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Critical Care Medicine

Adult Medicine

Some distinctives of our inpatient family medicine service:

Altoona Family Physicians

AFP Inpatient Service Goals and Objectives

Resident Year:                       PGY1, PGY 2 and PGY3

 AFP Faculty Contact:           Jennifer Good, MD

 Rotation description and general goals:

             The inpatient hospital service of Altoona Family Physicians is at the Altoona Hospital campus of the Altoona Regional Health System.  Patients are admitted to the inpatient hospital service as “unassigned” admissions from the Altoona Hospital Emergency Department, patients from the residency patient panel (Altoona Family Physicians and Williamsburg Family Physicians) and Glendale Area Medical Center.  Patients of the residency program who are admitted to other services (eg. Surgery or Psychiatry) are seen in consultation by the inpatient medicine service.

             The residents spend 3 months on the inpatient service during their PGY1 year and one month during the PGY2 and PGY3 years.  The residents at Altoona Family Physicians spend a total of 5 months on the inpatient medicine service during their residency.

             While on this rotation residents are expected to arrive on time for morning report at 7:15 am on weekdays and at a mutually agreeable time for all on the weekends.  Residents are expected to be present at sign-out rounds with the night float team at 6:00 pm each evening.  It is expected that at least one representative from the medicine team be available to round on each day on the weekend, while ensuring that each resident has a total of 4 days off during the entire month long rotation.  Scheduled vacation is not permitted during this rotation.

            The overall goal of the Inpatient Medicine Service curriculum is to train family medicine residents to provide independent care for common medical problems requiring hospital admission and to utilize appropriate consultation with specialists when additional assistance is required.  The curriculum is structured such that residents gradually progress from care that is dependent on close supervision by senior level residents and faculty to unsupervised, independent care by the time the resident graduates.  Resident’s hospital practice is assessed and reviewed with the resident at each quarterly resident evaluation.

Teaching Methods:  the inpatient family medicine affords many opportunities for teaching, including but not limited to:

·         Didactic teaching:  There is a noon conference four to five days a week which covers a broad range of clinical topics.  Attendance at these conferences is mandatory. 

·         Clinical teaching:  The inpatient family medicine team makes daily, bedside teaching rounds with the faculty attending physician.  Additionally, there is ample opportunity for interaction with specialty attending physicians through their consultative role in assisting with patients. 

·         Morning report:  Morning report occurs daily and most days a faculty physician is in attendance. 

Supervision:

·         PGY1 level residents have immediate supervision by a PGY2 or PGY3 level resident that is available in the hospital at all times.

·         There is a faculty on-call at all times available by pager should assistance be required by any resident in dealing with questions while on the inpatient family medicine or night float rotation.

·         Each patient on the inpatient family medicine service is seen and examined daily by the faculty attending (including weekends).

·         Faculty are apprised of any procedure being done by the resident while on the inpatient service and are expected to supervise that procedure if either the resident or faculty feels supervision is necessary.

Resident Evaluation: 

            Each resident on the inpatient family medicine rotation is evaluated using a competency-based evaluation tool at the end of the rotation.  These evaluations are reviewed by the family medicine faculty quarterly and reviewed with the resident at the resident’s quarterly evaluation.  Occasionally, situations arise which require more immediate feedback and in these situations the resident is given feedback by the faculty on the inpatient service, the faculty advisor or the program director.  Specific resident evaluations include:

·         Evaluation by resident peers (senior resident is evaluated by the intern; the intern is evaluated by the senior resident).

·         Evaluation by the faculty attending on inpatient.  (As each faculty is on inpatient for one week, the resident may by evaluated independently by three to four faculty members in a one month rotation).

·         Evaluation by nursing staff and case management staff.

Program Evaluation:

·         Each resident (intern and senior resident) is expected to complete a written evaluation of the inpatient rotation and each inpatient faculty each month that they are on inpatient.

·         The inpatient curriculum is reassessed annual as part of the Altoona Family Physicians annual curricular review.

SAMPLE SCHEDULE: 

PGY 1

PGY 2 and PGY 3:

 PGY 1:

·         Complete an admission history and physical examinations on all patients admitted to the inpatient medicine services.  These history and physicals will be dictated into the hospital dictation system at the time of admission.  These H & Ps are reviewed by the attending physician on the inpatient service.  Additionally, a small number of each resident’s H & Ps are provided to the faculty advisor for review.

·         Write admission orders for each patient admitted to the inpatient service at the time of the patient’s admission.  It is expected that these orders will be legible, and reflect an appropriate diagnostic and therapeutic approach to the patient’s medical problems.  These admission orders are reviewed by the senior resident (either on AFP service or night float) and the inpatient attending.

·         See each patient daily (once by the daytime inpatient team and once by the night float resident) and writing a legible and informative progress note.  The progress note will follow a “SOAP” format.  These progress notes will be reviewed by the attending physician on the inpatient service.

·         Complete a discharge summary on each of their patients upon discharge from the hospital.  These discharge summaries are to be done within 24 hours of the patient’s hospital discharge and follow a standard format (see resident handbook).  Compliance with this requirement is ensured by the Altoona Regional Health Systems HIM department. 

PGY 2 and PGY 3:

·         Be competent in all of the patient care skills expected of the PGY 1 resident, and is expected to complete the above tasks if the intern is in the office or involved in other clinical activities.

·         Supervise the PGY1 resident in all of the above responsibilities. 

·         Perform inpatient family medicine consults on hospitalized patients upon request.  These consults are to be done within 24 hours of request (4 hours if the patient is in a critical care unit) and are reviewed by the inpatient attending.

All Residents:

·         Understand the diagnosis and treatment of common illnesses requiring acute hospitalization, including but not limited too:  acute respiratory failure, acute and chronic congestive heart failure, acute coronary syndromes, acute and chronic renal failure, acute neurological syndromes including stroke and TIA, common infections such as cellulitis, UTI, sepsis and respiratory infections.

·         Understand iatrogenesis and risks of hospitalization

·         Understand pain assessment and management in the hospitalized patient.

·         Understand nutritional support in the hospitalized patien

PGY 2 and PGY 3 Residents:

·         Understand the principles of pre-operative evaluation of the surgical patient, including cardiovascular risk assessment, pre-operative management of diabetes and hypertension, pre-operative anticoagulation management and pre-operative glucocorticoid management.

·         Understand the principles of post-operative care, including post-operative blood pressure management, post-operative diabetes management and post-operative nutritional support.

·         Understand the principles of post-operative pain management, including use of patient-controlled analgesia.

·         Understand principles of inpatient medical treatment of the pregnant patient.

All Residents:

·         Read on a regular basis about the cases that they are seeing on the inpatient family medicine service. 

·         Present patients daily at morning report.  It is expected that these presentations be accompanied by a current, evidence based treatment plan.  These presentations will be assessed by the faculty members in attendance at morning report and the resident given feedback via rotation evaluations.

·         Present interesting cases weekly at the all-residency family medicine rounds.  It is expected that the resident at the time of these presentations can serve as the “expert in the room” and is aware of the most appropriate diagnostic and treatment modalities for the patient.

·         Locate, appraise and assimilate evidence from scientific studies related to their inpatients’ health problems.

·         Utilize information technology to optimize learning.

·         Participate in the education of patients and their family members.

·         Participate in the education of medical students and other residents through presentations and discussions at morning report, teaching and attending rounds and in a more formal setting at weekly family medicine rounds.

PGY 2 and 3:

·         Serve as a model of problem based learning improvement for the more junior member of the team, and is expected to assist the residents and medical students in locating and appraising medical information, and occasionally providing that information for them.

Communication with colleagues/continuity of care 

·         Establish face-to-face contact with their hospitalized inpatient’s PCP following noon conference daily to keep their primary care physician apprised of the patient’s inpatient course.  If the primary care physician is not at noon conference, or an emergency keeps the hospital resident from noon conference, a brief update can be sent to the primary care resident through the EMR.

·         Send a brief discharge note (including all medication changes and outstanding problems/diagnostic tests) to the primary care physician through the EMR at the time of the patient’s hospital discharge.

·         Communicate effectively with physicians, other health professionals and health related agencies.

·         Act in a consultative role to other physicians and health professionals.

·         Maintain comprehensive, timely and legible medical records.

·         Ensure safe transition of patient care with complete sign-out in the morning and evening and communication with primary care physician.

Communication with patients

·         Create and sustain a therapeutic and ethical relationship with patients.

·         Provide appropriate patient education on diagnoses and treatment plans based on the literacy level of patients and their caregivers.

·         Responsibility in patient care by responding in a timely fashion (< 20 minutes) to all pages.  Their attention to this requirement will be assessed in rotation-end evaluations by nursing staff.

·         Compassion, integrity and respect for others.

·         Sensitivity and responsiveness to a diverse patient population, including, but not limited to diversity in gender, age, culture, race, religion, disabilities and sexual orientation.

·         Respect for patient privacy and autonomy

·         Regularly contact other health professionals caring for their patients in the hospital, including but not limited to nursing staff, case management staff, respiratory therapists, physical and occupational therapists and pharmacists.  This objective will be assessed in part by evaluations done at rotation end by nursing and case management staff.

·         Work effectively in the Altoona Regional Health System and cooperate with hospital-wide quality initiatives, such as DVT prophylaxis, infection control protocols, stroke protocols etc.

·         Request specialty consultation when indicated.

·         Incorporate considerations of cost awareness and risk-benefit analysis in patient care.

·         Work within interdisciplinary teams in order to provide quality, comprehensive inpatient care.

·         Participate in identifying system error and in implementing potential systems solutions.