Internal Medicine Inpatient Service at Crawford Long Hospital

Hospital Medicine

Internal Medicine/Family Medicine Inpatient Service

I.Rationale

Family physicians manage inpatient medical patients and require an expertise in this area.The Family Medicine inpatient rotation will enable the resident to begin a successful career in family medicine and develop competence in the inpatient arena. This will be achieved through a progressive teaching curriculum which emphasizes a balance of didactic and bedside instruction in the inpatient setting.

II.Goals

Residents will be evaluated on the following six competencies, eventually achieving the expected level of a board certified family physician. Achievement of satisfactory performance levels for all six competencies will be necessary for successful completion of the rotation.

III.Objectives

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. 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.

C. Gain knowledge of the common medical problems and symptoms that require hospital

admission and management.

D. Develop a differential diagnosis for a these medical problems.

E. Learn appropriate laboratory and radiological testing required to investigate diagnoses in a

cost-effective, evidence-based medical approach.

F. Study and gain understanding of the following medical conditions:

1. Chest Pain

2. Myocardial infarction

3. Heart Failure

4. Atrial Fibrillation

5. Dysrhythmia

6. Stroke

7. Pneumonia

8. Urosepsis

9. COPD/Asthma exacerbation

10. DKA

11. Abdominal Pain

12. PUD/GI bleed

13. Symptomatic anemia

14. HIV Infections

15. Asthma

16. Acute Pancreatitis

17. Diarrhea

18. Dehydration/volume depletion

19. Acute Renal Failure

20. Electrolyte Imbalance

21. Pulmonary Embolism/DVT

22. Substance Abuse

23. Overdose

24. Suicidal Ideation/Depression

25. Malnutrition

26. Hypertensive Crisis

Learning Activities
X / Attending Rounds / Research Conference / X / Outpatient Clinics
X / Multidisciplinary Rounds / X / Ethics/Comm Conference / X / Direct Patient care
X / Grand Rounds / X / Specialty Conference / X / Resident Seminar
Sub-Specialty Conference / X / Noon Conference / X / Journal Club
X / Morning Report / X / Faculty Supervision / X / Readings
X / Didactics / X / Procedures
Other
Evaluation Methods
X / Attending Evaluation / X / Directly Supervised Procedures / X / Morning Report
X / Program Director
Review / X / In-Training Exam / X / Faculty Supervision and Feedback
360 ᵒ evaluation / Videotape Review / X / Quarterly Review
Other

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. Residents are expected to:

Collect information in a focused manner to analyze the patient’s problem. Plan work up

and treatment in a cost-effective, evidence-based manner.

1. Perform a thorough, focused examination appropriate to the symptoms ordifferentialdiagnosis.

2. Plan appropriate work-up appropriate for the patient's medical condition.

3. Integrate medical, clinical, and environmental data to plan sufficient and costeffective testing and treatment for the patient.

Perform, with the goal of obtaining competency, all medical and invasive procedures considered essential for the area of hospital medicine practice

1. Venipuncture

2. Lumbar puncture

3. Running Codes

4. Intubation

5. Start IV’s

6. Placement of NG Tubes

7. Placement of urinary catheter

8. Paracentesis

9. Thoracentesis

10. Joint Aspiration

11. Blood Gas interpretation

C. Develop competency in describing the indication for and interpretation of the following:

1. Plain x-ray interpretation (Chest, extremities, KUB)

2. CT scan with and without contrast (head, chest, abdomen/pelvis, extremities)

3. MRI with and without contrast (head, chest, abdomen/pelvis, extremities)

4. Ultrasound (Abdomen/pelvis, thyroid)

5. Bone Scan

6. PET scan

7. Pharmacologic and Exercise Stress Testing

8. Stress ECHO

9. EKG interpretation

D. Communicate effectively and demonstrate caring and respectful behaviors when interacting

with patients and their families.

E. Gather essential and accurate information about their patients.

F. Make informed decisions about diagnostic and therapeutic interventions based on patient

information and preferences, up-to-date scientific evidence, and clinical judgment.

G. Develop and carry out patient management plans.

H. Counsel and educate patients and their families.

I. Use information technology to support patient care decisions and patient education.

J. Provide health care services aimed at preventing health problems or maintaining health.

K. Work with health care professionals, including those from other disciplines, to provide patient-

focused care.

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.

D. Arriveat the hospital in a timely fashion to round on patients and attend morning report.

E. Work effectively as a member of ateam.

Respect patient privacy by guarding medical records and discussion of personal information aboutpatients.
Assist patients and their families in planning for future care needs and care decisions based on prognosis for the disease.
Support the patient in their healthcare decisions.
Demonstrate professional, respectful demeanor when addressing team members, patients, ancillary staff, and consultants.
Appear professionally dressed and well groomed.
Completes H&P’s, progress notes and discharge summaries in a timely fashion.
Attends required daily conferences and grand rounds.
Responds to pages and floor calls in a timely fashion.

Learning Activities
X / Attending Rounds / Research Conference / Outpatient Clinics
X / Multidisciplinary Rounds / X / Ethics/Comm Conference / X / Direct Patient care
Grand Rounds / Specialty Conference / Resident Seminar
Sub-Specialty Conference / Noon Conference / X / Journal Club
Morning Report / X / Faculty Supervision / Readings
Didactics / Procedures
Other
Evaluation Methods
X / Attending Evaluation / Directly Supervised Procedures / X / Morning Report
X / Program Director
Review / In-Training Exam / X / Faculty Supervision and Feedback
360 ᵒ evaluation / Videotape Review / X / Quarterly Review
Other

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 theirown education.

G. Learn to incorporate health promotion and disease prevention into patient care.

H. Use evidence-based medicine, evaluation of available evidence, and use of best-available

evidence at morning report meetings and during routine clinical care.

Learning Activities
X / Attending Rounds / Research Conference / Outpatient Clinics
X / Multidisciplinary Rounds / Ethics/Comm Conference / X / Direct Patient care
Grand Rounds / X / Specialty Conference / X / Resident Seminar
Sub-Specialty Conference / Noon Conference / X / Journal Club
X / Morning Report / X / Faculty Supervision / X / Readings
Didactics / Procedures
Other
Evaluation Methods
X / Attending Evaluation / Directly Supervised Procedures / X / Morning Report
X / Program Director
Review / In-Training Exam / X / Faculty Supervision and Feedback
360 ᵒ evaluation / Videotape Review / X / Quarterly Review
Other

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:

Develop patient sensitive skills for interviewing that allow accurate, and complete collectionof information regarding symptoms, the family and the community that affect thepatient's healthand care.
Develop skills in communicating results to patients, their families, other health careproviders.
Develop skills in educating patients and their families, in dealing with sensitive issues for

patients and families, and in negotiating a plan of investigation and treatment with thepatientand family.

Develop professional relationships with co-workers, consultants, ancillary staff and other

professionals to enable assembling of health care teams and mobilization of community resources tooptimize care of the patient.

Develop an understanding of the role of the family medicine consultant, and is able to support

thepatient through the process of consultation, medical evaluation, treatment, rehabilitation and long-term care.

Use professional language and demeanor when communicating with other residents, with Family Medicine attending physicians, with physicians from other services, with non-physician clinical staff, with non-physician non-clinical staff, and with patients and their families.
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.

Learning Activities
Attending Rounds / Research Conference / X / Outpatient Clinics
Multidisciplinary Rounds / X / Ethics/Comm Conference / X / Direct Patient care
Grand Rounds / Specialty Conference / Resident Seminar
Sub-Specialty Conference / Noon Conference / X / Journal Club
Morning Report / X / Faculty Supervision / Readings
Didactics / Procedures
Other
Evaluation Methods
X / Attending Evaluation / X / Directly Supervised Procedures / Morning Report
X / Program Director
Review / X / In-Training Exam / X / Faculty Supervision and Feedback
360 ᵒ evaluation / Videotape Review / X / Quarterly Review
Other

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.

Learning Activities
Attending Rounds / Research Conference / X / Outpatient Clinics
X / Multidisciplinary Rounds / X / Ethics/Comm Conference / X / Direct Patient care
X / Grand Rounds / X / Specialty Conference / Resident Seminar
Sub-Specialty Conference / Noon Conference / X / Journal Club
Morning Report / X / Faculty Supervision / X / Readings
Didactics / Procedures
Other
Evaluation Methods
X / Attending Evaluation / X / Directly Supervised Procedures / Morning Report
X / Program Dir
Review / X / In-Training Exam / X / Faculty Supervision and Feedback
360 ᵒ evaluation / Videotape Review / X / Quarterly Review
Other

III.Instructional Strategies (see above)

Direct patient care 4.0 - 4.5 days per week in Emory University Midtown Hospital and 0.5 – 1.0 days per week in the Family Medicine Clinic at Dunwoody, providing continuity care.
Completing a thorough H&P, assessment, differential diagnosis, and plan to be presented to the faculty member and inpatient team as appropriate to the particular setting.
Didactics during Internal Medicine noon conferences, weekly grand rounds, bedside roundsand morning report.
Associated rotations for additional hospital medicine experience: Emergency Medicine including adult and pediatric, ICU, Pediatric Wards, Geriatrics
Required readings of the following Monographs:

1. Advances in Hospital Medicine (Dec 2006)

2. Heart Failure Update (Aug 2009)

3. Fluids and Electrolytes (Jan 2006)

IV.Evaluation Strategies (see above)

Observation by Family Medicine faculty
EMR documentationcritique by faculty
Procedure competence certification
End of rotation evaluations for Family Medicine Service
Family Medicine and Internal Medicine Conference attendance
In-training exam profiles
Resident evaluation of rotation and faculty
Completion of required readings and scoring >90% on open book Monograph quizzes

V. Implementation Methods

Family Medicine Inpatient Service block: Hospital medicine experience with core family medicine faculty (Schayes, Blount, Nwosu, Beck, Johnson).

Contact: The resident is expected to arrive for morning report at 7:30 a.m. the first day of the rotation. The team meets on the 6th floor, 61 West Peachtree Building. The family medicine ward attending varies weekly.

Location: Emory University Hospital Midtown

550 Peachtree Street

Atlanta, GA 30308

The ward attending cell phone number is: 678-687-1540

Family Medicine Center: PGY1 - One half day per week

PGY2 –Two half days per week (may vary depending on number of residents on

service)

PGY3- Two half days per week (may vary as above)

Call/Vacation: Night shift is on the Family Medicine Service from 6:30pm to 8:30am on weekdays and 8:30am to 9:30am on Saturdays and Sundays. Vacation is NOT ALLOWED on this rotation.

Supervision: Attending faculty will be asked to complete evaluations of performance. Procedure documentation should be initialed by the supervising physician, whether faculty or senior resident, and must be done with supervision until proficiency is established by an attending with use of the competence form.

Conferences: The resident is expected to attend all internal medicine noon conferences, Friday morning grand rounds, and family medicine didactic conferences as able.

Required Readings: Monographs (see above)

PGY 1 Responsibilities

Admissions by junior residents include a dictated H&P, problem list construction, development of appropriate differential diagnoses, daily note composition, and planning patient care. The H&P must be dictated within 24 hours. The resident is responsible for notifying the attending faculty regarding an admission as soon as adequate information is obtained which indicates admission is necessary. All patients presenting to L & D triage or admission require notifying the attending faculty.
All patients should be cared for jointly by residents on the service.
Track and report on current test results, workup plans, and management plans.
Discuss patient assessment and plan for new and old patients with the senior resident to

refine the management of the case. Notify the attending faculty of any change in status of the patient.

Communicate regularly with the patient's primary care physician.
Keep a current problem list.

Last Updated April 19, 2013

Follow the patient closely to develop a sense of the course of illness and effect on the patient and family's psychological and physical state.
Read regarding patients on the service and contribute information to morning report and team rounds as appropriate.
Coordinate the care by health care team members for their patients.
Work with the team, patient, and family in preparing for discharge and followup care with their primary care physician or with the resident if no primary physician exists for the

patient.

Call the senior resident for assistance before the work load becomes excessive and when the problems in a patient exceed their competence and confidence.
The primary resident on the service caring for a patient will first-assist in the operating room for surgical cases arising on the service whenever possible.
Plan a followup home visit on one of the patients discharged from the service during that rotation.
See patients in the FMC 1 session per week.
Help problem solve when relationship problems occur with attendings, residents, hospital staff, or rotation arrangements.
Complete an end of the rotation evaluation on the rotation and the attending.
Complete diagnosis and procedure cards in an ongoing fashion and encourage the attending to initial the cards.
If the attending has not arranged a midrotation evaluation session with the resident, the resident will request time for discussion of performance and goals for the service.

Workload and Call Responsibilities

All residents are expected to be in the hospital from 7:30 a.m. to 7:00 p.m. Monday through Friday or as designated by an individual faculty member or preceptor, who may require earlier, later, or weekend hours to arrange the best learning experience. If unexpected illness or emergencies occur the resident should make every possible effort to notify the Program Director, Program Coordinator, and the preceptor for the rotation to which he is assigned. If FMC time is affected, the medical director should be notified of the problem. During the above hours the resident is expected to carry his/her beeper and respond within 15 minutes to pages. During the above hours the resident is expected to carry the cell phone for the Service, and answer the telephone promptly when called.

If the resident will not be available by beeper during those hours or if the beeper has been left at home, the hospital operator, FMC receptionist, and program coordinator must be notified as to how the resident or the person covering their duties can be reached for emergencies. During vacations or other periods of absence during routine patient care hours, the resident should call the operator and have the beeper status changed to "not available" or pages transferred to a covering resident or on call group. Scheduled vacations and leaves do not require specific notification of these people. If a resident must leave during the day, the preceptor for the rotation must give permission and the resident must make arrangements for coverage of emergencies.