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Subspecialty Rotation: Physical Medicine & Rehabilitation (PMR) **All Goals and Objectives for this rotation are identical across all PL years** Primary Goals for this Rotation Competency 5.86 GOAL: Prevention, Counseling and Screening (PM&R). Understand the role of the pediatrician in preventing conditions affecting muscular/neurological functions in children, and in counseling and screening individuals at risk for these disorders. 5.86.1 : Provide routine counseling to all parents and patients about: 1. Prevention of brain and spinal cord injuries through the appropriate use of car restraint systems and protective sports equipment 2. Recognition of activities associated with neurologic injuries, including water sports and trampoline play, and strategies to reduce risk 3. Genetic and familial basis for certain disabling conditions 4. The influence of alcohol on fetal development and its contribution to developmental and behavioral problems 5. Federal and state programs available to provide individualized and appropriate educational services to children of all abilities, in the least restrictive environment IC, PC, K 5.86.2 : Provide counseling to parents and patients with specific conditions about: 1. The rights of the child and family when physical or developmental disabilities are present, including Family Medical Leave Act (FMLA), Individuals with Disabilities Education Act (IDEA), and the Americans with Disabilities Act (ADA) 2. The natural history of cerebral palsy, from infancy to early adulthood, including the impact of illness on the individual, family and community 3. The role of folic acid in preventing neural tube defects and the importance of adequate intake prior to conception in all sexually active females of childbearing age 4. The role of early intervention in conditions affecting muscular/neurological function IC, PC, K 5.87 GOAL: Normal Vs. Abnormal (PM&R). Distinguish normal from pathological conditions affecting muscular/neurological functions in children. 5.87.1 : Differentiate the child with idiopathic toe walking from the child with mild spastic diplegic cerebral palsy through the recognition of obligate vs. nonobligate gait patterns and the signs and symptoms of upper motor neuron disease. PC, K 5.87.2 : Explain the time course for the acquisition and loss of primitive reflexes and the implications of persistence. K 5.87.3 : Identify the spectrum of normal muscle tone and discuss the clinical significance of hypertonicity and hypotonicity. PC, K 5.87.4 : Recognize developmental variations in growing preterm infants and distinguish normal variations from early signs of cerebral palsy. K, PC 5.87.5 : Assess motor strength in children of all ages and distinguish those children with normal strength from those with proximal, distal and global weakness. PC 5.87.6 : Recall the clinical uses and side effects of commonly used medications to improve muscular/neurological function in children within disabling conditions (e.g., baclofen, intrathecal baclofen, botox, etc.). K, PC 5.88 GOAL: Undifferentiated Signs and Symptoms (PM&R). Evaluate, treat and/or refer children with presenting signs and symptoms that may indicate conditions affecting muscular/neurological functions. 5.88.1 : Create a strategy to determine which of the following signs and symptoms would be improved through PM&R interventions and refer these children. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Abnormality of tone Alterations in strength Asymmetrical use of extremities Loss of range of motion Failure to thrive Dysphagia and feeding difficulties Recurrent respiratory illnesses Hip asymmetry Recurrent urinary tract infections Developmental delays PC, K 5.89 GOAL: Common Conditions Not Referred (PM&R). Diagnose and manage patients with conditions affecting muscular/neurological function that generally do not require referral. 5.89.1 : Diagnose, explain and manage the following PM&R conditions: 1. 2. 3. 4. 5. Chronic constipation Post-traumatic epilepsy Gastroesophageal reflux Autonomic dysreflexia following spinal cord injuries Impulsivity and attention deficits following traumatic brain injuries 6. Gastrostomy tube related issues (dislodgement, granulomas, leakage, local infections, participation in PC, K activities) 7. Decubitus ulcers, grades 1 and 2 8. Bladder colonization vs. infection in children with neurogenic bladder dysfunction 9. School failures in children with chronic or disabling conditions 5.90 GOAL: Conditions Generally Referred (PM&R). Recognize and initiate management of children with conditions affecting muscular/neurological function that generally require referral. 5.90.1 : Identify, explain, initially manage and refer the following conditions affecting muscular/neurological function: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Cerebral palsy Spina bifida Brachial plexopathies Spinal cord injuries Strokes Congenital syndromes affecting development and function Post-traumatic brain syndrome Neuromuscular disorders Limb deficiencies Post-acute burn rehabilitation 5.90.2 : Identify the role and general scope of practice of PM&R; recognize situations where children benefit from the skills of specialists trained in caring for children; and work effectively with these professionals to care for children with neuromuscular disorders. PC, K SBP 5.91 GOAL: Case Management (PM&R). Understand the general pediatrician's role in providing case management and coordination of services for children with common chronic conditions. 5.91.1 : Develop and implement a case management plan for the following chronic conditions with functional limitations: 1. 2. 3. 4. Cerebral palsy Spina bifida Limb deficiencies Post-traumatic brain syndrome 5.91.2 : Provide counseling and support to the family of a child with physical limitations who needs additional care coordination and access to community resources. 6.95 GOAL: Pediatric Competencies in Brief (Subspecialty Rotation). Demonstrate high standards of professional competence while working with patients under the care of a subspecialist. [For details see Pediatric Competencies.] SBP, PC, K IC, PC, SBP 6.95.1 : Competency 1: Patient Care. Provide family-centered patient care that is development- and age-appropriate, compassionate, and effective for the treatment of health problems and the promotion of health. PC 6.95.1.1 :Use a logical and appropriate clinical approach to the care of patients presenting for specialty care, applying principles of evidence-based decision-making and problem-solving. PC 6.95.1.2 :Describe general indications for subspecialty procedures and interpret results for families. PC, K 6.95.2 : Competency 2: Medical Knowledge. Understand the scope of established and evolving biomedical, clinical, epidemiological and social-behavioral knowledge needed by a pediatrician; demonstrate the ability to acquire, critically interpret and apply this knowledge in patient care. K 6.95.2.1 :Acquire, interpret and apply the knowledge appropriate for the generalist regarding the core content of this subspecialty area. K 6.95.2.2 :Critically evaluate current medical information and scientific evidence related to this subspecialty area and modify your knowledge base accordingly. K, PBLI 6.95.3 : Competency 3: Interpersonal Skills and Communication. Demonstrate interpersonal and communication skills that result in information exchange and partnering with patients, their families and professional associates. IC 6.95.3.1 :Provide effective patient education, including reassurance, for a condition(s) common to this subspecialty area. IC, PC 6.95.3.2 :Communicate effectively with primary care and other physicians, other health professionals, and health-related agencies to create and sustain information exchange and teamwork for patient care. IC, SBP 6.95.3.3 :Maintain accurate, legible, timely and legally appropriate medical records, including referral forms and letters, for subspecialty patients in the outpatient and inpatient setting. PC, SBP 6.95.4 : Competency 4: Practice-based Learning and Improvement. Demonstrate knowledge, skills and attitudes needed for continuous self-assessment, using scientific methods and evidence to investigate, evaluate, and improve one's patient care practice. SBP, K, PC 6.95.4.1 :Identify standardized guidelines for diagnosis and treatment of conditions common to this subspecialty area and adapt them to the individual needs of specific patients. K, PC 6.95.4.2 :Identify personal learning needs related to this subspecialty; systematically organize relevant information resources for future reference; and plan for continuing acquisition of knowledge and skills. K, PBLI 6.95.5 : Competency 5: Professionalism. Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diversity. P 6.95.5.1 :Demonstrate personal accountability to the well-being of patients (e.g., following up on lab results, writing comprehensive notes, and seeking answers to patient care questions). P 6.95.5.2 :Demonstrate a commitment to carrying out professional responsibilities. P 6.95.5.3 :Adhere to ethical and legal principles, and be sensitive to diversity. P 6.95.6 : Competency 6: Systems-based Practice. Understand how to practice high-quality health care and advocate for patients within the context of the health care system. SBP 6.95.6.1 :Identify key aspects of health care systems as they apply to specialty care, including the referral process, and differentiate between consultation and referral. SBP 6.95.6.2 :Demonstrate sensitivity to the costs of clinical care in this subspecialty setting, and take steps to minimize costs without compromising quality SBP 6.95.6.3 :Recognize and advocate for families who need assistance to deal with systems complexities, such as the referral process, lack of insurance, multiple medication refills, multiple appointments with long transport times, or inconvenient hours of service. SBP, IC 6.95.6.4 :Recognize one's limits and those of the system; take steps to avoid medical errors. SBP, P, PBLI Procedures 7.1.GOAL: Technical and therapeutic procedures. Describe the following procedures, including how they work and when they should be used; K, PC competently perform those commonly used by the pediatrician in practice. Gastrostomy tube replacement Tracheostomy tube: replacement 7.2. GOAL: Diagnostic and screening procedures. Describe the following tests or procedures, including how they work and when they should be used; K, PC competently perform those commonly used by the pediatrician in practice. Developmental screening test Hearing screening Vision screening Source Kittredge, D., Baldwin, C. D., Bar-on, M. E., Beach, P. S., Trimm, R. F. (Eds.). (2004). APA Educational Guidelines for Pediatric Residency. Ambulatory Pediatric Association Website. Available online: www.ambpeds.org/egweb. [Accessed 03/24/2011]. Project to develop this website was funded by the Josiah Macy, Jr. Foundation 2002-2005. Core Competencies: K Medical Knowledge PC - Patient Care IPC - Interpersonal and Communication Skills PProfessionalism PBLI - Practice-Based Learning and Improvement SBP - Systems-Based Practice Performance Expectations by Level of Training Beginning Developing Accomplished Competent Description of identifiable performance characteristics reflecting a beginning level of performance. Description of identifiable performance characteristics reflecting development and movement toward mastery of performance. Description of identifiable performance characteristics reflecting near mastery of performance. Description of identifiable performance characteristics reflecting the highest level of performance. Medical Knowledge Patient Care PL1 PL1, PL2 PL2, PL3 PL3 PL1 PL1, PL2 PL2, PL3 PL3 Interpersonal and Communication Skills Professionalism Practice-Based Learning and Improvement Systems-Based Practice PL1 PL1, PL2 PL2, PL3 PL3 PL1 PL1 PL1, PL2 PL2, PL3 PL2, PL3 PL3 PL3 PL1 PL1, PL2 PL2, PL3 PL3