Other integrative curricular areas Internal medicine physicians must have a broad range of knowledge which includes an understanding of conditions and topics that are normally considered to be the purview of other medical specialists. Specific areas of importance to internal medicine specialists include rehabilitation medicine, nutrition, occupational and environmental health, ophthalmology and otolaryngology. Knowledge and experience in these areas is gained in a variety of s throughout the three year training program. The resident core series includes topics in all of these integrative disciplinices. s are also expected to read independently and to seek out clinical experiences as needed to supplement the resident s individual experience during required rotations. A variety of s are offered to give residents this opportunity. The provides an opportunity for residents to enhance skills in integrative disciplines in the outpatient. s work with a practicing internist in the community, and also work with one or more specialist physicians to enhance skills in their area of expertise. s design their own curriculum and may elect to work with any one or two of a wide variety of medical subspecialists, including ophthalmologists, otolaryngologists and others. A description of the is appended. Other s provide additional learning opportunities. Occupational and environmental medicine is particularly important in pulmonary and musculoskeletal disease. Gastroenterology includes additional training in nutrition, especially in patients with gastroenterologic disease requiring special dietary intervention. The endocrinology rotation provides opportunities for residents to learn more about dietary interventions for diabetes and obesity. The use of rehabilitation medicine is emphasized in the musculoskeletal, the geriatric rotation, as well as neurology and inpatient medicine. Additional details are provided in the curricula for these rotations. The following sections describe the skills that residents should acquire by the end of the training period in each of these integrative disciplines. The rotations and activities in which they are most likely to acquire these skills are identified, as well as the core competency associated with that skill and the means of assessment. Areas addressed are: Rehabilitation Medicine Nutrition Occupational and Environmental Medicine Ophthalmology Otolaryngology 1
Rehabilitation Medicine The general internist will be responsible for care of many patients who may have suffered neuromusculoskeletal system impairments that have resulted in residual disability. As a primary care provider, the general internist will need to be aware of the effects of such disabilities on other body systems and on the patient s ability to perform the routine activities of daily living and to fulfill various societal roles. The internist should understand the role that physical medicine and rehabilitation can play in the maintenance and restoration of function, and be able to work with health care providers in this area to ensure the best outcome for the patient. SKILLS AND Know the differences among impairment, disability, and handicap Know how to diagnose and manage the common musculoskeletal disorders, including fibromyalgia, myofascial pain, repetitive motion disorders, and overuse syndromes COMPET ENCY ROTATION Allied Specialty Service Setting Service Musculoskeletal Rheumatology Elective Teaching rounds Primary care lecture series core s Mini CEX Know how to recognize the complications of prolonged bed rest (contractures, pressure sores, deep venous thrombosis, osteoporosis, muscular deconditioning, and others) Be able to describe various physical medicine treatment modalities Know the physiologic effects of aerobic exercise s Musculoskeletal Rheumatology Cardiology Teaching rounds Primary care seminar series Primary care seminar series 2
SKILLS AND Know and appropriately use the allied health professionals (for example, physical therapist, occupational therapist,, speech and language pathologist, and others) to optimize patient care Know when to use the various assistive devices that may reduce disability, including wheelchairs, prosthetics, orthotics, and others. Know how to order these devices COMPET ENCY ROTATION Musculoskeletal Rheumatology Musculoskeletal Rheumatology Primary care seminar series Primary care seminar series Know the principles of uation and management of chronic pain Conference Know the methods for minimizing long-term disability from acute illnesses (for example, prophylaxis against venous thrombosis, bed sores, contractures) Be able to assess the effects of impairment on a patient s daily function Critical care unit Musculoskeletal Rheumatology Teaching Rounds M and M s core s 3
Nutrition Clinical nutrition focuses on the importance of nutrition in the maintenance of health and the interrelationship between nutrition and disease. Areas of interest for the general internist include enteral and parenteral nutritional support for hospitalized, homebound, or chronic care patients; and the role of nutrition in disease prevention. The curriculum should emphasize nutritional assessment and management of patients with nutritional deficiencies or excesses, hypersensitivities, eating disorders, nutritional diseases, and other pathologic conditions in which nutrition therapy would be beneficial. SKILLS AND Identify from the history important risk factors for malnutrition In a patient with risk factors for malnutrition or eating disorders, know how to screen for malnutrition through physical examination and appropriate procedures Know the dietary management for these common clinical conditions: obesity, hypertension, hyperlipidemia, diabetes, osteoporosis, congestive heart failure, liver failure and renal insufficiency Know the indications for and content of enteral and parenteral nutrition Demonstrate appropriate use of dieticians, pharmacists and other members of the health care team to optimize nutritional status of medicine patients COMPE TENCY IP/C ROTATIONS s s s s s based based based based based 4
Occupational and environmental medicine Occupational and environmental medicine is concerned with the diagnosis, treatment, and prevention of disease caused by agents in the environment. It focuses on preventing and treating occupational diseases and injuries; controlling or assessing health hazards in both the workplace and living environments; and fostering employee and public health through clinical care, education, and counseling programs. The general internist needs to know about health hazards in the home or workplace, how to do a preliminary uation, when to refer to an occupational medicine specialist, and how to assist in long-term management of work-related illness and disability. SKILLS AND Know how to take both a systematic occupational and environmental screening history and how to take an in-depth history when the patient s complaints or physical findings suggest an occupational or environmental health hazard Know the principles that help the physician decide whether an illness is caused by health hazards in the living and working environments Know how to apply epidemiologic principles to the uation of individual patients and, once a risk is identified, to coworkers and the community at large Be able to describe the basic principles of disease prevention and how to apply them to occupational and environmental effects on health Be able to counsel patients and others at risk about potential hazards in the community and workplace COMPE TENCY IP/C PBL PBL PBL PBL ROTATIONS Pulmonary Pulmonary Pulmonary Pulmonary Pulmonary core s core s Journal Club 5
SKILLS AND Know how to assess impairment and disability Be able to describe the physician s role in disability programs, including worker s compensation and Social Security Know how to uate complaints that could be environment-related and know when to refer to a specialist in occupational medicine Know the ethical, legal, and regulatory concerns specific to occupational and environmental medicine COMPE TENCY ROTATIONS Setting Rheumatology Setting Rheumatology Setting Rheumatology Setting Rheumatology 6
Ophthalmology (May also be a 2-week outpatient clinic rotation) Ophthalmology is the branch of medicine that investigates and treats disorders of the eye. The ophthalmologist is concerned with visual function and with infectious, inflammatory, traumatic, degenerative, and neoplastic disorders. The general internist must be able to uate many ophthalmologic complaints, including pain, redness, itching, and visual changes. He or she should be able to identify and treat frequently encountered problems, such as conjunctivitis, and identify problems requiring referral. In addition, the general internist must be able to recognize the fundoscopic findings of systemic illness, including hypertension and diabetes mellitus, and realize that ocular complaints may herald other illness. The table indicates specific skills the resident should acquire during the three years of training, the rotations and activities where the resident is likely to learn about these conditions, the core competencies and means of assessment. s who wish to augment their clinical skills in this area may choose to do the office medicine and work one-on-one with an ophthalmologist. Eye disorders commonly management by internists and procedures relevant to the uation of patients with ophthalmologic disorders are listed. SKILLS AND Be able to obtain a history relevant to ophthalmologic disorders, including risk factor for ophthalmologic disease, relevant facts from the HPI, and red flags that may indicate a need for emergent referral Be competent in the examination of the eye, including examination of external structures, the cornea, pupils, iris, extraocular movements, and fundoscopic exam. Have the medical knowledge to identify common ophthalmologic diseases, and to recognize atypical presentations or red flags requiring referral to a specialist Recognize ophthalmologic signs and symptoms of systemic disease Be able to initiate treatment for ophthalmologic disorders COMPE TENCY ROTATIONS Teaching round Intraining exam 7
commonly managed by internists. Ophthalmologic Conditions commonly uated/managed by internists: Blepharitis Cataracts Conjunctivitis Corneal abrasions Corneal infection Detachment of retina or vitreous Dry eye syndromes Foreign bodies, external and superficial Glaucoma Herpes zoster ophthalmicus Hordeolum, chalazion Keratitis, corneal ulcer Macular degeneration Optic atrophy Procedures: should be familiar with the following procedures and their role in the uation and management of patients with ophthalmologic conditions. Flourescein examination of the cornea Removal of superficial foreign body Slit lamp examination Flourescein angiographic Laser treatment for diabetic retinopathy Cataract surgery 8
Otolaryngology (May also be a 2-week at an outpatient clinic) Otolaryngology involves the diagnosis and management of disorders of the ears, nose, and throat. The general internist should be able to uate and manage such common disorders as pharyngitis, otitis, and sinusitis and recognize more complicated conditions that require subspecialty consultation. He or she should play a key role in screening for and prevention of aerodigestive tract malignancies, which occur particularly often in patients who smoke. The general internist should also be competent in uating such specific symptoms as hoarseness, hearing loss, and facial pain. The table indicates specific skills the resident should acquire during the three years of training, the rotations and activities where the resident is likely to learn about these conditions, the core competencies and means of assessment. s who wish to augment their clinical skills in this area may choose to do the office medicine and work one-on-one with an otolaryngologist. Disorders commonly management by internists and procedures relevant to patients with ENT disorders are listed. SKILLS AND Be able to obtain a history relevant to ear, nose and throat disorders, including risk factor for disease, relevant facts from the HPI, and red flags that may indicate a need for emergent referral Be competent in the examination of the ear, nose and throat including examination of external structures and otoscopic exam Have the medical knowledge to identify common ear,nose and throat diseases, and to recognize atypical presentations or red flags requiring referral to a specialist Recognize otolaryngologic signs and symptoms of systemic disease Be able to initiate treatment for ear, nose and throat disorders commonly managed by internists. COMPE TENCY ROTATIONS Teaching round Intraining exam 9
Otolaryngology conditions commonly uated/managed by internists Ears -Benign positional vertigo -Cerumen impaction -Otitis -Sensorineural hearing loss -Acute labyrinthitis -Eustachian tube dysfunction Nose -Epistaxis -Rhinitis, allergic -Sinusitis -Nasal polyps -Rhinitis, vasomotor -Septal deviation -Rhinitis medicamentosa Throat -Laryngitis -Masses or lesions of the oral cavity -Pharyngitis -Sleep apnea -Peritonsillar abscess -Acute epiglottitis Procedures: s should be familiar with the following procedures in the uations and management of patients with disorders of the ear, nose and throat: Cerumen removal X-ray/CT of the sinuses/mastoids Transillumination of the sinuses Throat culture Laryngoscopic examination of the oropharynx 10