1. General Information
  1. Organization and Structure
  1. The Department of Medicine at the University of North Carolina at Chapel Hill provides an integrated, progressive experience for residents in their 36- month training period. The goal of our curriculum is to prepare residents to be well- trained general internists. We believe this type of training not only prepares our residents for careers in General Internal Medicine but also provides the necessary foundations for further training as a subspecialist.

The curriculum in the Department of Medicine changes greatly from the PGY 1 year to the PGY 3 year. The PGY 1 year consist of 9 months of inpatient rotations and 3 months of ambulatory medicine. During the second and third years, residents spend an increasing amount of time in the outpatient setting, so that by the time a resident is in the PGY 3 year, a majority of rotations occur in ambulatory medicine. The curriculum will be specifically described for each of the 3 year of training.

The PGY 1 Year

Each PGY 1 resident must develop competence in the following categories:

Patient Care

Medical Knowledge

Practice Base Learning and Improvement

Interpersonal and Communication Skills

Professionalism

System Based Practice

In the context of monthly rotations, competency is defined for each of the categories.

Patient Care- medical interviews, physical examinations, review of data, procedural skills, diagnostic and therapeutic decision making

Medical Knowledge- basic and clinical science, evidence- based medicine, literature searching

Practice Based Learning and Improvement- evaluation of own performance, incorporation of feedback, use of technology for patient care and self improvement

Interpersonal and Communication Skills- establishment of relationships with patients and families, education and counseling of patients, team skills with colleagues

Professionalism- demonstration of respect, compassion, integrity, and honesty, commitment to self assessment, acknowledges errors, considers needs of patients and colleagues

System Based Practice- ability to utilize resources, use a systematic approach to reduce errors and improve patient care

These competencies are reviewed with all residents and the faculty and serve as the foundation for monthly evaluation. The evaluation tool includes a description of each of the core competencies and a scale of evaluation for each from 1-9. A copy of the evaluation took is included in Section ___.

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The PGY 1 curriculum consists of a series of monthly rotations linked with a number of Departmental teaching conferences.

The monthly inpatient rotations for each PGY 1 resident are as follows:

Cardiology/MICU- 2 months

Inpatient General Medicine Ward- 2months

Inpatient Subspecialty Wards- 5months

On all inpatient rotations the role of the PGY 1 resident is to serve as the primary physician for all of his/her patients. In this role the PGY1 resident:

  1. Performs a history and physical examination on each new patient
  2. Enters all orders
  3. Communicates with the patient and ward team regarding daily progress
  4. Enters a history and physical and daily progress notes into the patient record
  5. Develops a diagnostic and therapeutic plan for each patient
  6. Enters a discharge summary in to the patient record

Cardiology -consists of 32 beds covered by four teams. Each team is made up of one upper level resident and one PGY 1 resident. One faculty member and one subspecialty fellow are assigned to each team to assist in patient management and to conduct teaching rounds. Didactic teaching rounds and bedside teaching occur daily. Also, there is a weekly core curriculum lecture series that is case- based.

A copy of the Cardiology Curriculum is included in Section 2. Common diagnoses of patients admitted to the cardiology service included myocardial infarction, arrhythmias, and chronic heart failure. Residents follow patients in the CCU (12 beds) and the general floor (20 beds). Residents on service place central lines including Swan Ganz catheters and perform arterial blood gases and thoracenteses.

ICU- Consist of 19 beds in a MICU. There are 4 teams, each team consisting of one upper level resident and one PGY 1 resident. One faculty member serves as the attending in the MICU. There is also a Critical Care Fellow. Teaching rounds include didactic presentations (30 min/day, 6 days/week), bedside teaching(2hours/day, 7days/week), and x-ray teaching (30 minutes/day,6days/week). There is a designated curriculum (Section 2). Patients admitted commonly have the following diagnoses: GI bleeding, septic shock, drug overdose, s/p cardiopulmonary arrest, DIC, COPD exacerbation, cystic fibrosis exacerbation, rejection s/p lung transplant, and acute renal failure. Residents perform all procedures.

Inpatient General Internal Medicine -consists of 2 general medicine services. For each service, there is one attending, one upper level resident, and two PGY 1 residents. Teaching rounds occur for one hour, five times per week covering a number of topics described in the Inpatient General Medicine curriculum (see Section 2). Patients admitted have a variety of problems including: community acquired pneumonia, COPD exacerbation, diabetic complications, and lupus complications. Residents perform all procedures.

Also, residents rotate at Wake Hospital, a community hospital in Raleigh, NC. There are four teams consisting of one attending, one upper level resident, and one PGY 1 resident. Teaching rounds occur for one hour five times per week covering topics in General Internal Medicine. Residents perform all procedures.

Inpatient Subspecialty Wards-

Service#beds

Medicine A-Geriatrics20

Medicine B- Nephrology20

Medicine E- Hematology/Oncology40

Medicine G- Pulmonary20

Medicine K- Infectious Disease20

For each service there is one attending, one upper level resident, and two PGY 1 residents. Each of these services has daily work rounds and attending rounds. Each service has designated reaching time occurring at a minimum of five hours per week. During teaching time a series of topics pertinent to each service are reviewed. A copy of each curriculum is included in Section 2. Residents perform all procedures on these services.

The PGY 1 Curriculum also includes the following rotations:

Emergency Medicine- 1 month

Same Day Clininc-1 month

Continuity Care/Ambulatory Elective- 1 month

Emergency Room – faculty from the Department of Emergency Medicine supervise PGY 1 residents. PGY 1 residents have a generic experience seeing medical, surgical, and obstetrics/gynecology patients. There are four hours of didactic teaching per week, which cover a wide variety of topics. Examples of monthly topics are included in Section 3.

Same Day Clinic- This is a walk in clinic for the established IM patients and also serves as an Urgent Care clinic. Faculty in the Division of General Internal Medicine supervise PGY 1 residents. A variety of outpatient problems are encountered. Didactic teaching takes place daily for 30 minutes. Subjects covered in the curriculum are included in Section 3.

Continuity Care/Ambulatory Elective- PGY 1 residents spend one month in the General Medicine clinics working with Faculty from the Division of General Medicine. Some of the modules include enhanced care in anticoagulation, diabetes, pain management, and travel medicine. Each resident also undertakes a CQI project. PGY 1 residents may also rotate on a subspecialty service of the Department of Medicine. Consultations are done on inpatients and outpatients and patients are also seen in subspecialty clinics. Division faculty provide supervision. Curricula for each rotation are included in Section 3.

Teaching Conferences

PGY1 residents attend a series of Departmental Conferences. The daily work schedule is set up to allow PGY 1 residents to attend the conferences (Table 1).

Table 1

UNC Department of Medicine- Schedule of Daily Activities

Time / Monday / Tuesday / Wednesday / Thursday / Friday
0700 / Pre Rounds / Pre Rounds / Pre rounds / Pre Rounds / Pre Rounds
07300
1000 / Work Rounds / Work Rounds / Work
Rounds / Work
Rounds / Work
Rounds
1000 / Residents Report / Residents Report / Residents
Report / Residents
Report / Residents Report
1100 / Attending Rounds / Attending Rounds / Attending Rounds / Attending Rounds / Attending Rounds
1200 / Core Curriculum / Core Curriculum / Intern Conference / Grand Rounds/ Morbidity and Mortality Conference / EBM Conference

Residents are expected to attend all conferences. The conferences are as follows:

Monday- Resident Core Curriculum Conference 1 hour

Tuesday- Resident Core Curriculum Conference 1 hour

Wednesday- Interns Conference 1 hour

Thursday- Grand Rounds 1 hour

Friday – EBM Conference 1 hour

The content of some of these conferences is briefly described. Lecture topics are included in Section 4.

Monday and Tuesday- Residents Conference- Faculty in the Department of Medicine presents a series of lectures covering focused topics.

Wednesday- Interns Conference- A lecture series o f Emergency Medicine Topics mixed with case based group discussion.

Thursday- Grand Rounds

Thursday- Mortality and Morbidity- The morbidity and mortality conference centers on a subject relating to patient care in the department. The Vice Chair of the department conducts this lecture.

Friday- Evidence Based Medicine Conference- An evidence based medicine discussion of selected literature by both faculty and residents.

The PGY 2 Year

Each PGY 2 resident must demonstrate competence in the following:

Patient Care

Medical Knowledge

Practice Based Learning and Improvement

Interpersonal and Communication Skills

Professionalism

System Based Practice

Competency is defined as outlined above for PGY 1 residents and is used for monthly evaluations of PGY 2 residents

The PGY 2 year is composed of a series of monthly rotations coupled with Departmental teaching conferences.

The monthly inpatient rotations for a PGY 2 resident are as follows:

  1. MICU- 1month
  2. Cardiology- 2months
  3. UNC inpatient Medicine Ward- 2-3 months
  4. Wake Med- 1 month
  5. Night Float- 2-3 2 week blocks

On inpatient rotations the role of the PGY 2 resident is to be in charge of the ward team. In this role the PGY 2 resident:

  1. Performs a history and physical examination on each new patient
  2. Reviews the treatment plan for each new patient with the PGY 1 resident
  3. Reviews the performance of MS 3 students
  4. Conducts daily work rounds
  5. Supervises all procedures

On night float the PGY 2 resident reports at 7pm and until 7 am. They are responsible for the primary evaluation and management of all non intensive care patients admitted to the Department of Medicine. At 7am the care of those patients goes to the incoming team on call. The Attending Physician of the service provides supervision.

Cardiology/ICU/Inpatient General Medicine Wards/Inpatient Subspecialty Wards -

These have been previously described under the PGY 1 resident. The role of the PGY 2 resident on these services is supervisory. The PGY 2 resident evaluates all patients on service and the PGY 2 resident is integral in constructing a plan of care, which is carried out by the PGY 1 resident. Another major responsibility is teaching. The PGY 2 resident teaches and supervises medical students on these services.

The PGY 2 curriculum also includes the following rotations:

Ambulatory General Internal Medicine- 2-3 months

Subspecialty Consultation- 2-3 months

Ambulatory General Internal Medicine– PGY 2 residents can choose from several month blocks focusing on outpatient skills of the generalist. Some of the choices are:

Wake Hospital Ambulatory Rotation

Siler City- PGY 2 residents spend the month in a community setting supervised by general internists.

Subspecialty Consultation-PGY 2 residents can choose among any subspecialty in the Department of Medicine. Consultations are done on inpatients. Patients are also seen in subspecialty clinics. Division faculty provides supervision. Curricula for each rotation are included in Section 3.

Teaching Conferences

Like PGY 1 residents, PGY 2 residents attend a series of conferences, which are integrated with the daily work schedule. Some have been described previously including Monday Resident Core Curriculum, Tuesday Core Curriculum, Thursday Grand Rounds and Friday Evidence Based Medicine. In addition, PGY 2 residents attend Morning report. This is case- based with residents presenting unknown patients to their peers. The presenting resident completes his /her presentation with a review of a particular subject. This review like all presentations is posted on the internet so that residents may review these at their leisure. These conferences are coordinated by the Chief Residents. The curriculum is set by the chief residents; a list of topics discussed is included in Section 4.

The PGY 3 Year

ACGME Competencies

Each PGY 3 resident must develop competency in the following:

Patient Care

Medical Knowledge

Practice Based Learning and Improvement

Interpersonal and Communication Skills

Professionalism

Systems Based Practice

Competency is defined as outlined above for the PGY 1 and PGY 2 residents and is used in monthly evaluation.

In many ways the PGY 3 year is similar to the PGY 2 year in that the residents function as described previously under the PGY 2 year, include teaching conferences. The rotations however, are different and are as follows:

  1. Wake Med- 1 month
  2. UNC Internal Medicine Wards- 1-2 months
  3. Same Day Clinic- 1 month
  4. Ambulatory General Internal Medicine- 2-3 months
  5. Subspecialty Consultations 2-3 months
  6. Special electives – 1 month
  7. MICU or Cardiology- 1-month
  8. Night Float- 2-3 2 week blocks

Inpatient General Internal Medicine Wards/ Inpatient Subspecialty Ward- The role of the PGY 3 resident is identical to that described previously for the PGY 2 resident.

Same Day Clinic- The role of the PGY 3 resident is identical to that of the PGY 1 resident

Ambulatory General Internal Medicine- PGY 3 residents can choose from several month blocks including those described for PGY 2 residents. There are additional choices as follows:

General Medicine Consults/Hospitalist Service- PGY 3 residents see patients on other services, providing General Medicine Consultations. Also a small number of inpatients are cared for. Supervision is provided by faculty from the Division of General Internal Medicine Hospitalist group.

Geriatric Medicine- PGY 3 residents are exposed to management of this population. Faculty trained in Geriatrics provide supervision

Subspecialty Consultations- The role of the PGY 3 resident is the same as described for the PGY 2 resident on those rotations.

Special Electives- These rotations are designed to enhance individual training. Residents pick a faculty mentor to conduct clinical or basic research. Rotations at other institutions or international rotations can also be done.

SECTION 2

INPATIENT CURRICULUM

Cardiology

Intensive Care Unit

General Medicine

Geriatrics

Nephrology

Hematology/Oncology

Pulmonary

Infectious Diseases

Endocrinology

Section 2

Inpatient Curriculum

General

Each inpatient service has designated teaching time, previously described in Section 1. It is the responsibility of the division faculty when on service to review a series of topics during the monthly rotation. The division faculty generates these topics with input from residents as well as data supplied to each division from preceding In-Training Examination. A dominant theme for these conferences is to review material a general internist must know about each discipline. The curricular goal for each resident is to have a working knowledge of these subjects.

Cardiology Inpatient Curriculum

Objective 1. Takes a history

Demonstrates knowledge necessary to obtain an orderly history on patients suspected of having cardiovascular diseases and recognizes the importance of

  1. Dyspnea ( resting, exertional, nocturnal, positional)
  2. Chest pain ( specifically, what constitutes “typical” angina)
  3. Edema
  4. Palpitations/arrhythmias
  5. Exercise tolerance
  6. History of hypertension and treatment
  7. History of rheumatic fever
  8. History of congenital heart disease
  9. History of cardiac murmurs or valvular disease
  10. Cardiovascular risk factors, including family history
  11. Presyncope and syncope
  12. Claudication

Objective 2. Performs a physical examination

Demonstrates knowledge necessary for performing an orderly, systematic and adequate physical examination of patients with cardiovascular problems and recognizes the importance of

  1. Arterial System &Jugular Venous Pulse
  1. Reports and demonstrates the correct method of measuring arterial blood pressure
  2. Is familiar with difficulties in measuring arterial blood pressure accurately:
  1. Variation between extremities, position, and level of extremity
  2. The auscultatory gap
  3. Proper cuff size
  1. Is familiar with normal and common abnormal findings found by inspection or palpation of the venous and arterial pulses, including the following:
  2. a,c,v waves; visual estimation of central venous pressure;hepatojugular reflux
  3. effect of inspiration on neck veins
  4. pulsusalternans, pulsusbisferiens, pulsusparadoxus
  5. aortic regurgitation and stenosis
  1. Examination of the Heart
  1. Discusses normal and common abnormal findings found by inspection and palpation of anterior chest including the following:
  1. Right and left ventricular heaves: palpable A –waves
  2. Thrills
  1. Understands the events of the cardiac cycle and the genesis of:
  2. S1,S2,S3,S4, summation of gallop, splitting of S2 ( normal &reversed), and opening snap
  3. Mitral valve clicks
  4. Semilunar valve ejection sounds
  5. Artificial valve sounds ( normal& abnormal)
  6. Innocent murmurs, including flow murmurs, venous hums
  7. Murmurs of valvularstenosis and regurgitation
  8. Maneuvers that alter murmurs, i.e. Valsalva, squatting, inspiration, expiration
  9. Pericardial rubs

Objective 3. Orders or performs diagnostic studies and interprets laboratory data in a reasonable and cost effective manner.

  1. Electrocardiography ( EKG)
  1. General knowledge of the range of normal variation in P, QRS, ST, T wave
  2. Understanding of EKG diagnosis of LVH, left atrial enlargement, acute ischemia and patterns of myocardial infarction
  3. Basic understanding of the diagnostic utility of the EKG in the diagnosis of arrhythmias
  1. Chest X-Ray
  1. General knowledge of normal chest x-ray findings
  2. Apvreciation of abnormalities- seen in:
  3. Heart failure
  4. Valvular disease
  5. Hypertensive disease
  6. Ischemic heart disease
  7. Common congenital abnormalities seen in adulthood
  1. Non-Invasive Testing
  1. Basic appreciation of the indications for:
  2. Echocardiographic assessment ( transthoracic and transesophageal) including 2D and Dopler echocardiography
  3. Ambulatory EKG ( Holter) monitor
  4. Exercise testing with and without perfusion scintigraphy. Including an understanding of the meaning of sensitivity and specificity with regards to the latter test in the diagnosis if coronary disease
  5. Tomographic imaging techniques, including MRI and CT
  1. Invasive Testing
  1. Basic knowledge of methodology involved in performing coronary angiography, left ventricular hemodynamic assessment and electrophysiologic testing; Understands the indications and risks of invasive diagnostic procedures

Objective 4.Understands the pathophysiology, natural history, clinical presentation, diagnostic work up and management of common cardiac disorders.