Department of Medicine - Knoxville

Residency Program

Curricula Areas- General Internal Medicine, Inpatient Care, PGY-I

1. Curricular Area:    General Inpatient Medicine PGY-1

2. Location:   UTMCK, various floors and Emergency Dept.

3. Faculty:   

    Mark Rasnake, MD, Program Director, IM Residency Program

    Calvin Bard, MD

    Daniel Ely, MD

    Kim Emmett, MD

    Crystal Gue, MD   

    Wesley Hayes, MD

    Judy Kinzy, MD

    Kim Morris, MD

    Daphne Norwood , MD , MPH

    Janet Purkey, MD

    Juli Williams , MD

    Richard L. Gibson, MD

4. Schedule:   Typically 7 AM until 5 PM

PGY-1 residents average six days and approximately 60 hours work per week on the General Inpatient Medicine Service. They have one 24 hour period off per week on average. They are limited to a maximum of 80 hours work per week when averaged over a four week period, receive at least ten hours off post call and do not work more than 30 hours continuous duty while on call.

PGY-1 residents alternate either day or night call every third day (night call every 6 th night). New patient admission responsibilities for PGY-1 residents are limited to 12 hours or less per call date.

Typical Schedule

* Optional for PGY-1 residents, Mandatory for PGY-2 and 3

# For Pre-call and on call teams only; not offered first day of each month. Also see Teaching Rounds Venue Worksheet

Please refer to the Resident Manual http://gsm.utmck.edu/IM/handbook.htm for further details regarding call duties and hospital admissions policies.

5. Related Conferences/Venues:   Morning Report, Department of Medicine Conference Room**; Grand Rounds, Morrison’s Conference Room***; Teaching Rounds, various hospital locations****; Various Specialty Noon Conferences+†; Journal Club, local restaurants†; Morbidity and Mortality Conference‡

6. Primary Goals:

The care of hospitalized patients with diverse medical problems remains essential to the practice of general internal medicine. The general internist may serve as the attending physician responsible for the overall coordination of the patient’s care as well as a consultant for patients admitted to a wide variety of services with varied medical needs. This rotation will provide residents with a diverse patient population, excellent hospital ancillary support and direct daily involvement with an attending physician for patient care decisions. It will allow the opportunity for progressive responsibility for inpatient care. The rotation will attempt to train residents to obtain competency in the following six core areas of internal medicine:

  A. Patient Care

    1. To have an integrated learning experience with acute illness.

    2. To develop thorough history and physical examination skills.

    3. To develop differential diagnoses based on integrating evidence obtained from the history, exam and diagnostic testing and relating that information with known facts of various diseases.

    4. To formulate diagnostic and therapeutic plans with some supervision.

    5. To demonstrate caring and respectful behavior.

    6. To learn how to manage the transition of patient care from the hospital  to the outpatient setting.

  B. Medical Knowledge

    1. To have a basic knowledge of pathophysiology.

    2. To develop an effective working knowledge of clinical problems often encountered in an inpatient setting.

  C. Practice-Based Learning and Improvement

    1. To develop a willingness to learn from errors.

    2. To learn how to access references such as textbooks, computer-based resources, and the opinion of colleagues to improve one’s knowledge on a continual basis.

    3. To teach other residents and students and improve one’s own teaching skills.

  D. Interpersonal and Communication Skills

    1. To learn how to communicate with patients, their families, other healthcare workers and consultants.

    2. To learn how to develop an effective physician: patient relationship.

    3. To learn how to present a case accurately and succinctly.

    4. To demonstrate legible, thorough charting in a timely manner.

  E. Professionalism

    1. To learn and demonstrate respect and compassion.

    2. To maintain professional appearance and demeanor.

    3. To demonstrate an understanding and consideration of ethical issues.

    4. To complete medical records in a timely manner.

F. Systems-Based Practice

    1. To understand how to utilize hospital-based systems to optimize care in a cost-effective manner.

7. Primary Objectives:

  A. The resident will learn to obtain an appropriate history, to perform a directed physical examination and to initiate treatment of patients with common complaints such as chest pain, dyspnea, cough, headache, dizziness, syncope, abdominal pain, diarrhea, fever, back and flank pain, weakness, edema, nausea, vomiting, hemoptysis, stroke, TIA, seizure, pressure ulcers, dysuria, urinary incontinence, encephalopathy, alterations in consciousness, metabolic abnormalities, hematologic abnormalities, diabetes mellitus and its complications, hypertension and its complications, GI bleeding, thrombosis, volume depletion, dehydration, renal insufficiency, generalized weakness and suicide ideation.

  B. Residents will learn to understand and utilize effective prophylactic therapy with anticoagulants.

  C. Residents will learn how to discuss end of life and withdrawal of care issues and how to discuss options regarding resuscitation with patients and their families.

  D. Residents will become proficient in many of the procedures commonly used in an inpatient setting, both those required by the American Board of Internal Medicine and those considered elective procedures§.

  E. Residents will develop and refine their oral presentation skills.

   F. Residents will develop effective systems to review radiologic and pathologic results including postmortem examinations of their patients.

  G. Residents will write all orders on patients on the General Inpatient Medicine Service when practically possible. Preferably, the PGY-1 will write most of the orders. A fourth year medical student may write orders on the patients they manage with the supervision of the Resident. Residents should discuss orders regarding major treatment decisions with the attending physician. Residents are expected to review all charts of patients on the service prior to sign out rounds so that consultant’s recommendations and test results may be acted upon in a timely manner.

8. Supplemental References, Suggested Readings :

  Rose, BD (Ed); Up-To-Date, Wellesley , MA , 2004. Available in Preston Medical Library and 24 hour online access. http://www.utdol.com/enterprise.asp The following topics should be read during the PGY-1 year:

    1. Estimation of Coronary Risk Before Non-Cardiac Surgery.

    2. Management of Anti-Coagulation Before and After Elective Surgery.

    3. Acute Withdrawal Syndromes.

    4. Pain Management and Addiction.

    5. Approach to the Patient with Abdominal Pain.

    6. Approach to the Patient with Dizziness.

    7. Approach to the Patient with Edema.

    8. Approach to the Patient with Fever of Unknown Origin.

    9. Approach to the Patient with Headache Syndromes Other Than Migraine.

    10. Approach to the Patient with Nausea and Vomiting.

    11. Approach to the Patient with Vertigo.

    12. Diagnostic approach to the Patient with Chest Pain.

    13. Etiology and Evaluation of Hemoptysis.

    14. Ethical Considerations and Effective Pain Management at the End of Life.

    15. Pressure Ulcers: Staging; Epidemiology; Pathogenesis; Clinical Manifestations.

    16. Prevention and Treatment of Pressure Ulcers.

    17. Recognition and Evaluation of Delirium.

    18. Approach to the Patient with Metabolic Acidosis.

    19. Diagnosis of Hyponatremia.

    20. Diagnosis of Hypokalemia.

    21. Diagnostic Approach to Hypercalcemia.

    22. Osmolal Gap.

    23. Simple and Mixed Acid-Base Disorders.

    24. Approach to the Patient with Anemia.

    25. Approach to the Patient with Abnormal Liver Function Tests.

    26. Diagnosis of an Acute Myocardial Infarction.

    27. Basic Principles of Electrocardiographic Interpretations.

    28. Evaluation of the Patient with Suspected Heart Failure.

    29. Evaluation of the Patient with Syncope.

    30. Management of Diabetes Mellitus in the Acute Care Setting.

    31. Clinical Features and Diagnosis of Acute Cholecystitis.

    32. Clinical Manifestations and Diagnosis of Acute Pancreatitis.

    33. Approach to the Patient with Lower Gastrointestinal Bleeding.

    34. Approach to the Patient with Upper Gastrointestinal Bleeding.

    35. Treatment of Chronic Constipation.

    36. Approach to the Patient with Abnormal Liver Function Tests.

    37. Clinical Use of Heparin and Low Molecular Weight Heparins.

    38. Clinical Use of Warfarin.

    39. Overview of the Clinical Manifestations of Sickle Cell Disease.

    40. Diagnostic Approach to the Patient with Community-Acquired Pneumonia.

    41. Exacerbations of Chronic Bronchitis.   

    42. Treatment of Community-Acquired Pneumonia.

    43. Soft Tissue Infections Due to Dog and Cat Bites.

    44. Treatment of Cellulitis.

    45. Acute Pyelonephritis: Symptoms, Diagnosis, and Treatment.

    46. Clinical Manifestations and Diagnosis of Influenza.

    47. Clinical Manifestations and Diagnosis of Volume Depletion.

    48. Fluid Replacement in Volume Depletion.

    49. Approach to the Patient with Renal Disease Including Acute Renal Failure.

    50. Etiology, Clinical Manifestations and Diagnosis of Subarachnoid Hemorrhage.

    51. Overview of the Evaluation of Stroke.

    52. Evaluation of the First Seizure.

    53. Treatment of Acute Exacerbations of Asthma.

    54. Overview of Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease.

    55. Approach to the Patient with Dyspnea.

    56. Clinical Manifestations of and Diagnostic Strategies for Acute Pulmonary Embolism.

    57. Treatment of Acute Pulmonary Embolism.

    58. Treatment of Deep Venous Thrombosis.

    59. Psychiatric Emergencies in Adults: Suicide Ideation and Behavior.

It is expected that each PGY-1 Resident will complete 12 topics per month-long rotation.

9. Procedures:

The PGY-1 Resident will learn the indications, contraindications and complications of procedural skills used commonly in the practice of General Inpatient Medicine. They will often have the opportunity to perform procedures which are required by the ACGME such as advanced cardiopulmonary resuscitation, central venous line placement, thoracentesis, abdominal paracentesis, nasogastric intubation, arthrocentesis of the knee, lumbar puncture, arterial puncture, and interpretation of electrocardiograms. In addition, they will have the opportunity to become more skilled in the interpretation of chest radiographs. The PGY-2 or 3 Resident and/or the attending physician will be responsible for the direct supervision of the procedure until a sufficient number of procedures has been completed to demonstrate competency. All procedures must be certified utilizing New Innovations. When the PGY-1 resident has demonstrated competency, he/she will be allowed to supervise others who are performing the procedure.

10. Other Resources:

The PGY-1 Resident will benefit from interactions with other members of the healthcare team including Nursing Staff, Case Managers, and Physical, Occupational, Speech and Respiratory Therapists. They will also interact with Attending Physicians from both medical and surgical specialties as well as resident physicians from other disciplines. A Clinical Pharmacologist and a Pharmacy Resident will participate in Management Rounds on most post call days.

11. Research Opportunities:

PGY-1 Residents are encouraged to develop case reports based on interesting patients seen on service. These may be submitted for publication or for oral or poster presentation at the Tennessee ACP meeting. Faculty members are available to assist with these efforts.

12. Method of Resident Evaluation:

Each resident is informally and continually evaluated during the course of the rotation. This evaluation will include global faculty evaluations, resident evaluations, nursing evaluations, early warning and praise cards and mini-CEX examinations (a minimum of four per year are expected). A summative evaluation form will be completed by each Attending Physician via New Innovations at the end of the rotation with direct verbal feedback given.

3. Method of Rotation Evaluation:

Residents are asked to provide direct feedback to the attending in an informal manner during the course of the rotation. They will complete a formal evaluation using New Innovations at the end of the rotation. Cumulative feedback to the attending faculty member will be given during the annual faculty evaluation by the Departmental Chair in a non-identifying manner. The residents will participate in a once yearly program evaluation.

**   See Morning Report Venue Worksheet

*** See Grand Rounds Venue Worksheet

****See Teaching Rounds Venue Worksheet

+ See noon Conference Venue Worksheet

† See Journal Club Venue Worksheet

‡ See Morbidity and Mortality Venue Worksheet

§ See Procedural Skills Venue Worksheet