick Leave... 77 Maternity and Extended Leave (frm GME plicy HS 4.0)... 78 Emergency Family Leave... 78 Interview/fellwship Leave... 79 Travel Plicy... 79 Away rtatins... 80 Mnlighting... 81 Clsing... 82 Summary... 82 6

INTRODUCTION MISSION T prvide the highest quality f educatin and training fr physicians in the field f Internal Medicine thrugh the emphasis f the Cre Cmpetencies as described by the Accreditatin Cuncil fr Graduate Medical Educatin (ACGME): Patient Care, Medical Knwledge, Prfessinalism, Systems - Based Practice, Practice - Based Learning and Imprvement, and Interpersnal and Cmmunicatin skills. EDUCATIONAL GOALS By the cmpletin f training, a graduate f this prgram will have all requisite cmpetencies f a general internist, and will be able t prvide utstanding care fr his r her patients ver the next 40-50 years. Key t this is t develp in the graduate self-sustaining and disciplined skills, attitudes, and behavirs t acquire and use new knwledge under whatever frm f medical care is practiced. Internists and subspecialists will be prblem slvers, change agents, and seekers f imprved health fr patients, ppulatins, and natins. By its nature, internal medicine is bth brad and deep in fcus, and includes biphysical aspects f nrmal and abnrmal human physilgy frm the mlecular t multi-rgan systems. It is n less cncerned with psychscial, ecnmic, ethical and humanistic/spiritual aspects f the health and functin f the individual patient frm the asymptmatic adlescent t the end-f-life issues f the dying patient. It is the intent f this prgram t prduce excellent internists and future subspecialists practicing with such breadth and depth f cmpetency t be recgnized by their peers and patients as truly excellent in the 6 Cre Cmpetencies f Practice, as utlined by the ACGME. PATIENT CARE Residents are expected t prvide patient care that is cmpassinate, apprpriate and effective fr the prmtin f health, preventin f illness, treatment f disease and palliatin f symptms. Patient care cmpetency cnsists f apprpriate and high quality diagnsis (histry, physical examinatin, lab/radilgy, prcedures), therapy (pharmaclgy, prcedures, patient educatin, discharge planning, fllwup), prgnsis, and dcumentatin (quality f clinical ntes). MEDICAL KNOWLEDGE 7

Residents are expected t demnstrate knwledge f established and evlving bimedical, clinical, and psychscial sciences, and demnstrate the applicatin f their knwledge t the prvisin f patient care and t the educatin f thers. PRACTICE BASED LEARNING/IMPROVEMENT Residents are expected t cnstantly evaluate their wn perfrmance, incrprate feedback and external evaluatin int their behavir t effect self-imprvement, use apprpriate knwledge and utcmeinfrmatin surces t manage their patients, track imprvements inefficiency and cst f care, and maximize quality f life f patients. INTERPERSONAL AND COMMUNICATION SKILLS Residents are expected t establish a highly effective and persnalized therapeutic relatinship with patients and families thrugh develping and maintaining excellent listening, narrative, and nnverbal skill. They are expected t prvide patients and families culturally and persnally apprpriate cunseling and educatin; and t educate clleagues and the public effectively n health and disease related matters. PROFESSIONALISM Residents are expected t demnstrate values that are exemplary f altruism, accuntability, excellence, duty, hnr, integrity, and respect fr thers. They are expected t be fully hnest, accept respnsibility, acknwledge failures, and seek cntinual imprvement fr the betterment f patients and clleagues. SYSTEMS-BASED LEARNING Residents are expected t demnstrate an understanding f the cntexts and systems in which health care is prvided, and demnstrate the ability t apply this knwledge t imprve and ptimize health care. MEDICINE QUALITY AIM At the same time, residents are expected t demnstrate attitudes, skills, and behavirs cnsistent with the fllwing Institute f Medicine Quality Aims: Safety: Aviding injuries t patients frm the care that is intended t help them. Timely: Reducing waits and ptentially harmful delays fr bth thse wh receive and wh give care. 8

Effective: Prviding services based n scientific knwledge t all wh culd benefit and refraining frm prviding services t thse nt likely t benefit (aviding underuse and veruse, respectively) Efficient: Aviding waste, including waste f equipment, supplies, ideas and energy Equitable: Prviding care that des nt vary in quality because f persnal characteristics such as gender, ethnicity, gegraphic lcatin and sci-ecnmic status. Patient centered: Prviding care that is respectful f and respnsive t individual patient preferences, needs and values and ensuring that patient values guide all clinical decisins. Every clinical rtatin will incrprate the 6 cmpetencies and 6 IOM Quality Aims cntextually fr the specific patients seen n that rtatin. Residents are evaluated n their learning and subsequent perfrmance f the attitudes, skills, and behavirs cmprising these general cmpetencies as specifically seen n the rtatins cnducted. RESPONSIBILITY The respnsibility fr the attainment f the missin, gals, and bjectives f this prgram belngs slely t the Prgram Directr. He/she is assisted by Assciate Prgram Directrs, wh are designated Key Faculty Members f this Prgram, wrking thrugh the Clinical Cmpetency Cmmittee. The Prgram Directr delegates t the faculty respnsibilities and activities f educatin and mentrship fr the daily implementatin f this prgram and hlds them respnsible fr their perfrmance thrugh feedback, recmmendatins and cunsel t the Chairman, Department f Medicine. METHODS USED TO ACHIEVE PROGRAM MISSION, GOALS, AND OBJECTIVES In all the methds used and enumerated belw, feedback by prgram directrs and faculty is critical t develpment and grwth f the resident. Just as imprtant is resident self-awareness and selfimprvement. Bth are abslutely fundamental t the develpment f life-lng habits f excellence in patient care, leadership, and schlarship. Self-awareness and feedback are cntinuus, spntaneus, and pertinent t the behavir and utcmes bserved. Faculty will be encuraged by the prgram directrs t be utstanding rle mdels fr residents. 9

EDUCATION GENERAL INPATIENT ROTATIONS Rtatin: General Inpatient Services (GRU and VA) EDUCATIONAL PURPOSE T prvide supervised patient care and educatinal pprtunities t develp the fllwing cmpetencies f internal medicine: humanistic practice, prfessinalism, medical ethics, lifelng learning, clinical methd, cntinuity f care, medical interview, physical diagnsis, clinical pharmaclgy, nutritin, palliative care, and discharge planning. The resident by the end f the rtatin shuld have imprved and advanced his level f cmpetency in the principles f management f the mst cmmn medical cnditins necessitating hspitalizatin n general medical wards. The gals and bjectives fr all the clinical rtatins can be fund n the website: http://www.gru.edu/mcg/residents/internalmed/dcuments/2014internalmedicinecurriculum1.pdf GOAL By the end f the rtatin, the educatinal participants will have prgressed in their understanding f physilgy and executin f clinical management f inpatients seen in this rtatin. Patient characteristics: Mst patients will be very ill, with near end-stage disease, pr prgnsis, and multiple interacting pathlgies. They will als have severe psychlgical, scial, ecnmic and spiritual cmplexities resulting frm and cntributing t their disease. Mst patients and their families will be suffering. They will cmprise adults frm age 18 upwards, representative f the Augusta ppulatin in make-up, frm predminantly pr t middle-class sci-ecnmic backgrund, f all races and bth genders. Predminant religius preference and cultural backgrund will be suthern Black evangelical Christian. Family and scial supprt will range frm extensive t absent. Patients will include thse transferred frm state crrectinal and dmiciliary facilities, as well as nursing hmes, intensive care units, and rehabilitatin facilities, emergency rms, clinics, and utside hspitals. Types f clinical encunters: In patient evaluatin, management and discharge planning. 10 Types f prcedures: Lumbar puncture, bladder catheterizatin, thracentesis, paracentesis, jint aspiratin, central venus catheter, arterial bld gas, peak flw measurement, PPD skin testing, NG tube, O2 mnitring, cgnitive assessment

Types f services prvided: Acute inpatient care, palliative care, discharge planning ROLE OF THE WARD ATTENDING Ward attending will teach students during ward teaching runds as apprpriate t their level, give feedback n knwledge, participatin in patient care, and demnstrated qualities f prfessinalism, cmmunicatin skill, practice-based learning, and systems-based practice. Teaching attending will review and grade 4 patient write-ups during the rtatin, and prvide students-nly bedside teaching fr 2 hurs weekly. 1. PGY-1, 2, and 3 residents, alng with the ward attending will participate in a facilitated grading sessin at the end f each MSM-3 student rtatin. Evaluatins Methd f evaluatin f resident cmpetence and quality f care: Expected standards f cmpetence and quality: Residents are expected t demnstrate attitudes, skills, and behavirs cnsistent with the cmpetency level apprpriate fr level f PGY training fr the fllwing a. ACGME Cmpetencies i. Patient care: physician patient interactin (physical and written) that is cmpassinate, apprpriate and effective fr the treatment f health prblems and prmtin f health, based n standards f evidence in the medical literature. ii. Medical knwledge: understanding and facility abut established and evlving bimedical, clinical and cgnate sciences (e.g. epidemilgical and scial-behaviral) and the applicatin f this knwledge t patient care. iii. Practice-based learning and imprvement that invlves investigatin and evaluatin f their wn patient care, appraisal and assimilatin f scientific evidence and imprvement in patient care. iv. Interpersnal and cmmunicatin skills: that result in effective infrmatin exchange and teaming with patients, their families and ther health prfessinals 11

v. Prfessinalism, as manifested thrugh a cmmitment t carrying ut prfessinal respnsibilities, adherence t ethical principles and sensitivity t a diverse patient ppulatin. vi. System-based practice, as manifested by actins that demnstrate an awareness f and respnsiveness t the large cntext and system f health care and the ability t effectively call n system resurces t prvide care that is f ptimal value. b. Institute f Medicine Quality Aims i. Safety: Aviding injuries t patient frm the care that is intended t help them. ii. Timely: Reducing waits and ptentially harmful delays fr bth thse wh receive and wh give care. iii. Effective: Prviding services based n scientific knwledge t all wh culd benefit and refraining frm prviding services t thse nt likely t benefit (aviding underuse and veruse, respectively) iv. Efficient: Aviding waste, including waste f equipment, supplies, ideas and energy v. Equitable: Prviding care that des nt vary in quality because f persnal characteristics such s gender, ethnicity, gegraphic lcatin and sci-ecnmic status. vi. Patient centered: Prviding care that is respectful f and respnsive t individual patient preferences, needs and values and ensuring that patient values guides all clinical decisins. 1. Methds f measurement a) Other direct bservatin by mre senir residents and attending n wrk and teaching runds, management f individual patients, bservatin f prcedures (Patient care, IOM Quality Aims) 12

b) Pre and pst tests based n assigned readings administered at beginning f mnth and subsequent mnth (Medical knwledge) are we ding this? c) Mnitring and recrding f adverse events as determined at mrning reprt and by reprt f nurses t attending (Patient care, practice based learning, prfessinalism). d) Mnitring f patient cmplaints t nurses, attendings, hspital. Scres n patient satisfactin surveys (Patient care, PBL, Systems-based practice, IOM Quality Aims) e) Prspective mnitring f cmpliance with specific patient care guidelines such as cmmunity acquired pneumnia, acute crnary syndrme, alchl withdrawal, ptassium infusin, and ther prtcls (Patient care, SMP) f) Graded essays and presentatins n tpics germane t patients seen n rtatin, submitted t prtfli as directed by attending (Medical knwledge, PBL). g) Attendance at required cnferences (Prfessinalism, PBL). h) Wrk hurs reprt t ensure n mre than 80 hurs wrk per week in accrdance with RRC guidelines (SBP, Prfessinalism). i) Mnitring f UHC cst, LOS, and utcme data fr team and individual members (Patient care, SBP, IOM Quality Aims) j) Frmal grading f patient evaluatin and management via One 45 system (all cmpetences). 2. Prvisin f Feedback a. Daily feedback is t be given t residents by superirs regarding perfrmance in all dmains as apprpriate: encuraging gd/excellent behavir, and facilitating recgnitin f areas needing imprvement and means t imprve. b. Mid rtatin feedback is t be given t residents by superirs regarding verall perfrmance in all 6 cmpetencies and all 6 quality dmains. When pssible this shuld be written, with specific gals fr imprvement during the remainder f the rtatin. 13

3. Dcumentatin f evaluatin: Evaluatin will be dcumented by cmpletin f frms abve, written dcumentatin f significant negative r psitive feedback (t prgram directr), and end f rtatin cmpletin f One 45 n line evaluatin by the attending, as well as peer evaluatins by residents. 4. Transmissin f evaluatin t resident a) End f rtatin utbrief: at end f rtatin, attending will meet with resident t discuss perfrmance and means f imprvement. b) Written evaluatin n One 45. c) Cmpilatin f all reprts int persnal perfrmance file and resident prtfli. DEFINITION OF LEVEL OF RESIDENT SUPERVISION BY FACULTY IN ALL PATIENT-CARE ACTIVIES Attending faculty physicians are ultimately respnsible fr the utcme f all patient care in bth the medical and legal sense. They delegate this care in rder t train residents hw t care fr patients themselves. Supervisin is graded t the level f training f the resident and educatin is individualized t the needs and level f the individual trainees n the ward team. The PGY-1 is respnsible fr up t 10 patients at ne time. The PGY-1 is the primary caregiver t the patient as is identified as the patient s dctr. He develps the diagnstic and therapeutic plan after discussin with the PGY-2/3 and attending, and is respnsible fr the implementatin f all diagnstic and therapeutic management, t include prcedure, retrieval and assessment f diagnstic tests and crdinatin f multidisciplinary, cnsultative, and discharge related resurces. The PGY 2/3 is respnsible fr up t 20 patients at ne time. He supervises the PGY-1 and sub-intern and students in perfrmance f duty, writes admissin histry, physical and initial plan f care, facilitates interpretatin f diagnstic and therapeutic utcme s and discharge planning. This resident is respnsible fr timely and cmplete dictated summaries, but may delegate this duty t the PGY-1, but nt any medical student. He mentrs and teaches subrdinates and nursing and ther ancillary care-givers, develps case reprts and clinical research apprpriate t case managed, and prepares discussin f cases fr management cnference, mrbidity/mrtality cnference, shw and tell, and ther departmental 14

cnferences. PGY-3 residents are expected t cnduct greater quantity and quality f teaching, mentring, and quality imprvement activities than PGY-2 residents. The attending is the final level f respnsibility t the educatinal and service mandates f the ward experience. The attending identifies the specific educatin needs f each f the subrdinate members f the ward team and facilitates their maximum cmpetency by supervising, evaluating, giving feedback, and teaching apprpriate t each team member, while assuring that excellent patient care is prvided. ACGME MILESTONES The ACGME Milestnes in clinical cmpetency and bservable prfessinal activities will be used in all rtatins t establish prgressin in cmpetency cmmensurate with training. The specific milestnes being assessed are: 15 PATIENT CARE PC 1: Gathers and synthesizes essential and accurate infrmatin t define each patient s clinical prblems PC 2: Develps and achieves cmprehensive management plans fr each patient PC 3: Manages patients with prgressive respnsibility and independence PC 4: Skill in perfrming prcedures PC 5: Requests and prvides cnsultative care MEDICAL KNOWLEDGE MK 1: Clinical knwledge MK 2: Knwledge f diagnstic testing and prcedures SYSTEMS BASED PRACTICE SBP 1: Wrks effectively within an inter-prfessinal team (e.g. peers, cnsultants, nursing, ancillary prfessinal and ther supprt persnnel) SBP 2: Recgnizes system errr and advcates fr system imprvement SBP 3: Identifies frces that impact the cst f health care, and advcates fr, and practices csteffective care. SBP 4: Transitins patient effectively within and acrss health delivery systems PRACTICE BASED LEARNING AND IMPROVEMENT

PBL 1: Mnitr practice with a gal fr imprvement PBL 2: Learns and imprves via perfrmance audit PBL 3: Learns and imprves via feedback PBL 4: Learns and imprves at the pint f care PROFESSIONALISM PROF 1: Has prfessinal and respectful interactins with patients, caregivers and members f the inter-prfessinal team (e.g. peers, cnsultants, nursing, ancillary prfessinals and supprt persnnel) PROF 2: Accepts respnsibility and fllws thrugh n tasks PROF 3: Respnds t each patient s unique characteristics and needs PROF 4: exhibits integrity and ethical behavir in prfessinal cnduct INTERPERSONAL AND COMMUNICATIONS SKILLS ICS 1: Cmmunicates effectively with patients and caregivers ICS 2: Cmmunicates effectively in inter-prfessinal teams (e.g. peers, cnsultants, nursing, ancillary prfessinals and ther supprt persnnel.) ICS 3: Apprpriate utilizatin and cmpletin f health recrds TEACHING METHODS BEDSIDE INSTRUCTION Bedside teaching runds n all subjects pertinent t specific patient at hand. This teaching methd cnstitutes majrity f minimum 4.5 hrs weekly teaching runds with attending physician. SMALL GROUP DISCUSSION Team runds r in team cnference discussing specific cases, general cncepts apprpriate t specific cases. PERSONAL FEEDBACK 16

Daily as indicated t specific residents by attending. Summary evaluatins are prvided at mid- and endrtatin. EVALUATION AND REVIEW OF WRITE UPS All write ups, prgress ntes, and discharge summaries will be reviewed by attending, with written crrectins and cmments t resident as indicated fr imprvement. Attendings are expected t cmplete ne frmal inpatient medical recrd review f each resident during the rtatin. DIDACTIC LECTURES Residents are expected t attend afternn reprt, nn cnferences, and Medicine Grand Runds while n service. Our three year blck lecture schedule reviews cre cntent, and shuld be supplemented with self-directed reading using the Harrisn s Curriculum and patient pathlgy as a guide. Residents are expected t present case management discussins at mrning reprt n assigned dates, in accrdance with case management frmat. ASSIGNED READINGS Residents are expected t have wrking knwledge acquired by develping a reading schedule, n their wn time, f n less than ne hur per day. EDUCATIONAL RESOURCES TO BE USED CHECK REQUIREMENT Required reading: Harrisn s, and prmpted by patient pathlgy/didactics. Likely pprtunistic reading: The Washingtn Manual, Up t Date, ther n-line resurces as apprpriate. Pathlgical material: bipsies, smears, cytlgy, autpsy material. Residents are encuraged t lk at all specimens persnally. Other educatinal resurces t be used: Pre and Pst testing as develped. HARRISON S CURRICULUM PLAN Residents will be assigned chapters belw as reading assignments Set chapters will be discussed each week 17

Residents will be assigned an individual chapter r chapters thrughut the year t present during Wednesday AR (date may be changed due t residents in clinic) Residents in Clinic will nt present but will still prvide study guides Each resident will frmulate a study guide reviewing the material in their chapter(s) This study guide will frm the basis fr resident evaluatin Failure t turn in timely wrk will result in prfessinalism vilatin and assignment f mre chapters/study guides Study Guides will be distributed t the husestaff as shared study material Harrisn s AR are NOT a time fr pwerpint presentatins f tpics but fr discussin f the week s readings and areas f cncern (high yield areas and/r cnfusing subjects) Cnference will be every Wednesday at 3pm Gals Imprve residents self-directed learning skills Reinfrce cncepts seen n Wards and in Clinics with reading materials Prduce study materials fr subsequent use in Bard Preparatin Please see accmpanying Blcks belw with dates General Internal Medicine Blck (11) (7/14-8/17) (4 weeks) Chapter 4 Screening and Preventin f Disease Chapter 8 Medical Evaluatin f the Surgical Patient Chapter 20 Syncpe Chapter 25 Cnfusin and Delirium Chapter 74 Vitamin and trace Mineral Deficiency and Excess Chapter 78 Evaluatin and Management f Obesity Chapter 79 Eating Disrders Chapter 82 Preventin and Early Detectin f Cancer Chapter 122 Immunizatin Principles and Vaccine use Chapter 241 The Pathgenesis, Preventin, and Treatment f Athersclersis Chapter 247 Hypertensive Vascular Disease Cardilgy Blck (12+2) (8/18-9/29) 1 week ECG at end f GIM Blck and 4 weeks Cards. Chapter 227 Physical Examinatin f the Cardivascular System Chapter 228 Electrcardigraphy Chapter 229 Nninvasive Cardiac Imaging Chapter 232 The Bradyarrhythmias 18

Chapter 233 the Tachyarrhythmias Chapter 234 Heart Failure and Cr Pulmnale Chapter 237 Valvular Heart Disease Chapter 238 Cardimypathy and Mycarditis Chapter 239 Percardial Disease Chapter 243 Ischemic heart Disease Chapter 244 Unstable Angina and NSTEMI Chapter 245 STEMI Chapter 248 Diseases f the Arta Chapter 249 Vascular Diseases f the Extremities Nephrlgy (10 assignments) (10/1-10/22) 4 weeks. Chapter 279 Acute Kidney Injury Chapter 280 Chrnic Kidney Disease Chapter 283 Glmerular Diseases Chapter 285 Tubulinterstitial Diseases f the Kidney Chapter 281/282 Dialysis/Transplantatin in Treatment f Renal Failure Chapter 286 Vascular Injury t the Kidneys Chapter 287 Nephrlithiasis Chapter 44 Aztemia and Urinary Abnrmalities (Fcus n Clinical Cntext) Chapter 45 Fluid and Electrlyte Disturbances Chapter 47 Acidsis and Alkalsis Pulmnary Critical Care (13) (10/29-11/16) 4 weeks; This includes Critical care as well. Chapter 250 Pulmnary HTN Chapter 252 Disturbances f Respiratry Functin Sectins n Apprach t the Patient in Gas Exchange sectin Clinical Crrelatins Sectin Chapter 264 Disrders f Ventilatin Sectins n Hypventilatin Syndrmes and Hyperventilatin nly Chapter 254 Asthma Chapter 260 Chrnic Obstructive Pulmnary Disease 19

Chapter 257 Pneumnia Chapter 261 Interstitial Lung Diseases Chapter 255 Hypersensitivity Pneumnitis Chapter 256 Occupatinal and Envirnmental Lung Disease Chapter 263 Disrders f the Pleura and Mediastinum Chapter 265 Sleep Apnea (Shrt Chapter), Chapter e51 Altitude Illness Chapter 268 Acute Respiratry Distress Syndrme Chapter 270 Apprach t Patient with Shck Brief review f Types f Shck Heme/Onc (20) (11/17-1/11) 6 weeks (with Hliday Schedule in between) Chapter 87 Cancer f the Skin Chapter 88 Head and Neck Cancer Chapter 89 Neplasms f the Lung Chapter 90 Breast Cancer Chapter 97 Gyneclgic Malignancies Cndense Breast and Gyn Cancers Chapter 91 GI Tract Cancer Chapter 92 Tumrs f the Liver and Biliary Tree Chapter 93 Pancreatic Cancer Cndense GI malignancies tgether Chapter 94 Bladder and Renal Cell Carcinmas Chapter 98 Sft Tissue and Bne Sarcmas Chapter 99 Carcinma f Unknwn primary Chapter 100 Paraneplastic Syndrmes Chapter 103/105 Fe Deficiency and Megalblastic Anemias Chapter 106-108 Hemlytic, Aplastic Anemias and PCV Chapter 109 Acute and Chrnic Myelid Leukemia Chapter 110 Malignancies f Lymphid Cells Chapter 111 Plasma Cell Disrders Chapter 112 Amylidsis 20

Chapter 116 Cagulatin Disrders Chapter 117-118 Arterial and Venus Thrmbsis/Anticagulant drugs. Gastrenterlgy (12) (1/12-2/8) 4 weeks Chapter 292 Disease f the Esphagus Chapter 293 Peptic Ulcer Disease and Related Disrders Chapter 294 Disrders f Absrptin Chapter 295 Inflammatry Bwel Disease Chapter 297 Diverticular Disease and Cmmn Anrectal Disrders Chapter 304 Acute Viral Hepatitis Chapter 305 Txic and Drug-Induced Hepatitis Chapter 306 Chrnic Hepatitis Chapter 307 Alchlic Liver Disease Chapter 308 Cirrhsis and its Cmplicatins Chapter 311 Diseases f the Gallbladder and Bile Ducts Chapter 313 Acute and Chrnic Pancreatitis Infectius Disease (8, large tpics ) (2/9-3/8) 4 weeks. This is a difficult sectin t assign readings fr as there are multiple chapters n less cmmn infectins that are bard favrites. Chapter 130 Sexually Transmitted Infectins Chapter 128/129 Acute Diarrheal and C. Diff Chapter 125/126 Infectins f sft tissues and Ostemyelitis Chapter 124 Infective Endcarditis Chapter 189 HIV: AIDS and Related Disrders Chapter 165 Tuberculsis Sectin 16 Funal Infectins Fcus n clinical aspects with Diagnses, clinical cntext and treatment Sectin 18 Prtzal Infectins Fcus n clinical aspects with Diagnses, clinical cntext and treatment Rheumatlgy/ Allergy Immunlgy (13) (3/9-4/5) 4 weeks (including 1 week fr Allergy) Chapter 332 Ostearthritis Chapter 333 Gut and Crystal-Assciated Arthrpathies Chapter 321 Rheumatid Arthitis 21

Chapter 334/335 Infectius Arthritis, Fibrmyalgia Chapter 319 SLE Chapter 320/324 Antiphsphlipid Antibdy Syndrme/ Sjgren s Syndrme Chapter 323 Systemic Sclersis and Related Disrders Chapters 322/327/328 Acute Rheumatic Fever, Behcet s, relapsing Plycndritis Chapter 329 Sarcidsis Chapter 388 Plymysitis, Dermatmysitis and Inclusin Bdy Mysitis Chapter 325 The Spndylarthritides Chapter 326 The Vasculitis Syndrmes Chapter 316 Primary Immune Deficiency Diseases Endcrinlgy (10) (4/6-5/3) 4 weeks Chapter 344 Diabetes Mellitus Chapter 353 Disrders f the Parathyrid Gland and Calcium Hmestasis Chapter 354/355 Osteprsis and Paget s Disease and Other Dysplasias f Bne Chapter 339 Disrders f Anterir Pituitary and Hypthalamus (Large!) Fcus n Prlactin, GH, Gnadtrpins and DI Chapter 341 Disrders f Thyrid Gland Chapter 342 Disrders f Adrenal Crtex Chapter 346 Disrders f the Testes and Male Reprductive System Chapter 347 The Female Reprductive System, Infertility and Cntraceptin Chapter 349/351 Disrders f Sexual Develpment/ affecting Multiple Endcrine Systems Chapter 357/360 Hemchrmatsis/Wilsn s Disease Neurlgy (10) 5/4-5/31 (4 weeks) Als have several Psychiatry tpics in here. Chapter e42 The Neurlgic Screening Exam (watch the vide) Chapter 369 Seizures and Epilepsy Chapter 370 Cerebrvascular Diseases Chapter 381 Meningitis, Encephalitis, Brain Abscess and Empyema Chapter 382/382 Chrnic and Recurrent Meningitis/ Prin Diseases Chapter 371 Dementia (relatively shrt) Chapter 372 Parkinsn s Disease and Other Mvement Disrders 22

Chapter 376 Trigeminal Neuralgia, Bell s Palsy, and Other Cranial Nerve Disrders Chapter 385/386 Guillain-Barre Syndrme/Myasthenia Gravis Chapter 391 Mental Disrders (LONG!) Chapter 394 Ccaine and Other Cmmnly Abused Drugs Last Blck (13) is kept fr Bard Review series similar t this year. EXPECTATIONS OF RESIDENTS AND ATTENDINGS AS TEACHERS ROLE OF THE PGY-1 They instruct students hw t write rders, d certain prcedures, arrange testing and cnsultatins, and find and interpret labratry and study results. They discuss n a daily basis management issues relating t jintly managed patients. They read, crrect, and cuntersign student s daily prgress ntes, and they cntribute t case-related teaching that ccurs n wrk runds, attending runds, and seminars. ROLE OF THE PGY-2/PGY-3 Residents review the expectatins f the student n the ward service and set standards that are specific t the service and t the resident s teaching style. Residents are expected t engage case-based teaching arund cases handled by students, specifically at times f decreased patient management activity, such as at night, n call, and prir t scheduled cnferences. This entails ensuring adequate data cllectin (apprpriate histry, physical and lab results) by the student, reviewing the student s understanding f each prblem and management plan, reviewing each student write-up; practice and cach the student in mck-presentatin f the case befre the student presents t the attending, and assist the student in gaining knwledge f key principles f pathphysilgy and case-management pertinent t the rtatin. Residents are als t prvide immediate and n-ging feedback t students n all aspects f their perfrmance, as well as prvide summative evaluatin at mid and end f rtatin. LINES OF COMMUNICATION Multiple lines f cmmunicatin are necessary t ensure bth educatinal and patient care bjectives. Patient/Family/Nurse cmmunicatin: The primary line f cmmunicatin is frm the patient t his r her physician, the PGY-1 r subintern. This physician shuld be the first t see patients daily, be the first t 23

enter the rm n wrk runds, and present cases at the bedside at teaching runds, unless the MSM-3 student is presenting. Majr request and needs are t be expressed by the patient and nurses t the PGY-1 and slved at that level first. Additinally, significant cunseling f the patient, such as results f diagnstic test, planned therapy, bad news, advance directives, etc., is the duty f the PGY-1 t initiate and cmplete. If cmmunicatin prblems exist between the patient r nurse and PGY-1 r subintern, the patient r nurse will next pursue cmmunicatin with the PGY-2/3. If cmmunicatin is unsuccessful here, the attending will be called. Any failure f cmmunicatin abve the level f the PGY-1 will be evaluated by the attending, with apprpriate feedback. Orders are t be written by the PGY-1 except in nly rare and emergent circumstances by ther n the team at the PGY2/3 r attending level. The attending is t be called by the PGY2/3 n each admissin within 4 hurs f acceptance. The attending is t be infrmed f the tentative diagnsis, management issues, and prgnsis in rder t determine his need t persnally evaluate the patient within a timely manner. The attending will see all patients and write his nte within 24 hurs f admissin. Fr cnsultatins, the primary line f cmmunicatin shuld be between the attending and attending cnsultant. The attending physician shuld sign all cnsult requests after discussing the reasn fr the cnsultatin with the residents. The attending may delegate calling in f cnsultatin by the resident if the typical prcedure invlves first discussin at a resident r fellw level. Cnsultatin recmmendatins are t be implemented nly after discussin by the attending and residents and discussin f decisins between the PGY-1 and patient. PROGRESSIVE PATIENT CARE RESPONSIBILITY OF RESIDENTS Fr each year f the prgram, residents will have increasing patient care, leadership, teaching, and administratin respnsibility. They demnstrate their cmpetency within the cntext f the patient care and educatinal respnsibilities expected f them. PGY-1 (CATEGORICAL AND PRELIMINARY) PGY-1 residents (interns) will attain cmpetency in the fllwing areas: Humanism, Prfessinalism, Medical Ethics, Clinical Methd, Cntinuity f Care, Medical Interview, Physical Diagnsis, Clinical Pharmaclgy, Medical Infrmatics. They will attain in-depth knwledge f clinical cnditins fund in inpatients, mst f whm are severely ill, with cmplex medical prblems. They will learn the basic rules f medical care and apply them t their patients in an increasingly persnalized manner. They will engage in supervised, meaningful care f limited numbers f patients t achieve these cmpetencies. 24

They will learn and be tested n key cmpetencies f data gathering and physical examinatin in nnpatient care settings. Categrical interns are respnsible fr cntinuity care f a panel f patients. Interns are respnsible t prvide pertinent and timely educatin t students wrking with them. PGY-2 PGY-2 residents will further develp and expand thse cmpetencies acquired as interns, and begin t acquire remaining cmpetencies. They will engage in supervised, meaningful care f increased numbers f patients wh have increasing cmplexity and ambiguity. Care will be increasingly persnalized and individualized t meet patient needs. PGY-2 residents are respnsible fr leading their inpatient ward team, teaching interns and students, participating in jurnal club, subspecialty cnference and mrning reprt teaching. They will learn the cmpetencies f practice-based learning and systems based practice thrugh participatin in seminars in medical ecnmics and schlarly activities such as evidence-based resident reprt and jurnal club. PGY-3 PGY-3 residents cntinue t expand and refine cmpetencies t qualitative and quantitative standards f excellence befre graduatin, enabling them t meet criteria t sit fr the examinatin f the American Bard f Internal Medicine and achieve passing scre. They will see mre patients in ambulatry and cnsultative settings, demnstrate refinement f the 6 cre cmpetencies and 6 quality cmpetencies t all areas f internal medicine practice, and increasingly fster imprvements in their wn care and the care prvided by the health care system. PGY-3 residents are respnsible fr leading their inpatient ward teams, participating in hspital quality assurance activities, teaching subrdinates and peers t include a nn cnference and increased numbers f ther cnferences. PGY-3 residents are expected t engage in schlarly activity, t include nn cnferences, jurnal club, written case reprts, published research, and/r paper presentatins, and reprts and essays pertinent t clinical rtatins as utlined belw. ATTENDING SUPERVISION POLICY DEFINITIONS 25

Supervisin - Supervisin refers t the dual respnsibility that an attending physician has t enhance the knwledge f the resident and t ensure the quality f care delivered t each patient by any resident. Such cntrl is exercised by bservatin, cnsultatin and directin. It includes the imparting f the attending physician s knwledge, skills, and attitudes by the attending physician t the resident and ensuring that patient care is delivered in an apprpriate, timely, and effective manner. POLICY The intent f this plicy is t ensure that patients will be cared fr by clinicians wh are qualified t deliver care and that this care will be dcumented apprpriately and accurately in the patient recrd. This is fundamental, bth fr the prvisin f excellent patient care and fr the prvisin f excellent educatin and training. Faculty supervisin f residents assures resident educatin. The quality f patient care, patient safety, and the success f the educatinal experience are inexrably linked and mutually enhancing. Incumbent n the clinical educatr is the apprpriate supervisin f the residents as they acquire the skills t practice independently and simultaneusly prvide the highest standard f patient care. SCOPE A. Attending physicians are respnsible fr the care prvided t each patient, and they must be familiar with each patient fr whm they are respnsible. Fulfillment f that respnsibility requires persnal invlvement with each patient and with each resident wh is participating in the care f that patient. Each patient must have an attending physician f recrd whse name is recrded in the patient chart. It is recgnized that ther attending physicians may, at times, be delegated respnsibility by the attending physician f recrd. In this case, the attending physician f recrd is respnsible t be sure that the residents invlved in the care f the patient are infrmed f such delegatin and can readily access an attending physician at all times and the attending f recrd, if necessary. B. Within the scpe f the training prgram, all residents must functin under the supervisin f an attending physician. Backup must be available at all times thrugh mre senir residents and apprpriately credentialed attending physicians. The levels f supervisin are: 1. Level 1 - The attending physician is physically present and directly invlved in the care/prcedure. 26

2. Level 2 - The attending physician is present in the perative/prcedural suite r n the unit and immediately available fr cnsultatin. 3. Level 3 - The attending physician is immediately available in the facility. 4. Level 4 - The attending physician is ff-site and able t be present in the hspital within a reasnable amunt f time. C. In rder t ensure patient safety and quality patient care while prviding the pprtunity fr maximizing the educatinal experience f the resident in the ambulatry setting, it is expected that an apprpriately privileged attending physician will be available fr supervisin during clinic hurs. Patients fllwed in mre than ne clinic will have an identifiable attending physician fr each clinic. Attending physicians are respnsible fr ensuring the crdinatin f care that is prvided t patients. POLICY STANDARDS Quality graduate medical educatin can ccur nly in settings that are characterized by the prvisin f high quality patient care. As a practical matter, preparing future practitiners t meet patients expectatins fr excellence requires they learn in envirnments epitmizing the highest standards f medical practice. Even mre imprtant, as an ethical matter, justifying the participatin f residents in the care f patients requires adherence t uncmprmised standards f quality medical care. A. The attending physician f recrd is respnsible fr the quality f all f the clinical care services prvided t his r her patients. B. All clinical services prvided by resident physicians must be supervised apprpriately t maintain high standards f care, safeguard patient safety, and ensure high quality educatin, based n patient acuity and a resident s graduated level f respnsibility. C. Attending physicians directly respnsible fr the supervisin f patient care services prvided by resident physicians must be as available t participate in that care as if residents were nt invlved; the presence f residents t cver patients n inpatient services r t prvide care in ambulatry settings des nt diminish the standards f availability required f the physician f recrd. D. Attending physicians are respnsible fr determining when a resident physician is unable t functin at the level required t prvide safe, high quality care t assigned patients, and must 27

have the authrity t adjust assigned duty hurs as necessary t ensure that patients are nt placed at risk by resident physicians wh are verly fatigued r, therwise, impaired. PROCEDURE A. All patient care perfrmed by residents during training will be under the supervisin f an attending physician credentialed t prvide the apprpriate level f care. The specifics f this supervisin must be dcumented in the medical recrd by the attending physician r resident accrding t Medical Staff rules and regulatins. B. The supervising/attending physician must be immediately available t the resident in persn r by telephne 24 hurs a day during clinical duty. Residency Prgram Directrs must assure this ccurs. Residents must knw which supervising/attending physician is n call and hw t reach this individual. C. Inpatient supervisin: The supervising/attending physician must btain a cmprehensive presentatin frm the resident including a histry and physical with c-signed attending attestatin fr each admissin. This must be dne within a reasnable time, but always within 24 hurs f admissin. The supervising/attending physician must als require the resident t present the prgress f each inpatient daily, including discharge planning. All required supervisin must be dcumented in the medical recrd by the resident and/r the supervising/attending physician accrding t Medical Staff rules and regulatins. D. D. Outpatient supervisin: The supervisin/attending physician must require residents t present each utpatient s histry, physical exam and prpsed decisins. All required supervisin must be dcumented in the medical recrd by the resident and/r the supervising/attending physician accrding t Medical Staff rules and regulatins. E. Cnsultative Service supervisin: The supervising/attending physician must cmmunicate with the resident and btain a presentatin f the histry, physical exam and prpsed decisins fr each referral. This must be dne within an apprpriate time but n lnger than 24 hurs after cmpletin by the resident f the cnsultatin request. All requires supervisin must be dcumented by the resident and/r the supervising/attending physician accrding t Medical Staff rules and regulatins. F. Prcedural supervisin: The supervising/attending physician must ensure that prcedures perfrmed by the resident are warranted, that adequate infrmed cnsent has been btained and that the resident has an apprpriate level f supervisin during the prcedure. The level f supervisin (accrding t the fur levels utlined previusly in this plicy) must match bth the 28

resident s ability t determine the apprpriateness f the prcedure and the resident s ability t perfrm the prcedure. All required supervisin must be dcumented by the resident and/r the supervising/attending physician accrding t Medical Staff rules and regulatins. G. Emergency supervisin: During emergencies, the resident shuld prvide care fr the patient and ntify the supervising/attending physician as sn as pssible t present the histry, physical exam and planned decisins. All required supervisin must be dcumented by the resident and/r the supervising/attending physician accrding t Medical Staff rules and regulatins. H. Each department develps specific guidelines cncerning resident supervisin and submits them t the GMEC fr apprval. These must include the fllwing key principles: 1. Clinical respnsibilities must be cnducted in a carefully supervised and graduate manner, tempered by prgressive levels f independence t enhance clinical judgement and skills. This supervisin must supply timely and apprpriate feedback abut perfrmance, including cnstructive criticism abut deficiencies, recgnitin f success, and specific suggestins fr imprvement. Resident supervisin must supprt each prgram s written educatinal curriculum. Resident supervisin shuld fster humanistic values by demnstrating a cncern fr each resident s well-being and prfessinal develpment. Faculty and residents must be educated t recgnize the signs f fatigue and adpt and apply plicies t prevent and cunteract the ptential negative effects. 2. Residents are supervised by teaching staff in accrdance with these established guidelines. 3. Faculty call schedules are structured t assure that supprt and supervisin are readily available t residents n duty. 4. The quality f resident supervisin and adherence t the abve guidelines are mnitred thrugh annual review f the resident s evaluatins f their faculty and rtatins by the GMEC (see Evaluatins f Rtatins and Faculty Members by Resident Plicy). 5. Fr any significant cncerns regarding resident supervisin, the apprpriate Residency Prgram Directr will submit a plan fr its remediatin t the GMEC fr apprval. 29

AMBULATORY AND CONSULTATIVE ROTATIONS (REQUIRED AND ELECTIVE) Ambulatry and Cnsultative Care experiences are extremely imprtant in preparing residents fr the bulk f their future practice. Residents will select these nn-ward mnths after declaring their track and discussing their desires with their advisr. In general, patients are seen bth in the clinics and in inpatient cnsultatin. Depending n the rtatin percentage f ambulatry time, zer, 50 r 100% mnth credit will be given fr Meaningful Patient Respnsibility fr rtatins listed. Patients with acute and chrnic illnesses in the named specialties are seen during the rtatin. Unless specified, rtatins are at the VA r bth VAMC and GRU. Applicatin fr specific nn-ward rtatins will be apprved by the Prgram Directr cntingent upn the chsen track f resident, perfrmance n in service exam subspecialty cmpnents, and availability f teaching space n the rtatin fr the mnth desired. Residents shuld plan their nn-ward rtatins early in the academic year and must have their request submitted by the 5 th f the previus mnth. CORE ROTATIONS Fr mre detailed infrmatin abut each rtatin, visit the IM Website. http://www.gru.edu/mcg/residents/internalmed/ ELECTIVES ROTATIONS Gastrenterlgy Cnsults/Clinics Cardilgy Cnsults/Clinics Cardilgy EP Neurlgy Inpatient r Outpatient University Hspital Hspitalist Rtatin ER Geriatric Clinics Rheumatlgy Cnsults/Clinics Pulmnary Cnsults/Clinics Endcrine Cnsults/Clinics Nephrlgy Cnsults/Clinics Infectius Disease Cnsults/HIV Clinic Wmen s Health 30

Sprts Med/Orthpedics/Rheum (Musculskeletal) Rehabilitatin-(VAMC Spinal Crd Unit) WIC (walk-in clinic) VAMC r GRU Dermatlgy Clinic/Cnsults Ophthalmlgy Research Mnth (needs defined and apprved research prtcl and mentr, cmpletin f Clinical Trials Cmpetency 4 mdule training prir) Off Campus Elective (maximum ne mnth at US ACGME apprved prgram, see plicy fr apprval) SUPERVISED CARE OF LIMITED NUMBERS OF HOSPITALIZED PATIENTS AND CONCURRENT EDUCATIONAL ACTIVITIES All patient care will be supervised by a designated attending physician wh is respnsible nt nly fr the utcme f the patient, but alng with the resident, attainment f the educatinal cmpetencies assciated with that patient r type f care. Each rtatin has specific detailed curriculum lcated n the GRU Internal Medicine Website. http://www.gru.edu/mcg/residents/internalmed/ Residents are expected t knw and cmplete specific requirements f each rtatin listed therein. Attendings will prvide equal emphasis n patient care and educatin during the time available. 1. General Medicine Wards Patients with mderate t severe acute and chrnic medical prblems requiring hspitalizatin. Cmpetencies primarily relate t management f cmplex, very ill patients with infectius, pulmnary, gastrintestinal, metablic, rheumatlgic, and neurlgic diseases within the hspital, and planning fr discharge fr cntinuity f care and maximal well being, incrprating palliative care principles and practice. 2. MICU Patients with severe cmplex acute and chrnic medical prblems requiring hspitalizatin in the intensive care unit. Cmpetencies relate primarily t care f severely ill patients with altered physilgy and include prcedure required t diagnsis and apprpriate manage such patients. 3. Cardilgy and CCU 31