The residents’ learning will primarily be focused on admitted patients throughout the night. Residents are expected to read about the medical issues of the patients admitted in preparation for discussion during signouts and morning report. This rotation is intended to allow residents to gain skill and experience in evaluating and managing hospitalized patients independently as well as honing their skills in prioritization of tasks, time management and systems based practice.
Residents and interns on the night float team should look at the online schedule (www.amion.com password unsomim) for their dates of service and supervising attending as well as information regarding the daytime admitting team from whom they will accept care of the patients. Evening sign-out is at 8pm and is usually in the WMC ED. The night float team is to contact the on call day team for sign-out when they arrive for their shift. All WMC general medicine teams (including attendings and residents), night float, ICU and cardiology residents meet at 7:00 a.m. seven days a week in the WMC cafeteria conference room for morning sign-out (7:00 to 7:30 a.m.).
All UNR attendings’ pager numbers are listed on the monthly schedules.
Questions may also be directed to the Chief Resident assigned to RMC, Dr. Nagesh Gullapalli (Associate Program Director for RMC) or to the Dr. Parker (Residency Program Director) at any time.
The night float team will be scheduled on amion.com for their nights of service. Residents on night float typically work 5 days a week with 2 days off. The work shift is 8pm to 9am (to allow for attendance at morning report). Morning report attendance and participation is mandatory daily but noon conference attendance is not required during the rotation. Residents are excused from all continuity clinic responsibilities during their night float rotation.
a. Relationship-building skills. Residents must demonstrate the importance of effective communication when caring for patients as they collect highly personal information.
i. PGY –1 and PGY-2 residents should consistently demonstrate integrity, respect, compassion and empathy for patients and their families. They should establish trust and recognize that the primary concern is the welfare of the patient. Residents at this level of training will respect personal preferences and understand patient rights. They will engage in shared decision making with their patients.
ii. PGY-3 residents should demonstrate the above and aid junior peers in effective communication with patients.
b. History taking. Residents must demonstrate an understanding of the importance of history in deriving a differential diagnosis.
i. PGY-1 residents will consistently gather essential and accurate information. The database will be organized in 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 laboratory investigations. By completion of PGY1, histories will be completely hypothesis driven.
ii. PGY-2 and PGY-3 residents will be precise, logical, and efficient in their data collection in addition to the above.
c. Physical Examination. Residents will demonstrate the importance of performing an appropriate and relevant physical exam.
i. PGY-1 residents will perform a comprehensive physical exam with a consistent sequence. Residents at this level will identify normal from abnormal and will describe the physiological and anatomical basis for findings. Residents will demonstrate the ability to augment their physical exam to elicit data not obtained with standard movements.
ii. PGY-2 residents, in addition to the above, will correctly detect subtle findings and understand their significance. They will be able to teach appropriate physical exam skills to junior peers and medical students.
iii. PGY-3 residents additionally will strive to perform a focused physical exam at the level similar to a sub-specialist, and understand the sensitivity and specificity of maneuvers.
Residents will progressively become more adept at assimilating information that they have gathered from the history and physical exam.
i. PGY-1 will be able to identify all a patient’s problems and develop a prioritized differential diagnosis. PGY-1 residents will begin to develop therapeutic plans that are evidenced or guideline based. Residents will establish an orderly succession of testing based on their history and exam findings. They will demonstrate appropriate use of diagnostic and therapeutic procedures.
ii. PGY-2 residents will regularly 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.
iii. PGY-3 residents will demonstrate the above and in addition, will demonstrate appropriate reasoning in ambiguous situations, while continuing to seek clarity. Residents at this level of training will not overly rely on tests and procedures.
They will assist junior trainees and medical students to become efficient managers through the appropriate use of clinical judgment and effective decision making. PGY-3 residents will consistently establish monitoring procedures and demonstrate the ability to change therapeutic programs for ineffectiveness or adverse side effects.
e. Oral Case Presentation Skills. Residents at all levels of training will be adept in oral presentation skills. This will be demonstrated by delivering a case presentation that is organized consistent with medical convention. They will include all important aspects of the history, physical exam, and laboratory investigations. The assessment will be well developed and include an in-depth differential diagnosis and carefully executed diagnostic and therapeutic plan. Extraneous information will be deleted and residents will appropriately and accurately field audience questions. Pertinent materials such as x-rays and EKG’s will be included and correctly interpreted.
f. Counseling. Residents will recognize the importance of clear and accurate instructions for patients and their families.
i. 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 as necessary.
ii. PGY-2 residents will effectively counsel and educate patients about pertinent health issues, tests and treatments. They will recommend appropriate screening exams by gender and age.
iii. PGY-3 residents, in the addition to the above, will consistently and thoroughly educate patients and their families, using patient education as a form of intervention and partnering.
g. Use of technology. Residents will understand the increasing role that technological advancements bring to the bedside.
i. PGY-1 residents will demonstrate use of computer-assisted databases for diagnosis and decision-making. They will regularly utilize drug information and drug-drug interaction programs.
ii. PGY 2 and 3 residents, in addition to the above, will utilize electronic databases for patient educational materials.
h. Procedures. Residents will competently perform medical procedures essential for the practice of general internal medicine.
i. PGY-1 residents will demonstrate knowledge of procedural indications, contraindications, necessary equipment, process for handling specimens and patient after-care. They will participate in informed consent and assist the patient with decision making through their knowledge. Residents will attend to the comfort of the patient. PGY-1 residents will be supervised for all procedures until certified competent by the Program. Procedures will be thoroughly documented.
ii. PGY-2/3 residents will be supervised where skill level dictates. They will demonstrate extensive knowledge and be facile in the performance of procedures while minimizing risk and discomfort to patients. They will assist their junior peers in skill acquisition.
i. Preventative Care. Residents will understand the importance of disease prevention and health maintenance
i. PGY-1 residents will demonstrate the ability to use electronic medical record (EMR) tools to ensure that their patients receive recommended screening tests and other preventative practices. Residents will utilize EMR tools for chronic illness care in an effort to decrease the incidence of complications in those with chronic disease states.
ii. PGY-2 and PGY-3 residents, in addition to the above, will demonstrate appropriate age-based screening and preventative care. These residents will remain vigilante for changes in recommendations from federal and professional societies and apply recommendations to their patient population.
iii. PGY-3 residents will demonstrate an understanding of public health and it’s broad implications to the population being served.
j. Patient-focused care. Residents at all levels of training will demonstrate sensitivity and responsiveness to patients’ age, culture, gender and disabilities. Residents will work effectively with allied health care professionals and physician consultants to provide effective patient-focused care.
Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to:
i. PGY1 residents will
1. Demonstrate knowledge of common procedural indications, contraindications, equipment, specimen handling and patient after-care.
2. Demonstrate knowledge of basic and clinical sciences.
3. Demonstrate satisfactory knowledge of common medical conditions, sufficient to manage urgent complaints with supervision. Residents must exhibit sufficient content knowledge of common conditions to provide care with minimal supervision by completion of the PGY1 year.
4. Score a passing grade of 40% on at least 60% of Board Review final exams.
ii. PGY2 residents will additionally
1. Demonstrate a progression in content knowledge and analytical thinking in order to develop well-formulated differential diagnoses for multi-problem patients.
2. Demonstrate understanding and responsiveness to socio-behavioral issues.
3. Develop knowledge of statistical principles. Understand and appropriately use sensitivity,
specificity, predictive values, likelihood ratio, number needed to treat, and odds ratios.
4. Score a passing grade of 50% on at least 60% of Board Review final exams.
iii. PGY3 residents will additionally
1. Demonstrate growing knowledge in the area of their chosen career path.
2. Demonstrate knowledge regarding performance of procedures while minimizing patient risk and discomfort.
3. Exhibit knowledge of effective teaching and evaluation methods, including RIME, one-minute preceptor, and evaluation techniques.
4. Successfully meet ECG reading requirements according to the ECG conference series
requirements.
i. PGY1 residents will
1. Exhibit use of UNR and hospital library resources.
2. Exhibit self-motivation to learn.
3. Demonstrate sufficient analytic skills necessary to develop appropriate assessments and plans for common medical diagnoses and complaints.
ii. PGY2 residents will additionally
1. Independently present up-to-date scientific evidence to support hypotheses.
iii. PGY-3 residents will additionally
1. Regularly display self-initiative to stay current with new medical knowledge.
2. Regularly demonstrate knowledge of the impact of study design on validity or applicability to practice.
Objectives
The ability to use clinical practice and direct patient care as a venue for
practice improvement and learning is a life long process; however it is
expected that a resident will satisfactorily function as follows:
a. Evidence Based Medicine: Location, appraisal, and assimilation of evidence from scientific studies related to patients’ health problems. Application of knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.
i. A PGY1 resident should demonstrate the ability to:
1. Be self motivated to acquire knowledge
2. Locate scientific literature to support decision-making
ii. A PGY2 resident should additionally:
1. Be able to appraise and assimilate scientific literature
2. Demonstrate understanding and use of an evidence based approach in providing patient care
3. Quickly access appropriate reference material for patients in the ICU
4. Voluntarily (without prompting or assignment) discuss and research relevant literature to support decisions
iii. A PGY3 resident should additionally
1. Effectively and efficiently use consulting services to improve both patient care and self-knowledge, appropriately integrating evidence based medicine with expert opinion and professional judgment
2. Acquire and use appropriate evidence-based information when acting as a consultant
3. Learn and be able to research non-internal medicine patient care issues
4. Apply knowledge of study design and statistics to relevant literature
5. Respond to critical problems in a manner reflecting more than rote learning and protocol management. S/he should be able to utilize and suggest data-driven
modification of protocols
Analysis of practice experience and performance of practice-based improvement activities using a systematic methodology. Obtaining and using information about their own population of patients and the larger population from which their patients are drawn.
i. A PGY1 resident should demonstrate the ability to
1. Understand his or her limitations of knowledge
2. Ask for help when needed
3. Admit to errors and seek help in remedying them
4. Accept feedback and develop self-improvement plans
5. Seek formative feedback on performance
6. Deliver care that reflects learning from previous experiences
7. Assess patient adherence to ambulatory regimens and accordingly modify prescribing practices
8. Participate actively in quality improvement practices pertaining to patient care (e.g., morbidity and mortality conferences)
9. Review autopsy findings to understand illness and the care of critically ill patients
10. Demonstrate improvement in clinical management by continually improving on their various rotations
ii. A PGY2 resident should additionally:
1. Use self-assessments of knowledge, skills and attitudes to develop plans with insight and initiative for addressing areas for improvement
2. Voluntarily plan learning experiences in procedures not yet mastered
3. Use unique cases seen in a rotation to self-assess performance patterns
iii. A PGY3 resident should additionally:
1. Analyze personal practice patterns systematically, and seek to improve patient care
2. Utilize ambulatory practice data to actively improve practice and patient management
3. Compare personal practice patterns to larger populations and seek to improve disparities in own patient care.
c. Information Technology: Using information technology to manage information, access on-line medical information; and support their own education
i. A PGY1 resident should be able to:
1. Use the handheld computers, and web-based resources to access medical literature and data to support and enhance patient care.
ii. A PGY2 resident should additionally
1. Independently use Pubmed or Ovid and other computerized connections to primary literature to enhance patient care
d. Teaching: Facilitation of learning of students, resident colleagues, and other health care professionals
i. A PGY1 resident should be able to
1. Facilitate learning of students and other PGY1
residents
ii. A PGY2 resident should additionally:
1. Facilitate education of PGY1 residents and other health care professionals
2. Demonstrate evidence based independent research and preparation when teaching.
3. Use interactions with nursing staff and other professionals as two-way educational opportunities
iii. A PGY3 resident should additionally:
1. When acting as a consultant, identify the questions and wishes of the physician requesting the consultation, and respond to these issues.
a. PGY-I:
i. Communication: PGY1 residents should:
1. Provide thorough yet succinct oral presentations regarding patient care, using appropriate medical terminology;
2. Provide thorough and complete written or electronic documentation of patient care (eg, progress or procedure notes, history and physical exams, consultant notes, discharge summaries), which are legible, timely and use appropriate medical terminology.
3. Demonstrate proficiency in use of verbal and nonverbal skills in interactions outside of the context of patient care.
ii. DPR: PGY1 residents should be able to establish rapport with patients from a variety of backgrounds; perform a medical interview that elicits both patient- and physiciancentered information, as well as testing diagnostic hypotheses; and effectively communicate uncomplicated diagnostic and therapeutic plans to patients or their
advocates.
iii. Ethically sound relationships: PGY1 residents should follow the tenets of ethics in patient care. Please refer to the Professionalism Competency Curriculum.
iv. Working within teams: PGY1 residents should be able to work as team members with senior residents and attending physicians, including the communication skills outlined
above and the coordination of patient care. When supervising medical students, first year residents should be able to observe students, demonstrate skills, and give constructive feedback. First year residents should be able to communicate effectively with ancillary staff to enhance patient care.
b. PGY-II: The successful PGY-II resident meets all PGY-I learning objectives and in addition, has further mastered the following:
i. Patient Communication: PGY2 residents should be able to engage patients in shared decision making for ambiguous or controversial scenarios, and conduct family meetings as in the setting of end of life decision making. They should be able to successfully negotiate most “difficult” patient encounters, such as the irate patient.
ii. Team Work: Second year residents should progressively assume a leadership role, facilitating interactions between team members. This includes establishing expectations,
overseeing patient care, ensuring participation in academic discussions, etc.
iii. PGY2 residents leading general medicine and ICU teams are responsible for ensuring successful inpatient-outpatient provider communications to maintain appropriate continuity of patient care.
c. PGY-III: The successful PGY-III resident meets all PGY-II learning objectives and in addition, has further mastered the skills below:
i. Patient Communication: Third year residents should be able to successfully negotiate nearly all “difficult” patient encounters with minimal direction.
ii. Team Work: Third year residents should function as team leaders with decreasing reliance upon attending physicians. They should also be able to function as a consultant
(including completion of appropriate documentation and verbal communication with the requesting physician), whether serving as a general medicine consultant to other
services or when on elective rotations.
Virtue Skill, Behavior, or Attitude Competence
1st -3rd Year Expectations
Administrative competence (punctual, completes tasks as asked, follows directions, timely response to staff needs including pages and abnormal lab results, follows up on patient care issues without prompting).
i. Self directed learning expected (e.g. reads about patients)
ii. spontaneously presents literature and evidence related to patient care
iii. Able to deliver bad news
iv. Understands and competent to work with patients regarding advanced directives, DNR status, futility, withholding* or withdrawing* therapy.
v.Able to assess and use informed consent and provision of care*
vi. Demonstrates honesty, tells the truth and is trustworthy
vii. Makes honest use of coding, billing, and referral principles.
viii. Understands and appropriately maintains patient confidentiality*
ix. Compassion, resident’s attitude manifests an interest in helping providing
compassionate*, quality care to all patients
x. Respect for Others Demonstrates respect and compassion for all patients*
xi.Understands and compassionately responds to issues of culture, age, sex, sexual orientation, and disability in patient care.
xii. Professional Responsibility Recognizes that physicians have a responsibility for the safety and well being of patient, colleagues, and staff;
xiii. Understands that there are moral and ethical concerns about receiving
gifts from patients and pharmaceutical representatives.
xiv. Willing to provide coverage for sick/unavailable colleagues
xv. Demonstrates intellectual curiosity
xvi. Spontaneously teaches and exhibits concern for the educational development of fellow residents and students
xvii. Provides leadership on teams and in the residency.
xviii. Understands that in the patient-physician relationship, the physician’s prime concern is the patient’s interest and not his or her own. (A fiduciary relationship)
xix. Social Responsibility Volunteers for activities that are for the “good of
the institution” (e.g. recruiting interviews, committee membership,etc).
xx. Participation in community organizations Not an objective
xxi. Responsive to the needs of society that supercede self-interest*
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:
a. Reflect on how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements affect their own practice.
i. By completion of PGY1, residents should display ability to work well within their core clinical team, including other residents/attending physicians/directly involved
nurses/respiratory therapists/other professionals involved in the care of their patients.
ii. By completion of PGY2, residents must also be able to work well with multidisciplinary teams, coordinating multi-specialty care and effectively working with case management and nursing in team settings such as family meetings and large
team discussions. By completion of PGY2, residents must be able to provide and document care in a timely and thorough manner to facilitate analysis of practice patterns
and use of information by other health care professionals.
iii. By completion of PGY3, residents should also strive to effectively coordinate care with other health care professionals as needed, and should strive to provide leadership role in management of complex care plans. By completion of PGY3 residents should also reflect understanding of external regulations and expectations and appropriately acknowledge effects of these elements on their own practice.
b. Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources.
i. PGY1-, residents must attend Morning Report Case Management discussion sessions, actively participating in educational sessions relating to medical practice and delivery systems.
ii. PGY2- By completion of the PGY2 year, residents should demonstrate a satisfactory level of understanding regarding medical delivery systems, including alternative care
resources, ambulatory care resources, rehabilitation resources, and other continuing care resources. Residents should also have a satisfactory understanding of methods of
controlling health care costs and appropriate allocation of resources.
iii. PGY3- By completion of the PGY3 year, residents should demonstrate a high level of understanding regarding medical practice and delivery systems, including methods of
controlling health care costs and appropriate allocation of resources.
c. Practice cost-effective health care and resource allocation that does not compromise quality of care.
i. By conclusion of the PGY1, residents must reflect sensitivity to costs and be able to incorporate fundamental costeffective analysis into care approaches, minimizing
unnecessary care.
ii. By completion of PGY3, residents should also strive to appropriately contain costs and conserve limited resources while preserving a high quality of care.
d. Advocate for quality patient care and assist patients in dealing with
system complexities.
i. By completion of PGY1, residents must identify, implement, document, and monitor established local patient care plans consistent with nationally published clinical practice
guidelines. Throughout the PGY1 year, residents must demonstrate dedication to high quality patient care.
ii. By completion of PGY2, residents must also demonstrate ability to effectively guide patients through the complex health care environment.
iii. By completion of PGY3, residents should also be capable of acting as a team leader during interdisciplinary Family Meetings regarding complex patient care needs.
e. Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance.
i. By completion of PGY1, residents must demonstrate ability to regularly and effectively work with the academic case manager, social workers, and other health care professionals to assess, coordinate, and improve patient care. The resident should reflect understanding of the benefits of such partnering activities on the operation of the health care system.
ii. By completion of PGY2, residents must also demonstrate ability to regularly and effectively work with other case managers, utilization review personnel, physician assistants, ambulatory practice office managers, and other providers within the larger health care system.
iii. By completion of PGY3, residents should also be able to partner with case managers and other providers to identify and act on improvement opportunities for the health care
system.