VA General Medicine Wards

Medicine

Educational Purpose:

This experience provides the Medicine house staff with experience in inpatient medicine. There are no subspecialty medicine services in the VAH, so all the medical admissions come to the General Medicine services. It is designed to develop the clinical skills necessary to diagnose and treat undifferentiated medical patients with a wide range of illnesses. The rotation provides each resident with graduated autonomy combined with direct supervision by expert faculty. There are 3 General Medicine Teams at the VAH. 

Goal:  Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Residents are expected to:

PGY 1

  1. To enhance the residents’ history taking and physical diagnosis skills.
  2. To develop differential diagnoses and formulate a treatment plan on acutely ill patients.
  3. To manage the inpatient illnesses which are commonly cared for by the general internist.

PGY 2 and 3

  1. To enhance the residents’ history taking and physical diagnosis skills.
  2. To develop differential diagnoses and formulate a treatment plan on acutely ill patients.
  3. To manage the inpatient illnesses which are commonly cared for by the general internist.
  4. To develop immediate and long term treatment goals of care.

Medical Knowledge Goals and Objectives:

Goal:  Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care.

Residents are expected to:

PGY 1

  1. To develop differential diagnoses and formulate a treatment plan on acutely ill patients.

PGY 2 and 3

  1. To develop differential diagnoses and formulate a treatment plan on acutely ill patients.
  2. To understand appropriate pain control and the tents of end of life care.
  3. To develop immediate and long term treatment goals of care.

Practice-Based Learning and Improvement Goals and Objectives:

Goal: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life long learning.

Residents are expected to develop skills and habits to be able to:

PGY 1

PGY 2 and 3

  1. To coordinate care using a multidisciplinary approach utilizing case managers, social workers and pharmacists to facilitate optimization of patient care.

Systems Based Practice Goals and Objectives:

Goal: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

Residents are expected to:

PGY 1

  1. To understand the indications/need for appropriate subspecialty consultation.
  2. To effectively lead an interdisciplinary team and to help teach other residents and students.

PGY 2 and 3

  1. To understand the indications/need for appropriate subspecialty consultation.
  2. To effectively lead an interdisciplinary team and to help teach other residents and students.
  3. To supervise the members of the team including medical students, medical interns, emergency medicine interns, neurology interns, as well as anesthesia interns.
  4. To coordinate care using a multidisciplinary approach utilizing case managers, social workers and pharmacists to facilitate optimization of patient care.

Professionalism Goals and Objectives:

Goal: Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

Residents are expected to demonstrate:

PGY 1

PGY 2 and 3

Interpersonal and Communication Skills Goals and Objectives:

Goal: Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates.

Residents are expected to:

PGY 1

  1. To enhance the residents’ history taking and physical diagnosis skills.
  2. To demonstrate interpersonal skills and to communicate with patients and families.

PGY 2 and 3

  1. To enhance the residents’ history taking and physical diagnosis skills.
  2. To demonstrate interpersonal skills and to communicate with patients and families.

Teaching Methods:

The majority of teaching on the General Medicine service is case-based on inpatient rounds providing excellent opportunities for education at the bedside. Teaching rounds occur daily with the attending physician. This teaching can include demonstration of history taking or examination skills, medical management, or exploration of medical knowledge. The attending physician also conducts didactic sessions on multiple occasions throughout the month. Residents are expected to attend Morning Report three days per week and Noon Conference daily. Additionally, Professor Rounds occur every fourth day at the bedside. Outstanding faculty members are chosen to augment teaching to the teams.

Mix of Diseases and Pathological Material:

Residents care for patients with a wide variety of clinical syndromes including chest pain, coronary artery disease, CVAs, CHF, diabetes mellitus, DKA, pneumonia, COPD, asthma, pyelonephritis, acute and chronic renal insufficiency, dementia, and many others. The vast majority of patients with neurologic illnesses are admitted to the General Medicine service as well. 

Patient Characteristics:

Residents care for a diverse patient population with respect to age, ethnicity, and socioeconomic status, including a diverse array of pathology seen at the VA medical center.

Types of Clinical Encounters:

The General Medicine rotation takes place in the Veterans Administration Hospital. Patients are admitted to the service through VA Urgent Care, VA Primary Care, outside Emergency Rooms, ICU transfers, and transfers from outside hospitals. The PGY 1 residents are responsible for performing the initial H and P and writing all orders under the supervision of the PGY 2 or 3 resident.

Procedures and Services:

Residents often have the opportunity to perform many procedures on the General Medicine service. Common procedures include central venous access placement, paracentesis, lumbar puncture, bone marrow biopsy/aspiration and thoracentesis among others. All procedures are appropriately supervised by the upper level resident. The attending physician and the Chief Resident are uniformly available to supervise procedures as well. Interns and residents are expected to interpret all EKGs and chest x-rays performed on their patients.

Supervision:

The team consists of a PGY 2 or 3 resident, two PGY 1 residents, a 4th year medical student, two 3rd year medical students, and the attending physician. The upper level resident directly supervises the interns and the medical students. The upper level resident leads rounds and helps formulate the care plan. The interns perform the H and P, write progress notes and write orders under the upper level resident’s supervision. All patient care encounters are supervised by the attending physician.

Educational Resources to be Used and Reading Lists:

The residents have access to all major Internal Medicine and subspecialty textbooks in the onsite library. Additionally, the house staff are expected to pull journal articles appropriate to the care of their patients. Up-To-Date is available in the VAH as well.

Method of Evaluation of Resident Competence:

Residents are evaluated using the global evaluation form. The Mini-CEX is often administered on this service as well. Each resident evaluates his or her peers as well. Patient Care is assessed based on direct observation and complete review of all records. Medical Knowledge is assessed through direct questioning and observation. Interpersonal Skills and Communication is assessed by observation of interactions with patients and families. The attending physician evaluates Professionalism through direct interaction and observation of the resident. Systems-Based Practice is evaluated based on interactions with the multidisciplinary team. The resident is expected to be an active participant in twice weekly discharge planning meetings with social workers, OT/PT, and nurses. Practice-Based Learning is evaluated based on the ability to consult the literature and to improve their performance throughout the rotation. Residents receive formative evaluation throughout the month.

The residents evaluate the rotation and the attending physician through the E*Value system. The General Medicine Division reviews the rotation evaluations and each attending anonymously receives his or her evaluations.