Educational Purpose and Goals
Patient care is of paramount importance for the internist. Skills required for good patient care include:

Our goal is to train physicians adept in these skills.

Principal Teaching Methods
Supervised Direct Patient Care

Residents will participate in rotations in both hospital-based and ambulatory settings.  Faculty and senior residents will supervise junior residents.  Patient Care will occur during rotations on General Medical Floors, Ambulatory Medicine, Emergency Medicine, Intensive Care Medicine, and Night Float.

Didactics and Small Group Discussion

 Morning Report
 Core Curriculum Noon Conferences
 Grand Rounds
 Teaching Rounds including Didactic Sessions
 Journal Club

Simulated Patients and Standardized Patients                                                                                        

Female pelvic examinations will be taught by standardized patient models supervised by a physician or nurse educator.The Procedure and Simulator Room will be utilized in a scheduled fashion for each resident to learn invasive procedures including central lines, arterial lines, lumbar puncture and other procedures.

Educational Content
Mix of Diseases: All residents will be exposed to an extraordinary array of diseases in patients ranging from adolescent to geriatric ages.

Patient Characteristics: Patients will include those of all sexes, races and socioeconomic backgrounds.
 
Learning Venues
All training is done at a large urban academic medical center which includes a general medical surgical hospital and in and out-patient psychiatric unit. The continuity clinic is located directly across the street from the hospital. The approximate mix is 65% inpatient and 35% outpatient activity during a three year curriculum.

Principal Ancillary Educational Materials
A wide-range of resources is available to residents.  At the beginning of each rotation, the residents are given detailed learning goals and objectives and a suggested reading list.  Residents have access to a library in the hospital staffed by a medical librarian and have access to the New York Medical College library 24/7 via a personal barcode password.

Methods of Evaluations
Resident Performance: For each major clinical rotation faculty attending physicians perform formal audits of residents' charts and complete a web-based electronic resident evaluation form that includes assessment of core competency performance in Patient Care.  Evaluations are shared with residents in a Mid-Month verbal feedback session and final evaluations are completed on-line and are immediately available for the resident review.
Evaluations remain part of the resident's file and are incorporated into the semiannual performance review by the Program Director.Formative evaluations are kept in a non-permanent part of the resident file.  At the time of graduation the Program Director completes a summative evaluation and letter which remains in the resident file permanently.
 

Faculty and Program Performance: Upon completion of each rotation, residents complete a service evaluation of faculty, facilities and service experience. For assurance of anonymity, the evaluations are given to the faculty annually.  They are reviewed by the Clinical Competence Committee annually.

Institutional Resources: Strengths and Limitations
Strengths:                                                                                                                                    

• Excellent patients mix, dedicated and interested faculty, congenial atmosphere.
  

Weaknesses:

• No setting for the care of transplant patients other than bone marrow transplantation patients.
• No Electronic Medical Record, especially Computerized Physician Order Entry.

Specific Competency Objectives for Patient Care
Relationship building skills:

• PGY 1 and 2 residents should consistently show respect, compassion, and empathy for patients and their families as well as integrity in collecting and reporting their findings.  They should establish trust and recognize that the primary concern is the welfare of the patient.  Residents will respect patient preferences and understand patient rights.  They will engage in shared decision making with their patients.
•  PGY 2,3 4 residents will aid junior peers in effective communication and serve as role models for patient care.

History taking:
Residents must demonstrate an understanding of the importance of history in deriving a differential diagnosis.

•  PGY 1 residents will consistently gather essential and accurate information.  The database will be organized in a manner consistent with accepted medical convention and charted in a timely and efficient manner.  The information will be comprehensive and include data gathered by other providers and will include laboratory investigations.
• PGY 2,3 4 residents will be precise, logical and efficient in their data collection in addition to the above.

Physical Examination:                                                                                                                             Residents will demonstrate the importance of performing an accurate and relevant physical examination.

• PGY1 residents will perform a comprehensive physical examination with a consistent sequence.  Residents at this level will identify normal from abnormal and will describe the physiological and anatomical basis for findings.
• PGY2,3,4 residents in addition to the above will correctly detect subtle findings and understand their significance.  They will be able to teach appropriate physical examination skills to junior peers and medical students.  They will strive to perform a focused physical examination ad understand the sensitivity and specificity of the maneuvers.

Clinical Judgment, Medical Decision making and Management Plans :                                               Residents will progressively become more adept at assimilating information that they have gathered from the history and physical examination.

• PGY 1 will be able to identify all of a patient's problems and develop a prioritized differential diagnosis.  They will begin to develop therapeutic plans that are evidence of guideline based.  Residents will establish an orderly succession of diagnostic studies based on their H&P.  They will demonstrate appropriate use of diagnostic and therapeutic procedures.
• PGY 2 residents will consistently integrate medical facts and clinical data while weighing alternatives and keeping in mind patient preference.  They will regularly incorporate consideration of costs, risks and benefits when considering diagnostic tests and therapies.  They will consistently monitor and follow-up patients appropriately and demonstrate the ability to change therapeutic programs for ineffectiveness or adverse side effects.
• PGY 3 and 4 residents will demonstrate the above and will demonstrate appropriate reasoning in ambiguous situations, while continuing to seek clarity.  At this level, residents will assist junior residents and medical students in their development.

Oral Case Presentation Skills:
Residents at all levels will be adept at oral presentation skills. Case presentations will be organized consistent with medical convention.  They will include important aspects of the history, physical exam and laboratory investigations.  The assessment will be well developed and include a differential diagnosis and a well-thought out diagnostic and therapeutic plan.  Extraneous information will be deleted and residents will accurately field listener questions.  Pertinent materials such as X-rays and EKG's will be included and correctly interpreted.
 

Counseling Skills:                                                                                                                                   Residents will recognize the importance of clear and accurate instructions for patients and their families.

• PGY 1 residents will give patients accurate instructions regarding usage of their medications and follow-up care.  They will document their counseling conversations and use flow sheets if necessary.
•  PGY2 residents will effectively counsel and educate patients about pertinent health issues, tests and treatments.  They will recommend appropriate screening exams by gender and age.
•  PGY 3 residents will in addition consistently and thoroughly educate patients and their families, using patient education as a form of intervention and partnering.
   

Use of Technology:
Residents will understand the increasing role that technological advancements bring to the bedside.

• PGY 1 residents will demonstrate use of the computer-assisted databases for diagnosis and decision making.  They will regularly use drug information and drug-drug interaction programs.
• PGY 2,3,4 residents will also utilize electronic databases for patient educational materials.

Procedures:
Residents will competently perform medical procedures essential for the practice of general internal medicine.
PGY 1 residents will:

• demonstrate knowledge of procedural indications, contraindications, necessary equipment, process for handling specimens and patient after-care.
• participate in obtaining informed consent and assist the patient with decision making through their knowledge.
• attend to the comfort of the patient. 
• be supervised for all procedures until certified competent.
•  thoroughly document procedures.

PGY2, 3 &4 residents will additionally:

• be supervised where skill level dictates.  
•  demonstrate extensive knowledge and be facile in the performance of procedures while minimizing risk and discomfort to patients. 
•  assist their junior residents in skill acquisition.

Preventative Care:                                                                                                                                 Residents will understand the importance of disease prevention and health maintenance.

• PGY 1 residents will demonstrate the ability to ensure that their patients receive recommended screening tests and other preventive practices. 
• PGY 2,3 &4 residents will demonstrate an understanding of public health and it's broad implications to the population being served.

Patient Focused Care:

• Residents at all levels will demonstrate sensitivity and responsiveness age, culture, gender and disabilities.  
•  Residents will consider the "whole patient" as a dignified person rather than a disease.  
•  Residents will work effectively with allied health professionals and physician consultants to provide effective patient-focused care.