Department of Medicine

2008-2009 Curriculum

A. General Information

1. Organization and Structure

a. The Department of Medicine at the University of North Carolina at Chapel Hill provides an integrated, progressive experience for residents in their 36-month training period. The goal of our curriculum is to prepare residents to be well-trained general internists. We believe this type of training not only prepares our residents for careers in General Internal Medicine but also provides the necessary foundations for further training as a subspecialist.

The curriculum in the Department of Medicine changes greatly from the PGY-1 year to the PGY-3 year. The PGY-1 year consists of 9 months of inpatient rotations and 3 months of ambulatory medicine. During the second and third years, residents spend an increasing amount of time in the outpatient setting, so that by the time a resident is in the PGY-3 year, a majority of rotations occur in ambulatory medicine. The curriculum will be specifically described for each of the 3 years of training.

The PGY-1 Year Competency- based Goals and Objectives

The PGY-1 curriculum is taught in a series of monthly rotations linked with a number of Departmental teaching conferences. On all rotations the role of the PGY-1 resident is to serve as the primary physician for all of his/her patients. In this role the PGY-1 resident:

1. Performs a history and physical examination on each new patient

2. Enters all orders 3. Communicates with the patient and ward team regarding daily

progress4. Enters a history and physical and daily progress notes into the

patient record5. Develops a diagnostic and therapeutic plan for each patient6. Enters a discharge summary into the patient record

The monthly rotations for each PGY-1 resident are as follows:

Cardiology/MICU - 2 monthsInpatient General Medicine Ward - 2 monthsInpatient Subspecialty Wards - 5 monthsEmergency Room - 1 monthSame-Day Clinic - 1 month

Ambulatory Elective-1 month

Cardiology - consists of 30 beds covered by four teams. Each team is made up of 1 upper level resident and 1 PGY-1 resident. One faculty member and one subspecialty resident are assigned to each team to assist in patient management and to conduct

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teaching rounds. Didactic teaching rounds and bedside teaching occur daily. Also, there is a weekly core curriculum lecture series that is case-based.

A copy of the Cardiology Curriculum is included in Section 2. Common diagnoses of patients admitted to the cardiology service include myocardial infarction, arrhythmias, and chronic heart failure. Residents follow patients in the CCU (12 beds) and the general floor (20 beds). Residents on service place central lines including Swan Ganz catheters and perform arterial blood gases and thoracenteses.

ICU - consists of 19 beds in a MICU. There are 4 teams, each team consisting of 1 upper-level resident and 1 PGY-1 resident. One faculty member serves as attending in the MICU, another in the RICU. There is also a Critical Care Fellow. Teaching rounds include didactic presentations (30 min/day, 6 days/week), bedside teaching (2 hours/day, 7 days/week), and x-ray teaching (30 minutes/day, 6 days/week). There is a designated curriculum (Section 2). Patients admitted commonly have the following diagnoses: GI bleeding, septic shock, drug overdose, s/p cardiopulmonary arrest, DIC, COPD exacerbation, cystic fibrosis, rejection s/p lung transplant, and acute renal failure. Residents perform all procedures.

Inpatient General Medicine - consists of 2 general medicine services. For each service, there is 1 attending, 1 upper level resident, and 2 PGY-1 residents. Teaching rounds occur for 1 hour, 5 times per week covering a number of topics described in the Inpatient General Medicine curriculum (see Section 2). Patients admitted have a variety of problems including: community -acquired pneumonia, COPD exacerbation, diabetic complications, and lupus complications. Residents perform all procedures.

Also, residents rotate at Wake Hospital, a community hospital in Raleigh, NC. There are four teams consisting of 1 attending, 1 upper level resident and 1 resident. Teaching rounds occur for 1 hour five times per week covering topics in General Internal Medicine. Residents perform all procedures.

Inpatient Subspecialty Wards

Service # BedsMedicine A - Geriatrics 24Medicine B - Nephrology 24Medicine E - Hematology/Oncology 48Medicine G - Pulmonary 24Medicine K - Infectious Diseases 24

For each service there is one attending, one upper level resident, and two PGY-1 residents. Each of these services has daily work rounds and attending rounds. Each service has designated teaching time occurring at a minimum of 5 hours per week. During teaching time a series of topics pertinent to each service are reviewed. A copy of each curriculum is included in Section 2. Residents perform all procedures on these services.

Emergency Room - faculty from the Department of emergency medicine supervise PGY-1 residents. PGY-1 residents have a generic experience seeing medical, surgical, and obstetrics/gynecology patients. There are four hours of didactic teaching per week, which cover a wide variety of topics. Examples of monthly topics are included in Section 3.

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Same-Day Clinic - faculty in the Division of General Internal Medicine supervise PGY-1-3 residents. A variety of outpatient problems are encountered. Didactic teaching takes place daily for 30 minutes to 1 hour. Subjects covered in the curriculum are included in Section 3.

This is a walk-in clinic for the established IM patients.

Ambulatory Elective – PGY-1 residents spend one month on a subspecialty service of the Department of Medicine. Consultations are done on inpatients and outpatients and patients are also seen in subspecialty clinics. Division faculty provides faculty supervision. Curricula for each rotation are included in Section 3

Teaching Conferences - PGY-1 residents attend a series of Departmental Conferences. The daily work schedule is set up to allow PGY-1 residents to attend the conferences (Table 1).

TABLE 1UNC Department of Medicine - Schedule of Daily Activities

Time Monday Tuesday Wednesday Thursday Friday0700 Pre-Rounds Pre-Rounds Pre-Rounds Pre-Rounds Pre-Rounds0730

1000Work Rounds Work Rounds Work Rounds Work Rounds Work Rounds

1000 1100

Residents ReportAttending Rounds

Residents ReportAttending Rounds

Residents ReportAttending Rounds

Residents ReportAttending Rounds

Residents ReportAttending Rounds

1200 Core Curriculum Core Curriculum Intern Conference

Grand Rounds/ Morbidity and

Mortality Conference

EBM Conference

Residents are expected to attend all conferences. The conferences are as follows:

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Monday – Residents Core Curriculum Conference - 1 hourTuesday – Residents Core Curriculum Conference - 1 hourWednesday - Interns Conference - 1 hourThursday - Grand Rounds - 1 hourFriday - EBM Conference - 1 hour

The content of some of these conferences is briefly described. Lecture topics are included in Section 4.

Monday and Tuesday - Residents Conference - Faculty in the Department of Medicine presents a series of lectures covering focused topics.

Wednesday - Interns Conference - A lecture series of Emergency Medicine Topics mixed with case-based group discussion.

Thursday – Grand Rounds

Thursday-Mortality and Morbidity–The morbidity and mortality conference centers on a subject relating to patient care in the department. The Vice-Chair of the department conducts this conference

Friday – Evidenced Based Medicine Conference – An evidence-based medicine discussion of selected literature by both faculty and residents.

The PGY-1 year

ACGME Competencies

Each PGY-1 resident must develop competence in the following:

Patient CareMedical KnowledgePractice-based Learning and ImprovementInterpersonal and Communication SkillsProfessionalismSystem-based practice

In the context of the above rotations, competency is defined for each of the categories

Patient care- medical interviews, physical examinations, review of data, procedural skills, diagnostic and therapeutic decision makingMedical Knowledge – basic and clinical science, evidence-based medicine, literature searching

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Practice-based Learning and Improvement – evaluation of own performance, incorporation of feedback, use of technology for patient care and self-improvement

Interpersonal and Communication Skills – establishment of relationship with patients and families, education and counseling of patients, team skills with colleagues

Professionalism – demonstration of respect, compassion, integrity, and honesty, commitment to self-assessment, acknowledges errors, considers needs of patients and colleagues

System-based Practice – ability to utilize resources, uses a systematic approach to reduce errors and improve patient care

These competencies are reviewed with all residents and faculty and serve as the foundation for monthly evaluation.

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The PGY-2 Year

Competency-based Goals and Objectives

The PGY-2 year is also composed of a series of monthly rotations coupled with Departmental teaching conferences. On inpatient rotations the role of the PY-2 resident is to be in charge of ward team. In this role the PGY 2 resident:

1. Performs a history and physical examination on each new patient2. Reviews the treatment plan for each new patient with the PGY 1

resident3. Reviews the performance of MS 3 students4. Conducts daily work rounds5. Supervises all procedures

On night float the resident assumes primary responsibility for the care of new patients in a role like that of the PGY 1 resident.

Monthly rotations for a PGY-2 resident are as follows:

6. MICU – 1 month7. Cardiology - 2 months8. UNC Inpatient Medicine Ward – 2-3 months9. Ambulatory General Internal Medicine – 2-3 months10. Subspecialty Consultation – 2-3 months11. Wake Med – 1 month12. Night Float 2-3 2 week blocks

Cardiology/ICU/Inpatient General Medicine Wards / Inpatient Subspecialty Wards- These have been previously described under the PGY-1 resident. The role of the PGY-2 resident on these services is supervisory. The PGY-2 resident evaluates all patients on service and the PGY-2 resident is integral in constructing a plan of care, which is carried out by the PGY -1 resident. Another major responsibility is teaching. The PGY-2 resident teaches and supervises medical students on these services.

Ambulatory General Internal Medicine - PGY-2 residents can choose from several month blocks focusing on outpatient skills of the generalist. Some of the choices are:

Wake Hospital Ambulatory Rotation - Siler City - PGY-2 residents spend the month in a community setting,

supervised by general internists.

Subspecialty Consultation - PGY-2 residents can choose among any subspecialty in the Department of Medicine. Consultations are done on inpatients. Patients are also seen in subspecialty clinics. Division faculty provides supervision. Curricula for each rotation are included in Section 3.

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Night Float - PGY 2 residents report at 7 PM and until 7 AM and are responsible for the primary evaluation and management of all non-intensive care patients admitted to the Department of Medicine. At 7 AM the care of those patients goes to the incoming team on call. The Attending Physician of the service provides supervision where the patient is admitted.

Teaching Conferences - Like PGY-1 residents, PGY-2 residents attend a series of conferences, which are integrated with the daily work schedule. Some have been described previously including Monday Resident Core Curriculum Tuesday Core Curriculum, Thursday - Grand Rounds, and Friday Evidence Based Medicine. In addition, PGY-2 residents attend Morning Report. This is case-based with residents presenting unknown patients to their peers. The presenting resident completes his/her presentation with a review of a particular subject. This review like all presentations is posted on the internet so that residents my review this at their leisure. These conferences are coordinated by the Chief Residents. The curriculum is set by the chief resident. A list of topics discussed is included in Section 4.

The PGY-2 Year

ACGME Competencies

Each PGY-2 resident must demonstrate competence in the following:

Patient CareMedical KnowledgePractice-based Learning and ImprovementInterpersonal and Communication SkillsProfessionalismSystem-based Practice

Competency is defined as outlined above for PGY 1 residents and is used for the monthly evaluation of PGY-2 residents

The PGY-3 Year

Competency –based Goals and Objectives

In many ways the PGY-3 year is similar to the PGY-2 year in that the residents function as described previously under the PGY-2 year, include teaching conferences. The rotations however, are different, and are as follows:

1. Wake Med – 0-1 Month2. UNC Inpatient Medicine Wards – 1-2 months3. Same Day Clinic - 1 month

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4. Ambulatory General Internal Medicine – 2-3 months5. Subspecialty Consultations – 2-3 months6. Special Electives - 1 month7. MICU or Cardiology – 1 month8. 2-3 2 Week blocks night float

Inpatient General Medicine Wards / Inpatient Subspecialty Wards - The role of the PGY-3 residents is identical to that described previously for the PGY-2 resident.

Same –Day Clinic - The role of the PGY-3 residents is identical to that of the PGY-1 resident.

Ambulatory General Internal Medicine - PGY-3 residents can choose from several month blocks including those described for PGY-2 residents. There are additional choices as follows:

General Medicine Consults- PGY-2 or 3 residents see patients on other services, providing General Medicine Consultations. Supervision is provided faculty from the Division of General Internal Medicine.

Geriatric Medicine - In a one-month block, PGY2-3 residents are exposed to outpatient management of this population. Faculty trained in Geriatrics provide supervision

Subspecialty Consultations - The role of the PGY-3 resident is the same as described for the PGY-2 resident on those rotations.

Special Electives - These rotations are designed to enhance individual training. Residents pick a faculty mentor to conduct clinical or basic research. Rotations at other institutions can also be done.

The PGY-3 Year

ACGME Competencies

Each PGY-3 resident must develop competence in the following:

Patient CareMedical KnowledgePractice-based Learning and ImprovementInterpersonal and Communication SkillsProfessionalismSystems-based Practice

Competency is defined as outlined above for PGY 1 residents and is used in monthly evaluation.

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SECTION 2INPATIENT CURRICULUM

Cardiology

Intensive Care Unit

General Medicine

Geriatrics

Nephrology

Hematology/Oncology

Pulmonary

Infectious Diseases

Neurology

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Section 2Inpatient Curriculum

General

Each inpatient service has designated teaching time, previously described in Section 1. It is the responsibility of the division faculty to review a series of topics during the monthly rotation. The respective division generates these topics with input from faculty and residents as well as data supplied to each division from the preceding In-Training Examination. A dominant theme for these conferences is to review material a general internist must know about each discipline. The curricular goal for each resident is to have a working knowledge of these subjects.

CARDIOLOGY INPATIENT CURRICULUM

OBJECTIVE 1. Takes a historyDemonstrates knowledge necessary to obtain an orderly history on patients suspected of

having cardiovascular diseases and recognizes the importance of

A. Dyspnea (resting, exertional, nocturnal, positional)B. Chest pain (specifically, what constitutes “typical angina)C. EdemaD. Palpitations/arrhytbiniasE. Exercise tolerance, semiquantitativeF. History of hypertension and u~eatrnentG. History of rheumatic feverH. History of congenital heart diseaseI. History of cardiac murmurs or valvular diseaseJ. Cardiovascular risk factors, including family historyK. Presyncope and syncopeL. Claudication

OBJECTIVE 2. Performs a physical examination

Demonstrates knowledge necessary for performing an orderly, systematic and adequate physicaL examination of patients with cardiovascular problems and recognizes the importance of

A. ARTERIAL SYSTEM & JUGULAR VENOUS PULSE

1. Reports and demonstrates the correct method of measuring arterial blood pressure

2. Is familiar with difficulties in measuring arterial blood pressure accurately:

a. Variation between extremities, position, and level of extremityb. The auscultatory gapc. Proper cuff size

3. Is familiar with normal and common abnormal findings found by inspection or palpation of the venous and arterial pulses, inc1uding the foilowing:

a. a,c,v, waves; visual estimation of central venous pressure; hepatojugular reflux

b. effect of inspiration on neck veinsc. pulsus alternans, pulsus bisferiens, pulsus paradoxusd. act-tic regurgitation and stenosis

B. EXAMINATION OF THE HEART

1. Discusses normal and common abnormal findings found by inspection and palpation of anterior chest. including the following:

a. Right and left ventricular heaves: palpable A-wavesb. Thrills

2. Understands the events of the cardiac cycle and the genesis of:

a. Si, S2, S3, S4, summation of gallop, splitting of 52 (normal & reversed), and opening snap

b. mitral valve clicksc. semilunar valve ejection soundsd. Artificial valve sounds (normal & abnormal)e. Innocent murmurs, including flow murmurs, venous hums, mammary

soufflesf. Murmurs of vaivular stenosis and regurgitationg. Maneuvers that alter murmurs, i.e. Valsalva, squatting, inspiration,

expirationh. Pericardial rubs

OBJECTIVE 3. Orders or performs diagnostic studies and interprets laboratory data in a reasonable and cost-effective manner

A. ELECTROCARDIOGRAPHY (EKG)

1. General knowledge of the range of normal variation in P, QRS, ST, T wave2. Understanding of EKG diagnosis of LVH, left atrial enlargement, acute ischemia and

patterns of mvocardial infarction3. Basic understanding of the diagnostic utility of the EKG in the diagnosis of

arrnytbmias

B. CHEST X-RAY

1. General knowledge of normal chest x-ray findings2. Apvreciation of abnormalities- seen in:

a. heart failureb. valvular diseasec. hypertensive diseased. ischemic heart diseasee. common congenital abnormalities seen in adulthood

C. NON-INVASIVE TESTING

1.Basic appreciation of the indications for:

a. echocardiographic assessment (transthoracic and transesoDhageal) including 2D

and Doppler echocard.iographyb. ambulatory EKG (Holter) monitorc. exercise testing with and without perfusion scintigraphv. Including an

understanding of the meaning of sensitivity and specificity with regards to the latter test in the diagnosis of coronary disease

d. tomograpbic imaging techniques, including MRI and CT

D. INVASIVE TESTING

1. Basic knowledge of the methodology involved in performing coronary angiographv,

left ventricular hemodynamic assessment and electrophysioiogic testing;understands the indications and risks of invasive diagnostic procedures

OBJECTIVE 4. Understands the pathophysiology, natural history, clinical

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presentation, diagnostic workup and management of:A. HEART FAILURE

1. Altered myocardial hemodvnamics as well as abnormal neuroendocrine responses2. Precipitating causes of worsened heart failure3. Mechanisms and importance of diastolic dysfunction4. Therapy including relative value and limits of diuretics. digoxin. vasodilators, beta

blockers, inotropes, fluid restriction, and other pharmacologic and non-pharmacologic therapies

B. CORONARY ARTERY DISEASE

1. Risk factors for coronary artery disease and their modification2. Differential diagnosis of chest pain3. Chronic and acute ischemic syndromes (unstable angina and acute MI) with

emphasis on proper history taking -4. Noninvasive and invasive testing in patients with suspected coronary artery

disease5. Complications in acute post-myocardial infarction syndromes such as arrhythmias,

sudden death, mechanical lesions, pericarditis and cardiac rupture6. Indications for coronary angiography7. Role of interventional procedures (e.g. PTCA) and cardiac surgery in treatment of

coronary artery disease

C. ARRHYTHMIAS

I. Bradyarrhythmias including various forms of conduction disturbances and AV block, with emphasis on the indications for pacing

2. Tachyarrhythmias, including an emphasis on the EKG diagnosis of wide complex tachycardias

a. atrial1. atrial tachycardia/AV nodal reentrant tachycardia2. atrial fibrillation3. atrial flutter

b. ventricular1. premature ventricular contractions (PVCs)2. ventricular tachycardia3. torsades de pointes

4. ventricular fibrillationc. pre-excitation syndromes (e.g. Wolff-Parkinson-White)

3. Understands the importance of the use of catheter ablation techniques in treatment ofsupraventricular arrhythmias, including atrial fibrillation

D. CARDIOMYOPATHY

1. Differential diagnosis and laboratory assessment2. Treatment including indications for cardiac transplantation and mechanical

cardiac support3. Follow-up of the post-transplant patient

E. VALVULAR HEART DISEASE

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1. Acute rheumatic fever, including diagnostic criteria2. Aortic stenosis/regurgitation3. Mitral stenosis/regurgitation4. Tricuspid stenosis/regurgitation5. Pulmonary stenosis/regurgitation 6. Mitral valve prolapse

F. PERICARDITIS

1. Acute: etiologv, symptoms and diagnosis2. Chronic: including large pericardial effusion, cardiac tamponade and the indications

for pericardiocentesis3. Diagnosis and management of constrictive pericarditis

G. CARDIAC TUMORS

1. Cardiac involvement in metastatic cancer2. Myxoma

H. CONGENITAL HEART DISEASE

1. Diagnosis, history and physical of the adult with congenital heart disease especially for the diagnosis of

a. atrial septal defectb. ventricular septal defectc. aortic stenosisd. pulmonic stenosise. coarctation of the aorta

2. Basic understanding of the adult with partially corrected congenital heart disease and post-op complications of the more common repair procedures such as:

a. transposition of the great vesselsb. tetralogy of Fallota. Ebstein’s anomaly

PULMONARY HEART DISEASE

1. Cor pulmonale2. Pulmonary embolism3. Primary pulmonary hypertension

J. CARDIAC INVOLVEMENT IN SYSTEMIC ILLNESSES

1. Diabetes mellitus2. Thyroid disease3. Obesity4. Thiamine deficiency5. Pheochromocytoma 6. Rheumatic disorders including scleroderma, SLE, temporal arteritis. polyarteritis

nodosa and rheumatoid arthritis7. Pulmonary embolism and deep venous thrombosis8. Arterial embolism

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K. PERIPHERAL VASCULAR DISEASE

1. Arteriosclerosis obliterans (ASO)

2. Aneurysms

a. abdominal aorticb. thoracic aortic (including aortic dissection)c. peripheral vascular

L. MISCELLANEOUS CARDIAC CONDITIONS

1. Trauma to the heart and great vessels 2. Infectious diseases

a. viral myocarditisb. infectious endocarditis

3. Assess preoperative risk for non-cardiac surgery

OBJECTIVE 5. Develops treatment plan for common cardiac problems A. For each major disease of the cardiovascular system identifies the appropriate therapeutic approach

B. Understands the indications for and can perform the following:

1. Cardiopulmonary resuscitation and advanced life support2. Emergency cardioversion3. Carotid massage4. Central venous pressure catheter insertion5. Recognizes the possible need, and requests medical consultation, for the

performance of the following therapeutic procedures:

a. transvenous pacemakerb. pericardiocentesisc. Swan-Ganz catheter insertiond. elective cardioversion

C. For each of the treatments and drug types listed below identifies indications, dose, mechanism of action, main effects, side effects, adverse reactions, interactions, cost, efficacy, and appropriate follow-up:

1. Digitalis and other inotropic agents 2. Antiarrhythmic drugs3. Diuretics 4. Calcium channel entry blockers5. Beta blockers 6. Angiotensin-converting enzyme inhibitors 7. Vasodilators 8. Anticoagulants & thrombolytic therapy 9. Antihypertensive agents10. Lipid-lowering agents

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11. Rheumatic fever prophylaxis 12. Endocarditis prophylaxis13. Nitrates14. Angiotensin receptor blockers15. Aldosterone antagonists16. Inotropes

D. Informed, aware, and able to participate in and teach to patients, students, medical personnel and colleagues regarding:

1. Preventive cardiology and patient education2. Psychological aspects of cardiac disease3. Behavioral therapy including stress management, risk factor reduction, etc.4. Proper nutrition, especially regarding lipid management and obesity5. Medical “cost/benefit” including different national systems and medical care rationing6. Preventive cardiology

7. The clinical trial and meta-analysis

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INTENSIVE CARE UNIT INPATIENT CURRICULUM

ResuscitationBCLS and ACLSShock: Causes, assessment and treatmentEarly Goal Directed Therapy for Septic Shock

PulmonaryRespiratory failure: Hypoxemic and HypercapnicIntubation criteria, oral/nasal/tracheostomy, complicationsMechanical ventilator modes, monitors and complicationsWeaning criteria and techniques, daily spontaneous breathing trialsARDS: Causes, Physiology, Therapy and ComplicationsAsthma and COPDPulmonary embolismPulmonary hemorrhage

CardiologyShock: Differential diagnosis and initial treatmentAcute MI: Diagnosis, treatment, and complicationsArrhythmiasPericarditis, Tamponade and Constrictive PericarditisCHF and Pulmonary edemaPulmonary artery catheters: Indications, placement, and interpretationInotropic drugs

NephrologyAcute Renal failure: Causes and treatmentRenal Replacement Therapy: Continuous and intermittentElectrolyte abnormalities: Na+, K+, C1-Acid-Base disturbances and compensationsMetabolic acidosis: Increased and normal anion gapUrine electrolytes

MetabolismNutrition: Assessment, requirements, eternal feeding, TPNDiabetic ketoacidosis and non-ketotic hyperosmolar comaAdrenal crisis and steroid therapy

GastrointestinalUpper GI hemorrhageLower GI hemorrhageLiver disease: Alcoholic, viral, otherPancreatitisThe acute abdomen: Causes and Assessment

PoisonsInitial assessment and treatment optionsAcetaminophenAnti-depressantsSalicylatesAlcohols

InfectionsPneumonias: Community-acquired, hospital-acquired including VAPAspiration pneumonitisCentral Line Related Bloodstream Infections: Prevention and managementTuberculosisImmunocompromised patients and opportunistic infections

HematologyAnemia and transfusionsThrombocytopenia, coagulopathy and DICHemolysisSickle Cell Disease

Administration/EthicsAdmission and discharge criteriaIllness severity scores and prognosesAdvance DirectivesUse/limitation of life sustaining treatmentsPractice and Systems Based Improvements: protocols and data monitoring

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GENERAL MEDICINE INPATIENT CURRICULUM

Likelihood Ratios; testing

Community Acquired Pneumonia

Physical Examination

Pulmonary Emboli

Chest Pain Evaluation; CAD

Diabetic Ketoacidosis, complications

Meningitis

Venous Stasis Ulcers

Peripheral Vascular Disease

W/U of Diarrhea

COPD, acute exacerbation

Depression, mood disorders

Stroke, endarterectomy

Hypertension Emergencies

Common Biliary Tract Diseases, Cholecystitis, Cholangitis

Dementia

Delirium

Diverticulitis

Avitaminoses

Peripheral Neuropathy

Cellulitis

Pulmonary Nodule

Anemia, chronic disease, liver disease, etc.

Pancreatitis

Poisonings, ethylene glycol, arsenic, etc.

Geriatrics Inpatient Curriculum

Geriatrics Curriculum for Internal Medicine Residents

Current requirements from the Residency Review Committee for Internal Medicine, as outlined by the Accreditation Council for Graduate Medical Education, specify that “Residents must have formal instruction and assigned clinical experience in geriatric medicine. The curriculum and clinical experience should be directed by an ABMS –certified geriatrician. These experiences may occur at one or more specifically designated geriatric inpatient units, geriatric consultation services, long-term care facilities, geriatric ambulatory clinics, and/or in home care settings.”

The Department of Medicine at the University of Chapel Hill currently has a separate Division of Geriatric Medicine with faculty and fellows in graduate medical training who are dedicated to the education of medical students and residents.

Currently residents receive training in the care of geriatric patients in both the inpatient and outpatient settings.

Inpatient Geriatric Curriculum:

UNC currently has a Geriatric Inpatient Service that is always staffed by one of the faculty from the Division of Geriatric Medicine. Internal Medicine residents who rotate on this service work closely with the Geriatrics Faculty Attending in the care of older adults with acute medical illnesses.

Based upon the guidelines as outlined by the AGS Education Committee in 2004, resident trainees on this rotation will meet the following goals in attitudes, knowledge and skills required for the appropriate care of older patients.

1. Attitudes: This training program encourages respect for older people and their autonomy. The rotation on the inpatient service promotes compassionate, high quality care. Residents gain an appreciation for the heterogeneity in older people in respect to functional status, health, values and personal preferences. The resident learns the skills needed to negotiate the goals of care with the patient and family. Our inpatient service offers a truly multidisciplinary experience and the resident learns the importance of this approach to caring for older patients. The resident on our service works closely with a Geriatric Nurse Practitioner, Recreational Therapist, Physical Therapy service, social worker and specialized nurses interested in the care of older adults. The resident on this service truly gains an appreciation for the fact that the maintenance of function and quality of life may be more the goal than cure.

2. Knowledge: Internal Medicine residents who complete a rotation on the inpatient service will know:

a. Age related changes b. Pharmacokinetics and the importance of polypharmacyc. Appropriate history and physical examd. Decision making capacity, competence, autonomy, ethical

considerationse. Role of exercise and rehabilitationf. Comprehensive geriatric assessmentg. Recognition of malnutrition

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h. Preoperative evaluation and postoperative care in older patientsi. End of life care, palliative treatments including management of pain,

dyspnea, and other symptoms

j. Evaluation and management of :

i. Cognitive impairment/dementiaii. Depressioniii. Incontinenceiv. Gait and balance disorders, fallsv. Immobility

vi. Pressure ulcersvii. Polypharmacyviii. Sensory impairmentix. Painx. Delirium

k. Difference in incidence, natural history, presentation, management, and outcomes of medical problems when they occur in elderly patients

3. Skills: The resident will be able to:

a. Perform assessments of basic and Instrumental Activities of Daily Living (ADL and IADL), cognitive function, and gait and mobility

b. Work within an interdisciplinary team to develop a plan of carec. Facilitate medical decision making with older patients, incorporating

medical assessment and patient values and preferencesd. Diagnose and manage acute and chronic multiple illnesses in older

patientse. Conduct discussions regarding goals of care and end of life care

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NEPHROLOGY INPATIENT CURRICULUM

I. Teaching materials

1. Reading materials: Selected articles and publications from journals and nephrology database. (Up to Date)

II. Topics to be discussed during Rounds:

1. Hemodialysis and peritoneal dialysis: techniques

2. Hemodialysis and peritoneal dialysis: dialysis prescription

3. Evaluation of kidney structure and functiona. Urinalysisb. Measurement of GFRc. Evaluation of proteinuriad. Measurement of urinary electrolytese. Renal imaging techniques

4. Chronic kidney disease

5. Acute kidney injury

6. Metabolic acidosis

7. Metabolic alkalosis

8. Disorders of water metabolism (hyponatremia and hypernatremia)

9. Disorders of potassium and magnesium metabolism

10. Disorders of calcium, phosphorus and bone metabolism

11. Overview of evaluation and treatment of hypertension

12. Glomerular syndromesa. nephritic syndromeb. nephrotic syndrome

13. Diabetic nephropathy

14. Principles of kidney transplantation

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HEMATOLOGY/ONCOLOGY INPATIENT CURRICULUM

Hematology/Oncology Inpatient Curriculum

Updated 6/2008

Goals: This rotation should acquaint you with the general principles of diagnosing and treating Hematologic and Oncologic diseases. The inpatient services are divided into one that focuses on patients with malignant hematologic diseases such as the leukemias(E1)and lymphomas and the other (E2) on the rest of oncology. While there is some overlap in the services, we suggest that you focus you reading on the service you were assigned to. Every effort will be made for you to do the other service at least once during your residency. A case based teaching program to supplement your reading that combines patients from both services is done from 11:30 to 12:15 on Mondays, Tuesdays, Wednesdays and Fridays.

1. Acute Leukemia a. ALLb. AML

i. Genetics of AML

c. Clinical Presentation of Acute Leukemiai. Laboratory Diagnosis

ii. Bone Marrow ExaminationD. General Therapy for Acute Leukemia’s

i. Therapy for ALLii. Therapy for AML

Tallman MS, Nabhan G: Acute promyelocytic leukemia.Blood 2002;99:759-67.

2. Sickle Cell Disorders3. Febrile Neutropenia and infected catheters

Mermel LA et al: Guidelines for the management of intravascular catheter related infections. Clin Infect Dis 32:1249, 2001

4. Thrombotic Disordersa. Major Risk Factorsb. Laboratory testing in thrombotic disordersc. Management of a thombotic defectd. Treatment and prevention of Thrombosis

5. Breast Cancera. Risk Factors for breast cancer and risk reduction strategiesb. W/U of a suspicious breast massc. Primary therapy for a newly diagnosed breast cancerd. Systemic therapy for breast cancere. Quality of life in breast cancer survivors

Fisher B et al: Twenty-year follow-up of a randomized trail comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation of the treatment of invasive breast cancer. N Engl J Med 347:1233, 2002

Wong ZW, Ellis MJ: First –line endocrine treatment of breast cancer: Aromatase inhibitor or antiestrogen? Br J Cancer 90:20, 2004

Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomized trails. Lancet 2005; 365, 1687

Ravdin PM et al: Computer program to assist in making decisions about adjuvant therapy for women with early breast cancer. J Clin Oncol 2001; 19:980m

. 6. Colorectal Cancer

a. Risk factors for colorectal cancerb. Clinical features of colorectal cancerc. Staging of colorectal tumorsd. Management of resectable colorectal tumorse. Post resection surveillance in colorectal cancerf. Management of patients with metastatic colorectal cancer

Baron J et al: A randomized trial of aspirin to prevent colorectal adenomas. N Engl J Med 348:391, 2003

Walsh JME, Terdiman JP: Colorectal cancer screening; JAMA 289:1288, 2003

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7. Lung Cancera. Clinical presentation of lung cancerb. Diagnosis and treatment of lung cancerc. Non-Small Cell Lung cancerd. Small Cell Lung cancer

American College of Chest Physicians: Diagnosis and management of lung cancer: ACCP evidence based guidelines. Chest, 123:1S, 2003

8. Cancer of Unknown Primary Sitea. Adenocarcinoma of Unknown primary siteb. Squamous cell carcinoma of unknown primary sitec. Poorly differentiated carcinoma of unknown primary site

Hainsworth JD, Greco FA: Management of patients with cancer of an unknown primary site. Oncology 14:563, 2000

9. Lymphadenopathy, lymphoma and Multiple Myeloma

Diehl V et al: Hodgkin’s lymphoma---Diagnosis and treatment. Lancet Oncol 5:19, 2004

Barlogie B et al: Treatment of multiple myeloma. Blood 103:20, 2004

10. Prostate Cancera. The screening controversyb. Treatment of prostate cancerc. The Gleason Scored. Comparison of Treatment modalitiese. Sequelae of treatment in prostate cancerf. Management of recurrent prostate cancer

Nelson WG et al: Prostate cancer. N Engl J Med 349:366, 2003

11. Testicular Cancer

Bosl GJ et al: Testicular germ-cell cancer. N Engl J Med 337:242, 1997

12. Oncologic Emergenciesa. Metabolic Emergences (Hypercalcemia, Hyperuricemia, and Hyponatremia)b. Hematologic Emergency: DVTc. Mechanical Emergencies (Spinal Cord Compression, SVC, Pericardial Effusión and

Tamponade)

Strewler GJ: The parathryid hormone-related protein. Endocrinol Metab Clin. North Amer 29:629,2000

Yim BT et al: Rasburicase for the treament and prevention of hyperuricemia. Ann Pharmacotherapy 37:1047, 2003

13. Chemotherapy, biotherapy and hematopoietic colony stimulate factors:

American Society of Clinical Oncology : Update of recommendations for use of hematopoietic colony stimlating factors: Evidence-based clinical practice guidelines. J Clin Oncol 2000: 20;3558-85

14. Antiemetics

Wiser, W.Practical management of chemotherapy-induced nausea and vomitingOncology 2005;5: 637-45

15. Pain Management

Levy MH: Pharmacologic treatment of cancer pain. N Engl J Med 335:1124, 1996

Pulmonary Inpatient Curriculum

Pulmonary Physiology

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Gas ExchangeMechanicsMeasures of Function

Arterial blood gasesLung volumes and DLCOImaging techniques

Obstructive Pulmonary (Airway) Diseases

Chronic BronchitisEmphysema

centrilobularpanacinar

Cystic FibrosisBronchiolitis

Bronchiolitis obliteransBOOPBronchiolitis obliterans associated with lung transplantation

Bronchiectasis

Asthma

Epidemiology and definitionClassification

"Intrinsic or nonallergic""Extrinsic or allergic"

PathogenesisClinical manifestations and diagnosisTherapy

Respiratory Infections

Community acquired pneumoniasInfections in the immunocompromised host

AIDSOther causes of immunosuppression

Tuberculosis and nontuberculous mycobacteriaAnaerobic lung infections and aspirationEmpyema

Intersitial Lung Disease

Idiopathic pulmonary fibrosisDrug inducedConnective tissue diseasesSarcoidosisEosinophilic granuloma

Lung NeoplasmsCarcinomasMesotheliomasBenign tumorsStaging evaluation

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Resectability

Lung Transplantation

IndicationsCommon diseases transplantedSingle versus double lung transplantsSurvivalComplications

Pulmonary Vascular Disease

Pulmonary thromboemboliPulmonary hypertensionPulmonary vasculitisAlveolar hemorrhage/hemoptysis

Miscellaneous

Pleural diseasesEffusionsPneumothorax

Occupational Lung diseasesSleep disordersLymphangioleiomyomatosis

MEDICAL HOUSESTAFF ACTIVITIES ON THE PULMONARYINSERVICE ROTATION

1. Each houseofficer will be expected to prepare a minimum of three 20-30 minute, informal lectures to be given to the rest of the team throughout the month.

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2. Houseofficers are expected to attend Chest X-ray Rounds Monday, Wednesday and Fridays at 2:30 PM.

3. The medical houseofficers are encouraged to attend the pulmonary lectures and conferences (Conference schedule enclosed).

MED G SYLLABUS JOURNAL ARTICLES

ASPIRATION PNEUMONIAAspiration Pneumonia. Lung Abscess, and Emphysema

ASTHMAReview Article-AsthmaThe Assessment and Management of Adults with Status Asthmaticus

COMMUNITY ACQUIRED PNEUMONIAAmerican Thoracic Society Clinical Guidelines for the Initial Management of Adults with Community-Acquired Pneumonia

Current Concepts-Community Acquired Pneumonia

ATS-Guidelines for the Initial Management of Adults with Community -acquired Pneumonia: Diagnosis, Assessment of Severity, and Initial Antimicrobrial Therapy

COPDManagement of Chronic Obstructive Pulmonary Disease-James F. Donohue, MI)Current Concepts-Management of Chronic Obstructive Pulmonary Disease

CYSTIC FIBROSISReview Article-Drug Therapy Management of Pulmonary Disease in Patients with Cystic Fibrosis

HEMOPTYSISMassive Hemoptysis: Assessment and Management

HOSPITAL-ACQUIRED PNEUMONIAHospital-acquired Pneumonia in Adults: Diagnosis, Assessment of Severity, Initial Antimicrobial Therapy, and Preventative Strategies

LUNG MALIGNANCIESPulmonary Manifestations of Extrathoracic Management LesionsStaging Systems of Lung Cancer

MYCOBACTERJAL DISEASESClarithromycin Regimens for Pulmonary Mycobacterium avium Complex

Control of Tuberculosis in the United StatesTreatment of Tuberculosis and Tuberculosis Infection in Adults and Children

PNEUMOCYSTIS CARINII PNEUMONIAMayo Clinic Proceedings-Pneumocystis carinii Pneumonia in Patients without Acquired Immunodeficiency Syndrome:Associated Illnesses and Prior Corticosteroid Therapy

Pneumocystis Carinii Pneumonia in Patients with the Acquired Immunodeficiency Syndrome

PULMONARY VASCULAR DISEASESInvasive and Noninvasive Diagnosis of Pulmonary Embolism-Preliminary Results of the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-ped)

Clinical Features of Pulmonary Embolism-Doubts and Certainties

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Value of the Ventilation/Perfusion Scan in Acute Pulmonary Embolism-Results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED)

Anticoagulation in the Prevention and Treatment of Pulmonary EmbolismVenous Thromboembolism

SARCOIDConferences and Reviews-Enigmas in Sarcoidosis

SLEEP APNEACurrent Concepts-Obstructive Sleep ApneaTreatment of Obstructive Sleep Apnea-A Review

MISCELLANEOUSMayo-Rare Pulmonary NeoplasmsMechanisms of Disease -HvpercaniaReview Article-Mechanisms of Disease-Pathophysiology of DyspneaDyspnea: Mechanisms, Assessment, and Management: A Consenus StatementReview Article-Primary Pulmonary Hypertension

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INFECTIOUS DISEASE INPATIENT CURRICULUM

Antibiotics I (antibacterials)

Antibiotics II (antivirals and antifungals)

Pneumonia

HIV I

HIV II

Sepsis

Endocarditis

Skin and Soft Tissue Infection (including osteomyelitis)

Diarrhea

Urinary Tract Infection

FUO

New and unusual infections, including Lyme Disease and RMSF

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NEUROLOGY INPATIENT CURRICULUM

CURRICULAR COMPONENT: NEUROLOGY WARD ROTATION

I. OVERALL EDUCATION GOAL:

The goal of the ward rotation for residents is to learn the evaluation and management of common neurological problems seen in the inpatient neurology setting. The resident will be part of the Neurology ward team consisting of the neurology attending, neurology senior resident, medicine and psychiatry interns, and medical students who are involved in the care of inpatients on the Neurology ward service.

II. OBJECTIVES:

1. The resident will become competent in obtaining a neurological history and performing a neurological exam on patients presenting to the Neurology inpatient service.

2. The resident will learn to effectively present neurological cases.

3. The resident will gain skill in the localization of various neurological symptoms and findings seen on the Neurology inpatient service.

4. The resident will learn to generate a differential diagnosis for common neurological symptomatology and findings seen on the inpatient service.

5. The resident will become an integral part of the Neurology team with the ability to both synthesize cases for presentation to the neurology senior resident and attending.

6. The resident will gain competence and skill in the assessment of common neurological problems seen on the Neurology inpatient service including TIA, stroke, delirium, intractable epilepsy, Parkinson’s disease, myasthenia gravis, acute and chronic inflammatory demyelinating polyneuropathy, polymyositis, acute low back pain, intractable headache, multiple sclerosis, and myelopathic disorders.

7. The resident will learn the appropriate and cost effective evaluation of patients presenting with various problems to the Neurology inpatient service.

8. The resident will gain ability in the use of laboratory tests, lumbar puncture, EMG/nerve conduction studies, EEG, evoked potentials, CT, MRI, and other studies in the evaluation and management of neurology inpatients.

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III. EVALUATION:

The residents will be evaluated directly by the faculty member assigned to the Neurology ward service. The faculty members will directly observe the residents’ presentation of cases, and their assessment and plan for the management of patients with neurological disorders. The attending will provide feedback to the resident during the rotation regarding their skills in the assessment and management of neurological patients. In addition, the faculty member will assess the resident’s ability to be an integral member of the Neurology ward team, including their ability to interact with other members of the ward team and ancillary personnel. At the end of the rotation, the faculty member will complete a standard evaluation form, which will be keyed to the learning objectives of the rotation.

IV. LEARNING ACTIVITIES OF THE ROTATION:

Residents on the Neurology rotation will round with the neurology ward team each weekday and on one weekend day. They will have an opportunity to present cases and be critiqued on both their evaluation and management ability. Residents will have the opportunity to observe the attendings history taking and neurological examination on neurology inpatients. The residents will also be present when the attending discusses their assessment of neurology inpatient cases with the neurology inpatient ward team, as well as didactic presentations by the attending on various neurological issues. The resident will have the opportunity to review neuroimaging studies with the Neuroradiology staff and the neurology inpatient attending. The neurology resident will also have the opportunity to review clinical neurophysiology studies done with the clinical neurophysiology attending staff. Throughout the rotation, the resident may attend the daily noon resident lectures which will cover various neurological topics, including the evaluation and management of a variety of disorders seen on the neurology inpatient service. This will include the Clinical Lecture Series, and other conferences.

Topics to be Covered

Intracranial Mass Lesions

Review of the Neurologic Exam

Spinal Cord Injury

Neuroradiology - What Study to Order

Coma

Management of Acute Spinal Disorders

Head Injury

Neuromuscular Disorders

Head CT and MRI Interpretation

Management of Back Pain

Pediatric Neurosurgery

Pain Management

Seizures

Pediatric Rehabilitation

Physical and Occupational Therapy

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Headache

Neuro-opthalmologic Evaluation

Stroke

Introduction to Rehabilitation

Management of Acute Spinal Disorders

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SECTION 3AMBULATORY CURRICULUM

Emergency Room

Same-day Clinic

Cardiology

Endocrinology

General Medicine

Hematology/Oncology

Pulmonary Disease

Digestive Disease

Infectious Disease

Rheumatology

Nephrology

Adolescent Medicine

Geriatric Medicine

PGY -1 Continuity Elective

PGY – 2/3 Continuity Elective

Enhanced Care Elective

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Section 3Ambulatory Curriculum

General

Each rotation has designated teaching times. The responsibility for teaching is given to the respective department or a division in the Department of Medicine. The topics are generated by the faculty with input from the Department of Medicine. These curricula are designed for consultation as well as direct patient care.

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EMERGENCY MEDICINE CURRICULUM

UNC Department of Emergency Medicine  

The Emergency Department (ED) attendings work 8 hour shifts, 7a-3:00p, 1p-9p, 10a-6p, 3p-11p, 6p-2a, and 11p-7a. Two attendings are on duty, with the exception of the time period from 2a to 10a when one attending is on duty. The ED has 3 main areas. The Acute Care area has 24 beds including 2 cardiac rooms and 3 trauma rooms. Team C is an adjacent area with 8 beds. Team C is open 9a to midnight daily. Pediatric Acute Care is a separate unit staffed by Pediatric attendings and residents. Pediatric Acute Care is open 9a-2a daily. After those hours, pediatric patients (ages 15 and below) are treated in the main ED. During your rotation, you will be assigned shifts in both the Acute Care area of the ED and the Minor Trauma area.  

Guidelines for HouseofficersDepartment of Emergency Medicine

The University of North Carolina at Chapel Hill Introduction and General PrinciplesWelcome to the Department of Emergency Medicine! During this rotation, you will learn skills that are essential to your medical education. You will be supervised by faculty members who are Board Certified or Board Eligible in Emergency Medicine. Our faculty have practiced in a variety of institutions and settings, and thus, your experience here will be enhanced by exposure to different styles of practice. Emergency Medicine differs in many respects from the inpatient and clinic settings. During this rotation, you will see a broad spectrum of illness ranging from the most trivial complaints to life-threatening disease. It is important to remember that all patients come to the ED for a reason. Many present to the ED early in the course of their illness, therefore a serious disease may initially present to you as an apparently benign complaint. Many may present with complaints that could best be handled elsewhere. It is our role to ensure our patients receive our best efforts to guide them through the increasingly complex healthcare system as well as to diagnose and treat acute care conditions. Remember the Emergency Department is an important portal of entry into the hospital and provides a strong impression of the institution to patients, their families, and referring physicians from other medical centers.  

House officer Requirements for Successful Completion ofEmergency Medicine Rotation

  1. Completion of the Online Orientation Module

Each houseofficer must complete the online orientation course and exam before starting their Emergency Medicine rotation. The orientation module is available online at www.med.unc.edu/wrkunits/2depts/emergmed.

 2. Assigned Shifts in the Emergency Department

Be prompt for your assigned shifts. If you are ill or must miss an assigned shift, you need to contact:

      Your chief resident. Chief residents from each rotating department will be responsible for providing replacement coverage for their individual department residents who are unable to fill an assigned shift.

      The ED attending physician working at the time your shift begins (966-4721).

 

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In order to successfully complete the ED rotation as required by your residency, you must complete all assigned shifts. Illnesses are only excused if verified by your personal physician (not a resident physician) or your residency director. 3. Resident ConferencesIn order for the Departments of Emergency Medicine, Medicine, Surgery, Family Medicine and OB/Gyn to meet the requirements of the Residency Review Committee, weekly attendance at our Emergency Medicine Conferences is MANDATORY. These conferences are held on Wednesday mornings from 7a to noon. The schedule of topics is available monthly. Emergency Medicine interns/residents are required to attend conferences 5 hours per week. Off-service interns/residents are required attend 3 hours per week. During your rotation, you will likely be scheduled in the ED on one or more Wednesday mornings. On these mornings you should attend sign out rounds and check in with the ED attending prior to departing for conference. When you are not scheduled to work in the ED, you should attend at least part of the Wednesday morning conference. Attendance will be taken at these conferences and reported to individual residency directors at the end of each rotation along with your final evaluation. 

If you have questions or concerns, please feel free to contact:Kevin Biese, MD

Assistant ProfessorEducation Director

966-6440 

 Guidelines for Housestaff:

Department of Emergency MedicineThe University of North Carolina at Chapel Hill

 Important Items to Keep in Mind: 1. Although you will be quite busy at times, make sure you speak to any family or visitors who may be in the waiting room after you have finished your evaluation. It is important to let them know how well the patient is doing and give them an estimate of the anticipated length of stay. Always overestimate the length of stay. Things take longer than you think. 2. Laboratory studies and X-rays are ordered only if they impact on acute treatment, immediate decision making, or are essential for the provision of follow-up care. The Emergency Department is not the place to begin an extensive workup of non-critical problems. 3. Every patient should be given instructions for follow-up care and referred to a follow-up physician, no matter how trivial the problem may seem. (see documentation and charting guidelines) 4. You should be able to arrive at a reasonable clinical diagnosis on most patients. If you lack a definitive diagnosis, you must have formulated a clear differential diagnosis and have ruled-out all possible life-threatening conditions before the patient can be discharged safely. 5. Information concerning patients seen or discussed in the ED is confidential. It should not

be discussed anywhere else, other than in a medical conference setting. This means you must not discuss patient

information in the hallways, nor the elevators, nor in downtown restaurants, etc. You are a professional and must conduct

yourself as such. 6. All patients who are seen in the Emergency Department are the ultimate responsibility of

the attending emergency physician. Consequently, THE EMERGENCY DEPARTMENT ATTENDING MUST SEE EVERY PATIENT AND SIGN EVERY CHART PRIOR TO THE PATIENT’S DISCHARGE, ADMISSION OR TRANSFER.

 

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7. Some patients have such serious illness at the time of presentation that they may decompensate in a very short period

of time. Because of this, there are certain circumstances when it is vital for you to notify the attending physician of the

patient’s condition IMMEDIATELY AND POSSIBLY BEFORE YOU HAVE FINISHED YOUR INITIAL

EVALUATION. (You will find a list of these circumstances attached in this handout.) If you think a particular

patient is unstable, alert the attending on duty. 8. T System: All ED patients are tracked on a computer system called T System. When you

arrive in the ED, you will be instructed how to use this system to sign up as the provider for the patients you are

evaluating. In order to access this system, you must have a valid UNC Hospital code and password. 9. As patients enter the Emergency Department, they are triaged by the nursing staff.

The triage designations are: 

  ESI-1 ESI-2 ESI-3 ESI-4 ESI-5Stability of vital functions

Unstable Stable Stable Stable Stable

Life-threat or organ-threat

Obvious Reasonably likely

Unlikely (possible)

No No

Severe pain or severe distress

Immediately Sometimes Seldom No No

Expected resource intensity

Maximum: staff at bedside continuously; mobilization of outside resources

High: multiple, often complex diagnostic studies; frequent consultation; continuous (remote) monitoring

Medium: multiple diagnostic studies; or brief observation; or complex procedure

Low: one simple diagnostic study; or simple procedure

Low: exam only

Med/staff response

Immediate team effort

Minutes Up to 1 hr Could be delayed

Could be delayed

Expected time to disposition

1.5 hr 4 hr 6 hr 2 hr 1 hr

Examples Cardiac arrest, intubated/hypotensive trauma patient, acute (<3 hr) MI or stroke

Most chest pain, stable trauma (MOI concerning), elderly pneumonia patient, altered mental status, behavioral disturbance

Most abdominal pain, dehydration, esophageal food impaction, hip fracture

Closed extremity trauma, simple lac, simple cystitis, typical migraine

Sore throat, minor burn, recheck

In general, patients should be seen in the order in which they arrive in the ED, however patients triaged as “1” or “2” should be evaluated before those

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designated “3-4-5”. If you are unsure which patient you should evaluate next, ask the attending or a senior resident to direct you.

 SCHEDULEHousestaff will be assigned to one section of the department and will report ONLY to the attending staffing that section.  RESPONSIBILITIES Role of the Emergency Department AttendingThe ED attending is primarily responsible for patient flow and consultation. The ED attending will be responsible for the supervision of all medical students and houseofficers. Housestaff cannot sign student orders. Role of the PGY-III ResidentThe PGY-III Emergency Medicine Resident has three main responsibilities in the ED:

1.      Directly evaluate patients as the primary physician, with particular attention to critically ill or injured patients.

2.      Ensure that patient flow in the ED is maintained.3.      Supervise one or more PGY-I residents who are working in the ED.4.      Perform or supervise procedures required for patient care.5.      At times, these residents may take a turn at being “in charge” of the ED under

the supervision of the attending.. Role of the PGY-I and PGY-II Residents and Medical StudentsThe PGY-I resident and medical student are primarily responsible for patient evaluation and management. Remember that you are here to learn and that specific questions are expected. It is better to ask and ask early! PATIENT CARE AND CASE PRESENTATIONIt will be the responsibility of the EM PGY-III resident, all PGY-I residents, and medical students to pick up new patients as they are added to the board by the triage nurse. Patients are to be seen according to their time of entry into the ED unless another patient with a potentially life-threatening complaint has not yet been evaluated. Patients with life-threatening complaints are designated by a triage classification of “1” (in red) and should be seen promptly. If you are not certain whether a particular patient is to be seen, ask the attending physician or triage nurse. The residents will see and evaluate the majority of patients. This initial evaluation is to consist of a history and physical examination, which may be “directed” if the patient has an obviously isolated problem (such as a minor extremity injury). All other patients should have a complete history and physical examination including social and family history, medications and allergies. This evaluation should take no longer than 5 to 10 minutes to complete.

 ANY PATIENT WITH A CONDITION WHICH MAY DETERIORATE PRECIPITOUSLY MUST BE CALLED TO THE ATTENTION OF THE ED ATTENDING IMMEDIATELY, EVEN IF THE INITIAL EVALUATION IS NOT COMPLETED. A list of such conditions is listed in this handout.After formulating a differential diagnosis and treatment plan, but before writing orders, the intern is to present the patient to the ED attending. At that time, an evaluation and treatment plan can be formulated and orders written. No verbal orders are acceptable. After all ancillary studies have been completed, the houseofficer is to present the case to the ED attending again, this time noting the results of laboratory values, X-rays, etc. At this time a disposition will be made and the patient will be either discharged, admitted or transferred to a different institution.  

  

TYPES OF PATIENTS SEEN

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Adult patients with a wide variety of complaints are seen in the Acute Care area of the ED. In addition to evaluating and treating patients with general medical and surgical problems, you will gain experience with patients whose complaints include the following:

Psychiatric - Our responsibility is medical clearance; be especially careful with elderly patients or those with confounding medical problems; some psychiatric patients will be seen directly by the Psychiatric consultants.

OB-Gyn - Women at 20 weeks or greater gestation are transferred directly to Labor and Delivery. The exceptions to this are if they have any type of trauma or a complaint totally unrelated to pregnancy. All women between 10-60 should be assumed to be pregnant until proven otherwise by a negative urine or serum pregnancy test.

Trauma - Major trauma patients, as determined by criteria, are seen by the Trauma team, EM Attending and Senior Emergency Medicine Residents. Patients with lesser trauma are evaluated and treated by the general ED staff.

Pediatrics (ages 15 and below) - These patients are seen directly by a Pediatric resident, either in Pediatric Acute Care (9a-11p) or in the Acute Care ED at other times.  ANCILLARY SERVICESLaboratory Studies 

1.      Laboratory studies are ordered in writing on the order sheet.  2.      Laboratory reports results can be obtained on the computer. Be sure to check

the computer frequently for results so the patient can receive disposition in a timely manner. 3.      All laboratory studies must be documented on the chart, including those

that are pending at the time of disposition.

 Radiologic Studies 

1.      If a patient needs an X-ray or other imaging study, write the order on the order sheet and give the order sheet to the clerk. You need to write a reason for the X-ray study, i.e. chest pain or SOB. The X-ray orders are entered into the computer by the nursing staff. 

2.      Look at the patient’s X-rays even though the radiologist’s interpretation is available. Remember that you have the advantage of knowing the patient’s clinical presentation and thus may notice something the radiologist might have misses.

 3.      If you have any questions regarding the interpretation of a particular

radiograph, you may consult the radiology attending or resident by dialing 68850. 4.      All radiologic studies must be documented on the chart!

 MEALSHousestaff are encouraged to briefly leave the ED for nutrition breaks as patient flow permits, but only after notifying the attending that they are leaving.   DOCUMENTATION STANDARDS It is your responsibility to see that these standards are met on every chart. Charts will be returned to you for completion if documentation standards are not met.   DISCHARGE INSTRUCTIONS AND FOLLOW-UP

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All patients are to receive a discharge instruction sheet prior to leaving the Emergency Department. There are specific items that must be included on the discharge form.    PATIENTS LEAVING THE EMERGENCY DEPARTMENT AGAINST MEDICAL ADVICE (AMA)All patients who threaten to leave the Emergency Department against medical advice (AMA) must be seen by the ED attending immediately. The patient is required to sign an AMA form on the back of the chart and must be properly informed of the risks of departing AMA.  SECURITY AND PARKINGEscorts to the parking decks are available 24 hours a day. USE THEM!! Use the Point to Point Service (962-7867) or have hospital security accompany you! You cannot park in the ED patient parking lot.  DRESS CODE AND IDENTIFICATIONName badges must be worn at all times. Housestaff are expected to look and act like professionals at all times. Scrubsuits are acceptable for wear in the Emergency Department provided they are clean and in good condition. Jeans, shorts, sweats and T-shirts are not permitted.  WHEN YOUR SHIFT ENDSYou must turn your patients over to an intern or resident on duty in the ED. If your patient is nearing completion of their evaluation – please fill out the chart completely including the discharge form if appropriate. If the evaluation is in progress, please have a clear plan to pass on to the next doctor.  

Medical Conditions RequiringImmediate Attending Physician Notification

 The following is a list of conditions that require immediate notification of the Emergency Department attending physician, regardless of your level of training. This list does not cover all possible situations, and you should feel free to notify the attending immediately if you have a patient you feel may deteriorate precipitously or if you are uncomfortable given your present level of training. 1. Any patient who presents with or develops acute cardiopulmonary arrest. 2. Any patient with a complete or partially obstructed airway. 3. Any patient who presents with or develops a significant cardiac arrhythmia, whether stable

or not. 4. Any patient with acute onset Alteration of Mental Status (AOMS). This includes any patient

presenting with this as the chief complaint or any patient whose mental status deteriorates while in the ED.

 5. Any patient with significant hypotension or hypertension. For these purposes, significant

hypotension will be defined as blood pressure of less than 100 mmHg systolic and significant hypertension will be defined as a blood pressure of greater than or equal to 180 mmHg systolic or hypertension associated with acute alteration of mental status.

 6. Any patient with severe respiratory distress. For these purposes, significant respiratory

distress will be defined as a respiratory rate greater than 30 breaths/minute, any patient with a pulse oximeter reading of less than or equal to 90 mmHg, any patient with an acute elevation of pCO2 greater than or equal to 60 mm Hg, any patient with a complaint of shortness of breath accompanied by diaphoresis, use of accessory muscles of

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respiration, cyanosis, alteration of mental status, bradycardia, or any other signs consistent with imminent respiratory failure.

 7. Any patient with significant tachycardia or bradycardia. For these purposes, significant

tachycardia is defined as a heart rate greater than or equal to 150 beats/minute and significant bradycardia is defined as a heart rate less than or equal to 60 beats/minute.

 8. Any patient with a significant cardiac arrhythmia. 9. Any patient with either clinical or EKG evidence of acute myocardial infarction. 

10. Any patient with a fever greater than 105 degrees Fahrenheit, any patient with significant alteration of mental status associated with a fever, or any patient with a fever and a potentially immunocompromised state (e.g. HIV disease, cancer patients, transplant patients, etc.)

11.   11. Any patient with significant hypothermia. For these purposes, significant hypothermia is

defined as a rectal temperature less than or equal to 95 degrees Fahrenheit. 12. Any patient with severe abdominal pain or abdominal pain associated with peritoneal

signs. 13. Any female with abdominal pain and a positive pregnancy test. 14. Any patient with significant upper or lower GI bleeding (whether hypotensive or not). 15. Any patient who develops seizure activity while in the Emergency Department. 16. Any patient with significant abnormality of any laboratory value (e.g.

hypo/hypernatremia, hypo/hyperkalemia, symptomatic hypercalcemia, hematocrit less than 28, etc.).

 17. Any patient with a history of significant trauma. 18. Any patient with a pregnancy and sign/symptoms of a precipitous delivery. 19. Any patient with an overdose of prescription or over-the-counter medications. 20. Any patient or visitor who gives evidence of becoming significantly agitated, violent, or

suicidal. 21. Any patient with a blood sugar of less than 70 mg/dL. 22. Any patient with a snakebite. 23. Any patient with significant bleeding, or bleeding associated with hemophilia (blood

dyscrasias). 24. Any patient with a significant allergic reaction. 

25. ANY PATIENT WHO YOU FEEL IS BEYOND YOUR PRESENT CAPABILITIES AS A RESIDENT, OR WHO YOU THINK MAY DETERIORATE SUDDENLY.

  

 Documentation Standards

The following information is required on all charts for all Emergency Department patients for legal and billing purposes. Please review this in conjunction with the copy of the chart included in this packet.

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 1. The Emergency Department uses the T System for charting. Please complete the T

System training module before starting your first shift. 2. For all patient charts, documentation should reach a “level 5” by the standards of the T

System Documentation System. Please confirm this before signing your chart. 3. It is important to write a short summary of your assessment and plan in each chart..

Based on the differential problem list that you have established, it should be obvious by reviewing the chart how you distinguished among the possibilities and came to your final diagnosis. Some examples: GI cocktail given, patient with complete relief; Phenergan 25mg IV given, nausea relieved and patient tolerating PO well. If you make a clinical diagnosis without any work-up, you need to explain that. For example: 20 year old white female with reproducible chest wall pain, no risk factors for CAD and no associated symptoms, likelihood of cardiopulmonary disease as the underlying etiology is very low. We will treat her with NSAID’s. Patient knows to return if symptoms change or worsen. 4. You need to list the medications the patient is taking and any drug allergies the patient

has. 5. If the patient is in the Emergency Room for a significant length of time waiting for disposition or a bed, you need to make note that you reevaluated the patient during this time. For example: 2:45 pm Patient now afebrile and tolerating oral fluids well. Many conditions such as respiratory distress, chest pain and abdominal pain require frequent reevaluation, and you need to document it. 6. If you call a consultant to see the patient, record the time and who you talked with. For example: 6 pm Discussed case with Dr. Smith(General Surgery) who will evaluate patient. “Curbside” consultations are not official. If there is really a question, the patient must be seen by the consultant. 7. Record a procedure note for all procedures done on the patient including laceration

repairs, lumbar punctures, central lines, etc.

8. Please select a disposition and diagnosis (often more than 1diagnosis) for each patient.

 DISCHARGE INSTRUCTIONS The T system has standard discharge instructions for many different diagnoses as well as medications Every discharged patient should receive 1 or more of these instruction sets.

 All patients should receive Follow-Up. Follow-up options include but are not limited to: 

1. Follow-up with their own doctor (MUST BE NAMED) for a specific period of time. If the patient is unable to identify an MD, a referral should be given.

 2. UNC Clinic Appointment:

Options for obtaining this are:* You can call and get an appointment for the patient (Mon-Fri 8a-5p)* Fill out a clinic referral sheet available in the ED, these are faxed to a central office where appointments are made,

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* You can give the patient the phone number for a specific clinic (listed in the T system discharge instructions) BUT, keep in mind, it may be several months before a patient can get an appointment.

 Welcome!

From the Nurses in the Emergency Department 

The following handout details survival skills for your emergency department rotation. We hope that it may be helpful to you.

 The ED is divided into several sections:         Triage        Acute Area        Team C        Pediatric Acute Care The nursing staff is assigned by “team.” One or two nurses are assigned to the triage area. These nurses are responsible for screening all patients and prioritizing their care. The Acute Area is divided into Team A and Team B. Two or more nurses are assigned to cover each of these teams. There are three trauma bays, including a pediatric resuscitation bay. There are two cardiac resuscitation rooms. The Acute Area is divided into the A and B teams which are each responsible for ½ the acute area of the department. Team C is a separate area that usually evaluates ESI score 4 and 5 patients (see above). A charge nurse is assigned to coordinate the care of the ED patients. At various times, the charge nurse will also have a patient care assignment. Two nurses are assigned to the trauma team. If there is a trauma in progress and the nurse assigned to a certain area becomes unavailable, refer all questions to the charge nurse.

Remember, if you are busy, so is the nursing staff!This is a team-oriented department. Help us and each other!

General Information  It is mandatory that you wear your name tag!  Familiarize yourself with the clean and dirty utility rooms on your first day. You will find this invaluable. Most of the equipment you need is located in these areas. Equipment is secured in the PYXIS. Tidy up after yourself after completing an exam or procedure. There are trash cans located at each patient care bedside. (This includes the lounge!) The ED staff is a lifeform in itself. The nursing assistants, clerks, nurses, and social worker can be great resources for the inside scoop on usual routines, community resources, etc.  Clerks can help you with phone calls and paging. Clerks answer the phones, even if you have paged someone. Listen to the intercom for your name or the person you have paged. The key staff in the ED have assigned intercom cell phones. Nursing Assistants can perform the following:

        simple wound preps        crutch set-up        lab transport

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        patient transport (excluding monitored patients)        room set-up        assist with procedures

 Remove all needles and sharps from trays and dispose of them in the sharps box!

 If a laceration needs sutures, anesthetize the wound prior to wound prep. The department’s infection rate has been consistently 0% because the NA’s do an excellent job. RN’s

 1. Unless the patient is acutely ill, please allow the RN to triage the patient prior to beginning

your exam or gathering information. 2. ED nurses will assess the acuity of patients and institute treatment and diagnostic

procedures prior to your seeing the patient. For example: monitoring, IV access. Orders still need to be written

for the patient. 

Educational Conferences

Emergency Medicine conferences are held Wednesday from 7:00 am to noon. All PGY1 residents assigned to the Emergency Department each month will be expected to attend.

Scheduling in the Emergency Department

PGY-1 Medicine Interns will work 12 hour shifts beginning at 7 am, 10 am, or 7pm. These times will rotate throughout the month.

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Same-Day Clinic CURRICULUM

Low Back Pain

Monoarticular Arthritis

Approach to Arthritis

Musculoskeletal Syndromes of the Neck and Arm

Depression

Initial Diagnosis and Management of Hypertension

Initial Diagnosis and Management of Type II Diabetes

Bronchitis

Rhinitis/Sinusitis

Headache

Pharyngitis/Mononucleosis

PID

Chest Pain

STD’s

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CARDIOLOGY AMBULATORY CURRICULUM

Consultations including preoperative evaluations will be handled by internal medicine residents, cardiology fellows and faculty. When the residents is not involved with patient work-ups, he or she can see patients in faculty clinics, participate in exercise stress testing, read EKG’s from teaching files and/or ACC patients. The following subjects will be reviewed on the month rotation

1.Evaluation of arrythmias in the post-operative patient2.Pre-operative risk assessment for the patient with known cardiac disease3.Evaluation and management of malignant hypertension4.Use of thrombolytic therapy5.Evaluation and management of shock in the post-operative patient6.Endocarditis prophylaxis7.Evaluation and management of lipid abnormalities8.Evaluation and management of peripheral vascular insufficiency9.Recognize common EKG abnormalities10.Recognize common echocardiographic abnormalities11.Evaluation and management of patients with left ventricular dysfunction

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ORIENTATION FOR ROTATION IN ENDOCRINOLOGY AND METABOLISM

Dear Residents and Students,  The Endocrine Division is delighted that you will be taking our Endocrinology and Metabolism Elective. Our clinic is located in Durham near Southpoints Mall off of Hwy 54 (Highgate Specialty Center, 5316 Highgate Dr, Suite 125, Durham NC, 27713. 919-484-1015). The majority of your time will be spent in the clinic working with various attendings and seeing a variety of Endocrine patients. On rare occasions, when too many residents/students are assigned to Endocrinology, you may be asked to spend a few days with the inpatient team. 

Clinic OperationsHighgate Specialty Center opens at 7:30am and closes by 5:30pm. Please

arrive by 8:30 each morning and look for Dr. O’Connell who will help coordinate the attending with whom you will work (usually Dr. O’Connell the first day and any day that other attendings are not available). We will try to have you work with almost every attending during your two weeks so you can see a wide variety of patients and styles. Dr. O’Connell is never at Highgate on Thursdays so if your first day is Thursday, simply come and introduce yourself to another attending who is present that day. Dr. Ontjes is usually there on Thursdays and is always amenable to working with residents and students.

The clinic is closed most Thursday afternoons to allow everyone to attend Thursday afternoon Endocrine Conferences.

 Conferences

Thursday afternoon Endocrine conferences as described below are from 3 pm to 5:30 pm. You are expected to attend these while on your Endocrine rotation. They are located in the GCRC conference room, 3rd floor bedtower.

3pm: Fellows conference: a faculty member will give a didactic lecture to the fellows/residents

4pm: Endocrine Journal Club:5pm: 30 minute case presentation and discussion by one of the fellows

EvaluationsPlease give your evaluation form (students) to the Elective Director, who will

then distribute it to the fellows and faculty in the division. Evaluations (students and residents) are compiled by the Elective Director after input from other members of the division.

We appreciate your attention to these matters and hope that you find your rotation with us to be educational and enjoyable. Please bring any concerns to our immediate attention. Sincerely, Tom O’Connell, MD (pager 216-6359)

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Resident Elective DirectorEndocrinology and Metabolism Thomas_oconnell@med.unc.edu

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Hematology/Oncology ConsultsCurriculum

Updated 6/9/2008

Outpatient Electives for Medical Residents. Out Patient block, Medical Residents

Overview:This is a 1month block of time designed to expose medical residents to some of the breadth of outpatient oncology or hematology patients. We suggest that the resident choose either the Oncology block or the Hematology Block and not make a combined block of the various clinics. This will enable the resident to get a good spectrum of one part of this broad field. The resident will see patients along with the attending physician and will be responsible for obtaining histories and examinations, dictate or type consult notes and progress notes, follow up on calls and tests. In many cases there will be a reading list to master. This can be discussed with the attending for each clinic. Residents are also encouraged to participate in the Division conferences and when possible, present at the Case of the month program. Participation at Case of the month should occur if this is offered during the resident’s rotation (The division can let the resident know ahead of time.). Outpatient Rotation.  Oncology

Monday Tuesday Wednesday Thursday Friday 7:30 GI Tumor Board. Gravely Gd Floor

7:30 am  Fellows’ Conference*** Room 3004 old clinic (check calendar)

7:30 am  Fellows’ Conference Room 3004 old clinic (check calendar)

7:30 am  Head and Neck Conference**.

GI Clinic with Dr O’Neil and Dr Bernard

Breast Cancer Clinic with Dr Carey**

 Thoracic Oncology

 GU ClinicCheck

12:30 Monday Lectures Divison lectures.*

Multidisciplinary Thoracic Oncology conference. Gravely Gd floor.

Breast Conference 10:30 to 12 Gravely Gd Floor

1:15 GU tumor board. Gravely Gd Floor

 

Breast Cancer Clinic with Dr Carey

Thoracic Oncology Breast Oncology GU clinic 

  ** If Dr Carey’s clinic does not take place go to head and neck clinic. Head and Neck Conference on Friday is optional but encouraged if you have seen these patients. ***Beginning in 1/2008, Fellows’ Conference is switching to Tuesdays.

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Outpatient Rotation Hematology

Monday Tuesday Wednesday Thursday Friday7:30 am  Fellows’ Conference Room 3004 old clinic (check calendar) **

7:30 am  Fellows’ Conference Room 3004 old clinic (check calendar) **

7:30 am  Fellows’ Conference. Room 3004 Old clinic

Hemophilia Clinic with Dr Key and Ma

 Sickle Cell Clinic

Heme Malignancy Clinic with Drs VanDeventer and Voorhees

 Parker conference at 11am if time. Gravely Gd Floor

Heme clinic, Dr Ma

12:30 Monday Division Lectures *

    

 1PM Heme conference

Coagulation Clinic with Dr Moll

Sickle Cell Clinic

 

Heme clinic, Dr Ma

Check with the Division re the Conference on Mondays for titles and place

**Beginning in 1/2008, Fellows’ Conference is switching to Tuesdays.

Check with Dr Ma. She may be moving her clinic to Thursdays. When that happens the clinic will be off site and you will not need to go to Parker Conferences.

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PULMONARY DISEASES AMBULATORY CURRICULUM

In overview, the medical resident’s activities will mirror the responsibilities of the Pulmonary consult Fellow, i.e., evaluation of inpatient and outpatient referrals and interpretation of standard pulmonary function tests. The resident will interact closely with the Pulmonary consult Fellow and Attending.

The overall educational goals will be accomplished through several formats:

1. Daily inpatient consults on all non—ICU pulmonary referrals (we average -1.5 consults per day).

2. Interpretation of pulmonary function tests and review of tests with the Attending physician. We perform about 600 individual pulmonary function tests per month. Specific attention will be focused on interpretation of blood gases and spirometric parameters. Understanding the indication for lung volume and DI.ICO tests will be a goal for the resident’s experience.

2. Work—up of a new pulmonary outpatient referral and follow—up of selected patients in each Wednesday’s day—long clinic. In conjunction with the consult fellow and clinic attending, this will involve selecting and interpreting appropriate pulmonary function tests.

4. Evaluation of sleep—clinic outpatient referrals on Friday mornings and review of sleep apnea studies in conjunction with a senior Fellow and the Attending. The goal will be to better define for the resident indications for obstructive sleep apnea studies.

5. Evaluation of outpatient “walk—in” referrals or outpatient consults who need to be “added—on” and seen on days other than Wednesday. We see 2—4 new patients per week by this route.

6. Presentation and discussion of cases at the weekly medicine— radiology—chest surgery—oncology conference (1 hour).

7. Three didactic conferences (1 hour each) per week related to critical care medicine, clinical topics, and review of research papers. These presentations draw on faculty and fellows from Pulmonary, Infectious Disease, Radiology, Critical Care Surgery, Anesthesiology, & etc.

8. The weekly pulmonary division clinico—pathologic “work” conference (2 hours) that involves presentation of difficult, complex, and/or interesting cases. Pathophysiologic concepts are emphasized.

9. Although the consult service performs a number of procedures, we will not emphasize the technical aspects of those studies except for aspects of the thoracentesis and/or pleural biopsy. The opportunity to observe decision—making about bronchoscopic procedures, and to visualize endobronchial anatomy during bronchoscopy, will contribute to the resident’s appreciation for the role of this procedure in the evaluation of pulmonary disease.

In summary, the medical resident will enjoy an integrated experience of inpatient and outpatient evaluations, learn the indications and interpretation of pulmonary functions tests, have exposure to patients referred for sleep—apena studies (and perhaps learn some

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indications for these referrals), better appreciate the role of fiberoptic bronchoscopy in evaluation of pulmonary disease, and expand their pulmonary physiologic concepts. Overall, this resident rotation complements the resident’s ICU and inpatient exposure to pulmonary diseases. It provides an experience that will be useful for most internal medicine physicians because pulmonary disease is a common cause for clinic visits to the internists.

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DIGESTIVE DISEASES AMBULATORY CURRICULUM

On the Digestive Diseases Consultation Service, residents have the opportunity to see patients with gastroenterology as well as hepatology disorders. The following subjects will be reviewed on the month rotation.

1. Evaluation and treatment of diarrhea2. Evaluation and treatment of jaundice3. Inflammatory bowel diseases4. Hepatitis - viral and non-viral5. Diagnosis and management of peptic ulcer disease6. Nutritional support - enteral and intravenous7. Colonoscopy - indication and screening8. Diagnosis and management of pancreatitis9. Diagnosis of esophageal motility disorders10. Evaluation and treatment of abdominal pain11. Diagnosis and management of cirrhosis12. Liver transplantation - indicators and outcomes13. Diagnosis and management of GI bleeding14. Appropriate use of radiologic studies of the gastrointestinal system15. Evaluation and management of gallstones/gallbladder diseases

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INFECTIOUS DISEASE AMBULATORY CURRICULUM

Role:

Residents play an important role on the consult service and in the clinic, where they help to manage outpatients with AIDS, chronic fatigue syndrome, and a variety of different infections including endocarditis and osteomyelitis. Residents are supervised by an attending physician.

Teaching Conferences:

Teaching conferences include a Wednesday clinical case conference at 8:30 a.m. and a Friday 8:30 a.m.conference which is didactic and/or research oriented.

Topics:

Topics covered through these conferences can be organized according to an organ system approach in Infectious Disease. These include 1) central nervous system infections, including meningitis and encephalitis; 2) infections of the eyes, ears, nose and throat; 3) infections of the upper and lower respiratory tracts; 4) infections of the cardiovascular system including endocarditis; 5) infections of the intestinal tract including infectious diarrhea and intra-abdominal catastrophe; 6) infections of the urinary tract, including sexually transmitted diseases; 7) systemic infections, including HIV; 8) infectious disease syndromes, including chronic fatigue syndrome. General lectures also include a) antibiotics, b) host defenses, c) microbial pathogenesis. Pathogenesis includes discussion of worms, protozoans, fungi, viruses and bacteria.

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Resident’s Responsibilitiesfor Consults and Ward Service

Rounds will begin at 1:30 PM in the Clinical Microbiology lab with discussion of sterile fluid infection, review of new micro data and “unknown” case presentations from Microbiology faculty.

Consultations & Rounds: Residents are responsible for full evaluations of patients seen in consultation. Residents are responsible for following in-patients daily, presenting patients during rounds, discussing differential diagnoses with the attending, and writing appropriate notes in the medical record. The on-call schedule and sequence of assignments will be discussed by the Attending or the Fellow at the beginning of the rotation.

Conferences

The following conferences are held weekly by either the Division of Infectious Diseases or the Department of Medicine. All listed conferences are required.

Day/Conference Time Place

Wednesday:Case Presentation 8:30am Orthopedic Conference Room

Thursday:Dept. of Medicine Grand Rounds 12:00pm Clinic Auditorium

Friday:ID Didactic/Research Conference 8:30am Clinic B Conference Room

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RHEUMATOLOGY / ORTHOPAEDICS AMBULATORY CURRICULUM

Welcome to the Division of Rheumatology and Immunology. Although rheumatologic and autoimmune disease are, in the aggregate, extremely common, physicians who miss this special opportunity for a rotation on a rheumatology service may never acquire the knowledge and skills required for caring for patients with these disorders. For this reason, emphasis during your rotation will be on learning “nuts and bolts” rheumatology:

a) signs and symptoms of the different arthritidesb) performance of a musculoskeletal history and examC) construction of common differential diagnosesd) choice and interpretation of laboratory tests and x-rayse) arthrocentesis and soft-tissue injection techniquesf) choice of therapy for commonly encountered conditions.

In addition, you will learn the basic elements of the pathogenesis and disease expression in rheumatologic disease. These educational objectives will be accomplished by seeing disease. These educational objectives will be accomplished by seeing patients, clinical discussions with faculty and fellows, literature searches and reviews, various lectures and conferences, and Bob Berger’s “tool-kit.”

Rheumatology is largely an out-patient specialty, and the major block of your time will be spent in the Musculoskeletal Module in the ACC. This module houses rheumatology and orthopaedic examining and consult rooms, facilities for physical therapy, occupational therapy, patient education, a library, and a special bone and joint x-ray suite. You will also see in-patient consults at UNCH. Scheduling of consult rounds, on-call responsibilities, your time in clinic, etc., will vary from month-to-month. Schedules and responsibilities will be discussed with you by the Attending and/or Fellow at the beginning of your rotation.

There are only four rules: 1) Be in clinic on time. Medicine residents and students should report to clinic at 9:00am. 2) If you are not called to see an urgent consult, be in the clinic. 3) Formal consult rounds will not be held until 3:30pm in order to minimize conflicts with your ambulatory care experience in the clinic. 4) Turn in the evaluation sheet and list of patients seen to me at the end of your rotation.

Resident’s Responsibilities for Clinics and Consults

Report to the musculoskeletal module, 1st floor, Ambulatory Care Center at 9:00 am following Morning Report. Meet for Consult Rounds at the film assembly desk (“cage “) in Radiology at the times designated by the Attending or Fellow.

Clinic Responsibilities:Residents will perform complete evaluations of new patients and return patients, as assigned by the Attending. The nursing staff may also direct residents to do initial work-ups on patients. Residents will be responsible for presenting patients to the Attending, developing a therapeutic plan, discussing differential diagnoses with the attending, and completing a write-up for the medical record.

Consultations & Rounds:Residents are responsible for full evaluations of patients seen in consultation. Residents are responsible for following in-patients daily, presenting patients during rounds, discussing differential diagnoses with the attending, and writing appropriate notes in the medical record. The on-call schedule and sequence of assignments will be discussed by the Attending or the Fellow at the beginning of the rotation.

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Schedule

The following schedule is subject to some change. Please check with your attending on the first day of the rotation to confirm the following schedule.Monday Tuesday Wednesday Thursday Friday8:30 - 3:30 8:30 - 12:00 8:30- 3:30 8:30 - 3:30Clinic Clinic Clinic Clinic

10:00-11:00Rheumatology 3:30-5:00 9:00-3:30 3:30-5:00Clinic orGrand Rounds Clinic or ClinicConsult Consult12:00-1:00 Rounds 3:30 - 5:00 Rounds

Clinic orImmunologyJournal Club 1:OO 3:30 ConsultClinic Rounds’2:00-3:00Research-in- 3:30- 4:30Clinic orProgress Consult3:30-5:00 RoundsClinic orConsultSounds’

Please note that this schedule only includes required events. Optional conferences, etc. are listed separately.

• NOTE: Consult rounds are held 2-3 days per week. Days of week may vary in different months. Formal consult rounds will not be held earlier than 3:30. Scheduling of consult rounds far the month will be defined by me Attending at Fellow at the beginning of each rotation.

Conferences

The following conferences are held weekly by either the Division of Rheumatology and Immunology or the Department of Medicine. Please note that several are required for medical students and others are optional. For more in formation regarding speakers and titles, contact the Rheumatology Division Office in 3330 Thurston Building, (919) 966-4191.

Day/Conference Time Place Required/Optional

MondayImmunology Journal Club 10:00am 3280 Thurston OptionalRheumatology Grand Rounds 12:00noon 3280 Thurston RequiredResearch-I n-Progress 2:00pm 3280 Thurston Optional

WednesdayLecture: Program On Aging 12:00 Noon Clinic Auditorium Optional

ThursdayDept. of Medicine Grand Rounds 12:00 pm Clinic Auditorium Required

FridayAmbulatory Care Conference 12:00 Noon Clinic Auditorium Optional

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Nephrology Ambulatory Curriculum

Nephrology Consultation Service Resident Curriculum

Role of Resident

Evaluation and discussion of patients with kidney disease, hypertension, and disorders of fluid, and electrolyte and acid-base balance disorders in the consultative setting under the supervision of Nephrology faculty.

Consults

Residents will see both hospitalized and ambulatory patients in consultation on a daily basis, unless assigned to their continuity clinic. Patients with a wide range of nephrologic diagnoses will be seen and discussed with the Nephrology Attending and fellow. Residents are expected to communicate consultative recommendations with the referring physicians, and to provide ongoing follow up while on the rotation.

Curriculum

Topics to be discussed during rounds as well as during formal didactic sessions will include the following:

Evaluation of kidney structure and function

o Urinalysiso Measurement of GFRo Evaluation of proteinuriao Measurement of urinary electrolyteso Renal imaging techniques

Chronic kidney disease

Acute kidney injury

General principles of dialysis

o Hemodialysiso Peritoneal dialysiso Continuous renal replacement therapies

Critical care nephrology

Metabolic acidosis

Metabolic alkalosis

Disorders of water metabolism (hyponatremia and hypernatremia)

Disorders of potassium and magnesium metabolism

Disorders of calcium, phosphorus and bone metabolism

Overview of evaluation and treatment of hypertension

Glomerular syndromes

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o nephritic syndromeo nephrotic syndrome

Diabetic nephropathy

Principles of kidney transplantation

Clinics

Participation in several Nephrology Subspecialty Clinics is available to residents interested in seeing patients with specific diagnoses and is optional. Residents will see patients under the direction of one of the Nephrology Attendings.

Monday PM Hypertension Clinic Tuesday AM and PM Transplant Clinic Thursday AM and PM Vasculitis Clinic

Renal Conferences

Residents are encouraged to attend the following Divisional Educational Conferences during the rotation:

Conference Time TopicLeader/Organizer

Hypertension 2nd and 4th Review of literature related to Drs. RomuloJournal Club Mondays hypertension Colindres and Steven

4-5 pm GrossmanTransplant 1st and 3rd Review of literature related to Dr. Randy Detwiler Journal Club Mondays kidney transplantation 4-5 PM Fellows Tuesday Review of topics in Drs. Romuloconference 4-5 pm clinical nephrology and Colindres and Gerald Renal physiology Hladik Nephrology Wednesday Review of nephrology Nephrology DivisionJournal Club 8:30-9:30 am literature; study of issues

related to design and analysisof clinical studies

Nephrology Wednesday Clinical nephrology Nephrology DivisionConference 4-5 pm

ADOLESCENT MEDICINE AMBULATORY CURRICULUM

1) Knowledge of the epidemiology of adolescent health issues• Describe the major causes of adolescent morbidity and mortality.

• Describe the ways that these issues are addressed in routine adolescent care.

• Understand that the rationale for guidelines for preventive adolescent health care

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is based on the major causes of adolescent morbidity and mortality.

• Describe guidelines for routine health screening, including laboratory tests.

2) Skill in communicating with adolescents• Recognize that adolescents should be interviewed privately as a routine part of

physician visits.

• Describe how the issues of consent and confidentiality are managed with minor adolescents.

• Perform a thorough history, including an adolescent risk assessment.

3) Understanding of normal adolescent development• Describe normal psychosocial and co2nitive development.

• Recognize that the timing of psychosocial and cognitive development is independent of pubertal development.

• Accurate assessment of Tanner staging.

• Describe the range of normal variation in timing of pubertal changes.

• Recognize and manage common concerns of puberty (e.g. Am I normal? Gynecomastia in males, Acne, etc.).

4) Sexuality• Perform a complete sexual history in a sensitive and age-appropriate manner.

• Demonstrate appropriate anticipatory guidance and risk-reduction counseling.

• Perform a complete pelvic exam including collection of cervical cytology and tests for STDs.

• Perform a male genital examination including tests for STDs.

• Teach self-breast examination and self-testicular examination.

• Provide contraception.• Instruct and demonstrate how to use condoms.

5) Common acute and chronic medical problems of adolescence• Recognize, evaluate, and manage common medical problems of adolescence (e.g.

acne, dysmenorrhea, STDs, pregnancy diagnosis, scoliosis, Osgood- Schlatter disease, headaches, etc.).

• Describe a strategy for evaluation and management of chronic somatic symptoms, including recognition that mental health problems may present as

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somatic symptoms.

• Understand the influence of puberty and adolescent development on chronic illness.

• Describe the issues regarding the transition of adolescent patients with chronic illness to adult care.

6) Identification and management of mental health problems• Recognize abnormal psychosocial development.• Recognize that significant psychiatric disease can present in adolescence.• Perform an assessment for depression and suicide, and describe appropriate

management of patients with varying risk of suicide.• Understand that mental health issues are often associated with multiple risk-

taking behaviors.• Describe strategies to persuade adolescents and parents of the need for

psychological evaluation and treatment.

7) Substance use• Perform an assessment of substance use, including tobacco, alcohol, illicit

drugs, and steroids.• Describe risk factors for substance abuse.• Describe physical symptoms or signs associated with substance use.• Describe management plans for adolescents with varying risk of substance

abuse.• Understand that mental health problems may be associated with substance use.

8) Nutrition eating disorders• Perform a nutrition history.• Demonstrate ability to accurately assess growth using height, weight, and BMI.• Describe counseling regarding healthy foods and eating patterns.• Describe management for mild to moderate obesity.• Recognize symptoms and signs of eating disorders, and describe strategy for

appropriate evaluation and management.

9) Sports Medicine• Perform a pre- participation sports examination.• Describe the indications for limiting/requiring protective devices for sports

activities.• Describe the initial management of common sports injuries.• Understand the importance of screening for abnormal eating patterns and steroid

use

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GERIATRIC MEDICINE CURRICULUMOutpatient Geriatric Curriculum:

Residents in Internal Medicine who complete the Outpatient Geriatric Rotation will be expected to meet the above goals in knowledge, attitude, and skill sets. Residents will work at all times with a Faculty member from the Division of Geriatric Medicine and will rotate through the following sites of care:

1. Long Term Care Communities: Residents will work with faculty and Geriatric Fellows and will see and evaluate patients who are in the outpatient clinic setting as well as the health center/skilled nursing care area in these communities. They will see patients who are older and completely independent who are followed for continuing care at the clinics on site, as well as patients with dementia and other functional limitations who reside in the nursing care area.

2. Hospice: Residents will evaluate patients with the hospice team by doing home visitations. Residents will also meet regularly with the hospice team and director to discuss patient management issues.

3. Geriatric Evaluation Clinic: Residents will work with faculty and Geriatric Fellows in the Evaluation Clinic by seeing and evaluating older patients with complicated issues who have been referred for complete geriatric assessments. Residents will work with an interdisciplinary team to develop a plan of care for patients.

4. Senior Center: Residents will work with one of our Faculty members and a trained Physical Therapist to conduct screenings and assessments of older adults.

5. Residents will also spend time with the Geriatric Psychiatry inpatient unit, Rehabilitation clinic, and memory disorders clinic. Residents may also chose to have additional time with faculty who work with incontinence, urogynecology, dementia, movement disorders, sleep disorders, or other specific interests.

6. Residents with interests in subspecialty training may chose to do additional work with faculty in congestive heart failure, nephrology, intensive care, or other areas of interest.

7. Residents will meet weekly with the division and the fellows for educational conferences.

Based upon:2004 The American Geriatrics Society: Curriculum Guidelines for Geriatrics Training in Internal Medicine Residency Programs. The AGS Education Committee. Updated Jan 2004.

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PGY -1 Continuity Elective

Enhanced Intern Outpatient Education Rotation and Ambulatory Medicine Tract & Chief Residency RestructuringLearners: Interns interested in careers in outpatient internal medicine. The emphasis will be acquiring outpatient skills in a diverse primary care setting. The acquired skills and experience will be generalizable to other outpatient internal medicine specialties.Objectives:

1. Fulfill the traditional core residency competencies of patient care, medical knowledge, professionalism, and interpersonal skills and communication in the outpatient setting. The resident will acquire intensive disease and condition specific outpatient training in the following domains:

a. Diabetes mellitusb. Anticoagulationc. Chronic pain and comorbid psychiatric conditionsd. Acute care medicine through the Same Day Clinice. Continuity clinicsf. Travel medicine through existing Internal Medicine Travel Clinicg. Women’s healthh. (Possibly dermatology. Dean Morrell open to this but

department has had faculty shortage.)2. Acquire first-hand experience with new competencies of practice-

based learning and systems-based practice within Internal Medicine Clinic Enhanced Care Program

a. Learn quality improvement methodologyb. Learn the importance of patient tracking through patient

registries/databasesc. Work in multidisciplinary teams consisting of physicians, clinical

pharmacists, nurse practitioners, physicians assistants, dieticians, nurses, care assistants, lab personnel

3. Provide intensive continuity with a panel of patients early in residency

Curriculum:Existing curriculum for residents on Continuity Elective with selective adaptations.

Infrastructure and Template:1. Capitalize on existing UNC Internal Medicine and Enhanced Care

Programs that already provide an educational environment for medical students, residents in continuity clinic, residents on continuity elective, and pharmacy students and residents.

2. Rotation would last one month

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Sample ScheduleMon Tues Wed Thurs Fri

Am CC Pain DM Conferences, QI Project, Reading

WH

Noon Ambulatory Conference

Grand Rounds

Pm Coag Precept/Mentor SDC CC SDC

Legend: DM=Diabetes program; Pain=Chronic pain management; Coag=Anticoagulation management; SDC=Continuity Clinic; TC=Travel Clinic; CC=Continuity Clinic; Preceptor/Mentor=One-on-one preceptorship and mentorship in attending clinicWH=Women’s health

Features:1. Two continuity clinics per week.2. Dedicated continuing education time on Thursday3. Balanced outpatient experience consisting of acute, continuity,

women’s health, travel clinic, and disease specific care.4. Preceptorship with mentoring and role-modeling by experienced

internal medicine faculty

Resources:1. Money: None requested2. Faculty: Sufficient3. Increased intern time4. Increased administrative support needed (see below).

Proposals for Securing More Intern TimeOptions:

1. Add Outpatient Internal Medicine (OIM) month as third non-inpatient, non-ER month for selected interns interested in pursuing outpatient internal medicine. This would constitute an ambulatory medicine tract.

2. Invite incoming interns to request OIM month as a rotation. Commentary: Would be a good recruiting tool. Could compensate for lost intern capacity by also offering hospitalist tract to upper levels who might want to pursue hospital medicine.

Capacity: One intern per month=One intern FTE. (Would prefer incremental approach with fewer intern months for first year or two to establish program.)

Practice-Based Learning Deliverable: QI project

Other ResponsibilitiesConsider recruiting motivated and interested residents in participating in the decision-making structure of the UNC Internal Medicine Clinic a la the

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University of Nebraska model that has cultivated ownership of clinic experience through substantive input of residents who sit on “board of directors” of clinic. This will be an enhance systems-based practice experience (i.e. cultivating ownership of patients through cultivation of ownership of the work environment. How can you foster learning of systems-based practice if residents feel they have no ability to influence the system?).

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Administrative Support for Expansion of Outpatient Education Experience

Review of Accomplishments to date:1. Established continuity elective (COE) as novel, diverse outpatient

experience for residents.2. Established SDC as venue for acute outpatient medicine care after

Urgent Care was decommissioned by hospital3. Initiated QI project for improvement of HTN.

Administrative Resources:1. ½ FTE for QI project (Annie Whitney, MS)2. Considerable burden of administrative work for COE and SDC currently

being performed by Dr. Chelminski and other general medicine staff.

Proposals for Augmenting Administrative Support:1. Hire purely administrative person (less desirable as this person will

probably not have ownership and show initiative.2. Designate ambulatory chief resident. Two options:

a. ?Third chief (expensive; chief residents paid for by department)b. Retain current complement of two chief residents but designate

one as ambulatory chief.c. Ambulatory chief would be expected to continue her or

his continuity clinic (analogous to chief residents attending on wards).

Division of General Medicine Commitments:1. Office space for administrative chief.2. Official and substantive role in the decision-making processes of the

clinic.3. Sponsor attendance at annual SGIM meeting.4. Provide certificate of advanced ambulatory competency to outpatient

chief

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PGY -2/3 Continuity ElectiveResident Continuity Elective

RationaleChronic disease has replaced acute disease as the principle consumer of health care resources; more than 75% of resources are expended on chronic illness care. Most chronic disease management occurs in ambulatory settings. Internal medicine residencies, however, have historically trained physicians in managing acute medical problems and have not provided structured, continuous training in ambulatory and chronic illness care. Chronic illness care poses a different set of challenges than acute illness care where patients are symptomatic and understand the imperative for intensive, structured medical care. Chronic illness often produces no symptoms, and prevention is the focus of management. Both providers and patients need to be aware that the absence or stability of symptoms does not preclude intensive patient care that is informed by data from clinical trials. This challenge requires a new set of skills that traditionally have not been imparted in internal medicine residencies.

Objectives1. To improve resident training in ambulatory medicine through

exposure to chronic disease management programs in the ambulatory care setting.

2. To develop skills that will prepare residents to provide high quality chronic illness care, regardless of which specialty of internal medicine they pursue. Residents will gain knowledge and expertise in the following areas:

Knowledge base for effectively managing chronic illness. Systems for tracking patient outcomes that improve the quality

of care. These systems rely on ancillary medical professionals, electronic medical records, databases and information technology.

Continuous quality improvement. This elective addresses a core competency emphasized by the ABIM for Improving Performance in Practice. The UNC model has been presented at national meetings and is being adopted at other institutions, though it has not yet directly been applied to resident education at our institution.

Collaboration with mid-level providers such as clinical pharmacists, physician assistants and nurse practitioners involved in chronic disease management

Structure1. Combine Urgent Care months with structured ambulatory care

time over a two month period. Total Urgent Care time will

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remain neutral at one month. By coupling acute and chronic medical care, this elective does not seek to de-emphasize the importance of acute care; rather, it will prepare residents for the realities of independent practice where both acute and chronic issues are addressed continuously.

2. The elective will be offered to residents at all levels of training. It will be an alternative to other electives and provide an additional outpatient option.

3. The resident will rotate through the existing disease management modules: anti-coagulation, chronic pain, diabetes mellitus.

4. The resident will manage patients independently using approved protocols. The resident will receive guidance from attending physicians and clinical pharmacists experienced with systematic disease management.

5. The resident will spend one half day a week seeing patients independently with an attending physician (team leader) who will provide direct teaching related to ambulatory internal medicine on a one-on-one basis. (Recall that the usual precepting and continuity clinic experience diffuses an attending’s attention over up to four residents at a time.) The resident and attending physician will be templated for 12 to 14 patients in this half day. Billing will therefore not need to adhere to the Primary Care Exception.

6. The resident will spend one half day per week in her or his own continuity clinic. The resident will have the option to schedule her or his patients for close follow up during other half days at the ACC when clinically indicated. This will provide an experience of close continuity that is currently lacking in resident continuity clinics.

Sample Elective TemplateMonday Tuesday Wednesda

yThursday Friday

Am DSM: Anticoag

CC UCC Grand Rounds/Conferences

UCC

Pm CC with team leader

DSM: DM UCC DSM: Pain UCC

LegendDSM= Disease state managementAnticoag= Anticoagulation managementDM= Diabetes mellitus management

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Pain=Chronic pain management

Logistics1. The new elective will have a capacity for 12 residents in the first

year.2. This will mean that two residents will be accommodated

simultaneously.

Team Leaders for Disease Management Precepting1. Michael Pignone, MD, MPH2. Darren DeWalt, MD, MPH3. Paul Chelminski, MD, MPH4. Second full time ACC clinician (?Cristin Colford)

Enhanced Care Elective Rotation UNC General Internal Medicine Clinic

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Ambulatory Care PreceptorshipAmbulatory Care Center, UNC Hospitals

Primary Preceptor

Paul Chelminski, MD, MPHAssistant Professor of MedicinePager: (919) 216-6163Office: (919) 966-0471Email: paul_chelminski@med.unc.edu

Disease Management Preceptors

Betsy Bryant Shilliday, Pharm.D., CDE, CPPClinical Pharmacist PractitionerAssistant Professor of MedicineAssistant Clinical Professor of PharmacyPager: (919) 216-5723Office: (919) 843-0391Email: betsy_bryant@med.unc.edu

Robb Malone, Pharm.D., CDE, CPPClinical Pharmacist PractitionerAssistant Professor of MedicineAssistant Clinical Professor of PharmacyPager: (919) 216-5736Office: (919) 843-0391Email: rmalone@med.unc.edu

Timothy Ives, Pharm.D., MPH, CDE, CPPClinical Pharmacist Practitioner Associate Professor of Pharmacy and MedicinePager: (919) 216-0193Office: (919) 843-0391Email: tjives@med.unc.edu

GoalThe Enhanced Care elective incorporates various components of outpatient medicine including disease management clinics, continuity

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clinic, urgent care clinic, and one-on-one preceptorship with an attending physician. This elective will provide the opportunity for the learner to build upon information acquired in his/her didactic education and to apply the knowledge and skills in direct patient care activities in the primary care setting and specialty outpatient clinics. This experience will be gained primarily under the Preceptorships of Drs. Betsy Bryant Shilliday, Robb Malone, Tim Ives, and Paul Chelminski.

Practice Site DescriptionThe Enhanced Care team is an interdisciplinary team that provides disease state management services to patients who have established care with a primary care physician in the UNC General Internal Medicine (GIM) clinic. The patient population consists of adults, ages 18 and older with a variety of medical conditions. Patients can be referred to any of three existing programs: 1) Anticoagulation 2) Diabetes and/or 3) Chronic Pain. Clinical experiences afforded to the learner include, but are not limited to: anticoagulation, hypertension, hyperlipidemia, diabetes mellitus, depression, arthritis, congestive heart failure, cardiovascular risk reduction, chronic pain and osteoporosis. The clinic is located on the 3rd floor of the Ambulatory Care Center (ACC) on Mason Farm Road, Chapel Hill, North Carolina.

Hours & Clinic Descriptions Hours of the rotation are typically Monday through Friday 8am to 5pm. However, afternoon hours may vary depending on patient workload and issues that arise during clinic hours.

Clinic TemplateMonday

Tuesday Wednesday

Thursday Friday

Am

UCC DSM: Anticoag

DSM: Pain Grand Rounds/Div.MeetingDSM Meeting

UCC

Pm

UCC Preceptorship with attending

DSM: DM CC UCC

UCC: Urgent Care Clinic; DSM: Disease Management; CC: Continuity Clinic

The Urgent Care Clinic will be Mondays and Fridays 8am to 5pm. This clinic will familiarize the learner with a variety of acute medical issues. The evaluation of this component of the rotation will occur through the normal evaluation process through supervising attending physicians and not separated out to this rotation.

The Continuity Clinic will be on Thursday afternoons and will allow the resident learner to increase clinic time for this 2 month block of time. The afternoon clinic slots will begin at 1:30pm. The evaluation

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of this component will be under the normal evaluation process of supervising attending physicians and not separated out to this rotation.

The one-on-one physician preceptorship will allow the resident learner to work in tandem with an attending physician in his or her outpatient clinic to improve outpatient management skills.

The Anticoagulation Clinic consists of a Clinical Pharmacist Practitioner, Physician Assistant, Nurse Practitioner, and Registered Nurse who see patients for warfarin initiation/education, INR monitoring, warfarin dosage adjustment and enoxaparin (Lovenox®) bridging. Patients are scheduled for 15-minute appointments as often as necessary but return to clinic at least once every four weeks while on warfarin therapy.

The Diabetes Clinic is a multidisciplinary clinic, consisting of Clinical Pharmacist Practitioners, Nurse Practitioner, Registered Dietician and Research Assistants, designed to medically manage and educate patients with uncontrolled diabetes. Patients are followed until their A1c reaches goal < 7%. Though emphasis is placed on diabetes management, clinical care encompasses cardiovascular risk reduction, hypertension, hyperlipidemia, congestive heart failure, depression and arthritis.

The Chronic Pain Clinic consists of a Clinical Pharmacist Practitioner, Nurse Practitioner, and Research Assistant specializing in disease management of chronic pain syndromes and associated psychiatric disorders (depression and anxiety). Patients are assessed using screening tools such as the Brief Pain Inventory (BPI) and Center for Evaluation Studies of Depression (CES-D), and use of physical assessment at every visit. Learners will be exposed to the prescribing and use of chronic controlled substances and adjunct analgesics. They will also become proficient in the outpatient monitoring of this patient population, including the potential for medication diversion.

Global Program Objectives3. To improve resident training in ambulatory medicine through

exposure to chronic disease management programs in the UNC Internal Medicine Clinic.

4. To develop skills that will prepare residents to provide high quality chronic illness care, regardless of which specialty of internal medicine they pursue. Residents will gain knowledge and expertise in the following areas: Knowledge base for effectively managing chronic illness.

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Systems for tracking patient outcomes. These systems rely on ancillary medical professionals, electronic medical records, databases and information technology.

Continuous quality improvement and systems-based practice which is a core competency required by the ABIM for Improving Performance in Practice. The resident will have opportunities to performing chart audits of their clinic patients with diabetes. After completion of the self-audit the resident will be able to consider how their performance can improve with their individual practice or with the system as a whole.

Collaboration with mid-level providers such as clinical pharmacists, physician assistants and nurse practitioners involved in chronic disease management

Specific Program Objectives

General:1. Develop a better understanding of the roles and functions of

disease management programs.2. Assess potential barriers to care including literacy, psychosocial

issues, finances, transportation, etc. and assist patients with those obstacles.

3. Focus clinic visit time on the specific chronic disease versus the patient’s acute problems or entire problem list.

4. Adopt a better understanding of the UNC pharmacy benefit program and disease management contracts.

Anticoagulation:1. The learner should familiarize himself/herself with CHEST

guidelines. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004 Sept; 126(3) supp.

2. Understand how to better manage warfarin therapy and bridging with low molecular weight heparin, while taking into account patient specific bleeding and thromboembolic risk factors.

3. Determine an appropriate INR goal for specific patient indications based on CHEST guidelines, learn how to properly adjust warfarin dose to target the goal INR and how to dose low molecular weight heparin for various bridging procedures.

4. Assess signs/symptoms of bleeding/bruising.5. Review current medication list, update in medical record and

address any drug-drug interactions, including over-the-counter (OTC) medications such as aspirin and NSAIDs.

6. Educate patient on vitamin K content of diet and importance of consistency while on warfarin therapy.

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7. Educate patient on role of warfarin therapy in relation to their indication for therapy, discussing duration of therapy.

8. Educate patient on proper use of OTC items such as pain relievers, herbals, vitamins, supplements, etc.

9. Adjust weekly warfarin dose to target goal INR for patient’s indication using nomograms and patient history.

10. Assess past medical history (PMH) for factors which put the patient at an increased risk for thromboembolic events.

11. Assess PMH for factors which may increase the patient’s risk for bleeding complications from warfarin therapy.

Diabetes:1. The learner should familiarize himself/herself with ADA

Guidelines 2005, JNC VII, and NCEP guidelines.2. Obtain a focused CV and DM history and ROS.3. Perform foot exams.4. Assess vaccination status.5. Assess tobacco use, determine stage of change, and recommend

appropriate intervention.6. Make appropriate referrals to ophthalmology and/or nutrition.7. Assess current DM, HTN, and lipid therapy for appropriateness.

Determine goal blood pressure and lipids based on patient’s co-morbid conditions and recommend additional therapy with evidence-based reason, if needed and according to protocols.

8. Assess current level of diabetes control, develop a medication regimen and

monitoring plan and properly adjust and/or add medications to obtain glycemic goals.

Pain:1. Assess the type and level of pain, develop a medication regimen

and monitoring plan to manage any combination of pain (e.g., nociceptive, neuropathic, inflammation)

2. Assess and manage co-morbid conditions associated with pain (e.g., depression, anxiety, sleep disorders, hypertension).

3. Learn how to more effectively control the prescribing of controlled substances in patients with chronic pain to protect oneself, the patient and the community from potential drug abuse and diversion (e.g., use of urine toxicology screening).

Responsibilities and Activities Take an active role in patient care. Collect pertinent information from each patient’s medical record

in preparation for clinic visits.

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Familiarize oneself with disease management protocols for each program.

Formulate a comprehensive, evidence-based, patient-centered therapeutic plan for each patient.

Work collaboratively with preceptors during clinic visits. Educate and collaborate with patients and their

families/caregivers at their respective literacy level to ensure a patient-centered model of care.

Document patient care activities for each visit as directed by preceptor

Provide timely patient follow-up via telephone when necessary. Attend grand rounds Thursday mornings at 7:30am, when

applicable in the 4th Floor Old Clinic Auditorium. Attend General Medicine Division meeting every Thursday

morning at 8:30am in the 5th Floor Conference Room of Old Clinic Building.

Attend Disease Management meeting every Thursday morning at 9:30am in room 3004 (Hematology/Oncology Conference Room), 3rd Floor Old Clinic Building.

Present at least one journal club of current literature related to pertinent chronic disease topics, with one being presented at General Medicine Division meeting at designated time.

Actively participate in ongoing disease management projects and Continuous Quality Improvement (CQI) initiatives pertinent to the disease management programs.

Required ReadingsAll required readings can be found in hard copy format as well as full text on a CD kept in the Learner’s Notebook.

Disease Management:1. Ofman J, Badamgarav E, Henning J et al. Does Disease

Management Improve Clinical and Economic Outcomes in Patients with Chronic Diseases? A Systematic Review. Am J Med. 2004;117:182-192.

2. Bodenheimer, T.; Wagner, E. H., and Grumbach, K. Improving primary care for patients with chronic illness. JAMA. 2002 Oct 9; 288(14):1775-9.

 

Anticoagulation:1. The Pharmacology and Management of the Vitamin K

Antagonists: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:204S-233S.

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2. Harrison L, Johnston M, Massicotte P et al. Comparison of 5 mg and 10 mg Loading Doses in Initiation of Warfarin Therapy. Annals of Internal Medicine. 1997;126:133-136.

3. Kovacs M, Rodger M, Anderson D et al. Comparison of 10 mg and 5 mg Warfarin Initiation Nomograms Together with Low-Molecular-Weight Heparin for Outpatient Treatment of Acute Venous Thromboembolism. Ann Intern Med. 2003;138:714-719.

4. Ridker P, Goldhaber S, Danielson E et al. Long-Term, Low-Intensity Warfarin Therapy for the Prevention of Recurrent Venous Thromboembolism. NEJM. 2003;348:1425-1434.

5. Kearon C, Ginsberg J, Kovacs M et al. Comparison of Low-Intensity Warfarin Therapy with Conventional-Intensity Warfarin Therapy for Long-Term Prevention of Recurrent Venous Thromboembolism. NEJM. 2003;349:631-639.

Supplemental Readings:6. Antithrombotic Therapy for Venous Thromboembolic Disease:

The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:401S-428S.

7. Antithrombotic Therapy in Atrial Fibrillation: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:429S-456S.

8. Antithrombotic Therapy in Valvular Heart Disease--Native and Prosthetic: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.     Chest 2004;126:457S-482S.

Diabetes:1. Krentz A, Bailey C. Oral Antidiabetic Agents: Current Role in

Type 2 Diabetes Mellitus. Drugs. 2005;65(3):385-411.2. MRC/BHF Heart Protection Study of cholesterol-lowering with

simvastatin in 5963 people with diabetes: a randomized placebo-controlled trial. Lancet. 2003;361:2005-2016.

3. Gaede P, et al. Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised study. Lancet. 1999;353: 617-622.

4. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and reisk of complications in patients with type 2 dieabetes (UKPDS 33). Lancet. 1998;352:837-853.

5. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet. 1998;352:854-865.

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Supplemental Readings:6. Rothman R, Malone R, Bryant B et al. A randomized trial of a

primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes. American Journal of Medicine. 2005;118:276-284.

7. Rothman R, DeWalt D, Malone R et al. Influence of Patient Literacy on the Effectiveness of a Primary Care-Based Diabetes Disease Management Program. JAMA. 2004;292:1711-1716.

8. Rothman R, Malone R, Bryant B et al. The Spoken Knowledge in Low Literacy in Diabetes Scale: A Diabetes Knowledge Scale for Vulnerable Patients. Diabetes Educator. 2005;31(2)215-224.

9. Rothman R, et al. Pharmacist-led, primary care-based disease management improves hemoglobin A1c in high-risk patients with diabetes. Am J Med Qual. 2003 Mar-Apr;18(2):51-8.

10. Clark PM, Gray AM, Briggs A, et al. Cost-utility analyses of intensive blood glucose and tight blood pressure control in type 2 diabetes (UKPDS 72). Diabetologia. 2005;48:868-877.

Pain:1. Holdcroft A, Power I. Management of Pain: Recent Developments. BMJ. 2003;326:635-639.2. Ballantyne J, Mao J. Opioid Therapy for Chronic Pain. NEJM. 2003;349:1943- 1953.3. Strasser F, Driver L, Burton A. Update on Adjuvant Medications for Chronic Nonmalignant Pain. Pain Practice. 2003;3(4):282-297. 4. Hammett-Stabler C, Pesce A, Cannon D. Urine Drug Screening in the Medical Setting. Clinica Chimica Acta. 2002;315:125-135. 5. Goldenberg D, Burckhardt C, Crofford L. Management of Fibromyalgia Syndrome. JAMA. 2004;292:2388-2395.

Supplemental Readings:11. Chelminski, P. R.; Ives, T. J.; Felix, K. M.; Prakken, S. D.;

Miller, T. M.; Perhac, J. S.; Malone, R. M.; Bryant, M. E.; DeWalt, D. A., and Pignone, M. P. A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity. BMC Health Serv Res. 2005 Jan 13; 5(1):3.

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12. Gardner-Nix J. Principles of opioid use in chronic noncancer pain. CMAJ.

2003;169(1):38-43. 8. Moulin, D. E.; lezzi, A.; Amireh, R.; Sharpe, W. K.; Boyd, D., and Merskey, H.

Randomised trial of oral morphine for chronic non-cancer pain. Lancet. 1996; 347(8995):143-7.

Assessment and Feedback Self Assessment: A verbal self-assessment will be completed by

all preceptors at the end of the fourth week of the rotation. A written self-assessment will be completed the last week of the rotation and reviewed/discussed with the learner upon completion of the rotation. You are welcome at any time to request an informal evaluation of your progress.

Preceptor Assessment: A written assessment of the disease management elective should be completed at the end of the rotation. Formative verbal assessment is appreciated throughout the month.

SECTION 4TEACHING CURRICULUM

Interns’ Conference

Ambulatory Care Conference

Internal Medicine Update Conference

Board Review

Occupational and Environmental Diseases

Bioethics and the Legal Principles of Medicine

Physician Impairment

Laboratory Medicine

Medical Informatics

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Evaluation

Violence

Gender-Specific Health Care

Palliation Care & Pain Management

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Section 4Teaching Curriculum

General

The Department of Medicine has daily teaching conferences that supplement teaching done on individual rotations. As previously mentioned in Section 1, these conferences are held at times that do not conflict with the activities of the respective services. The formats of these conferences have also been described in Section 1.

Content is planned so that each resident is exposed to the breath of information necessary to become a well-trained general internist. Specific curricula are also incorporated into these conferences. These curricula are described in this section.

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INTERNS’ CONFERENCE

All PGY-1 residents are excused from clinical dates each Wednesday from noon to 1:00 pm. At the beginning of the academic year, each conference is led by a member of the faculty who discusses a topic pertinent to PGY-1 management of patients. Topics included are outlines below. Following this series of conferences, the format for this conference changes to case-based teaching of 1-2 topics per session. This format continues throughout the year.

Topics for Conferences

EMERGENCIES NEPHROLOGYAnaphylaxis / PEHematology/Oncology Emergency

SVC SyndromeTumor LysisHypercalcemiaCord Compression

Pneumothorax / Aortic Dissection

CARDIOLOGYHypertensionAtrial FibrillationMyocardial InfarctionCongestive Heart FailureEKG Interpretation

NEUROLOGYSeizuresCVAAltered Mental Status

PULMONOLOGYChronic Obstructive Pulmonary DiseaseLung CancerAsthmaPneumonia

INFECTIOUS DISEASESHuman Immunodeficiency VirusTuberculosisMeningitis

Acute Renal FailureChronic Renal Failure

ENDOCRINOLOGYThyroid DiseaseAdrenal Disease

DIGESTIVE DISEASESPUDPancreatitisLiver Failure / ETOH Liver DiseaseHepatitisDiarrhea

HEMATOLOGY/ONCOLOGYAnemiaBreast CancerProstate CancerColon Cancer

RHEUMATOLOGYRheumatoid Arthritis/OsteoarthritisLupusSarcoidosis

INTRO TO EVIDENCE BASED MEDICINE

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AMBULATORY CARE CONFERENCE

This conference occurs each Friday from noon to 1 pm and is attended by PGY-1, -2, and -3 residents. Each conference is led by a PGY-2 or PGY-3 resident. The resident researches the topic, presents a key article, and critically appraises the article and the literature. The focus of this conference is evidence-based medicine.

Topics for Conference

HEENTSinusitis/Rhinitis/Otitis/LaryngitisHearing LossPharyngitisBlinding Eye Diseases

RespiratoryCough/BronchitisPulmonary NoduleOutpatient Management of Asthma

CardiovascularEvaluation and Treatment of HypertensionTesting strategies for Suspected Coronary Artery DiseasePeripheral Vascular Disease (arterial)Chronic Venous DisordersCarotid Bruits and TIA’s

GIIrritable Bowel SyndromeDiverticular DiseaseDyspepsiaConstipationDiarrheaAvitaminoses

EndocrineOutpatient Management of Type I DMOutpatient Management of Type II DMOsteoporosisGoiter and Thyroid NodulesHyper- and Hypothyroidism

MusculoskeletalLow Back PainCommon Foot Problems in Primary CareEvaluation of Musculoskeletal Complaints-1- Neck and UE-2- Hip and LEGout/CPPD

Gynecologic/GenitourinaryPrescribing Oral Contraceptives

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Menopause/Hormone Replacement TherapySTD’s/Vaginitis/ Safe Sex CounselingPelvis Inflammatory DiseaseSexual DysfunctionBPH/ProstatitisUTI/Asymptomatic BacteriuriaNephrolothiasisDysfunctional Uterine BleedingHematurias/ProteinuriaIncontinence

NeurologicDizzinessSyncopeHeadachePeripheral Neuropathy

PsychiatricAnxiety/Panic DisorderManagement of Chronic Benzodiazepine UseNarcotic Addiction/Narcotic-seeking BehaviorRecognition of Abuse in the outpatient setting (Domestic

violence/Incest/Rape)Depression in Primary CareInsomniaRecognition of Personality Disorders in the Outpatient Screening

DermatologyOutpatient Dermatology

Screening/PreventionSmoking: Counseling and CessationTuberculosis Screening and ProphylaxisImmunizations and Post-Exposure ProphylaxisGeneral Principles of Screening and Prevention CareCholesterol ScreeningBreast Cancer ScreeningCervical Cancer ScreeningTraveler’s RecommendationsColorectal Cancer ScreeningProphylaxis for Procedures

MiscellaneousOutpatient Management of HIV infectionPreoperative Medical Evaluation in the clinic setting

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INTERNAL MEDICINE UPDATE CONFERENCE

This conference occurs each Monday from noon to 1 pm. A series of topics is selected, each one reviewed by a faculty member of the Department of Medicine. The subjects are chosen based upon resident performance on the ACP sponsored In-Training Examination. All residents attend this conference. The following subjects are reviewed in this conference.

CARDIOLOGY DIGESTIVE DISEASE INFECTIOUS DISEASESMI diagnosisMI ManagementArrhythmiasDiagnostic TestingEKG & Physical ExamCHF ManagementChest pain evaluationHTN etiologyHTN ManagementEndocarditis diagnosisEndocarditis ManagementCAD interventions

ICUAortic AneurysmShockRespiratory FailureARDSPulmonary EmbolismPneumoniasIonotropic MedsDKAOverdoses

NEPHROLOGYHyponatremiaAcidosisAlkalosisElectrolytesUrine ElectrolytesHypernatremicHematuria/ProteinuriaLupus/VasculitisTransplantsUrinalysisDialysis / ARF

NutritionUpper GI bleedLower GI bleedLiver FailurePancreatitisDiarrheaCholecystitis/CholangitisDiverticulitisInflammatory Bowel DiseasePeptic Ulcer DiseaseCirrhosis

HEMATOLOGYSickle cell diseaseDICCoagulopathiesHemolysisAnemiaThrombocytopeniaAnticoagulation - How to

GENERAL MEDICINEVenous stasis ulcerDepressionStrokeBack painDementiaNeuropathyScreeningOccupational Health & ExposureOccupational Health - Toxins

ETHICSDNRApache Score/ PrognosisLegal

MeningitisHIV 1 - Opportunistic Infect.HIV 2 - Anti retroviralHepatitisAntibiotics IAntibiotics IIFever of unknown originSepsisUrinary Tract InfectionsRare infections

PULMONARYAsthmaPulmonary noduleTuberculosisInterstitial lung diseasePleural effusionsPulmonary Function Tests

ONCOLOGYLung Cancer ILung Cancer IILeukemia ILeukemia IIHem/Onc emergenciesLymphomaBreast cancerColon cancerProstate cancerMyelophthystic disordersMultiple myelomaBone marrow transplantation

RHEUMATOLOGYCrystal diseaseInflammatory arthritisAutoimmune

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INTERNAL MEDICINE BOARD REVIEW

At the conclusion of each academic year, a review of Internal Medicine is given to prepare PGY-3 residents for the certification examination in Internal Medicine. The core of this review is a series of lectures given by faculty members. All PGY-3 residents are excused from clinical duties to attend.

The goal of each lecture is to give a broad overview of the subjects. Each lecture has an accompanying handout. These are collected so that each participant receives a syllabus for the course.

OCCUPATIONAL AND ENVIRONMENTAL DISEASES

Internists must always consider that certain symptoms and disease processes are related to exposures in the occupational setting or particular environmental settings. At the completion of training, residents should have a working knowledge and sufficient patient experience to satisfy the following goals:

Incorporate in a history occupational and environmental exposures.

Identify physical and laboratory findings suggestive of occupational/environmental exposure - alopecia, wheezing, hearing loss, chest x-ray abnormalities of silicosis, asbestosis, CO poisoning, lead exposure.

Understand appropriate reporting to monitoring agencies

Know the procedure and how to assess disability

Know how to counsel patients about exposure risks

The information necessary to meet these goals is the subject of several teaching conferences. It is also part of the Curriculum of the Pulmonary service as well as Allergy Clinic, and part of Rheumatology rotation.

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BIOETHICS AND THE LEGAL PRINCIPLES OF MEDICINE

On a day-to-day basis, residents face ethical issues. Residents must gain expertise in the following subjects and be familiar with their societal and legal boundaries.

Understand living wills and power of attorney and incorporate this into a history

Be able to define criteria for withdrawal of support

Be able to counsel a patient when the patient refuses treatment or is ambivalent about treatment.

Understand the legal aspects of confidentiality

Understand what constitutes malpractice and steps to prevent litigation.

Develop expertise with the dying patient and family.

Understand the role of hospice and be familiar with referral criteria

Be familiar with surrogate decision-making and permission for treatment.

Understand the legal aspects of “Do not resuscitate” orders.

Understand the legal aspects of confidentiality of medical records.

These subjects are reviewed in several teaching conferences in the Department of Medicine. Some of these issues are part of the curriculum in the ICU and the general medicine inpatient service. Finally, at least three Grand Rounds per year are devoted to these subjects.

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PHYSICIAN IMPAIRMENT

A significant number of physicians are impaired by alcohol, chemical dependency, and/or psychiatric dysfunction. The recognition of such physicians, how they can be referred for help, and their outcome should be appreciated by residents. Specifically, the following aspects of physician impairment should be part of the knowledge base in internal medicine.

What constitutes physician impairment and how to identify it.

What is appropriate treatment for impaired physicians?

Recognition of the disease of addiction.

The utility of a contract for an impaired physician.

This subject and its components will be reviewed in a series of ’ conferences conducted by members of the North Carolina Physicians Health Program, a group of experts in the field of physician impairment. Educational reading materials will be provided at the conferences.

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LABORATORY MEDICINE

As part of a diagnostic evaluation, internists often order and subsequently interpret a variety of laboratory tests. Internists should demonstrate competency in these areas for the tests listed. This information is reviewed in the subspecialty and general medicine curricula.

Allergy and Immunology - levels of complement, C1 esterase, eosinophil count

Cardiology - cardiac enzymes, nuclear heart scan

Dermatology - Tzanck smear, microscopic exam for scabies

Endocrinology - bone mineral densitometry, serum glucose, gylcosylated hemoglobin, serum gonadotropins, serum lipids, serum prolactin, thyroid function tests, thyroid scanning, urine metanephrines, serum calcium, serum phosphate

Gastroenterology - assays for H. pylori, serum tests for liver diseases, colonoscopy, stool for O&P, ercp, fecal electrolytes and osmolality, gall bladder scan, serum gastrin, viral hepatitis serology, liver biopsy, stool fat, endoscopy

Hematology - bone marrow aspirate and biopsy, cytogenetics, clotting assays, iron studies, lymph node biopsy, electrophoresis, B12 levels

Infectious Disease - CD4 counts, csf analysis, ELISA, PCR, serology for common infections, syphilis serology

Nephrology - 24-hour urine electrolytes, fractional excretion of sodium, creatinine clearance, renal biopsy, serology for glomerulornephritis, renal angiography

Neurology - anticonvulsant drug levels, carotid Dopplers, imaging of CNS, sleep study

Oncology - cytology, estrogen/progesterone receptors, serologic tumor markers

Pulmonary - bronchoscopy, pleural fluid analysis, and lung scans

Rheumatology - antinuclear antibodies, ESR, complement levels, rheumatoid factor, synovial analysis for crystals.

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MEDICAL INFORMATICS

The extent of medical information, both educational as well as related to patient care, is vast. Organization of this information is critical for an internist to function effectively. To this end, an internist must have certain knowledge of computer systems to design an information system that is reliable and accessible. The following curricular goals should be achieved.

Be able to use basic word processing

Be able to use CD-ROM’s and the Internet for education and literature searching

Be able to use computer systems for patient care

Know essential aspects of information storage.

To emphasize these goals, each resident attends a course to develop skills in using the clinical workstations at the UNC Hospitals. Furthermore, there are instructional conferences on CD-ROM for educational use.

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Violence

An internist must be able to recognize signs and symptoms of abuse as well as know how to manage or refer patients who are victims of abuse. The following objectives will be addressed in didactic sessions.

1. to learn the signs and symptoms of domestic abuse

2. to learn the signs and symptoms of sexual abuse

3. to learn the signs and symptoms of elder abuse

4. to learn about the hospital & community resources to deal with these problems

5. to learn the legal issues involved in abuse

These subjects are discussed at the departmental level, usually at Grand Rounds, by experts in abuse. These experts work under the Beacon Program at the UNC Hospitals, which includes faculty members from the Department of Medicine, the Department of Social Services, & the Legal Department.

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Gender-Specific Health Care

Women’s Health

The general internist will be called upon to perform health maintenance, recognize and treat common disorders, and refer appropriately for complex diseases of women.

In preparation for these functions, the following objectives should be met in the residency:

1. be able to perform bimanual pelvis examination, including preparing pap smears

2. be able to perform a breast examination and instruct patients in self-examination

3. know health maintenance guidelines for these examination (1, 2)

4. be able to prescribe common contraceptives

5. understand the evaluation of galactorrhea

6. be able to diagnose and treat common STD’s-syphillis, gonorrhea, herpes

7. be familiar with rape protocol

8. understand the presenting signs of sexual abuse

9. be familiar with the evaluation of pelvic pain

10. know the physical signs of cystocele, rectocele, uterine prolapse

11. be familiar with the presenting signs of pregnancy

12. be able to prescribe and understand the risks and benefits of hormone replacement

Physical examination skills for these objectives will be met in the continuity clinic, urgent care, general medical rotations, as well as the Emergency Room. Didactics on these subjects are covered in these different rotations as well as in Department conferences including Grand Rounds, ACC conferences, update conferences, and resident’s report.

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Men’s Health

The general internist also will be involved in health maintenance, referral, diagnosing and treating disorders specific to men. The following objectives should be met:

1. be able to perform a genital examination, including examination of the prostate.

2. know the health maintenance guidelines for the genital examination, including PSA screening

3. recognize presenting symptoms of prostate cancer

4. be able to diagnose and treat prostatitis

5. be able to diagnose and treat common STD’s-syphillis, gonorrhea, and herpes

6. be familiar with the evaluation of impotence

7. be able to recognize and diagnose common hernias

8. be able to recognize and treat epididymitis

9. be familiar with the evaluation of a testicular mass

10. understand the pathophysiology of gynecomastia

The appropriate skills and didatics will be covered in the same manner as described for women’s health issues.

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Palliative Care and Pain Management

A number of diseases that the general internist faces have no effective treatment. For these diseases once a diagnosis is made, the internist may have to focus all efforts on palliation and terminal care. The following objectives should be met to prepare residents for these patient care situations:

1. to develop an understanding of palliation care as perceived by the patient & family

2. to learn the role of the health care team in the delivery of palliation care

3. to learn the role of the hospice in the care of terminally ill patients

4. to learn the principles of symptoms management including pain, nausea, vomiting, & dyspnea

5. to understand about the financial aspects of palliation care, particularly in the home

These subjects will be covered in a series of lectures by expert faculty. Dr. Stephen Bernard, Division of Hematology/Oncology, will give several of these. He has specific training & conducts an elective course in the School of Medicine in palliation care. Members of the Department of Anesthesiology who serve on the pain consultation service will also participate. Regarding specific experience, the Geriatrics rotation includes time at a hospice.

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SECTION 5

EVALUATION

Resident performance must be evaluated on every rotation. The categories of evaluation as defined by the Residency Review Committee (RRC) for Internal Medicine are as follows:

1. Patient Care2. Medical Knowledge3. Practice-Based Learning and Improvement4. Interpersonal and Communication Skills5. Professionalism6. Systems-based Learning

The resident evaluation form asks faculty to evaluate residents in each of the competencies. A copy is enclosed. The competencies have been reviewed with the Attendings in departmental conferences.

Separate evaluation forms have been developed for Continuity Clinic and Same-day clinic. The form will be filled out by the clinic preceptor for each clinic session for residents and the data will be aggregated twice a year by the director of the clinic. Copies of the forms are included.

All residents are required to complete a clinical evaluation exercise in the first 6 months of the PGY 1 year. A copy of this form is included.

All residents are evaluated semi- annually by the Program Director. At the end of each year a global evaluation is submitted to the American Board of Internal Medicine. It is reviewed with the resident and a copy is provided for each resident.

Residents are asked to evaluate the faculty on each rotation and to evaluate the curriculum annually. Faculty are also asked to evaluate the curriculum Copies of these forms are provided.

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Procedure Competency

The American Board of Internal Medicine requires that residents perform safely and competently the following procedures:

1. ACLS2. Drawing venous blood3. Drawing arterial blood4. Pap smear and endocervical culture5. Placing a peripheral venous line

For other procedures the Board requires that residents know the indications, contraindications, management of complications, and interpretation of results. Performing these procedures is not required for Board certification. These include:

1. Paracentesis2. Arterial line placement3. Arthrocentesis4. Central venous line placement5. Incision and drainage of an abscess6. Lumbar puncture7. Nasogastric intubation8. Pulmonary artery catheter placement9. Thoracentesis

The Department of Medicine has responded to this initiative by developing a comprehensive procedure curriculum. This is given to all PGY 1 residents. First residents are required to watch videos and read selected articles about the procedures. The next step is a half-day workshop in our simulation lab where residents practice central venous line placement, peripheral venous line placement, and lumbar puncture. Clinical instructors are present for each procedure. A post –workshop is given to each resident. All residents are given a procedure log to use throughout the residency to record all procedures done. The information includes any complications and the supervisor for the procedure. The log becomes part of the resident’s permanent folder.

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Curriculum Evaluation2008

PGY 1 ___ PGY 2 ___ PGY 3 ___ (Please designate your year.)

Strongly Agree Agree Neutral Disagree Strongly Disagree

Scale: 1 2 3 4 5

1. Grand Rounds topics were clinically relevant and contributed to my knowledge base. _____

2. CPC’s presented a wide array of diseased processes and contributed to my knowledge base._____

3. Noon Conferences were clinically relevant and contributed to my knowledge base._____

4. Teaching conferences placed an appropriate emphasis on Evidence-Based Medicine_____

5. Teaching conferences placed too much emphasis on Evidence-Based medicine._____

6. The In-Training Examination adequately assessed my fund of information. _____

7. Residents Report presentation’s contributed to my knowledge base. _____

8. The case-based format of Residents Report was an effective learning environment. _____

9. The housestaff website was an effective tool for literature searching._____

10. My schedule allowed me adequate time to read. _____

Please feel free to add individual comments:

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Curriculum Evaluation2008

Instructor/Assistant Prof ___ Associate/Full Professor ___ Division ___ ________

Strongly Agree Agree Neutral Disagree Strongly Disagree

Scale: 1 2 3 4 5

1.Grand Rounds topics were clinically relevant and contributed to my knowledge base. _____

2.Morbidity/Mortality conferences were clinically relevant and contributed to my knowledge base. _____

3.Textbooks are a main source of reference to prepare resident lectures _____

4.Journal articles are a main source of reference to prepare resident lectures _____

5.Electronic references are a main source to prepare resident lectures _____

6.When I am attending, I hold teaching rounds at least 3 times a week _____

7.When I am attending, I do bedside teaching at least 3 times a week _____

8.The current call schedule for residents facilitates teaching _____

9.The electronic record facilitates teaching _____

10.The Department values my teaching efforts _____

Please feel free to add individual comments:

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