NMC San Diego Medicine Curriculum for Students (Rev 04/02)

INTERNAL MEDICINE WARD CURRICULUM FOR STUDENTS 1. Purpose and Educational Value: The general medicine ward rotation exposes students to common medical problems of hospitalized patients. This is an opportunity for students to diagnose and manage acute medical problems and to create effective care plans following discharge from the hospital. In every case, however, the safe and efficient provision of medical care must take precedence over any training opportunities a patient might provide. a. Service on the inpatient medicine wards provides the opportunity to learn diagnostic and management skills in a condensed, efficient way. The ward experience allows students to refine history and physical examination skills, develop experience in the selection of diagnostic tests, and learn to manage a wide variety of diseases. A major advantage of ward training is the rapid feedback to students after they order diagnostic tests or begin new treatments. b. Students acquire intensive experience working with other health care personnel, including nurses, social workers, pharmacists, ward clerks, residents from other specialties, and attending physicians from other disciplines. c. Students learn to interact with patients and their families in the acute care setting. d. Students learn the communications skills needed for dealing with referring physicians and other health care personnel. 2. Principle Teaching Methods Patients who are admitted to the general medicine service serve as a stimulus for teaching rounds and independent study. a. Teaching rounds are conducted by the attending physician for a minimum of three days per week, for a minimum contact time of 4.5 hours per week. Each Wednesday, the department chairman will make additional teaching rounds with one of the ward teams. b. Management rounds are conducted at least daily between the attending physician and at least one resident. Management rounds review practical fundamental skills of hospital management as applied to each patient on the team. c. Work rounds are held at least daily. As a minimum, the resident, interns and student(s) meet before morning report to discuss each patient on the service and develop the days management plan. Thus, students must arrive early enough to examine and collect data on their patients before work rounds can begin. Work rounds should not be combined with teaching rounds or management rounds. d. A series of lectures are scheduled to enhance the learning of trainees on general ward medicine. They include: (1) The Internal Medicine core curriculum (Noon Conference) is a mandatory conference offered five days per week in the Pathology Conference Room, on the third floor of
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NMC San Diego Medicine Curriculum for Students (Rev 04/02)

Building 1. Presentations are made by faculty, guest lecturers with special expertise, residents and fellows. (2) Morning report is held Monday-Friday at 0800 in the Radiology Conference Room on the second floor of Building 1 with mandatory attendance for all students assigned to general medicine wards or ambulatory medicine/subspecialty rotations. The team on call the previous day will present an interesting case for discussion, preferably of a patient they have just admitted. Normally, the patients intern or student makes the presentation. Attendance is mandatory for all housestaff on the general medicine wards. (3) Second Half is a 30 minute mandatory conference held immediately following morning report. The period is used to discuss issues in ambulatory medicine, required curriculum topics not readily presented elsewhere, and topics of interest to the trainees. (4) Monthly morbidity and mortality conferences are presented by the residents with commentary provided by the faculty. Pathological materials are reviewed with Pathology staff. Attendance is mandatory. (5) IM Grand Rounds is a monthly conference with guest speakers who present state of the art topics in immunology and current therapies. Attendance is required for all medicine trainees, including students, and staff. e. Students are expected to read independently on the patients admitted to their services. On-line resources are available in the ward team rooms, but students are expected to bring and use a standard textbook of internal medicine. f. Every first and third Friday all interns, residents, students and staff assigned to the general medicine wards meet at 0800 in the Clinical Investigation conference room (1-G) to review inpatient medical records for quality assurance and improvement. 3. Educational Content a. The mix of patients on the general medicine services is representative of the spectrum of medical problems that commonly confront internal medicine physicians. In addition, since NMC San Diego is one of the militarys largest tertiary care centers, housestaff can expect to work with many patients admitted for subspecialty care. b. Patients admitted to the teaching service include unassigned patients admitted through the emergency department, established clinic patients from the residents ambulatory clinic, faculty patients, patients transferred from other services, and patients received from all parts of the Pacific theater via the aeromedical evacuation system. The San Diego areas very large dependent and retiree population ensures an excellent mix of genders, ethnic groups and age groups, comparable to what is seen in the other major medical centers in San Diego County. c. The mix of diseases one might encounter on this service is included as an enclosure. 4. Types of Clinical Encounters

NMC San Diego Medicine Curriculum for Students (Rev 04/02)

a. The housestaff are the primary care providers for patients admitted to the general medicine teaching services. Students work directly for housestaff, thus becoming primary providers. b. The patient load for each resident, intern and student varies widely and is, to some extent seasonal. The volume and acuity of admissions parallel the activity seen in other hospitals in the San Diego region. As more complicated care is rendered in the outpatient setting, the length of stay in the hospital decreases. This translates into lower patient loads for the same number of admissions. Student workload varies directly with the demonstrated ability of the individual student but in no case will exceed the limits set for interns in the Internal Medicine Residency Policies and Procedures. 5. Procedures: The ward team can expect to perform arterial blood gas sampling, lumbar puncture, thoracentesis, and paracentesis. Students should have priority in performing procedures on those patients for whom they bear primary responsibility. Although they will not be routinely asked, they will have the opportunity to perform venipuncture, bladder cathterization and nasogastric intubation. An individual certified as competent must be present throughout the procedure. Indications, contraindications, prerequisite studies and technique for each procedure are contained in the IM residency procedures curriculum. 6. Call overview: Distribution of patients among teams is built around a 4 day cycle. The chief of residents may vary this schedule as necessary to ensure patient safety. Day 1- Short call: The team takes the previous evenings night float admissions and the first admissions of the day until 1300, to a maximum of 4 new patients. Additionally, the short call team can take up to 2 bounce-back patients, who previously were cared for by that teams resident during his/her current rotation. Day 2 - Pre-call: Continuity clinic day, no admissions. Day 3 - Long call: The team takes admissions from 0600 until 0600 the next morning with the following modifications: a. The first four admissions before 1300 go to the short call team as above. b. Admissions after 2100 go to the night float team Sunday through Thursday. Day 4 - Post call, no admissions. 7. Checkout rounds will be held daily to arrange patient cross-coverage. Rounds will be between 1600-1700 on weekdays and 0900-1000 on weekends and holidays in the long call teams office. The resident, interns and students on call will be present. Interns and students from the other teams will rotate through to turn over index cards on every patient and to verbally present the significant details of those patients who are likely to require cross-cover services. When a night float team is scheduled to take late call, the on-call team will turnover to them in a similar fashion at 2100. 8. Night float turnover: Patients admitted by the night float team will be turned over to the
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NMC San Diego Medicine Curriculum for Students (Rev 04/02)

short call team at 0700. The entire receiving team should be in attendance at turnover. Turnover will be completed before morning report. 9. Time off on ward rotations: In general, students should have the opportunity to take a full, continuous 24 hours away from the hospital every week. Within one week of student arrivals on his/her service, each ward resident will turn in to the chief of residents a list of their days off for their entire four-week rotation. The list may be forwarded by email. These days off need not be confined to weekends and holidays. They can start at any time of the day, but they may not be less than 24 consecutive hours. 10. Administrative responsibilities: Students will write the admission history and physical examinations, daily progress notes, event notes, procedure notes, medical orders, consultations, on- and off-service notes, transfer notes and discharge notes. On- and off-service notes may substitute for daily progress notes. Students will also be responsible for notifying physicians when their patients are admitted. The admission H&P should be completed by the end of the work period during which the admission occurred. All student notes and orders must be cosigned by a physician on the team. Students may not give verbal orders. 11. Information Resources: a. Each student should bring at least one comprehensive textbook of medicine. This text should be read in a directed fashion according to the patients admitted to the service. All students also are strongly advised to procure an up-to-date manual of therapeutics for use on the wards. b. Each ward team room has a networked computer. Housestaff can perform medline and Ovid searches and access the internet at any time. c. The internal medicine residents library (3-3) is easily accessible 24 hours a day. It is stocked with a wide range of current specialty and subspecialty textbooks, as well as several board review programs. The computer has interactive texts on CD-ROM, as well as Medline and Ovid capability. c. For the rare occasions that the information available via the residents library is not sufficient to care for a particular patient, the medical center library is accessible after hours via the OODs desk (2-6400). The library contains most major textbooks and journals, as well as free photocopy facilities. Several on-line and CD-ROM search engines are available. 12. Methods of Evaluation a. Faculty should provide informal feedback to students at every opportunity during the rotation. Faculty should verbally review performance of each trainee at the mid-point of the rotation. If significant deficiencies are noted, formal documentation should be forwarded to the Program Director for review. Finally, the attending will complete an evaluation form, to be reviewed with the trainee at the end of the rotation. b. At the end of the rotation, each student will be asked to provide a written critique on a form provided by the medical education office.
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NMC San Diego Medicine Curriculum for Students (Rev 04/02)

13. Service issues: There are no service issues associated with this rotation. Only in an emergency, such as a mass casualty, will students be required to draw blood, start IVs, transport patients or care for patients who are not on a teaching service. The chief of residents should be notified immediately of any attempts to require trainees to perform such services.

NMC San Diego Medicine Curriculum for Students (Rev 04/02)

Mix of Diseases The illnesses one sees on the medicine wards encompass the broad range of internal medicine and its subspecialties. It is not possible to predict precisely what each trainee will experience on a given rotation. The following diagnoses were compiled developed from the list of cases presented at morning report over the course of a year. By the time they graduate, IM residents should have had personal experience caring for patients with most of the diagnoses listed below. Students should have had experience with those listed in italics. Allergy/Immunology: Anaphylaxis, antibiotic desensitization. Cardiology: CHF exacerbations, atrial fibrillation, other atrial dysrhythmias, the evaluation of chest pain, pericarditis, unstable angina, myocardial infarction. Endocrinology: hyperglycemia, hypoglycemia, hyperosmolar coma, hyperthyroidism, diabetic ketoacidosis, carcinoid, pheochromocytoma Gastroenterology: ascites, inflammatory bowel disease, jaundice, cholangitis, infectious diarrhea, C. difficile colitis, small bowel obstruction, spontaneous bacterial peritonitis, complications of liver transplantation, hepatitis, cirrhosis, pancreatitis, upper GI bleeding, lower GI bleeding. General: hypertension ,tachycardia, fever, decubitus ulcers, pain control, rehabilitation medicine, hip fracture, alcohol withdrawal. Hematology/Oncology: solid tumors, lymphomas, chronic leukemias thrombocytopenia, acute leukemias, complicaions of anticoagulant therapy, complications of bone marrow transplantation, sickle cell crisis, hemolytic anemia, indications for blood transfusion, deep venous thrombosis, neutropenic fever and other complications of chemotherapy, use of G-CSF. Infectious Diseases: urosepsis, neurosyphilis, FUO, malaria, encephalitis, endocarditis, disseminated coccidiomycosis, osteomyelitis, diabetic ulcers, varicella infection, EBV infection, complications of HIV infection, opportunistic infections, pyelonephritis, pneumonia, meningitis, cellulitis Neurology: status migrainus, multiple sclerosis, Guillain-Barre Syndrome, parkinsonism, stroke, new seizure disorders, mental status changes, weakness, vertigo. Nephrology: complications of kidney transplantation, diabetes insipidus, rhabdomyolysis, acute renal failure, hypercalcemia, hyponatremia, hypokalemia, hyperkalemia, calciphylaxis, CAPD peritonitis, rapidly progressive glomerulonephritis Pulmonary: drowning, pneumothorax, pleural effusions, hemoptysis, bronchiectasis, tuberculosis, pulmonary embolism, pulmonary hypertension, COPD, bronchitis, asthma, hypoxemia Rheumatology: rheumatoid arthritis, rheumatic fever, systemic lupus erythematosis, vasculitis, acute arthritis, myositis
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NMC San Diego Medicine Curriculum for Students (Rev 04/02)

Toxicology: prescription drug toxicities, drug overdose.