1. INTRODUCTION
The Division of Internal Medicine at McGill University offers a 2-year specialty training program in General Internal Medicine for Internal Medicine residents who wish to practice general internal medicine.
The activities of the Division of Internal Medicine at McGill are primarily centered at 3 hospital sites: McGill University Health Centre (Royal Victoria Hospital and Montreal General Hospital sites), and the Sir Mortimer B. Davis Jewish General Hospital.
A resident may apply to the General Internal Medicine Fellowship Program on successful completion of three core years of internal medicine training.
2. DEFINITION
A general internist is an adult medicine specialist who is trained and skilled in the diagnosis and comprehensive management of a broad spectrum of diseases, conditions or complications involving one or more organ systems. The general internist is able to integrate the care of several medical conditions in one individual. General internists are experts in the diagnosis and care of patients presenting with undifferentiated symptoms as well as known disease states. They are experts in the care of patients presenting with either a single active problem in the face of multiple stable comorbidities or patients with multiple active decompensated comorbidities requiring concurrent diagnosis and treatment, both in the acute care and ambulatory setting. This includes maintaining stability of multiple comorbidities during decompensation of one facet of their illness or during physiological stresses such as during pregnancy or the peri-operative period. Often the general internist is the first specialist a patient sees who is capable of coordinating the care of the patent efficiently and in a timely manner. The general internist is capable of providing expert, professional, and comprehensive medical care in a variety of hospital and out-patient settings, including critical care, both in urban and community centres. Moreover, many general internists play an important role in teaching internal medicine to students, residents, and other physicians, and may participate in research within their particular area of interest and expertise (e.g. medical education, epidemiology, hypertension, out-patient medicine or health administration).
3. GENERAL OBJECTIVES
The resident under appropriate supervision, will acquire the knowledge, skills, and attitudes common to general internal medicine practice, which will allow the resident to practice independently as an effective internist in the setting in which he or she will eventually function. Upon completion of training, the resident is expected to identify, diagnose, and treat uni-system and multi-system disease both in the hospital and outpatient setting. The resident must be able to provide comprehensive care of the whole patient often with multiple comorbidities in the perioperative and critical care situations. The resident must acquire the knowledge relating to the pregnant state to be able to diagnose and manage medical complications in the obstetric patient. Finally, the resident must demonstrate the knowledge, skills, and attitudes relating to gender, culture, and ethnicity, and incorporate these into the practice of general internal medicine.
4. SPECIFIC PROGRAM OBJECTIVES
The general internal medicine resident is expected to achieve competency in the areas described below and show appropriate evolution over the 2 years of training.
4a. Medical Expert
The curriculum is structured to occur primarily through the patient-care context under the tutelage of attending physicians, in addition to journal club settings, and academic teaching rounds. Regular evaluation of the resident’s knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. The resident’s knowledge and skills in this domain will also be evaluated in an annual oral examination.
General Requirements
Be able to demonstrate expert knowledge in the diagnosis, treatment, and management of the following:
- Multi-system failure in the acute care setting (including critical care)
- Chronic multi-system failure in the ambulatory care setting
- Undifferentiated symptoms in the ambulatory care setting
- Common medical problems in both the acute and ambulatory care setting
- Acute illness in the context of multiple co-morbidities
- Complicated multi-organ diseases (such as lupus or sarcoidosis)
Specific Requirements
1. Demonstrate expertise in developing a differential diagnosis of patients presenting with undifferentiated symptoms or acute illness of unknown etiology
2. Demonstrate the ability to maintain up to date knowledge of the broad base of internal medicine and apply it to the care of general internal medicine patients
3. Demonstrate expertise in peri-operative care including risk stratification, risk modification and post-operative medical management
4. Demonstrate expertise in the management of medical problems of pregnancy, including an understanding of the physiological changes in pregnancy, the impact of pregnancy on medical disorders and the application of therapeutics in pregnancy
5. Recognize drug interactions and side-effects in patients with multiple co-morbidities, elderly patients, pregnant patients, peri-operative patients and patients with organ impairment
6. Demonstrate expertise in these basic Internal Medicine procedural skills*:
- lumbar puncture
- Abdominal paracentesis
- Endotracheal intubation
- Central venous catherization
- Peripheral arterial catheter insertion
- Knee joint aspiration
- ECG interpretation
- Advanced Life Support
7. Demonstrate competency in the following procedures*:
- Swann-Ganz placement and hemodynamic monitoring
- Mechanical ventilation
- Electrical cardioversion
- Exercise stress testing
- Ambulatory ECG monitoring
- Temporary pacemaker insertion
- Transthoracic pacing
8. Pursue opportunities to gain expertise in the following additional procedures* depending on future career interests and the needs of the community wherein the general internal medicine resident is expecting to practice:
- Echocardiography
- Chest Tube Insertion
- Pulmonary Function Testing and Spirometry
- Sleep studies
- Endoscopic Procedures (pulmonary and GI)
- Bone Marrow Aspiration and biopsy
- Skin biopsy
- Joint Aspiration and injection
- Hemodialysis and peritoneal dialysis
*For any given procedure the general internal medicine resident will be able to describe the indications, the contraindications, the potential complications and the available alternatives. For any given procedure, the general internal medicine resident will be able to interpret the results. Training in additional procedures to those listed above may be required depending on future practice location.
4b. Communicator
The curriculum is structured to occur primarily in the patient-care context through the principles of verbal and written communication with patients, families, colleagues, and other health-care professionals, and in discussions and presentations with health-care professionals. Regular evaluation of the resident’s knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation.
As a result, the general internal medicine residents will be able to:
- Establish effective therapeutic relationships with patients and families
- Obtain and synthesize relevant history from patients, families, and communities
- Discuss appropriate information with patients, families and the health care team
- Provide clear, concise and timely verbal and written communication to other specialties such as surgery, obstetrics, family physicians and other subspecialists who would be involved in the care of patients with multi-system illness
- Discuss risk-benefit of diagnostic and therapeutic options in patients with multi-system illness, including in the setting of pregnancy and surgery
4c. Collaborator
The curriculum is structured to occur primarily through the patient-care context. It is within this context that the general internal medicine resident participates as a collaborative member of a multi-disciplinary team in providing medical care, education, and research. Regular evaluation of the resident’s knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation.
As a result, the general internal medicine residents will be able to:
- Consult effectively with other physicians and health care professionals
- Define their role as a consultant while involved in the care of surgical and obstetrical patients
- Contribute effectively to other interdisciplinary team activities
- Facilitate the care of patients through partnerships with the surgical and/or obstetrical team
- Help in the coordination of linking patients to outpatient health care settings and/or other in-patient health care settings
4d. Manager
The resident should be able to perform and interpret diagnostic and therapeutic procedures and tests, and should be able to demonstrate an understanding of their costs, limitations, and predictive values.
As a result, the general internal medicine residents will be able to:
- Be able to utilize resources effectively to balance allocate finite health care resources wisely
- Work effectively and efficiently in a health care organization
- Utilize information technology to optimize patient care, life-long learning and other activities
- Coordinate multiple diagnostic and therapeutic interventions for the general internal medicine patient
- Recognize issues pertaining to running a medical office including staffing, billing, record-keeping and follow-up of patients
4e. Health Advocate
The curriculum is structured to occur through the patient-care context. It is in this context that the general internal medicine resident participates as an advocate for optimal health and well being of the patient and society as a whole. Regular evaluation of the resident’s knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation.
As a result, the general internal medicine residents will be able to:
- Identify the important determinants of health affecting patients
- Contribute effectively to improved health of patients and communities
- Promote preventive health care (e.g. smoking cessation and treatment of obesity)
- Implement preventive strategies such as cancer screening and the treatment and/or prevention of osteoporosis
- Recognize and respond to issues where advocacy is appropriate, such as universal access to health care
4f. Scholar
The curriculum is structured to occur through journal clubs, academic Internal Medicine Division rounds, and completion of a research project and/or case report and/or literature review. As well, the general internal medicine resident is strongly encouraged to participate in a structured epidemiology curriculum which is offered as part of the McGill Summer Epidemiology Program. Regular evaluation of the resident’s knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation. Furthermore, the residents have the opportunity to present their work to their colleagues and medical university community at the annual “Resident Research Evening” and “Clinical Vignettes Evening”. Presentation of appropriate work at provincial, national, and international conferences is strongly encouraged. As well, publication in local, national, and international journals is recommended and supported.
As a result, the general internal medicine residents will be able to:
- Develop, implement, and monitor a personal continuing education strategy
- Critically appraise sources of medical information
- Facilitate learning of patients, medical residents and students, and other health professionals
- Demonstrate scholarly activity in one or more of the following categories:
- a) Research (Clinical Epidemiology, Basic Science, Clinical Research, Clinical Trials, and/or Medical Education)
- b) Medical Education
- c) Ethics
- Demonstrate the ability to formulate focused questions related to practice, and use a variety of search skills and resources to access and appraise appropriate information
- Demonstrate effective teaching skills in areas unique to general internal medicine and participate in teaching workshops and academic rounds aimed at junior internal medicine residents
4g. Professional
The curriculum is structured to occur primarily through the patient-care context. Regular evaluation of the resident’s knowledge, skill, and attitudes in this domain are part of the monthly evaluation scheme for each clinical rotation.
As a result, the general internal medicine resident will be able to:
- Deliver quality care with integrity, honesty and compassion
- Exhibit appropriate personal and interpersonal professional behaviours
- Practise medicine ethically consistent with obligations of a physician
- Recognize limitations in skill and know when to refer to another health provider
- Recognize and know how to address unprofessional behaviours in medical practice