Curriculum For Resident Training in Clinical Infectious Diseases Division of Infectious Diseases University of California, Davis School of Medicine

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1 Curriculum Fr Resident Training in Clinical Infectius Diseases Divisin f Infectius Diseases University f Califrnia, Davis Schl f Medicine Faculty Representative: Stuart Chen, MD Prgram Directr Reviewer: Craig Keenan, MD Resident Reviewer: Revisin Date: February 28, 2008 I. Statement f Philsphy Management f Infectius Diseases is an increasingly cmplex subspecialty f Internal Medicine. The Divisin f Infectius Diseases is cmmitted t training residents in the aspects f clinical infectius diseases t acquire cmpetency f a general internist. This includes inpatient and utpatient rtatins that prvide a brad range f pathlgy in adult and geriatric patients. The faculty is respnsible fr teaching and evaluating the residents by prviding supervisin f patient care. The residents demnstrate their cmpetence by presentatins t the supervising faculty justifying their plans with the clinical evidence and literature-based strategies fr diagnsis and management. They are respnsible fr attending teaching cnferences. The verall gal f training is t develp cmpetent, independent thinking physicians. II. List f Faculty Richard B. Pllard, M.D. Divisin Chief Stuart H. Chen, M.D. Fellwship Prgram Directr, Clinical Directr Infectin Cntrl and Hspital Epidemilgy Neil M. Flynn, M.D., M.P.H. Jay V. Slnick, M.D., Ph.D. Pal Tria-Canci, M.D. Clinical Directr CARES Javeed Siddiqui, M.D. David Asmuth, M.D. Hien Nguyen, M.D. Gregry Melcher, M.D. Raymnd Byun, M.D. Dnna DeFreitas, M.D. Archana Maniar, M.D. III. Educatinal Purpse Infectius Diseases remain a majr cause f mrbidity and mrtality. In additin, new rganisms have been emerging, lder pathgens have been re-emerging and the specter f biterrrism requires a brad range f knwledge fr physicians practicing clinical infectius diseases. The purpse f this is t bradly train ur residents t treat and manage patients with

2 infectius diseases in a changing wrld. The residents serve as cnsultants in the hspital as well as in the utpatient setting. Demnstratin f cmpetency will be evaluated by using the fllwing cmpetencies. IV. Teaching Methds 1. Direct Supervised Patient Care: The primary methd f teaching is at the patient s bedside. The resident evaluates the patient independently and presents t the faculty member, wh supervises the clinical practice. 2. Didactics: A jurnal club and case cnference prvide didactic teaching. Self-directed learning by reading textbks and current literature is an expectatin. V. Educatinal Cntent 1. Mix f diseases/patient characteristics/patient encunters: all inpatients are seen n a cnsultative basis frm all services at the UC Davis Medical Center. Outpatient visits in the Infectius Diseases Clinic at UC Davis als ccur. Such patients have a wide mix f acute and chrnic infectius diseases, bth cmmunity and hspital-acquired. It includes immunsuppressed patients after transplantatins, as well as patients with HIV disease. UC Davis sees patients frm a vast range f sciecnmic and cultural backgrunds, including large numbers f immigrants. Thus, bth cmmn and uncmmn cnditins may be seen n the cnsult service. 2. Clinical Venue: All patients are seen in the UC Davis Medical Center in the hspital r in the Infectius Diseases Clinic at the Ambulatry Care Center. VI. Educatinal Gals and Objectives 1. General Gals: The verall gals f the ID Rtatin include the fllwing: a. Learn hw t btain relevant infrmatin fr the slutin f prblems presented by infectius diseases b. Learn t d a directed histry and physical examinatin c. Learn t cllect relevant labratry data d. Evaluate results f micrbilgical cultures and susceptibility testing e. Assess the risks and benefits f relevant diagnstic prcedures f. Understand the ratinale fr selectin and use f antibitics n the UCDMC hspital frmulary g. Select antibitics and usual dsing regimens frm the hspital frmulary h. Learn hw t interpret the antibigram in the selectin f an antibitic i. Understand the rle f the cnsultant, the imprtance f cmmunicatin clarity f recmmendatins j. Master the physical diagnstic skills necessary t be an effective internal medicine physician. k. The resident must be able t evaluate a patient with an infectius disease and determine the diagnsis and a plan fr management. l. The resident must have physical access and be able t effectively use the Clinical Micrbilgy Labratry, ther pathlgy labratries and radilgy and understand the results prvided.

3 m. The resident must understand the crrect use f antimicrbial drugs and the utility f antimicrbial frmularies. The resident will interact with the pharmacy and ther healthcare prviders in rder t ptimally utilize these imprtant drugs as part f the Antimicrbial Stewardship Prgram. n. The resident must be able t critically interpret the medical literature and research data. 2. Rtatin Specific Cmpetencies: Residents will take the ID rtatin in any f their PGY years. Thus, these Rtatin-Specific cmpetencies shuld be demnstrated by the end f the rtatin fr all residents. Patient Care a. Residents must be able t btain an accurate histry fcusing n the issues f particular interest t infectius diseases and perfrm a cmplete and accurate physical exam. The resident must als demnstrate the ability t accurately review medical recrds. b. Residents must be able t synthesize patient data and the literature t cme t an accurate differential diagnsis, demnstrate sund clinical judgment, apprpriately use antimicrbial agents, and incrpratin f the patient preferences int the final plan. Medical Knwledge c. The resident must demnstrate knwledge f the literature in Infectius Diseases related t patients fllwed. d. Residents shuld have an understanding f the basic pharmaclgy and antimicrbial spectrum fr the cmmn antibitic classes and cmmnly used antibitics (including vancmycin, linezlid, cephalsprins, penicillins, flurquinlnes, aminglycsides, antifungal agents, sulfnamides, tetracyclines, and macrlides). e. The apprpriate use f antimicrbial agents is an imprtant skill that must be understd. References 1. Mandell, et al. Principles and practices f Infectius Diseases, 6 th Ed. 2. Guidelines: Antimicrbial Stewardship CID 2007; 44: f. Residents shuld als demnstrate knwledge fr the diagnsis and management f the fllwing majr clinical syndrmes: Meningitis Recgnize clinical presentatin f acute meningitis. Understand causative agents, diagnstic tls available and treatment. Recgnize the differences in etilgy and presentatin in immuncmprmised hsts. Reference N Engl J Med 2006; 354:

4 Sepsis Recgnize clinical and physilgic manifestatins f sepsis. Learn a thughtful apprach t discvering cause f syndrme. Understand the apprpriate use f antimicrbials in sepsis syndrme. Learn the use f adjunctive therapies in the patient with sepsis. Reference N Engl J Med. 2006; 355: Urinary Tract Infectins Understand spectrum f illness: Pyelnephritis, cystitis, prstatitis, abscess Knw apprpriate management issues in relatin t the treatment and preventin f UTIs. References CID 1999; 29: , CID 2007; 44: CID 2001; 33: Skin and Sft Tissue Infectins Understand spectrum f illness including cellulitis, erysipelas, fasciitis, furunculsis, flliculitis and impetig. Define the likely pathgen fr each f these syndrmes. Knw clinical manifestatins, predispsing hst factrs, classic expsures, and apprpriate treatment. In particular, understand the management f infectins with Methicillin-Resistant Staphylcccus aureus (MRSA) differentiating hspital and cmmunity-assciated strains. Reference N Engl J Med. 2007; 357:

5 Pneumnia Learn t perfrm a physical exam t diagnse this infectin Develp knwledge f different bacterial, viral, fungal causes f pneumnia Understand the treatment f pneumnia. References CID 1999; 29: ; CID 2007; 44: CID 2001; 33: Endcarditis and intravascular infectins Understand the epidemilgy in relatin t etilgic agents and risk factrs Learn t perfrm a physical exam t lk fr the clinical manifestatins f disease Learn the utility and limitatins f varius diagnstic tests including echcardigram. Apply the mdified Duke Criteria t help in determining the diagnsis Learn treatment strategies fr the management f endcarditis. Reference N Engl J Med. 2001; 345: Ostemyelitis and Prsthetic Jint Infectins. Recgnize the cmmn bacterial pathgens assciated with stemyelitis Understand the utility and pitfalls f the varius clinical, labratry and imaging mdalities used t diagnse and mnitr disease Develp knwledge cncerning duratin f therapy fr stemyelitis, based n pathgen, duratin f illness and presence r absence f rthpedic devices References Infect Dis Clin Nrth Am. 2005; 19: JAMA. 1998; 279:

6 HIV infectin Understand serlgy t establish the diagnsis f HIV infectin Develp knwledge abut antiretrviral agents indicatins, drug interactins, cmmn side effects, develpment f resistance Develp knwledge abut rle f resistance testing, interpretatin f gentypic and phentypic resistance tests Develp knwledge abut the clinical presentatin, diagnsis and treatment f pprtunistic infectins References Guidelines fr treatment f HIV and pprtunistic infectins: Cccidiidmycsis (ccci) Understand the epidemilgy f ccci, clinical presentatin, diagnsis and therapeutic management f lcalized and disseminated ccci. Understand the clinical presentatin f lcalized and disseminated ccci Understand the diagnstic apprach t the patient with suspected r prven disseminated ccci Understand the principles f antifungal therapy fr lcalized and disseminated ccci, with an emphasis n the rle f triazle agents Reference Clin Infect Dis. 2005; 41: Tuberculsis Understand the epidemilgy f tuberculsis Understand the pathgenesis, clinical stages (latent versus active disease) and clinical manifestatins f tuberculsis Understand the rle f tuberculin skin testing in the diagnsis f tuberculsis, including interpretatin f PPD skin test Becme familiar with the use f antimicrbial therapy in the management f latent and active tuberculsis First line vs. secnd/third line agents Cmmn side effects f antituberculus agents Peridic labratry tests and clinical exams used t mnitr fr txicity f antituberculus therapy References Am J Respir Crit Care Med. 2007; 175: 541-6

7 MMWR Recmm Rep. 2000; 49(RR-6): 1-51 Candida species Understand micrbilgy, pathgenesis, and pathlgic findings. Learn spectrum f clinical manifestatins. Thrush, esphagitis, cutaneus syndrmes, fungemia and deep rgan manifestatins. Knw apprpriate management f infectins with Candida sp. as determined by cultures f bld r sterile bdy fluids; Endcarditis, line infectins and peritnitis Understand relatinship between different species particularly the nn-albicans candida and antifungal agents. Reference N Engl J Med. 2006; 355: Practice-Based Learning and Teaching g. The resident must be able t critique his/her wn perfrmance. h. The resident must be receptive t cnstructive criticism. i. The resident shuld learn frm his/her wn errrs and errrs f clleagues. j. Actively educate clleagues, patients and self with a variety f surces f infrmatin. k. Access and critically evaluate the medical literature. This will demnstrate evidence f independent schlarship. l. Apply and pen minded and analytical apprach t acquiring new knwledge. Interpersnal and Cmmunicatin Skills m. Develp a gd wrking relatinship and rapprt and cmmunicate clearly t ther physicians, ther healthcare wrkers and patients. n. Present cases in a cncise and fcused manner. Understand what infrmatin is required t make an accurate and cmplete presentatin (pertinent psitives and negatives).. Maintain cmprehensive, timely and legible medical recrds. Prfessinalism p. The resident is expected t demnstrate respect, cmpassin and integrity when wrking with patients and families. q. The resident is expected t demnstrate respect and integrity with fellw physicians and healthcare prviders. r. The resident is required t adhere t HIPAA standards fr patient cnfidentiality. s. The resident is expected t adhere t principles f scientific and academic integrity.

8 t. The resident shuld demnstrate the ability t recgnize and identify deficiencies in peer perfrmance in a cnstructive manner. u. The resident must take respnsibility fr prviding quality patient care. v. The resident must acknwledge mistakes withut being defensive. System-Based Practice w. Be able t understand the systems available fr patient care. x. Wrk within reginal and natinal medical systems t deliver ptimal medical care. y. Maintain credentials t be an active member f the medical staff. VII. Structure f the Rtatin a. Respnsibilities f the Resident 1. The resident will be physically present at the apprpriate site fr the rtatin. The resident will be prvided all weekends free frm clinical service while n the cnsultatin service blck. The resident will be respnsible fr being present frm 7:00 AM 5:00 PM. The residents will nt be assigned night call. The resident must infrm the prgram directr regarding any schedule change. 2. Inpatient Cnsultatin Service a. The resident will be respnsible fr management f his/her patients i. Determining the apprpriate strategy fr diagnsis and treatment f the patient. ii. Suggest apprpriate times t sign ff f patients iii. Residents will be released t g t clinic and cnferences in a timely manner iv. The resident will present cases t the faculty physician. v. The resident will be respnsible fr interactin with the requesting services. 2. Outpatient Clinic at UC Davis Medical Center a. The resident will see and evaluate patients referred t the clinic fr cnsultatin. b. Residents will attend ID clinic 1-2 times per week n Weds and/r Thursday mrning. c. The resident will present the patients t the faculty physician t develp the plan fr management. VIII. Respnsibilities f the Faculty 1. The faculty is assigned t the Inpatient Cnsultatin Service in 2-week blcks. The faculty is als assigned t ne Infectius Diseases Clinic at UCDMC. 2. The faculty member is expected t be present fr runds n the cnsultatin service and in the clinic t staff the patients. 3. On the cnsultatin service the faculty member is expected t perfrm teaching runds daily. 4. In the clinic the faculty member is expected t see and evaluate all f the resident s patients and participate in the develpment f a plan f actin.

9 5. The faculty member is expected t prvide an envirnment cnducive t learning. 6. The faculty member is expected t respnd t questins apprpriately. 7. The faculty member is expected t participate in weekly cnferences such as jurnal club and case cnference. 8. The faculty member must prvide verbal feedback t the fellw at the end f each rtatin. 9. The faculty member must prvide written evaluatins at the end f each rtatin fr the cnsultatin service.