Download Hospital Medicine - Danbury Hospital

Curriculum on Hospital Medicine Rotation for Internal Medicine
Residents
Faculty Representatives: Damanjeet Chaubey, MD, MPH, FACP, Janaka Periyapperuma, MD,
Gustavo Alday, MD
Faculty Editor: Janaka Periyapperuma, MD
Resident Representative: Oana Penciu, MD, Buddhini Gurusingha, MD
Date: April 2013
General Educational Objectives
The purpose of this rotation is to introduce and familiarize the resident with Hospital Medicine and the
role of the Hospitalist as a Medical Consultant. It should also provide an understanding of the essential
knowledge, skills and attitudes expected of physicians working as Hospitalists. Core competencies in
Hospital Medicine include the most common and fundamental elements of inpatient medical care without
exhaustively listing every clinical entity encountered. Hospitalists subscribe to systems organizational
approach to clinical management and processes of care within the hospital. This systems approach, more
than any level of knowledge or skill, is required to effectively and efficiently practice in the hospital
setting.
The overall objectives are to provide the resident with a critical, in depth approach to the diagnosis and
management of common medical problems encountered in the inpatient setting. Emphasis is placed on
cost effective use of laboratory, radiological and therapeutic procedures, and the pharmacology and
appropriate use of drugs.
The objectives of this rotation are
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Gain clinical experience with acute and chronic disease co-management in surgical patients,
especially lung disease, heart disease, diabetic mellitus, hypertension and peripheral arterial
disease.
Develop and strengthen knowledge, attitudes and skills in Perioperative Medicine.
Develop and strengthen knowledge, attitudes and skills in common general medical conditions
which require inpatient care
Develop and strengthen knowledge, attitudes and skills in Palliative Care Management.
Develop and strengthen knowledge, attitudes and skills in managing patients assigned to 24 hour
Medical Observation unit
Critically appraise and present a relevant journal article to the fellow residents in the Internal
Medicine Journal Club
At the end of the rotation the resident is expected to
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Have an understanding and experience of acute and chronic disease co-management in surgical
patients, especially lung disease, heart disease, diabetic mellitus, hypertension and peripheral
arterial disease.
Be able to perform Pre-operative medical evaluations of surgical patient under supervision and
have an understanding of the indications for further testing prior to the planned surgery. The
resident is also expected to gain knowledge and experience in managing common medical
problems during the perioperative period and to recognize and treat common medical
complications during this period (exacerbation of CHF, COPD, control of blood sugar in
diabetic patients, control of hypertension, diagnosing and treating DVT/Pulmonary
embolism, acute coronary syndrome, alcohol withdrawal syndromes etc.)
Have gained knowledge, attitudes and skills in common general medical conditions which require
inpatient care
Have a better understanding of knowledge, attitudes and skills in managing patients who are
receiving palliative care with the main focus on symptom management, education of the
patient and the family and providing compassionate supportive care
Be able to manage patients assigned to 24 hour Medical Observation unit for chest pain, Transient
ischemia attacks, Atrial fibrillation, Acute gastroenteritis, Acute asthma exacerbation and
Anaphylactic reactions
Have gained skills to critically appraise a journal article and to explain it to fellow residents
Rotation Specific Competency Objectives
1. Patient Care
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Demonstrate approach to providing consultative opinions for common medical problems.
Use laboratory, radiologic and other common diagnostic procedures in a cost-effective manner
and discuss risk/benefit analysis of these studies.
Discuss appropriate diagnostic and management steps for common medical emergencies and
perioperative medical problems.
Elicit a thorough history, review the medical record and inquire about functional capacity in
patients undergoing surgery.
Perform targeted physical examination, focused on the cardiovascular and pulmonary systems
and other systems based on patient history.
Perform a directed and cost effective diagnostic evaluation based on patient relevant history and
physical examination findings.
Employ published algorithms and validated clinical scoring systems, when available, to assess
and risk stratify patients.
Assess the urgency of the requested evaluation and provide feedback and evaluation in an
appropriate timeframe.
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Recognize medical conditions that increase risk for perioperative complications and make
specific evidence based recommendations to optimize outcomes in the perioperative period.
Determine the perioperative medical management strategies require to address specific disease
states.
Reassess patients for postoperative complications and make medical recommendations as
indicated.
Give recommendations and follow up care for patients eligible for palliative care
2. Medical Knowledge
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Discuss approach to common inpatient medical problems.
Explain the effect of anesthesia and surgical intervention on physiology.
Explain the goals and components of preoperative risk assessment.
Identify the patients who require selective preoperative testing based on patient specific factors,
type of surgery, and urgency of surgical procedure.
Describe risk factors for perioperative complications.
Explain risks for perioperative complications in specific patient populations.
Explain pharmacologic therapies that should be modified or held prior to surgery.
List widely accepted risk assessment tools and explain their value and limitations in patients
undergoing nonvascular surgery.
Describe the evidence supporting prophylactic perioperative ß-blockade.
Describe basic principles and eligibility of patients for palliative care
3. Interpersonal and Communication Skills
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Communicate with patients and families to explain the Hospitalists role in their perioperative
medical care, any indicated preoperative testing related to their medical conditions or risk
assessment, and any adjustment of pharmacologic therapies.
Communicate with patients and families to explain any indicated perioperative prophylactic
measures.
Communicate with patients and families to explain the need for follow-up medical care postdischarge.
Initiate indicated perioperative preventive strategies.
Recommend specific prophylactic measures, which may include ß-blockade, VTE prophylaxis, or
aspiration precautions, to avoid complications in the perioperative period.
Serve as an advocate for patients.
Promote a collaborative relationship with surgical services and other sub specialists involved in
patient care which includes effective communication.
Assess pain in perioperative patients and make recommendations for pain management when
indicated.
Facilitate discharge planning early in the hospitalization, including communicating with the
primary care provider, and presenting the patient and family with contact information for
follow-up care.
Utilize evidence based recommendations for the evaluation and treatment of patients in the
perioperative period.
4. Professionalism: Refer to ACGME core competencies
5. Practice Based Learning: Refer to ACGME core competencies
6. Systems Based Practice: Refer to ACGME core competencies
Teaching Methods
The consultative team consists typically of a hospitalist and one resident. This team is responsible for
providing medical consultations for inpatients at Danbury Hospital. Primary teaching mechanism is daily
consultation rounds which include didactic sessions and patient management rounds. The
multidisciplinary aspects of medicine are emphasized in conferences with the other sub specialists
including but not limited to, gastroenterology, pulmonary, cardiology, infectious disease, rheumatology,
neurology and radiology departments.
The major responsibility of the resident is to independently evaluate patients for whom a medical
consultation has been requested. The resident will formulate his/her own differential diagnosis,
management plan, and discuss these aspects with the supervising Hospitalist. The Hospitalist will provide
didactic sessions to the resident based on their cases. The resident is responsible for writing a consultation
report, conveying management recommendations to the primary team, closely following the progress of
the patient and making further recommendations. The resident will also be responsible for providing short
didactic sessions on subjects of interest to the supervising hospitalist. There are usually 4-5 patients per
resident per day. The resident should be punctual and should inform the supervising hospitalist of his/her
unavailability for rounds in advance (this may be due to other resident obligations including clinic, cross
coverage etc.)
Procedures/Special testing
Not applicable for this rotation.
Educational Content
Diseases that the resident will encounter include those which include but not limited to cardiac,
respiratory, gastroenterology, musculoskeletal, neurological systems as well as multisystem disorders
such as diabetes, atherosclerotic vascular disease, and autoimmune conditions.
Patient characteristics include hospitalized medical patients, and medical consultations done on patients in
the emergency room as well as perioperative medical evaluations and management. Types of encounters
include inpatient and emergency room consultations and follow up of inpatients. Sometimes the
consultation starts in post-surgical recovery rooms. Patients range in severity, but tend to be acutely ill
with multi-organ system processes. Patients' age range from 16 through 100 +, and include both genders
and various ethnicities. Residents will also get exposure to inpatient palliative and end of life care
discussions and follow up with the palliative care team or the supervising hospitalist.
Reading lists and other educational resources
These are the recommended topics for Reading List section of our curriculum
 Journal of Hospital Medicine (Society of Hospital Medicine)
 Go to Up To Date online 13.1, enter “Preoperative Evaluation”
 Overview of the principles of medical consultation
 Preoperative medical evaluation of the patient
 Assessing surgical risk in patients with liver disease
 Estimation of perioperative coronary risk before non-cardiac surgery
 Evaluation of perioperative pulmonary risk
 Identification and management of alcohol use disorders in the perioperative period
 Management of anticoagulation before and after elective surgery
 Management of high-risk patients with vascular disease prior to major non-cardiac
surgery
 Medical consultation for patients with hip fracture
 Medical management of the dialysis patient undergoing surgery.
 Noninvasive cardiac diagnostic testing of patients with vascular disease prior to major
non-cardiac surgery
 Overview of the management of postoperative pulmonary complications
 Perioperative care of the surgical patient with neurological disease
 Perioperative management of heart failure in non-cardiac surgery
 Perioperative management of diabetes mellitus
 Perioperative management of hypertension
 Perioperative medication management
 Preoperative assessment of hemostasis
 Preoperative evaluation and perioperative management of patients with rheumatic disease
 Risk stratification of patients with vascular disease prior to major non-cardiac surgery
 Strategies to reduce postoperative pulmonary complications
 The surgical patient taking corticosteroids
 The surgical patient with valvular heart disease
 Postoperative fever
 Complications of bariatric surgery
 Transition of medical care before patient is discharged from the hospital
Resident schedule
Medical residents will rotate in two or four week blocks during this rotation. Work hours are
from 8:30/9:00 a.m. to 4:00 p.m. or 12:00 noon (on the days the resident has to attend a
continuity clinic or has Friday night float coverage). The resident should report to the Hospital
medicine coordinator after their Morning report/Grand rounds and to get the list of new medical
consult requested for the day. They will individually evaluate the patient and discuss the plan of
care with the supervising hospitalist. New consults called in during the day will also be assigned
to the resident. Residents should also follow up the patients from the previous encounters
(depends on the number of new patients for the day). The resident will also round with the
Palliative care team (Karen Mulvihill, PhD/Julia MacMillan, APRN) one day during their 2
week block. They will also rotate with the supervising hospitalist assigned to the "Observation
Unit" 1-2 days during a 2 week block. The resident will also be assigned to present a clinically
relevant Journal article at a General Internal Medicine Journal Club, under supervision of a
supervising hospitalist during their rotation. This will be done at the Hospitalist meeting which is
on Tuesdays from 1:00 p.m. to 2:30 p.m. The resident has to ensure that they schedule this
during their rotation.
Method of Evaluation of Resident's Competence
The resident will meet with Dr. Janaka Periyapperuma or Dr. Gustavo Alday at the beginning
and end of the rotation. After each block rotation faculty provides a review of the resident’s
competency based performance. The resident will receive direct feedback at the end of the
rotation from Dr. Janaka Periyapperuma or Dr. Gustavo Alday. These evaluations will be
submitted to the Internal medicine residency program coordinator for use in overall evaluation of
the residents. In turn the resident evaluates the faculty’s performance as well as the rotational
experience.
Topics of noon conferences in Hospital Medicine
1. Palliative care
2. Pain management I
3. Pain management II
4. Breaking bad news
5. Advance care planning
6. General medicine Board Review I
7. General medicine Board Review II
8. Denial management, clinical documentation
9. Pre-operative medical evaluation
10. Peri-operative medical management
11. Transition of care
12. Medical error, Root cause analysis
Damanjeet Chaubey, MD
Karen Mulvihill, PhD
Damanjeet Chaubey, MD
Karen Mulvihill, PhD
Damanjeet Chaubey, MD
Karen Mulvihill, PhD
Damanjeet Chaubey, MD
Karen Mulvihill, PhD
Damanjeet Chaubey, MD
Karen Mulvihill, PhD
Lily Singhaviranon, MD
Janaka Periyapperuma, MD
Aparna Oltikar, MD
Janaka Periyapperuma, MD
Damanjeet Chaubey, MD
Aparna Oltikar, MD
Damanjeet Chaubey, MD
Content of noon conferences in Hospital Medicine
1. Palliative care
The lecture starts with an introduction to the concepts of palliative care including
definitions of palliative care and hospice, symptom management, role of medications and
barriers to palliative care. Under symptom management emphasis is given to
pathophysiology, causes, management and non-pharmacologic intervention of common
symptoms including restlessness, terminal congestion, nausea, vomiting, constipation,
diarrhea, anorexia, cachexia, fatigue, fluid balance, skin issues, odors and insomnia. The
pathophysiology of the dying process, bereavement, counseling of the patient and family
members are also included. Another aspect of this lecture is the legal issues in palliative
care including Medicare and Medicaid coverage for end of life care, identifying the next
of kin, barriers to transition of care and the process of obtaining a DNR status for the
mentally challenged individuals.
2. Pain management I & II
This lecture includes the discussion of general principals of pain, pathophysiology,
different classes of pain medications (NSAIDS, opioids etc.), indications for each class
and how to interchange these medications. Ways to recognize substance abuse and how
to manage difficult and demanding patients are also discussed. The second lecture mainly
concentrates on how to convert a dose of one narcotic into another and case discussions
on this theme. The adjunct therapy to narcotics and other pain medications are also
discussed.
3. Breaking bad news
A methodical six step process of breaking bad news which includes getting started,
assessing what the patient know, how much information the patient wants to know,
sharing the information, responding to feelings and planning and follow up is discussed
in detail. This lecture also includes methods of communication, discussion of prognosis,
tips on DNR discussions, common pit falls and statements to avoid and conflict
resolution.
4. Advance care planning
The lecture start with definitions and goes on to review a 5 step process including
introduction in to the topic of advanced directives, engagement of the patient and
structure discussions, documentation of patient preferences, reviewing and updating the
plan and finally applying the advanced directives when needed. Special attention is given
to common pit falls and preparing the patient and family for the last hours of life.
5. General Medicine Board Review I & II
These two lectures consist of discussing multiple choice questions similar to those in
ABIM Internal Medicine Board Exam. A wide range of topics in general internal and
hospital medicine is covered mainly using MKSAP board review questions.
6. Denial management and clinical documentation
This lecture starts with an overview of health care economics and how hospitals are paid
for the services they provide. The main focus is on how to document clinical findings
which is congruent with current medical standards. Residents are explained in detail
about how appropriate clinical documentation drives the reimbursements for the services
provided by physicians.
7. Pre-operative medical evaluation
This lecture focuses on evaluation of surgical patients for their risk of mainly cardiac
events and respiratory complications before the planned surgery. The need for further
non-invasive cardiovascular testing in the appropriate patients, the risk factors which will
lead to delaying or cancelling surgery and correct clinical documentation is also
discussed. Indications for peri-operative beta blocker usage, usage of antiplatelet agents
and anticoagulants, managing blood sugar in the diabetic patient, optimizing pulmonary
status prior to surgery and deep vein thrombosis prophylaxis is also included.
8. Peri-operative medical management
Management of blood sugar, atelectasis, pain, deep vein thrombosis prophylaxis, intra
venous fluids is discussed. Main focus of this lecture is on anticipation and early
intervention of post-surgical medical complications such as hypoxemia due to multiple
causes including atelectasis, pneumonia, pulmonary embolism, congestive heart failure,
differential diagnosis and management of post-operative fever, delirium, renal failure,
anemia, nausea/vomiting, diarrhea/constipation and management of narcotic pain
medications. Another important aspect of this lecture is on when to restart patient's home
medications with special attention to oral diabetic medications, antihypertensive
medications, diuretics, anticoagulants and antiplatelet agents and safe hand off of the
patient to the next care provider upon discharge from the hospital.
9. Transition of care
The main focus of this lecture is on how important the transition of care between patients
care providers is on safety and patient outcomes. The importance of communication
(verbal and document), accountability of care, medication reconciliation, discharge
summaries and instructions, follow up investigations and patient education on the
transition plan is discussed in detail. Another part of this lecture is patient expectations
and satisfaction.
10. Medical error, root cause analysis
Preventing medical error is an important part of patient care. This lecture starts with
definitions pertinent to the topic including medical errors, near misses and an
introduction to regulatory authorities who monitor medical errors in the institution as well
as the other outside regulatory agencies. Main focus is on how to identify and report
medical errors and near misses and the fundamentals of root cause analysis and how to
act upon the results to prevent future events. Few clinical cases will be discussed to
provide the residents a chance to apply these principals in to practice.