Curriculum

THOMAS JEFFERSON UNIVERSITY DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE RESIDENCY PROGRAM THREE YEAR CURRICULUM

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YEAR 1

JFMA:  First year residents spend twelve weeks on family practice inpatient service. Following these rotations, first-year residents will be able to:

1. perform an appropriately directed and thorough clinical history including gathering data relevant to estimating risk for illness, morbidity and mortality;
2. perform an appropriately directed and thorough physical examination, including the ability to perform focused and detailed examinations relevant to the patients symptoms;
3. estimate each patient's severity of illness;
4. determine the need for immediate treatment;
5. establish priorities in the management of each patient; this competency encompasses priority testing as well as treatment;
6. appropriately communicate clinical finding to coworkers, particularly residents, attending physicians and consultants;
7. initiate evaluation and emergent treatment for a variety of common symptoms including (although not necessarily confined to) patients presenting with chest pain, abdominal pain, fever, respiratory symptoms such as shortness of breath, lower extremity edema, bowel dysfunction, urinary tract dysfunction, dysfunction of the neurological system;
8. initiate management and outline a general management plan for patients with conditions including (but not necessarily confined to) asthma, coronary artery insufficiency, cerebral vascular insufficiency, pulmonary embolism, pneumonia, diverticulitis, cholecystitis, pancreatitis, bleeding from the GI tract, pyelonephritis, deep vein thrombosis, cardiomyopathy with congestive heart failure, and sepsis;
9. Initiate evaluation and management of acute illness in patients with immune deficiency, particularly HIV-related illness.

Pediatrics-A.I. duPont:  First year residents spend two blocks on the inpatient pediatric services at A.I. DuPont.  The goal of this rotation is for the resident to understand and demonstrate the principles and methods of caring for hospitalized pediatric patients.  Upon completion of this rotation, residents will be able to:

1. obtain an appropriately directed and thorough clinical history from patients and family members;
2. perform an appropriately directed and thorough physical examination, including the ability to perform examinations relevant tot he patients symptoms;
3. carry out initial evaluation of pediatric patients presenting with symptoms referable to disorders of the respiratory tract, GI tract, neurological system, as well as patients with fever and dehydration;
4. Initiate management of pediatric patients with asthma, pneumonia, with and without respiratory distress, sepsis, meningitis, fever of unknown origin, gastroenteritis including evaluation and management of hydration status, soft tissue infection including septic arthritis, growth insufficiency including evaluation of social support.

Obstetrics:  The first-year obstetric experience focuses predominantly on peri-partum and post-partum management as well as obstetric delivery.  At the end of this four-week rotation, the resident will be able to:

1. obtain an appropriate history and perform an appropriate physical exam for women presenting in labor, including evaluation of the cervix and uterus;
2. understand the stages and mechanisms of labor and how they impact management decisions;
3. perform an uncomplicated vaginal delivery with supervision, including performance and repair of episiotomy;
4. understand the indications for fetal monitoring and interpret fetal monitoring strip with supervision;
5. conduct an organized evaluation of a women presenting in possible labor;
6. perform an organized evaluation of the post-partum patient;
7. evaluate the pregnant woman for possible complications of pregnancy with a special focus on pre-eclampsia;
8. Initiate early management for patients with pregnancy complications, particularly pre-eclampsia, and being to develop a clear understanding of indication for consultation.

Emergency Room: Following the four-week Emergency Room experience, residents will be able to:

1. understand and apply basic principles of triage;
2. assess severity of illness for patients of all ages presenting to an emergency department with appropriate supervision;
3. carry out an appropriately directed history and physical examination for patients presenting with an acute problem;
4. Develop an appropriate outline for initial management for acutely ill patients presenting to the emergency department, including appropriate request for supervision and consultation.

Although predominant emphasis in this first-year emergency department rotation is also given to data gathering, priority setting and formulation of initial management with appropriate consultation, special emphasis is also given to initial management of patients presenting with chest pain, shortness of breath, abdominal pain and fever.  Emphasis on management is given to stabilization of the acutely ill patient, establishment of airway, breathing, and circulatory supports.  All residents are certified in basic and advanced CPR prior to completion of their residency.  The course may or may not be taken during the emergency department rotation.

Surgery:  This rotation is comprised of four weeks of inpatient surgery, three weeks of outpatient surgery, and one week of vacation (during outpatient surgery). The goal of the surgical rotation is to improve residents' understanding of the role of surgical evaluation management and the patient's physiologic response to surgical intervention as well as to improve procedural skills.  Specific objectives are that residents will be able to:

1. recognize a variety of acute surgical problems;
2. perform an appropriately directed history and physical;
3. elicit symptoms and signs of conditions that require surgical management;
4. develop an approach to diagnostic evaluation of potential surgical conditions;
5. develop an initial management plan that emphasizes stabilization of the patient and, when relevant, preparation for surgery;
6. carry out appropriate procedures to prepare patients for surgery;
7. have an approach to post-operative management, emphasizing appropriate rehabilitation;
8. begin to develop an approach to managing coexisting medical conditions for patients with surgical problems;
9. developed increased comfort with procedural skills including, although not restricted to:
10. insertion of central venous catheter
11. insertion of arterial catheter
12. insertion of femoral vein catheter
13. variety of suture techniques
14. insertion of chest tube
15. skin and subcutaneous incisions
16. draining abscesses and removing subcutaneous or cutaneous lesions
17. techniques to establish hemostasis

Family Practice Center A & B: The goal of these two four-week blocks is to orient interns to functioning in the family practice center.  This includes introduction to and appreciation of the role of each office staff member, understanding charting procedures, overview of billing with an emphasis in the role of the provider, case management and introduction to ambulatory care.  An additional goal is to increase the number of patients for whom the first year resident provides continuous primary care.  Specific objectives are that residents will be able to:

1. identify each office staff member and have a general understanding of the role that they play in the provision of care;
2. accurately complete clinical encounter and billing forms for each visits;
3. begin to develop time management and documentation skills appropriate for the primary care setting;
4. utilize appropriate resources available in the office setting;
5. develop techniques to establish rapport with patients at initial visit;
6. Begin to develop an approach to the biopsychosocial model including taking a history relevant to social supports, stressors, and perceived stress.

The Family Practice Center Orientation month includes an introduction to community medicine with exposure to clinical care in multiple community settings.  The goals of these sessions are that residents will be able to understand the concept of community oriented primary care, have an overview of the health problems of the Philadelphia area, and develop an initial understanding of the role of social agencies and the departmental social worker in addressing patient and family needs.  This is accomplished through a series of community and home visits, including clinical care and health education.  Interns will also develop an appreciation of the role of drug treatment programs through a rotation in a methadone treatment center.

Intensive Care Unit:  The resident will rotate 4 weeks in the intensive care unit.  The goal of this rotation is to become familiar with the acute care and management of severely ill patients.  At the completion of their rotation residents will be able to:

1. assess and treat acute coronary syndrome;
2. recognize and treat cardiac arrhythmias and heart block;
3. manage and diagnose septic shock;
4. recognize and treat ARDS;
5. Discuss prognoses and code status with patients’ families.

Geriatrics:  The goal of the Geriatrics rotation is to provide learning opportunities that will allow residents to develop the knowledge, skills, and approach necessary to:

1. Show respect/compassion for the autonomy and dignity of older persons;
2. Optimize the function and value of life of those with multiple chronic and incurable conditions through understanding of the interdisciplinary approach to care;
3. Understand the impact on medical decision-making of patients’ values and preferences.
4. Evaluate and manage common geriatric syndromes; and
5. Understand regulations for the care of patients in long-term care facilities, including the use of physical restraints and psychotropic medications.

YEARS 1, 2, 3

Behavioral Science:  A biopsychosocial understanding of the patient is central to the work of the family physician.  The goal of the behavioral medicine curriculum is to assure that the resident is competent in attending to behavioral medicine issues in the clinical setting.  This will involve attitude, knowledge and skills in attending to the following areas:

1. the biopsychosocial model of illness
2. doctor patient relationship
3. interviewing, communication and case formulation
4. life cycle and family issues
5. physician "coping" resources
6. mental disorders
7. behavioral problems
8. psychiatric emergencies
9. psychotherapeutic interventions
10. psychosocial interventions

Practice Management:  Residents learn practice management longitudinally over the three years of residency.  The modalities for learning include experiential learning, monthly conference, office committees and team meetings.  The goal of this experience is to learn the skills necessary to efficiently deliver patient care and to continuously improve the multiple elements of care delivery within a medical practice.  At the completion of this experience residents will be able to:

1. accurately code and bill for all services provided
2. understand the issues involved in office facilities including deign/layout, buying equipment, laboratory regulations, office based procedures
3. understand the organizational structure of the office including chain of command, number and types of support staff
4. understand the operations of the office including patient flow, scheduling, responsibilities of varies staff, telephone triage system, chart and filing options
5. understand issues of employee relations including recruitment, hiring, evaluation
6. utilize computers for multiple aspects of patient care including scheduling, obtaining patient laboratory data, and researching medical questions
7. understand and be able to assess the different practice opportunities available to family physicians
8. Understand the basic concepts of managed care and continuous quality improvement.

All residents attend Practice Management meetings at noon on the 3rd Thursday of the month.  All second years attend Patient Education Committee on the 1st Thursday of the month at 8 am.  All third years attend Performance Improvement Committee on the 3rd Thursday of the month.  All first years attend patient education and performance improvement committee meeting during their FPC Blocks.  All residents attend team meetings on the 2nd Thursday of the month.

YEAR 2

Newborn - Pediatrics: The goal of this 2-week rotation is to develop an approach to evaluation of the newborn.  Upon completion of the rotation the resident will be able to:

1. utilize prenatal and perinatal history to assist in appropriate evaluation of the newborn;
2. conduct an appropriate directed physical examination of the newborn including evaluation of physical maturity using appropriate scales;
3. assist in and develop an approach to assessment and stabilization of the newborn including applying the APGAR scale;
4. recognize and initiate treatment of common problems arising in the newborn period including but not limited to jaundice/hyperbilirubinemia, sepsis, hypoglycemia, trauma (cephalohematoma, clavicular fracture), withdrawal from maternally ingested substances, apnea, congenital abnormalities;
5. provide instruction to parents of newborns regarding immediate newborn care as well as anticipatory guidance;
6. provide arrangement for follow-up care with particular emphasis on overcoming barriers to follow-up care for needy individuals;
7. monitor infants through the delivery of appropriate immunization and other preventive therapies;
8. counsel patients about the issues involved in circumcision of newborn males.

Outpatient Pediatrics: The goal of this four-week rotation is to gain experience and expertise in managing routine outpatient pediatric problems.  Upon completion of the rotation the resident will be able to:

1. conduct a thorough history and physical on children including age appropriate screening;
2. address age appropriate health maintenance issues for children;
3. understand the complexities of the current immunization schedule ;
4. diagnose and treat common outpatient pediatric problems including but not limited to:

-       otitis media
-       rashes
-       failure to thrive and obesity
-       urinary tract infections
-       asthma and bronchiolitis
-       behavioral issues
-       developmental delay.

Obstetrics: The obstetrics experience in the second year includes 2 weeks on the labor and delivery floor.  The objectives for this two week rotation are similar to the objectives for the first year rotation.  Increased emphasis is given in the second-year to prenatal care. Specific objectives for prenatal care are that residents will be able to:

1. estimate gestational age and estimate the date of delivery;
2. recommend and orchestrate appropriate testing for women with newly diagnosed pregnancy;
3. counsel patients about appropriate genetic testing options based on the risks of individual pregnancy;
4. track the health and progression of the pregnancy through appropriate history, physical, and testing items;
5. identify factors which contribute to pregnancy risk and appropriate counsel and refer high risk patients;
6. Appropriately refer women to social support agencies as dictated by the risk of the mother.

Gynecology:  Residents have a four-week rotation in outpatient gynecology. The goal of this rotation is to increase the resident’s expertise with gynecologic disorders.  At the end of the rotation the resident will be able to:

1. evaluate and manage common outpatient gynecologic disorders including abnormal uterine bleeding, menstrual disorders, pelvic inflammatory disease, menopausal concerns and hormone replacement, urinary incontinence, sexually transmitted diseases;
2. demonstrate primary care management of infertility and identify indications for referral; apply comprehensive approach to evaluation and management of chronic pelvic pain;
3. evaluate the abnormal pap smear and management of cervical dysplasia including colposcopy, cervical biopsy and endocervical curettage;
4. evaluate abnormal uterine bleeding and perform an endometrial biopsy.

Dermatology: The goal of the rotation is to help residents be able to recognize, describe and treat common dermatological conditions.  At the end of this rotation residents will be able to:

1. Perform an appropriate history and total skin exam;
2. Recognize and treat a variety of dermatological conditions;
3. Perform common dermatological procedures including punch biopsies, excision of skin lesions, cryosurgery, incision and drainage, intralesional injections, scraping and KOH preparation.

YEARS 2 AND 3

Sports Medicine:  The goal of these rotations is to improve residents' ability to accurately diagnose a wide variety of musculoskeletal complaints in both children and adults.  At the end of the rotation, residents will be able to:

1. Perform preparticipation physical examinations that screen for cardiac and musculoskeletal injury risk;
2. Prescribe physical therapies and orthotics based on patients presenting diagnoses;
3. Diagnose by history and physical exam common athletic and performance injuries and manage them appropriately;
4. Demonstrate proficiency in joint injection;
5. Order diagnostic imaging appropriate to the work-up of presenting musculoskeletal complaints and have familiarity interpreting results;
6. Provide sideline coverage for teams at the high school and collegiate level;
7. Employ the biopsychosocial model to provide general medical care to athletes at all levels.
8. be familiar with common variants in childhood lower limb development including understanding indications for intervention;
9. Conduct appropriate examination of the back, diagnose common sources of back pain, and understand basic principles of management of back problems.

Elective: Residents have six –weeks of elective in the second year and eight –weeks of electives in the third year.  These are rotations developed by the resident to meet his or her individual needs and interests.  The program director and the resident’s advisor monitor the content of the electives. The resident is expected to develop specific goals and objectives for each elective.

Pediatric Emergency Room: Residents have a 4-week rotation in the emergency department at A.I. Dupont Hospital in year 2 and a 2 week rotation in the ER at St Christopher’s Hospital for Children in year 3.  The goal of these rotations is to solidify skills of assessment and management of acutely ill children presenting to a community pediatric emergency department. Upon completion of this rotation residents will be able to:

1. Assess and treat emergent and urgent illnesses in pediatric populations with particular emphasis on the child presenting with wheezing, fever, laceration, poisoning, and injury;
2. Recognize and be familiar with mechanisms to report childhood abuse;
3. Perform common procedures including splinting, laceration repair, lumbar puncture, bladder catheterization and suprapubic bladder tap, venipuncture, and insertion of intravenous lines.

Maternal-Child Health:  In the second and third year, residents spend six weeks total as the obstetrics coverage for the family practice center (FPC) and actively works in Labor & Delivery.  Specific objectives for the Maternal-Child Health block are that the resident will be able to:

1. evaluate and triage pregnant patients who present to the delivery room and the FPC;
2. evaluate and follow pregnant patients who are admitted to the hospital for medical problems (i.e. admissions for asthma, pyelonephritis);
3. evaluate and manage patients in preterm labor;
4. perform circumcisions including dorsal penile nerve block on newborn males;
5. evaluate and follow newborns in the nursery. (see Goals and Objectives for Newborn-Pediatrics)

Family Medicine; Inpatient/Night Float:  Second year residents spend eight weeks and third year residents spend four weeks as the supervisory resident on the inpatient family medicine service.  Additionally, residents spend six weeks total in Year 2 & 3 as the supervising resident on night float.  The goal of this rotation is to help the resident become independent in management of acutely ill adult medical patients.  Specifically, residents will be able to:

1. assess severity of illness and the need for inpatient care in emergency room and outpatient settings;
2. organize and implement an efficient, cost effective inpatient plan;
3. provide appropriate supervision for junior residents and senior medical students;
4. serve the role as principle communicator with the patient, family, and caretakers;
5. facilitate the transition from inpatient to outpatient care using discharge planning, home health agencies, and primary physicians;
6. teach colleagues and students on clinically-generated topics;
7. present cases from the inpatient service in monthly morbidity and mortality rounds.
8. Present cases from night float in Friday AM Conferences.

FPC (Longitudinal Experiences):  The goals of this rotation are for the resident to be exposed to and become skilled in the management of a broad range of family medicine issues including geriatric medicine, adolescent medicine, and home visits and to further develop efficiency and proficiency in a busy office practice.  At the end of this rotation the resident will be able to:

1. efficiently evaluate and manage common ambulatory care problems
2. perform comprehensive adult physical exams and health maintenance
3. perform well child care including anticipatory guidance and health maintenance
4. perform a comprehensive evaluation of the adolescent patient
5. document clinical activity in the medical record in a timely, concise fashion that appropriately reflects level of service billed and problem addressed
6. accurately complete all office billing forms for each visit
7. demonstrate improved time management skills by providing timely care to an increasing number of patients over the three years.
8. utilize office staff in supportive behavior that facilitates efficient patient care
9. conduct a thorough home visit on home bound patients with attention to both medical and social needs
10. provide assessments and management of complex elderly patients in a nursing home and understand the importance of team management and collaboration in the care of these patients.

Community Medicine: This is a longitudinal experience occurring over the second and third year of residency after an introduction during the FPC blocks in Year 1.  The goal of this experience is for residents to be skilled at implementing the community oriented primary care model in a given community.  At the completion of this experience residents will be able to:

1. conduct needs assessments on an identified population;
2. access epidemiologic data about a geographically defined community;
3. collaborate with other health professionals, social service agencies, and community members in designing interventions to impact the health of a community;
4. understand the community’s role in health problems and solutions;
5. practice COPC through health education;
6. deliver healthcare in established COPC models.

YEAR 3

Subspecialty Selectives:  Third-year residents have a longitudinal experience with a variety of sub-specialty areas during FPC Longitudinal B.  A brief discussion of the goals and objectives of required subspecialties is below.

Otolaryngology:  The goal of the rotation is to help residents develop an organized approach to assessment of complaints referable to the ears, nose and throat areas.  Specific objectives are that residents will be able to:

1. perform a complete head and neck examination, including use of nasal speculum;
2. participate in indirect and direct laryngoscopy, bimanual oral exam;
3. perform an exam to screen for head and neck cancers;
4. diagnose and manage common ENT problems including:

-       acute and chronic sinusitis;
-       allergic syndromes;
-       a variety of acute and chronic diseases of the middle ear;
-       acute and chronic pharyngitis;
-       dizziness and vertigo;
-       tinnitus and hearing loss;
-       hoarseness.

Subspecialties:
Urology:  The goal of the urology rotation is to introduce residents to evaluation of symptoms referable to the urologic system, particularly in men.  Specific objectives are that residents will be able to:

1. perform a complete urologic exam including rectal, prostate, and testicular exam.
2. detect prostate cancer through physical examination and appropriate testing;
3. diagnose and initiate management of common urologic problems including:

-       acute and chronic prostatitis;
-       renal calculi;
-       benign prostatic hyperplasia;

4. understand approach to evaluation of common urologic problems including:

-       male infertility;
-       male sexual dysfunction;
-       scrotal masses;
-       hematuria;
-       penile disorders including priapism and peyronie’s disease.

Ophthalmology:  The goal of the rotation is to help residents develop an organized approach to assessment of complaints and preventive health care needs referable to the eye.  Residents will be able to:

1. conduct an appropriately directed ophthalmologic history and physical examination;
2. conduct a physical examination with instruments that are routinely available to the family physician;
3. understand the role of additional ophthalmologic instruments, specifically indirect fundoscopy, fluroscein angiography, and slit-lamp examination;
4. understand the initial management of eye injuries;
5. understand the progression of chronic open angle glaucoma and resultant physical finding;
6. understand the indications for ophthalmologic consultation.

Rheumatology:  Upon completion of the rotation residents will be able to:

1. conduct an appropriate history and physical exam for patients with joint complaints
2. construct an appropriate differential diagnosis for patients with joint pain;
3. perform arthrocentesis;
4. administer therapeutic intra- and extracurricular injections.

Population health:   An overall goal of our residency program is to train residents to meet the population health needs of underserved communities.  The population health block is an innovative 2 week experience during the 3rd year with the goals of providing residents with on-site exposure to the work of public health agencies and federal and city based projects in chronic disease management as well as to participate in interdisciplinary teams providing care and services to vulnerable populations.  At the completion of this experience residents will be able to:

1. Understand the role of community-based organizations and health centers in
   enhancing the health of individuals and populations, and in augmenting the
   health delivery system.
2. Identify specific health and social needs of selected vulnerable populations.
3. Identify barriers to care for specific vulnerable populations
4. Assist members of vulnerable population to overcome internal and external barriers to health and medical care.
5. Understand the role of community health education in disease management in selected populations.
6. Understand and implement methods for assessing the health needs, assets and barriers of populations/neighborhoods.
7. Provide care to vulnerable populations with cultural and linguistic competence

Cardiology:  Residents have a 2-week rotation in cardiology.  The goal of this rotation is enhance the clinical skills in cardiology and learn appropriate indications for diagnostic modalities.  Upon completion of the rotation residents will be able to:

1. perform comprehensive cardiovascular history and physical exam;
2. demonstrate competence in interpretation of 12 lead ECG;
3. exhibit timely and cost effective use of diagnostic modalities in assessing the ambulatory cardiac patient including exercise and pharmacological ECG, echocardiographic and nucleotide stress testing, ambulatory ECG monitoring, echocardiography;
4. assess and manage common ambulatory cardiac diagnoses including HTN, CAD, CHF, valvular disease, atrial fibrillation;
5. Demonstrate appropriate use of common pharmacotherapeutic agents in office including antihypertensives, diuretics, digoxin, coumadin, nitrates, anti platelet agents, lipid lowering agents.

Procedures/COPC:  On this longitudinal rotation, residents focus on a variety of office procedures for a half-day per week for over four weeks.  Residents learn a variety of techniques for removal of skin lesions, treatment of subcutaneous infections, flexible sigmoidoscopy and colposcopies.  In addition, COPC occurs on Wednesday afternoons (Please see Community Medicine Goals and Objectives).

Day Float:
Residents will be available and flexible to respond to evolving needs in the day-to-day care of FPC patients in both the inpatient and outpatient setting.  Residents are to check in daily with the inpatient team to assist with Admissions, complete work on the team, and supervise interns and students.  Residents may be needed to assist on outpatient care in order to ensure continuity of deliveries and peer FPC hours.  Residents will also see consults in conjunction with the hospital service attending, including preoperative clearance and co-management of patients on other services.