Department of Medicine - Knoxville

Residency Program

Curricula Areas- General Internal Medicine, Inpatient Care, PGY-II, III

1. Curricular Area:    General Inpatient Medicine PGY-2 and 3

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 Gibson, MD

4. Schedule:   Typically 7 AM until 5 PM

PGY-2 and 3 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.

New patient admission responsibilities for PGY-2 and 3 residents are limited to 12 hours or less per call date. PGY-2 and 3 residents are on day call every third day and are excused from their continuity clinic responsibilities on these days.

Additionally, PGY -2 and 3 residents are assigned to night float duty four to six weeks per year. During this experience, they take call from 7 PM until 7 AM for five days alternating with five days off. They present the new patients in a succinct manner and participate in an interactive session regarding the case at Morning Report. The resident is then excused from usual responsibilities including noon conference and continuity clinic.

Typical Schedule

* 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 effectively coordinate patient care among all members of the health care team.

    2. To independently formulate diagnostic and therapeutic treatment plans.

    3. To counsel and educate patients and their families.

    4. To competently perform those procedures essential to the practice of an internist.

    5. To function as an effective Internal Medicine consultant.

  B. Medical Knowledge

    1. To develop a deeper understanding of pathophysiology.

    2. To develop critical reading skills of the medical literature.

  C. Practice-Based Learning and Improvement

    1. 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.

    2. To gain competence in bedside teaching.

    3. To analyze one’s own practice for areas in need of improvement.

  D. Interpersonal and Communication Skills

    1. To learn how to communicate with patients, their families, their primary care physicians, 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 establish and demonstrate a sense of responsibility for a patient population.

    2. To oversee a health care team.

    3. To develop conflict management and negotiation skills.

  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 effectively evaluate and develop appropriate recommendations for preoperative assessment and consultations to a general inpatient medicine service.

  C. Residents will understand and utilize effective prophylactic therapy with anticoagulants.

  D. 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.

  E. Residents will learn appropriate admission criteria to distinguish patient placement in either a routine hospital bed or a critical care unit.

  F. 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.

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

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

  I. Residents will write all orders on patients on the General Inpatient Medicine Service when practically possible. Preferably, the PGY-2 and 3 residents will review orders written by the PGY-1 residents and medical students to insure accuracy and appropriateness. The PGY-2 and 3 residents will cosign orders written by the fourth year medical student. Residents should discuss orders regarding major treatment decisions with the attending physician. The 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-2 and 3 years:

  1.    Anaphylaxis.

  2.    Drug Fever.

  3.    Pharmacologic Use of Glucocorticoids.

  4.    Management of High-Risk Patients with Vascular Disease Prior to Major Non-Cardiac Surgery.

  5.   Preoperative Assessment of Hemostasis.

  6.   Overview of the Recognition and Management of the Drug Abuser.

  7.   Treatment of Alcohol Abuse and Dependence.

  8.   Ethical Issues Near the End of Life.

  9.   Elder Abuse.

  10.   Medical Consultation for Patients with Hip Fracture.

  11.   Overview of Falls in the Elderly.

  12.   Urinary Tract Infection Associated with In-Dwelling Bladder Catheters.

  13.   Approach to the Patient with Thrombocytopenia.

  14.   Approach to the Patient with Thrombocytosis.

  15.   Clinical Use of Coagulation Tests.

  16.   Sputum Cultures.

  17.   Overview of the Principles of Medical Consultation.

  18.   Perioperative Management of Diabetes Mellitus.

  19.   Perioperative Medication Management.

  20.   Surgical Patient Taking Corticosteroids.

  21.   The Surgical Patient with Valvular Heart Disease.

  22.   Management of Anticoagulation Before and After Elective Surgery.

  23.   Epidemiology and Causes of Heart Failure.

  24.   Overview of the Therapy of Heart Failure Due to Systolic Dysfunction.

  25.   Diagnostic Approach to Infective Endocarditis.

  26.   Diagnostic Approach to Hypercalcemia.

  27.   Treatment of Bleeding Peptic Ulcers.

  28.   Acalculus Cholecystitis.

  29.   Acute Cholangitis.

  30.   Approach to the Patient with Incidental Gallstones.

  31.   Diagnostic Approach to the Patient with Jaundice or Asymptomatic Hyperbilirubinemia.

  32.   General Principles of the Management of Variceal Hemorrhage.

  33.   Treatment of Acute Diverticulitis.

  34.   Approach to the Patient with Acute Diarrhea.

  35.   Clinical Manifestations and Diagnosis of Clostridium Difficile Infection.

  36.   Treatment and Prophylaxis of Spontaneous Bacterial Peritonitis.

  37.   Clinical Manifestations and Diagnosis of Hepatic Encephalopathy.

  38.   Diagnosis and Evaluation of Patients with Ascites.

  39.   New Anticoagulants.

  40.   Overview of the Management of Sickle Cell Disease.

  41.   Approach to the HIV-Infected Patients with Pulmonary Symptoms.

  42.   Aspiration Pneumonia.

  43.   Nosocomial Pneumonia.

  44.   Clinical Features and Diagnosis of Pelvic Inflammatory Disease in Adolescents.

  45.   Clinical Features and Diagnosis of Pelvic Inflammatory Disease in Adults.

  46.   Clinical Features and Microbiology of Osteomyelitis.

  47.   Dehydration is Not Synonymous with Hypovolemia.

  48.   Diagnosis and Acute Management of Suspected Nephrolithiasis.

  49.   Prostatitis Syndromes.

  50.   Anticoagulation to Prevent Embolization and Atrial Fibrillation.

  51.   Clinical Diagnosis of Stroke Subtypes.

  52.   Management of Status Epilepticus.

  53.   Guillain-Barré Syndrome.

  54.   Pathogenesis and Management of Status Asthmaticus.

  55.   Approach to the Patient with Muscle Weakness.

  56.   Somatoform Disorders.

  57.   Factitious Disorder.

  58.   Somatization.

It is expected that the resident will complete 12 topics per month-long rotation.

9. Procedures:

The PGY-2 and 3 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. Once competency is achieved, the PGY-2 or 3 Resident will assist their peers in skills acquisition by direct supervision of procedures performed by the PGY -1 Resident until competency is demonstrated. All procedures must be certified utilizing New Innovations.

10. Other Resources:

The PGY-2 and 3 Residents 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-2 and 3 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.

13. Method of Specialty 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