1. GENERAL INTERNAL MEDICINE CONSULT SERVICE
The General Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in General Internal Medicine Consult Service.
1a. Medical Expert
General Requirements
Demonstrate effective consultation services with respect to patient care and education in a variety of clinical settings (example: surgery, obstetrics, and psychiatry).
Integrate consultative skills in a variety of in- and out-patient care settings.
Specific Requirements
Be able to deliver expert care effectively as an internal medicine consultant in a variety of clinical situations which may include:
- Preoperative assessment (assessing perioperative cardiac and pulmonary risk, risk stratification, risk modification, and providing recommendations for post-operative medical management).
- Disease management during the operative period (example: insulin therapy in an insulin dependent diabetic).
- Postoperative care and management (electrolyte imbalances, cardiovascular complications, infection, thrombotic complications, mental status changes, coagulopathies, anemia, thrombocytopenia, respiratory complications, pain management, and gastrointestinal complications)
- Drug related complications (be able to understand the drug-related treatment of patients with multiple illnesses, elderly patients, pregnant patients, patients with organ impairment, and perioperative patients)
- Assessment and management of the critical care patient.
- Performance of a procedure (example: lumbar puncture, bone marrow aspirate and biopsy, arthocentesis, thoracocentesis, paracentesis, intubation, central venous catherization, echocardiography, stress testing)
- Diagnosis and/or management of medical illnesses in the psychiatric patient, including understanding the complications and side-effects of commonly prescribed psychiatric drugs. Be able to assess and manage complex multi-system medical problems in non-medical patients (example: Diabetic management of a surgical patient).
Be able to assess and manage complex multi-system medical problems in non-medical patients (example: Diabetic management of a surgical patient).
1b. Communicator
Be able to effectively provide clear, concise, and timely verbal and written communication to the consulting physician and health care team.
Be able to establish therapeutic relationships with patients and family.
Be able to elicit a pertinent history from the patient and consulting physician and health care team.
Be able to discuss the risk-benefit of diagnostic and therapeutic options in patients with multi-system illness, and/or in the setting of pregnancy and surgery.
Be able to effectively define the role of a consultant to the patient and family in the context of the patient’s overall medical care.
Be able to effectively communicate to the patient and family one’s medical assessment and proposed recommendations in the context of the patient’s overall health plan.
1c. Collaborator
Be able to identify and recognize the need to and benefit of working closely with the consulting physician and health-care team in providing optimal patient care.
Be able to contribute effectively to interdisciplinary team activities (example: discharge planning).
Be able to aid the consulting physician and health care team in linking patients to outpatient health care services.
Be able to recognize limitations in skill and knowledge and consult sub-specialists for optimal patient care.
1d. Manager
Be able to effectively and efficiently manage the consult service often while attending to other clinical duties.
Be able to prioritize requests for consults.
Demonstrate expertise in the coordination of multiple diagnostic and therapeutic interventions, often within a short period of time (example: investigation of thrombocytopenia in a patient with a hip fracture awaiting surgical repair).
Demonstrate the ability to use available medical and technical resources effectively.
1e. Health Advocate
Facilitate learning of patients, house staff/students and other health professionals.
Be able to educate patients and their families regarding the factors that impact on their health.
1f. Scholar
Be able to educate patients and their families regarding their medical condition.
Be able to teach the consulting physician and medical team who are managing the patient.
Be able to critically appraise sources of medical information.
Be able to develop, implement and monitor a personal continuing education strategy.
1g. Professional
Be able to apply a knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice.
Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice.
Be able to recognize and resolve ethical issues as they arise in clinical practice.
Be able to recognize and deal with unprofessional behaviours in clinical practice.
2. COMMUNITY MEDICINE
The General Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in Community Medicine.
2a. Medical Expert
General Requirements
Demonstrate effective consultation skills with respect to patient care and education in geographic areas that have limited access to sub-specialists.
Be able to provide medical care in a variety of clinical settings (example: critical care unit, emergency room, and ambulatory care clinics). Be able to execute and interpret common procedures performed by general internists in the community.
Specific Requirements
Be able to deliver expert care effectively and in an ethical manner in a variety of clinical situations which may include:
- Perioperative medical assessment (see General Internal Medicine Consultation).
- Pregnancy-related medical problems (see Medical Problems in Pregnancy).
- Critical care (see Intensive Care).
- Common medical problems the ambulatory care setting (see Longitudinal Ambulatory Clinic).
- Emergency room consultation.
Be able to demonstrate expert knowledge in the diagnosis 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.
- high acuity illness with disease in any one system complicated by other co-morbidities.
- an illness that spans multiple organ systems (example sarcoidosis).
Be able to perform with expert skill and interpret the results of diagnostic procedures commonly performed by general internists in the community (example: exercise electrocardiography testing).
Be able to understand the indications for transfer to a tertiary-care center for further patient care or work-up.
Be able to determine the indications for consultation with sub-specialists often via telephone and/or video conference.
2b. Communicator
Be able to effectively communicate with patients and their families with respect to their medical conditions.
Be able to interact effectively with other health-care professionals, especially family physicians who will be managing the patients on a long-term basis.
Be able to document the patient’s admission and progress accurately with emphasis on the relevant issues.
Be able to understand the need for, benefits and limitations of telephone consultations for physicians in remote communities.
2c. Collaborator
Be able to identify the recognize the need to and benefit of working with other physicians and health-care professionals, specifically with other family physicians who are providing primary care for patients.
Be able to contribute effectively to interdisciplinary team activities.
Be able to aid the consulting health care team in linking patients to outpatient health care services.
2d. Manager
Be able to prioritize requests for consults and learn to manage one’s time efficiently.
Be able to use health-care resources cost-effectively in the context of limited access to technological resources. In particular, the resident should gain experience and understanding with the transfer of patients to other centers for diagnostic tests and consultations with other sub-specialists.
2e. Health Advocate
Be able to educate and counsel patients and families regarding the factors that impact on their health.
Be able to contribute to and improve the health of the local community (example: help implement social programs for alcohol and drug dependence).
2f. Scholar
Be able to critically appraise sources of medical information in the context of limited access to sub-specialists.
Be able to educate patients and their families regarding their medical condition.
Be able to teach medical students, residents, and other health-care professionals, especially family physicians who will be managing the patients as primary-care givers.
Be able to develop, implement and monitor a personal continuing education strategy.
2g. Professional
Be able to apply a knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice.
Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice.
Be able to recognize and resolve ethical issues as they arise in clinical practice.
Be able to recognize and deal with unprofessional behaviours in clinical practice.
3. MEDICAL PROBLEMS IN PREGNANCY
The General Internal Medicine resident is expected to achieve competency in the areas described below during their rotations in Medical Problems of Pregnancy.
3a. Medical Expert
General Requirements
Be able to demonstrate expertise in the management of pregnancy-related medical problems.
Be able to demonstrate an understanding of the physiological changes that occur in pregnancy.
Be able to understand the impact of pregnancy and the postpartum period on chronic medical conditions.
Be able to understand drug-prescribing in pregnancy and the postpartum period.
Be able to be an effective consultant to obstetricians and gynecologists.
Know when to consult maternal-fetal experts and/or medical sub-specialists.
Specific Requirements
Be able to demonstrate expert knowledge in the diagnosis and management of medical conditions specific to pregnancy and/or the postpartum period such as:
- Gestational hypertension
- Preeclampsia
- Eclampsia
- Gestational diabetes
- Cardiomyopathy of pregnancy
- Liver disease: Hyperemesis gravidarum, extra-hepatic cholestatsis of pregnancy, HELLP, fatty liver of pregnancy
- Postpartum thyroid dysfunction and transient hyperthyroidism of hyperemesis gravidum
- Venous thromboembolism
Be able to demonstrate expert knowledge in the management of common medical disorders in the pregnant patient such as:
- Chronic hypertension
- Heart diseases (valvular heart disease)
- Respiratory diseases (pneumonia, asthma)
- Endocrine diseases (diabetes mellitus, thyroid storm, Grave’s disease, Hashimoto’s thyroiditis)
- Renal diseases (acute and chronic renal disease, urinary tract infection)
- Venous thromboembolic disease
- Neurological disorders (migraines, seizures, multiple sclerosis)
- InfeIctious (HIV, TB)
- Gastrointestinal disease (Inflammatory bowel disease, viral hepatitis, autoimmune hepatitis)
- Collagen vascular diseases (rheumatoid arthritis and SLE
Be able to understand the use of medications during pregnancy and lactation.
- Understand the known pregnancy and lactation risks of medications being used.
- Know the diagnostic indication of drug therapy during pregnancy and lactation.
- Consider the need for dose adjustment of medications during pregnancy and lactation.
- Know how to monitor drug levels in the pregnant patient.
- Know when to consult a geneticist to counsel the patient about the known risks of a medication during pregnancy.
Be able to understand physiologic changes that occur in pregnancy with respect to blood volume, hemodynamics, cardio-respiratory physiology, and renal physiology.
Be able to perform a physical exam and expertly interpret physical findings and symptoms in the pregnant patient such as fever, dyspnea, palpitations, and chest pain.
Be able to understand the effect of imaging techniques on the pregnant patient.
3b. Communicator
Be able to effectively communicate with patients and their families issues relating to their pregnancy, health, and fetal well-being.
Be able to effectively provide clear, concise, and timely verbal and written communication to the consulting obstetrician and health care team.
3c. Collaborator
Be able to interact effectively with other health-care professionals, specifically consulting obstetricians/family doctors, maternal-fetal experts, high-risk obstetrical units, and geneticists.
Be able to aid the consulting physician and/or health care team in linking patients to outpatient health care services.
Be able to assist the health care team in helping organize social support for the pregnant patient and family if necessary
3d. Manager
Be able to manage an effective in-hospital and out-patient consulting service in maternal-fetal health.
Be able to effectively utilize resources such as medical sub-specialists and maternal-fetal experts.
3e. Health Advocate
Be able to educate and counsel pregnant patients on behaviours that impact on her health and fetus such as smoking, illicit drug use, and alcohol.
Be able to advise women on the importance of prenatal care on obstetrical outcomes such as maintaining a healthy weight, taking folic acid, and avoiding smoking, illicit drug use and alcohol.
3f. Scholar
Be able to educate pregnant patients and their families regarding their medical condition.
Be able to teach the consulting physician and medical team who are managing the patient.
Be able to develop, implement and monitor a personal continuing education strategy.
3g. Professional
Be able to apply a knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice.
Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice.
Be able to recognize and resolve ethical issues as they arise in clinical practice.
Be able to recognize and deal with unprofessional behaviours in clinical practice.
4. CRITICAL CARE MEDICINE
The General Internal Medicine resident is expected to achieve competency in the areas described below during their rotations in critical care medicine (intensive care medicine and/or coronary care medicine).
4a. Medical Expert
General Requirements
Be able to demonstrate expert knowledge in critical care physiology and medicine.
Be able to demonstrate expert skill and knowledge in invasive hemodynamic monitoring.
Be able to diagnose and manage critical care patients often with complex multi-system medical problems.
Be able to perform with expert skill procedures common in the critical care setting.
Be able to demonstrate expert knowledge in resuscitation.
Specific Requirements
Intensive Care Medicine
Be able to deliver expert care in the diagnosis and management of a variety of ICU-related situations, which may include:
- Cardiac arrest
- Respiratory failure
- Clinical shock syndromes
- Multi-organ failure
- Cardiac arrhythmias
- Acid-base disorders
- Toxicology
- Fluid and electrolyte disorders
- Acute life threatening CNS disorders (example: meningitis, cerebral haemorrhage)
- Acute renal failure
- Infectious diseases (example: central venous catheter sepsis, nosocomial pneumonia)
- Acute endocrine disorders (example: diabetic ketoacidosis, adrenal insufficiency)
- Coagulopathies (example: disseminated intravascular coagulopathy)
- Pregnancy-related critical illnesses (example: HELLP syndrome, eclampsia)
- Nutrition and metabolism
Be able to expertly manage complex peri-operative cases and high-risk cardiac surgery.
Be familiar with mechanical hemodynamic support (intra-aortic balloon pumps, right and left ventricular assist devices, implantable left ventricular assist systems).
Be able to demonstrate an expert understanding of pharmacotherapeutics commonly used in the intensive care setting (example: vasopressors).
Be able to demonstrate an expert knowledge of prognostic scoring systems commonly used in the critical care setting (example: APACHE II).
Be able to demonstrate expert knowledge in the various modes of dialysis and hemofiltration.
Coronary Care Medicine
Be able to deliver expert care in the diagnosis and management of a variety of acute cardiac conditions, which may include:
- Acute coronary syndrome and myocardial infarction
- Congestive heart failure
- Valvular heart disease and septal defects
- Cardiomyopathies
- Pulmonary hypertension
- Arrhythmias
- Cardiac tamponade
- Cardiogenic shock
Be able to perform an adequate history and physical examination of the cardiovascular system.
Be able to expertly manage a cardiac arrest and supervise the cardiac arrest team.
Know the indications, outcomes, and complications of interventional cardiac procedures such as coronary angioplasty and coronary arterial bypass surgery.
Demonstrate expert knowledge in the appropriate selection of investigative procedures (such as ECG, exercise stress testing, echocardiography, cardiac catherisation and angiography) according to the clinical scenario.
Know the indications, outcomes, and complications of the various non-invasive cardiac stress tests (see Non-invasive Cardiology).
Be able to demonstrate an expert understanding of the pharmacology, therapeutic indications, adverse drug reactions and interactions of commonly used cardiovascular medications in the coronary care unit (example: vasopressors, thrombolytics).
Be able to demonstrate insight into the rehabilitation of the cardiac patient and advise the patient accordingly.
Procedures
Demonstrate expertise in the performance of procedures common to the critical care setting:
- Intubation and mechanical ventilation
- Central venous line placement
- Pacemaker insertion
- Swann Ganz insertion
- Arterial line insertion
4b. Communicator
Be able to effectively communicate with patients and especially their families on a daily basis, providing information on prognosis, test results, and therapeutic options.
Be able to interact and communicate effectively with the critical care team.
Be able to communicate information clearly, precisely, and compassionately to patient’s families so that informed decisions regarding end of life can be made (example: withdrawing life support in a patient clinically brain dead).
Be able to provide a clear and concise summary of events and follow-up plan to the health care team that will be receiving the patient once discharged from the critical care setting.
Be able to expertly evaluate medical house-staff (residents and medical students) and provide them with constructive feed-back.
4c. Collaborator
Be able to work closely and effectively with critical care nurses, nutritionists, respiratory therapists, pharmacists, and consulting physicians.
Be able to recognize difficult ethical issues and work closely with hospital ethicists.
4d. Manager
Be able to effectively manage, supervise, and direct the critical care health care team (students, junior and senior residents, and nurses).
Be able to demonstrate leadership in acute critical care situations.
Be able to manage effectively health-care resources in the critical care setting, such as bed allocation and prioritization of requests for admissions.
Be able to effectively direct the transport of critical care patients from other hospitals.
4e. Health Advocate
Be able to educate and counsel patients and families regarding the factors that impact on their health.
Be aware of potential candidates for organ transplant.
4f. Scholar
Be able to direct the teaching curriculum of medical students and junior and senior residents.
Be responsible for supervising residents performing procedures and giving them guidance and feedback on performance.
Be able to promote and direct critical care teaching rounds.
Be able to critically appraise sources of medical information with respect to critical care.
Be able to educate patients and their families concerning their medical conditions and expected prognosis.
Be able to educate other health professionals such as critical care nurses.
Be able to develop, implement and monitor a personal continuing education strategy.
4g. Professional
Be able to apply a knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice.
Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice.
Be able to recognize and resolve ethical issues as they arise in clinical practice.
Be able to recognize and deal with unprofessional behaviours in clinical practice.
5. CO-ATTENDING ON A CLINICAL TEACHING UNIT
The general internal medicine resident is expected to achieve competency in the areas described below during their rotation of co-attending on a clinical teaching unit.
5a. Medical Expert
Be able to demonstrate expert knowledge in the diagnosis, management, and treatment of medical conditions commonly admitted to a general internal medicine clinical teaching unit.
Be able to show expert skills in the administration and management of an in-patient clinical teaching unit, as well as teach these skills to the senior residents.
Be able to provide an excellent educational experience for the medical students and residents in conjunction with the senior residents and attending.
Be able to evaluate and provide feed-back to the medical students and residents in conjunction with the Attending.
5b. Communicator
Be able to demonstrate appropriate physician-patient-family relationships.
Be able to observe and provide constructive feedback to students and residents on their physician-patient-family relationships.
5c. Collaborator
Be present and contribute to weekly multidisciplinary rounds in support of a multidisciplinary approach to patient care.
Promote inter-professional care amongst medical students, interns, and residents, showing by example and by teaching how each member of the multidisciplinary team contributes to the overall care of the patient.
Be able to work closely and co-operatively with the attending physician, the head nurse, and the senior residents
5d. Manager
Be able to assist the medical team in timely discharges.
Be able to guide and assist the senior medical residents in the organization of daily ward activities such as teaching rounds, radiology rounds, and sign out rounds.
Be able to guide students and residents in dealing with problems that often lead to inefficiency, such as expediting diagnostic procedures, facilitating transfers to other wards or hospitals, and calling consultants.
5e. Health Advocate
Facilitate learning of patients and other health-related professionals such as nurses and pharmacists.
Be able to educate patients and their families regarding the factors that impact on their health.
5f. Scholar
Be able to teach expertly both medical students and residents.
Encourage academic activity for students and residents, such as identifying and writing up of case reports and quality assurance projects.
Be able to critically appraise sources of medical information.
Be able to guide medical students and residents in literature appraisal.
Be able to develop, implement and monitor a personal continuing education strategy.
5g. Professional
Be able to apply a knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice.
Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice.
Be able to show by example ethical and professional conduct to the students and residents.
Be able to recognize and resolve ethical issues as they arise in clinical practice.
Be able to recognize and deal with unprofessional behaviours amongst the medical team.
6. NON-INVASIVE CARDIOLOGY
The General Internal Medicine resident is expected to achieve competency in the areas described below during their rotation in non-invasive cardiology.
6a. Medical Expert
able to demonstrate expert knowledge in the methods of evaluation of the patient with suspected coronary artery disease, which include:
- cise electrocardiography
- ise echocardiography
- macologic stress nuclear testing
- macologic stress echocardiography
able to demonstrate an expert understanding of the indications and contraindications to cardiac stress testing.
erstand the diagnostic performance characteristics of the various cardiac non-invasive stress tests (sensitivity, specificity, positive and negative predictive value), as well as the limitations of each of these tests.
Understand the appropriateness of the various cardiac stress tests in various patient subsets according to established guidelines.
Be able to show expert skill in the performance and interpretation of exercise electrocardiography stress testing.
6b. Communicator
Be able to effectively provide clear, concise, and timely verbal and written interpretation of test results to the referring physician, and if necessary interventional cardiologist and/or cardiac surgeon.
Be able to communicate effectively to the patient the reasons, limitations, and potential complications of the non-invasive cardiac stress test, as well as the results.
Be able to accurately communicate to patients their risk of coronary artery disease.
6c. Collaborator
Be able to identify and recognize the need to and benefit of working closely with referring physicians, as well as interventional cardiologists and cardiac surgeons.
Be able to recognize limitations in skill and knowledge and consult cardiologists for optimal patient care.
6d. Manager
Be able to prioritize effectively referrals for cardiac stress testing.
6e. Health Advocate
Be able to educate patients and their families regarding the factors that impact on their cardiac health (example: smoking, obesity, diet, and exercise)
Support and contribute to social programs aimed at decreasing cardiac disease (example: smoking cessation programs).
Promote and participate in cardiac rehabilitation programs.
6f. Scholar
Be able to develop, implement and monitor a personal continuing education strategy.
Be up to date with evolving guidelines in non-invasive cardiac stress testing.
6g. Professional
Be able to apply a knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice.
Be able to apply a knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice.
Be able to recognize and resolve ethical issues as they arise in clinical practice.
7. LONGITUDINAL AMBULATORY CLINIC
The General Internal Medicine resident is expected to achieve competency in the areas described below while attending their longitudinal ambulatory care clinic.
7a. Medical Expert
Demonstrate expert knowledge in the diagnosis, investigation, and treatment of medical conditions often referred to an outpatient internal medicine clinic, which may include
- Uncontrolled hypertension
- Complications of diabetes mellitus
- Work-up of new anemia
- Increased liver enzymes
- Hyper or hypothyroidism
- New renal failure
- Hypo- or hyperthyroidism
- New Atrial fibrillation
Be able to clearly formulate a problem list and devise an appropriate plan for investigations and/or treatment using available resources in the outpatient setting.
Be able to assess and manage complex multi-system medical problems in the outpatient setting and provide clear recommendations and directions to referring physicians.
7b. Communicator
Be able to effectively provide clear, concise, and timely verbal and written communication to the consulting physician.
Be able to keep well-organized and eligible medical records.
Be able to provide relevant and up-to-date medical information to referring physicians, using the consultation as an opportunity to teach the referring physician.
Be able to communicate to the patient the potential risks and benefits of therapy and/or investigations in a clear and concise manner, using easy to understand language so that the patient can make informed decisions.
Be able to communicate to the patient his/her role as a consultant.
7c. Collaborator
Be able to identify and recognize the need to work closely with the referring physician.
Be able to work closely with the patient and their family in forging an effective patient-family-physician relationship so as to promote cooperation and compliance.
7d. Manager
Be able to use health-care resources cost-effectively in the context of an ambulatory care setting where diagnostic tests are not always readily available.
Be able to conduct and maintain a professional ambulatory care practice.
Be able to direct and supervise effectively health-related professionals working with the resident, such as nurses, secretaries, and physician-assistants.
Be able to plan follow-up visits accordingly, so that both patient and referring physician are satisfied.
Be able to educate and counsel patients and families regarding the factors that impact on their health.
Provide health-related information and resources for patients, such as pamphlets describing general internal medicine, and patient-education articles and/or websites on common medical conditions such as hypertension.
7f. Scholar
Be able to formulate a program of personal continuing education, such as creating learning projects based on cases seen in the ambulatory clinic.
Be able to critically appraise the medical literature, and use this knowledge accordingly in complicated clinic cases.
Be able to educate medical students and/or junior residents attending the ambulatory clinic.
7g. Professional
Be able to apply a knowledge of the professional codes and norms of behaviour that govern the behaviour of physicians in clinical practice.
Be able to apply a knowledge of the legal codes and norms of behaviour that govern the behaviour of physicians in clinical practice.
Be able to recognize and resolve ethical issues as they arise in clinical practice.
Be able to recognize and deal with unprofessional behaviours amongst the clinic personnel.