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    • Clinical and Research Rotation Curriculum Supplement to Residency Program Manual The Department of Physical Medicine and Rehabilitation The University of North Carolina at Chapel Hill School of Medicine Michael Y. Lee, M.D., M.H.A. Professor & Chair Program Director
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement 2
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement PURPOSE OF SUPPLEMENT This Supplement to the Physical Medicine and Rehabilitation Residency Manual is designed to help residents, faculty, and others in the Department of Physical Medicine and Rehabilitation at UNC-CH become acquainted with details of the clinical and research rotation curriculum. It includes goals, competency-based educational objectives, learning activities/resources, and various aspects of the rotations of the residency program. Please read it carefully as all individual program plans are based on this general information. If you have any comments or suggestions regarding the manual or the residency program, please contact the Residency Program Coordinator or Residency Program Director. Information in this manual is subject to change. Education Committee: Michael Y. Lee, M.D., M.H.A. Lisa Blankenship, M.D. James Eby, M.D. Patricia Gregory, M.D. Karla Thompson, Ph.D. Robert Yang, M.D. Last Revision: December 2007 3
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement TABLE OF CONTENTS Page PURPOSE OF SUPPLEMENT…..………………………………………… 1 TABLE OF CONTENTS…………………………………………………… 2 I. INTRODUCTION…………………………………………………………… 3 II . FUNDAMENTAL CLINICAL SKILLS TRAINING (PGY-1)…………… 5 (includes Clinical Curriculum, Objectives and Didactic Curriculum information) A. Internal Medicine Inpatient Service……… 5 B. Internal Medicine—Rheumatology...……. 9 C. Internal Medicine--Urgent Care………… 11 D. Neurosurgery……………………………. 12 E. Burn & Plastic Surgery…..………..……. 13 F. Neurology……………………………….. 15 G. Trauma Surgery…………………………. 16 H. Emergency Medicine……………………. 19 I. Physical Medicine & Rehabilitation…….. 20 III. PHYSICAL MEDICINE AND REHABILITATION CLINICAL AND RESEARCH CURRICULAR COMPONENTS (PGY 2-4)……………. …… 21 A. Inpatient Rehabilitation…………………………………………………… 21 1. Brain disorders (Stroke, TBI)……………………………………... 24 2. Spinal Cord Injury/Musculoskeletal………………………………. 28 3. Amputee…………………………………………………………… 31 B. Pediatric Rehabilitation Services………………………………………….. 35 C. Adult and Geriatric Inpatient Consultation Services……………………… 40 D. Adult Outpatient Rehabilitation Services...………………………………. 45 E. Electrodiagnostic Medicine (EMG/NCS)……………………………........ 50 F. Community and Cardiac Rehabilitation…………………………………. 56 G. Electives………………………………………………………………. … 59 H. Research………………………………………………………………….. 60 4
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement I. INTRODUCTION The Department of Physical Medicine and Rehabilitation offers a three-year program (PGY 2-4) for residents who complete their fundamental clinical skills training at an institution other than the University of North Carolina and a four-year program (PGY 1-4) for those who enter the program as PGY-1 resident. Information on the PGY 1 clinical curriculum in this supplement applies only to residents who complete the four-year training program at UNC. The first year of the four years of training is designed to develop fundamental clinical skills. This year of training in fundamental clinical skills must consist of an accredited Transitional Year or include at least six months of inpatient responsibility in an accredited training program in family practice, internal medicine, obstetrics-gynecology, pediatrics, or surgery, or any combination of these patient care experiences. The remaining months of this year may include any combination of accredited specialties or subspecialties. Accredited training in any of the specialties or subspecialties selected must be for a period of at least four weeks. A maximum of eight weeks may be in non-direct patient care experiences. Training in fundamental clinical skills must be completed within the first two years of the four-year training program. The University of North Carolina accepts one to two residents per year at the PGY-2 level contingent on satisfactory completion of one year's accredited training in fundamental clinical skills, and provides three years of Physical Medicine and Rehabilitation training. The program also appoints one to two applicants per year at the PGY-1 level and provides four years of training, including 12 months in fundamental clinical skills and 36 months of Physical Medicine and Rehabilitation. For the 36 month Physical Medicine and Rehabilitation experience, the training program includes 12 months with direct responsibility for complete management of hospitalized patients on the Physical Medicine and Rehabilitation service. Residents also spend 12 months of their training in caring for outpatients, including a significant experience in the care of patients with musculoskeletal problems. The remaining time is spent on rotations to complement the clinical experience of a well-rounded training program, including 6 months of electrodiagnosis, pediatric, adult and geriatric consultation experience, cardiopulmonary rehabilitation, community rehabilitation and elective experiences. A summary of each post-graduate year of training follows. 5
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement A. Clinical Curriculum 1. PGY-I Internal Medicine—6 months Neurosurgery—1 month Burn & Plastic Surgery—1 month Neurology—1 month Trauma Surgery—1 month Emergency Medicine—1 month PM&R—1 month 2. PGY-II Brain (stroke and brain injury) inpatient rehabilitation—4 months Spinal Cord Injury & Musculoskeletal inpatient rehabilitation—4 months Adult & Geriatric Rehabilitation consults—2 months Adult & Geriatric outpatient rehabilitation clinics—2 months 3. PGY-III Electrodiagnostic Medicine (EMG/NCS)--4 months Pediatric Rehabilitation clinics and consults—4 months Adult & Geriatric consults—2 months Adult & Geriatric outpatient rehabilitation clinics—2 months 4. PGY-IV Electrodiagnostic Medicine (EMG/NCS)--2 months Adult & Geriatric outpatient rehabilitation clinics—2 months Amputee & General Inpatient Rehabilitation—4 months Community rehabilitation & Cardiac rehabilitation—1 month Research—1 month Electives--2 months 6
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement II. FUNDAMENTAL CLINICAL SKILLS (PGY-1 YEAR) A. INTERNAL MEDICINE--INPATIENT SERVICES (Duration: 4 months) Goals: The resident will be able to provide comprehensive, coordinated, and patient-centered care to adults with a broad range of medical disorders treated by internists. This includes diseases affecting the major organs including the heart and circulatory system, lungs, and kidney. In addition, the resident will gain familiarity with management of critically ill patients through experiences in the intensive care unit. Objectives: a. Demonstrate the ability to perform relevant and focused history and physical examination of patients with medical disorders b. Demonstrate working knowledge in the diagnosis and management of patients with common general medical disorders including: • Cardiology, including management of hypertension, atrial fibrillation, myocardial infarction, congestive heart failure, and interpretation of EKGs • Hematology/Oncology, including management of anemia, breast cancer, prostate cancer, and colon cancer • Infectious diseases, including human immuno-deficiency virus, tuberculosis and meningitis • Geriatrics, including cognitive impairment/dementia and delirium, depression, urinary and fecal incontinence, syncope/balance disorders/falls, immobility, pressure ulcers, drug induced illness and sensory impairment • Nephrology, including acute and chronic renal failure • Pulmonary, including chronic obstructive pulmonary disease, lung cancer, asthma, and pneumonia • Gastroenterology, PUD, pancreatitis, liver disease and failure, hepatitis and diarrhea • Endocrinology, including diabetes, thyroid disease and adrenal disease c. Demonstrate familiarity with the treatment options utilized by internal medicine physicians and subspecialists in the approaches to patients with general medical disorders. d. Understand the roles of physicians and allied health professionals in the management of patients with general medical conditions. Learning Activities: 1. Clinical Curriculum INPATIENT WARD SERVICES The medical inpatient service consists of subspecialty wards and general medicine wards in the UNC Hospitals. There are seven subspecialty services: Cardiology (including CCU), GI, Hematology/Oncology, Infectious Diseases, Pulmonary, Renal, Neurology and two General 7
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Medicine services. In addition, there is a separate Medical Intensive Care/Respiratory Intensive Care Unit rotation. Each ward team consists of an attending physician, a PGY 2 or PGY 3 resident, 2 PGY 1 residents and 1-2 medical students. For subspecialty services, the attending physician is from that subspecialty. On-call duties are every fourth night. There is a cap of 5 admissions per call day. These occur between 8am-11pm. After 11pm, a Night Float resident takes all admissions. There is no short call system. Rounds sessions on the inpatient services include: Work Rounds: These rounds begin daily at 7:30 a.m. The ward resident, interns, and students evaluate each patient on the service and determine the plans for the day. The resident is responsible for assuring that rounds are efficient and educational. Attending Rounds: These sessions are held daily separate from work rounds. All new patients are presented to the attending. Evaluation and treatment plans are discussed in a didactic format, which includes a review of the medical literature. Ongoing problems of all patients currently on the service are reviewed. X-ray Rounds: These sessions, schedule three-days per week, involve a review of each patient’s x-rays with a radiologist. All ward team members and the attending physicians participate. Inpatient Internal Medicine Ward services include the following: A. Med A- Geriatrics 8 Bedtower B. Med B- Nephrology 3 West C. Med C/D- Cardiology/CCU 3 Anderson D. Med E1- Hematology/Oncology 6 East E. Med E2- Hematology/Oncology 6 East F. Med G- Pulmonary 6 Bed Tower G. Med K- Infectious Diseases 6 Bed Tower H. Med U- General Medicine (Burnett) 8 Bed Tower I. Med W- General Medicine (Welt) 8 Bed Tower J. Med I- MICU/RICU 2 Anderson K. Wake Medicine--The experience of the department's house staff is complemented by working at Wake Medical Center in Raleigh, NC. Wake Medical Center is a 560-bed hospital, which admits patients with a variety of acute Internal Medicine problems. The inpatient service is comprised of four Internal Medicine ward teams. A typical team includes a resident, intern, acting intern, and third-year medical students. Interns spend 1-2 months on the inpatient service, second-year residents spend 1 month on the inpatient service, and third-year residents may elect to do the inpatient service or consult service. The faculty is comprised of full-time UNC faculty and a chief resident, supplemented by volunteer clinical faculty from the community. On average, there are two educational conferences each day. The ride to Raleigh takes approximately 40 minutes from Chapel Hill. 8
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement 2. Schedule Time Monday Tuesday Wednesday Thursday Friday 0700 Pre-Rounds Pre-Rounds Pre-Rounds Pre-Rounds Pre-Rounds 0730- Work Work Rounds Work Rounds Grand Rounds Work Rounds Rounds 0900 (8-9) 0930 Residents Residents Residents Work Rounds Residents Report Report Report Report 1030 Attending Attending Attending Attending Attending Rounds Rounds Rounds Rounds Rounds 1200 Core Clinical Core Ambulatory Curriculum Pathology Curriculum Care Conference/ Conference Morbidity and Mortality Conference 3. Didactic Curriculum: TEACHING CONFERENCES & ROUNDS The resident training is dependent on a variety of planned conferences and rounds sessions. These include: Grand Rounds: a weekly one-hour presentation based on clinical issues. An attempt is made to incorporate recent developments in an area of interest into the topic discussed. Clinical Pathological Conference (CPC): a weekly one-hour diagnostic discussion of a challenging patient involving a member of the Department of Medicine faculty with input from Radiology and Pathology. One CPC each month is organized in the format of a Morbidity and Mortality Conference, which focuses on how the management of specific patient cases could have been improved. Interns Conference: a core curriculum of topics related to patient care. Topics are presented by faculty and are focused at the intern level. Evidence-Based Medicine Conference: a weekly one-hour discussion of current literature pertaining to diagnosis, therapy and management of clinical problems. The residents are divided by residency year for individual discussion led by a member from each year. Faculty experts in evidence-based medicine attend. Residents’ Report: a one-hour daily discussion of patients on one or more of the medical services. The chief residents organize the topic with the assistance of the chair of the department, the program director, and/or a faculty member with special expertise in the problems being discussed. Second-year and third-year residents lead the discussions. Core Curriculum of Internal Medicine Seminar: a twice-weekly noon-time lecture series for all residents. Faculty review important topics in Internal Medicine. 9
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Outpatient Morning Report: a one-hour daily discussion of patients seen by residents in Urgent Care or outpatient clinics during the previous days. The discussion is led by the Associate Chairman for Education of Internal Medicine and focuses on diagnostic or treatment dilemmas in the day-to-day care of difficult outpatients. Emphasis is placed on preventive health measures such as screening and immunizations. Evaluations: The resident’s performance is observed on a daily basis by the attending physicians on the service. A written evaluation is completed at the end of the rotation. The resident will also complete a written evaluation of the effectiveness of the attending as a teacher and the rotation as a whole. INTERNAL MEDICINE RESIDENCY PROGRAM MANUAL The entire Internal Medicine Residency Program Manual is available and can be obtained from the Physical Medicine and Rehabilitation Residency Program Coordinator and/or Internal Medicine Residency Program Coordinator. 10
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement B. INTERNAL MEDICINE--RHEUMATOLOGY (Duration: 1 month) Goal: The resident will be able to provide comprehensive, coordinated, and patient-centered care to adults with rheumatologic disorders, including rheumatoid arthritis, degenerative joint disorders, and other conditions as a result of the rotation in rheumatology. Objectives: a. Demonstrate the ability to perform relevant and focused history and physical examination of patients with rheumatologic disorders. b. Demonstrate working knowledge in the diagnosis and management of patients with common rheumatologic disorders. c. Demonstrate familiarity with the treatment options utilized by rheumatologists in their approach to patients with rheumatologic disorders. d. Understand the roles of physicians and allied health professionals in the management of patients with rheumatologic disorders. Learning Activities: 1. Clinical Curriculum The majority of the rotation will be spent in the outpatient clinic setting. Residents will perform complete evaluations of new patients and return patients, as assigned by the attending. The nursing staff may also direct residents to perform initial work-ups on patients. Residents will be responsible for presenting patients to the attending, developing a therapeutic plan, discussing differential diagnoses with the attending, and writing appropriate notes in the medical record. Residents are also responsible for full evaluations of patients seen in consultation. The on-call schedule and sequence of assignments will be discussed by the attending or the fellow at the beginning of the rotation. 2. Schedule Monday Tuesday Wednesday Thursday Friday AM Rheum/Sanford/ Rheum/Sanford/ Grand Rheum/ACC/ Rheum/ACC/ Dr. Porter Dr. Rivadeneira Rounds/Lectures Dr.Rivadeniera Dr.Rivadeniera PM Rheum/Sanford/ Rheum/Sanford/ Spine/UNCH/ Rheum/ACC/ Rheum/ACC/ Dr. Porter Dr. Rivadeneira Dr. Yang Dr.Rivadeniera Dr.Rivadeniera Primary Faculty of the Rotation: Dr. Alfredo Rivadeneira Alfredo_Rivadeneira@med.unc.edu Dr. Kinga Porter Magyar@med.unc.edu Dr. Robert Yang Robert_Yang@med.unc.edu 3. Didactic Curriculum: TEACHING CONFERENCES & ROUNDS Multiple didactic lectures are held during the rheumatology rotation, including the following: 11
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Mondays: Immunology Journal Club, Rheumatology Grand Rounds and Research-In-Progress seminars Tuesdays: Clinical pathology conference Wednesdays: Program On Aging Lecture Thursdays: Department of Medicine Grand Rounds Fridays: Ambulatory Care Conference Evaluations: The resident’s performance is observed on a daily basis by the attending physicians on the service. A written evaluation is completed at the end of the rotation. The resident will also complete a written evaluation of the effectiveness of the attending as a teacher, and the rotation as a whole. 12
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement C. INTERNAL MEDICINE--URGENT CARE (Duration: 1 month) Goal: The resident will be able to evaluate and treat common urgent medical issues in a thorough, patient-centered manner. Objectives: 1. Demonstrate the ability to perform a focused but detailed history for common non-emergent medical conditions. 2. Demonstrate the ability to utilize clincal pathways to provide appropriate care to patients. These include UNC Hospital pathways as well as recommendations from nationally recognized groups such as the US Public Health Service and peer reviewed literature. 3. Order, interpret, and utilize appropriate laboratory and imaging studies in the management of the patients 4. Generate a comprehensive treatment plan for the patient in a timely fashion and effectively communicate this plan to the patient. Learning Activities: 1. Clinical Curriculum 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 to 1 hour. Patients with non-emergency but acute or sub acute medical issues are seen on a walk-in basis. Common diagnoses encountered include low-back pain, upper respiratory infections, gastrointestinal problems, headaches, sexually transmitted diseases and urinary tract infections. 2. Didactic Curriculum: TEACHING CONFERENCES & ROUNDS Urgent Care Seminar: A daily morning conference for residents working in the Medicine Urgent Care Clinic. The discussion is evidence-based and focuses on clinical reasoning, diagnostic testing, and thresholds for treatment of common problems. Evaluations: The resident’s performance is observed on a daily basis by the attending physicians on the service. A written evaluation is completed at the end of the rotation. The resident will also complete a written evaluation of the effectiveness of the attending as a teacher, and the rotation as a whole. 13
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement D. NEUROSURGERY (Duration: 1 month) Goal: The resident will be introduced to the provision of comprehensive, coordinated, and patient-centered care for adults with acute neurosurgical disorders, including head trauma, spinal cord injury, intracranial mass lesions, intracerebral hemorrhages, myelopathies and other neurosurgical conditions. Objectives: a. Demonstrate the ability to perform relevant and focused history and physical examination of patients with neurosurgical conditions. b. Demonstrate working knowledge in the diagnosis and management of patients with common neurosurgical disorders. c. Demonstrate familiarity with the treatment options utilized by neurosurgeons in the approach to patients with neurosurgical disorders. d. Understand the roles of physicians and allied health professionals in the management of patients with neurosurgical conditions. Learning Activities: 1. Clinical Curriculum The Division of Neurosurgery at The University of North Carolina has a long standing tradition of excellence in clinical care and resident education. Residents work with neurosurgery residents and residents from other departments to care for a variety of neurosurgical patients, including spine surgery, vascular surgery including endovascular neurosurgery, neuro-oncology, pediatric neurosurgery and functional/epilepsy surgery. 2. Didactic Curriculum: TEACHING CONFERENCES & ROUNDS Conferences include: weekly Surgery Grand Rounds, Neurosurgery Clinical Conference, Neuropathology Conference and Neuroscience Seminar Series. Other sessions include monthly journal club, cadaver dissection, neuro-oncology conferences and epilepsy surgery conferences. Residency teaching includes daily attending rounds, informal weekend lectures after clinical rounds and Wednesday lunch lecture. Evaluations: The resident performance is observed on a daily basis by the attending physicians on the service. A written evaluation is completed at the end of the rotation. The resident will also complete a written evaluation of the effectiveness of the attending as a teacher and the rotation as a whole. Primary Faculty Dr. Matthew Ewend matthew_ewend@med.unc.edu Dr. Eldad Hadar eldad_hadar@med.unc.edu 14
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement E. BURN & PLASTIC SURGERY (Duration: 1 month) Goal: The resident will be able to provide comprehensive, coordinated, and patient-centered care to children and adults with soft tissue disorders including burns and wound care, as a result of the rotation in Burn/Plastic Surgery. Objectives: a. Demonstrate the ability to perform relevant and focused history and physical examination. b. Demonstrate familiarity in the management of complications with patients with burn and wound. c. Demonstrate working knowledge of Burn and Plastic surgical approaches to patients with burn and soft tissue disorders. d. Understand the roles of physicians and allied health professionals in the management of patients with burn, wound and plastic surgical needs. Learning Activities: 1. Clinical Curriculum PGY-1 residents spend 1 month on the plastic surgery/burn service. The plastic surgery service offers evaluation, medical treatment and state of the art surgical procedures for children and adults in the areas of craniofacial surgery, breast reconstruction, microvascular surgery, reconstructive surgery of burns and difficult wounds, malignancies of the skin, head, neck and other areas of the body as well as the full spectrum of aesthetic surgery for men and women. Residents also spend time at the North Carolina Jaycee Burn Center, which is recognized as one of the best comprehensive burn centers in the world. Since opening Feb. 23, 1981, the 21-bed North Carolina Jaycee Burn Center has treated thousands of patients with severe burn injuries and saved many lives. In addition to inpatient care at the NC Jaycee Burn Center, there is a weekly burn reconstruction clinic to help patients attain the objective of optimal long-term function via staged procedures and therapeutic interventions. Scar formation and management as well as the prevention of deformities and contractures are all addressed through a multidisciplinary team approach. Relationships are built and maintained with the patient and family to aid the complete physical and psychological recovery of each patient. 2. Schedule Monday Tuesday Wednesday Thursday Friday AM ACC/Hultman Burn Clinic/ Team Burn Clinic/ Burn Clinic/ Peck, Liu rounds with Peck Peck inpatient burn service PM Hand OT/ACC Burn Clinic/Peck. Burn PT/OT Plastic Burn Clinic/ Team Conference Surgery/ Peck 1400-1530 Main OR/Hultman 15
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Primary Faculty of the Rotation: Michael Peck michael_peck@med.unc.edu Scott Hultman cshult@med.unc.edu Gloria Liu gloria_liu@med.unc.edu 3. Didactic Curriculum: TEACHING CONFERENCES & ROUNDS Weekly plastic surgery didactic conferences include Selected Readings Conference, where all the major areas of Plastic Surgery are discussed in a one-year cycle, and Case Conference where the residents present actual surgical cases of interest with a review of the literature and possible treatment options. Monthly conferences include Journal Club where four to six articles are selected, distributed then discussed, and Morbidity/ Mortality Conference. The series of rounds and conferences have been developed to assure residents in the program are educated in the broad scope of Plastic Surgery. There are four weekly interdisciplinary conferences that residents can attend to expand their clinical knowledge base regarding specific areas. These conferences include: Perinatal Care Conference, Craniofacial Conference, Breast Conference and Melanoma Conference. Evaluations: The resident’s performance is observed on a daily basis by the attending physicians on the service. A written evaluation is completed at the end of the rotation. The resident will also complete a written evaluation of the effectiveness of the attending as a teacher and the rotation as a whole. 16
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement F. NEUROLOGY (Duration: 1 month) Goal: The resident will be able to provide comprehensive, coordinated, and patient-centered care for patients with acute stroke, multiple sclerosis, myopathies, peripheral neuropathies and other neurological disorders, as a result of the rotation in Neurology. Objectives: a. Demonstrate the ability to perform relevant and focused neurological history and physical examination. b. Demonstrate familiarity in the management of complications with patients with neurological disorders including acute stroke management, multiple sclerosis, myopathies and peripheral neuropathies. Learning Activities: 1. Clinical Curriculum During the PGY-1 year, interns spend one month assigned to the Neurology Inpatient Service, where patient care is performed under the direct supervision of a full-time attending neurologist. The resident interprets diagnostic procedures and participates in the teaching of medical students and interns. Residents, under direct supervision of attending neurologists, have primary responsibility for the care of patients on the adult or pediatric inpatient services and outpatient clinics. Anesthesia and Psychiatry interns, and medical students are assigned to the adult inpatient service on a monthly basis. Additional Physical Medicine and Rehabilitation, Pediatric, Psychiatry, and Neurosurgery residents may rotate on the neurology services for experience in Neurology. The total number of patients seen in the neurology clinics exceeds 15,000 per year. Approximately 800 patients are admitted to the inpatient neurology service per year, and approximately 1,200 patients on other inpatient services are seen in consultation by the Neurology residents annually. 2. Didactic Curriculum: TEACHING CONFERENCES & ROUNDS Neurology Grand Rounds are held weekly. The emphasis in these conferences is on resident participation, clinical case presentations, and basic science and clinical neurology correlation. Clinical conferences in neuropathology, neurophysiology, sleep medicine, epilepsy surgery, muscle biopsy, and child neurology are held weekly. The residents also have weekly lectures on various clinical neurology and related basic science topics. These include neuroanatomy, neurochemistry, neurophysiology, neuropathology, and other selected topics in basic neurology. The monthly Journal Club sessions review a clinical topic in depth, with emphasis on resident participation. Evaluations: The resident’s performance is observed on a daily basis by the attending physicians on the service. A written evaluation is completed at the end of the rotation. The resident will also complete a written evaluation of the effectiveness of the attending as a teacher and the rotation as a whole. 17
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement G. TRAUMA SURGERY (Duration: 1 month) Goal: The resident will be introduced to comprehensive, coordinated, and patient-centered care to children and adults with traumatic disorders including multiple orthopedic injuries, abdominal trauma, chest trauma, head injury and spinal cord injury, as a result of the rotation in Trauma Surgery. Objectives: Core Competency - Patient Care 1. To know current details of all assigned patients. 2. To gather and interpret essential and accurate information about the patient’s health status, including a. Learning to obtain clinical information rapidly and effectively from family or caregivers of trauma patients b. Obtaining relevant information from nurses and hospital departments (e.g., radiology, laboratory, and hospital information systems), c. Obtaining information from referring physicians and referring hospitals 3. To learn the principles of pre and postoperative management, including: a. Fluid and electrolyte management, b. Pharmacological management, including pain and sedation, antibiotic dosing and pharmacology, c. Recognition and management of respiratory distress and shock, d. Wound care e. Follow-up and outpatient management, including referrals and resources for social work, rehabilitation and physical medicine 4. To perform basic clinical procedures, including: a. Primary closure of incisions, b. Management of open and infected wounds, c. Venipuncture, d. Intravenous line placement, e. Placement of urinary catheters Core Competency - Medical Knowledge 1. To expand the fund of knowledge from textbooks, journals, and electronic media. 2. To critically evaluate the literature based upon methodology and statistical techniques, a survey of related articles, and resident-initiated discussions with attending staff and other experts. 3. To participate in scheduled conferences. 4. To teach medical students. Core Competency - Practice-based learning and improvement 1. To evaluate patients critically with the goal of generating a working diagnosis and treatment plan. 2. To understand the medical, surgical, and scientific bases of a patient’s condition and his or her treatment plan. 18
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement 3. To obtain consultations and other opinions regarding a patient’s status, work-up, or hospital course when necessary. Core Competency – Interpersonal and Communication Skills 1. To present clinical information on work rounds clearly and concisely. 2. To write orders legibly. 3. To write progress notes legibly with sufficient detail so that patients’ condition, status and care plans are clear. 4. To work effectively with attending staff and house staff colleagues in surgery and consultative services, medical students, nurses, ancillary personnel, pre-hospital personnel. 5. To keep senior residents and attending staff informed, particularly with “problem” cases, unstable patients, and changes in-patient condition and care plan. 6. To foster teamwork and a work environment based upon communication, respect, trust, and honesty. 7. To foster a social environment based upon tolerance for other opinions, backgrounds, and cultures. Core Competency - Professionalism 1. To demonstrate compassion and integrity through respectful patient care, family interactions, and communication with other health care providers. 2. To understand when expert medical advice is necessary. 3. To obtain expert medical, nursing, or other opinions when limits of knowledge, experience, and training are reached. Core Competency - Systems-based practice 1. To effectively transfer care when duty hours are completed. 2. To responsibly accept the on-call care responsibilities of patients who are not on the primary service. 3. To apply standardized care plans, and the rationale behind them, including: a. Bowel preparation procedures, b. Preoperative antibiotic regimens, c. S.B.E. prophylaxis, d. Tetanus prophylaxis, e. Universal precautions, f. Aseptic technique, g. Care of central lines, h. Care of gastrostomies/enterostomies, i. Postoperative feeding regimens (e.g., gastric vs. post-pyloric regimens) 4. To attend care conferences on assigned patients 5. To write notes with sufficient detail to satisfy the requirements of governmental agencies, health care payer organizations, including: a. Admission histories, physical examinations, and care plans, b. Daily progress notes, c. Discharge summaries 19
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Learning Activities: 1. Clinical Curriculum PGY-1 residents spend one month on the Trauma Surgery service. Patient care is overseen by ABS certified Trauma/Critical Care Specialists and is directed by the General Surgical Chief Resident with assistance from a senior resident and at least two junior residents. Approximately 2000 multiply-injured patients are admitted annually to the Center and are cared for by a fully- staffed infrastructure which is certified through the North Carolina Office of Emergency Medical Services (OEMS). 2. Didactic Curriculum: TEACHING CONFERENCES & ROUNDS Medical students, residents, fellows, and nurses participate in regularly scheduled teaching rounds. In addition to weekly General Surgery Grand Rounds, the Critical Care Service maintains a weekly Critical Care Grand Rounds schedule and hosts a critical care-specific mortality and morbidity conference. The Multi-disciplinary Trauma Conference (MTC) facilitates discussion among trauma specialists in related medical and surgical fields. Evaluations: The resident’s performance is observed on a daily basis by the attending physicians on the service. A written evaluation is completed at the end of the rotation. The resident will also complete a written evaluation of the effectiveness of the attending as a teacher and the rotation as a whole. 20
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement H. EMERGENCY MEDICINE (Duration: 1 month) Goal: The resident will be able to provide comprehensive, coordinated, and patient-centered care to patients presenting to the Emergency room. Objectives: 1. Demonstrate the ability to perform relevant and focused history and physical examination. 2. Demonstrate familiarity in the management of complications with patients with urgent and emergent medical conditions. 3. Demonstrate working knowledge of the management of medical emergencies and urgent medical issues. 4. Understand the roles of physicians and allied health professionals in the management of patients who present to the emergency room. Learning Activities: 1. Clinical Curriculum Interns spend one month in Emergency Medicine with residents in Emergency Medicine and other disciplines. This training program at the University of North Carolina Hospitals is a PGY-1 through PGY-3 residency and is approved by the Residency Review Committee of the Accreditation Council for Graduate Medical Education, with 8 emergency medicine residents per class. The residency was established in 1995 with the University of North Carolina Hospitals, a 665-bed, tertiary care, level-one trauma center serving as the primary site. The Emergency Department moved to new, state-of-the-art, facilities in 1996 and sees over 50,000 patients a year. The Department of Emergency Medicine, with more than 20 faculty members, is dedicated to academics and education in the specialty of Emergency Medicine. 2. Schedule PGY-1 Interns will work 12-hour shifts beginning at 10 am, 12 noon, or 2:00 pm. These times will rotate throughout the month. Depending on how many individuals are available to work and vacation schedules, these people will typically work 5 of 7 days or 4 of 6 days. 3. Didactic Curriculum: TEACHING CONFERENCES & ROUNDS Educational Conferences Emergency Medicine conferences are held Tuesday from 7:15 am to noon. All PGY-1 residents assigned to the Emergency Department each month will be expected to attend. Evaluations: The resident’s performance is observed on a daily basis by the attending physicians on the service. A written evaluation is completed at the end of the rotation. The resident will also complete a written evaluation of the effectiveness of the attending as a teacher and the rotation as a whole. 21
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement I. PHYSICAL MEDICINE AND REHABILITATION (Duration: 1 month) Goal: The resident will be introduced to the provision of comprehensive, coordinated, and patient-centered care to adults with rehabilitation disorders including stroke, traumatic brain injury, spinal cord injury, amputations, joint replacements, polytrauma, and other conditions, as a result of the introductory rotation in Physical Medicine and Rehabilitation. Objectives: a. Demonstrate the ability to perform relevant and focused history and physical examination of patients with functional limitations for patients on the Physical Medicine and Rehabilitation inpatient service. b. Demonstrate working knowledge in the diagnosis and management of patients with common rehabilitation disorders. c. Demonstrate familiarity with the treatment options utilized by physiatrists in the approaches to patients with disabilities or functional limitations. d. Understand the roles of physicians and allied health professionals in the management of patients with disabilities or functional limitations. (Refer to the relevant sections of the rotation-specific objectives included for the PGY 2-4 rotations in this supplement.) Learning Activities: 1. Clinical Curriculum During the PGY-1 year, residents spend one month on one of the inpatient rehabilitation units under the direct supervision of an attending physician and senior resident (PGY 2-4). Interns are introduced to basics of Physical Medicine and Rehabilitation and learn to take a physiatric history and perform a directed physiatric physical examination and participate in the clinical curriculum with the senior resident. Interns will follow approximately one-half of the patients on the assigned service. The senior resident will oversee the care of all of the patients assigned to the intern. Interns are also given responsibility for supervising and teaching medical students assigned to the service. 2. Didactic Curriculum: TEACHING CONFERENCES & ROUNDS PGY-1 residents participate in many of the didactic sessions as detailed below for PGY 2-4 years, including the weekly resident lecture series, monthly resident case presentation, morbidity and mortality conference, medical student presentations, and journal club. Evaluations: The resident’s performance is observed on a daily basis by the attending physicians on the service. A written evaluation is completed at the end of the rotation. The resident will also complete a written evaluation of the effectiveness of the attending as a teacher and the rotation as a whole. Primary Faculty Dr. Gloria Liu, Inpatient SCI/Musculoskeletal gloria_liu@med.unc.edu Dr. Lisa Blankenship, Inpatient Brain lisa_blankenship@med.unc.edu 22
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement III. PHYSICAL MEDICINE AND REHABILITATION CLINICAL AND RESEARCH CURRICULAR COMPONENTS (PGY 2-4) A. Inpatient Rehabilitation 1. Brain disorders (Stroke, TBI) 2. Spinal Cord Injury & Musculoskeletal 3. Amputee & General B. Pediatric Rehabilitation Services C. Adult and Geriatric Inpatient Consultation Services D. Adult Outpatient Rehabilitation Services E. Electrodiagnostic Medicine (EMG/NCS) F. Community and Cardiac Rehabilitation G. Research H. Electives A. INPATIENT REHABILITATION (Duration: 12 months) Residents will spend 12 months on the inpatient rehabilitation unit. During inpatient rehabilitation rotations, the resident will serve as the primary care physician for rehabilitation patients, conduct patient care conferences with the rehabilitation team, and participate in scheduled and ad hoc educational sessions. A typical patient load includes a service of ten to twelve patients. Residents assume an increasing level of practice independence as their experience and abilities dictate. Residents work side by side with the PM&R faculty to care for patients. The inpatient rehabilitation unit is a state-of-the art 30-bed rehabilitation unit located on the 7th floor of the main hospital. While assigned to an adult rehabilitation service, the resident will be responsible for approximately seven to 10 patients. The inpatient rehabilitation unit admits more than 500 patients per year. Trained allied health personnel will perform most routine ancillary procedures, such as starting intravenous fluids (including blood), performing venipunctures and electrocardiograms, and drawing blood gases. OVERALL EDUCATIONAL GOALS: Refer to the individual rotations for specific goals and objectives. The general educational goals for the resident on the PM&R Inpatient service are as follows: • To learn to perform a comprehensive evaluation of each patient and give recommendations on treatment of conditions pertinent to Physical Medicine and Rehabilitation and any attendant functional deficits. • To recognize acute management of the variety of medical conditions seen in an inpatient rehabilitation patient population and determine the potential complications, the prognosis, and the potential functional outcomes of each. • To understand recommendations for transfer to an appropriate level rehabilitation setting to address functional issues. • To understand and develop recommendations for appropriate ongoing rehabilitation care following dismissal from the inpatient rehabilitation unit. • To develop in all of the six general competencies areas. 23
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement LEARNING OBJECTIVES: Refer to specific inpatient rehabilitation rotations for learning objectives. RESIDENT RESPONSIBILITIES: Perform the following tasks: • Perform history and physical examination on all patients on day of admission. • Do a complete chart review, interview and exam, and contact care providers and/or family as needed for necessary information. • Review and discuss with referring services or therapists – as indicated. • Dictate an appropriate history and physical to facilitate information transfer and billing. • Pre-round on all patients on the inpatient rehabilitation service and develop appropriate medical and rehabilitation plan for issues as they arise. Document appropriately in daily progress note. • Attend and lead multidisciplinary rehabilitation conferences. • Attend and lead multidisciplinary family conferences on an as needed basis. • Supervise and teach medical students rotating on the inpatient service (review and cosign medical student note) • Arrange for follow-up medical and rehabilitation treatment and care. • Dictate dismissal summary of rehabilitation course and ongoing care. Attend the following: • Attending rounds – daily with attending, usually following consult rounds • Multidisciplinary rounds – weekly with attending and other team members as assigned • Team conferences – weekly with rehabilitation team members • Family conferences – as scheduled • Educational activities – all PM&R scheduled educational activities ATTENDING RESPONSIBILITIES: • Schedule time for attending rounds with resident to maximize learning opportunities • Observe resident’s presentation of patients and offer feedback • Monitor resident’s performance of physical exam and give feedback and coaching • Review competency-based issues with resident and provide feedback • Make assignments for attending round discussions and follow-up • Accept feedback regarding teaching and the rotation • Model evidence-based approach to physiatric management • Model and foster patient advocacy and humanistic and ethical behavior • Review mid-rotation and final rotation evaluations EVALUATION: 24
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Resident’s performance is observed daily by the attending on service during inpatient and outpatient clinical activities. A written evaluation is completed at the end of the resident rotation. The residency program is committed to following the guiding principles as put forth by the ACGME Outcome Project. Residents will be evaluated for progress towards achieving competency in the following areas: • Medical knowledge • Patient care • Professionalism • Practice-based learning and improvement • Communication skills • System-based practice The standard departmental written evaluation form will be used. Residents will also be evaluated by medical students whom they supervise on their abilities relative to the above competencies. Residents will complete a written evaluation of the rotation and the effectiveness of the attending as a teacher at the midpoint and end of the rotation and will provide input to the supervising attending on the evaluation of medical students under their supervision. 25
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement 1. BRAIN INPATIENT REHABILITATION Overall Educational Goal: As a result of the resident’s rotation in this discipline, the resident will be able to provide comprehensive, coordinated and family centered care to patients with stroke, traumatic brain injury, brain tumors and other or acquired brain injuries resulting in disability. Objectives: Patient Care • Demonstrate the ability to perform a general medical and rehabilitation physical examination including language exam, upper motor neuron distribution of weakness, visual field testing, demonstration of hemi-inattention/neglect). • Demonstrate the ability to use neuro imaging studies (i.e., CT scan, MRI) to correlate with the clinical examination. • Be familiar and comfortable managing the following conditions: stroke, traumatic brain injury, primary and metastatic brain tumors, and other acquired brain disorders. • Know and be able to apply key concepts of family centered care for patients with a disability. Medical Knowledge • Identify stages of recovery from stroke, subarachnoid hemorrhage, and traumatic brain injury and predictors of functional outcome. • Understand benefits and risks of pharmacologic management for seizure prophylaxis and depression. • Describe appropriate orthotic and splinting needs for patients with brain injury • Demonstrate appropriate application of neuromuscular re-education including gait re- education techniques to treatment programs. • Correctly identify the management of speech and swallowing disorders. • Develop working knowledge of different types of mobility aids, orthotics, prosthetics, and adaptive equipment used to maximize functional independence in patients with acquired brain disorders. • Be able to diagnose, quantify, and manage spasticity in patients with disabilities. • Become familiar with neuropharmological management following traumatic brain injury. • Identify and manage heterotopic ossification and contractures following traumatic brain injury. Practice-based Learning and Improvement • Appraise and assimilate medical knowledge to improve patient care of patients with acquired brain disorders. Interpersonal and communication skills: • Effectively exchange information and collaborate with patients and their families • Effectively exchange information with other health professionals. • Demonstrate the ability to write adequately detailed therapy prescriptions based on functional goals for physiatric management. 26
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Demonstrate appropriate interpersonal skills, compassion, and leadership skills in the patient care conference and multidisciplinary team conference. • Prescription writing: write inpatient therapy orders and prescribe home health or outpatient prescriptions that include the following essential elements: diagnosis, parts to be treated, procedures to be used with specifications to techniques and time, special instructions or cautions, home instructions for the patient and number and frequency of treatments. Professionalism: • Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to patients of diverse backgrounds. • Know and be able to apply key concepts of family centered care for patients with a disability. • Perform duties with a professional supportive attitude demonstrating mutual respect for patients, family, rehabilitation team members, and other health professionals. Systems-based practice: • Understand the social and economic impact of medical decisions on patients and society and the need to be the primary advocate for patients’ needs. • Coordinate effectively and efficiently an interdisciplinary team of allied rehabilitation professionals for the maximum benefit of the patient. • Provide documentation in the medical record to support the level of service required for billing purposes. Learning Activities of the Rotation: During this rotation, the residents will: • Be encouraged and expected to ask whenever there is a question. • Participate in inpatient and outpatient team conferences, medical rounds, family conferences and discharge planning conferences. • Observe therapy sessions provided by therapy services (PT, OT, SLP, and RT). • Observe neuropsychological evaluation and counseling session. • Participate in bedside and ad hoc teaching sessions during clinical care. • Review related classic and current journal articles with the attending. • Review textbook chapters related to the above Goals and Objectives. • Review assignments below and complete learning objectives of each assignment. Reading assignments: # 1-8 are from the Study Guide edition of the Archives of Physical Medicine and Rehabilitation and are available on Blackboard. 1. Stroke and Neurodegenerative Disorders. 1. Acute Stroke Evaluation, Management, Risks, Prevention, and Prognosis. Bryan J. O’Neill, MD, Carolyn C. Geis, MD, Ross A. Bogey, DO, Alex Moroz, MD, Phillip R. Bryant, DO. 27
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Assignment objectives: (a) To summarize the acute evaluation and management of stroke, particularly in the young stroke patient; and (b) to review the risk factors for stroke and secondary prevention measures. 2. Stroke and Neurodegenerative Disorders. 2. Stroke: Comorbidities and Complications. Alex Moroz, MD, Ross A. Bogey, DO, Phillip R. Bryant, DO, Carolyn C. Geis, MD, Bryan J. O’Neill. Assignment objectives: to summarize common comorbidities and complications encountered by patients after stroke. 3. Neurodegenerative Disorders. 3. Stroke: Rehabilitation Management Ross A. Bogey, DO, Carolyn C. Geis, MD, Phillip R. Bryant, DO, Alex Moroz, MD, Bryan J. O’Neill, MD. Assignment objectives: (a) To identify and review the treatment options for poststroke spasticity; (b) to review the use of body weight–supported treadmill training in stroke patients; (c) to describe virtual reality training as an adjunct in stroke rehabilitation; (d) to review vestibular rehabilitation; (e) to discuss advances in aphasia treatment; (f) to discuss cognitive retraining; and (g) to provide an update on treatment of neglect syndromes. 4. Congenital and Acquired Brain Injury. 1. Brain Injury: Epidemiology and Pathophysiology Brian D. Greenwald, MD, Derek M. Burnett, MD, Michelle A. Miller, MD. Assignment objectives: (a) To summarize brain injury epidemiology and prevention strategies across the age spectrum, (b) to review the pathophysiology of pediatric and adult brain injury, and (c) to classify brain injury by severity scales. 5. Congenital and Acquired Brain Injury. 2. Brain Injury Rehabilitation: Medical Management Derek M. Burnett, MD, Thomas K. Watanabe, MD, Brian D. Greenwald, MD Assignment objectives: To present guidelines for assessment, treatment, and management of the patient who has acute brain injury. 6. Congenital and Acquired Brain Injury. 3. Rehabilitation Interventions: Cognitive, Behavioral, and Community Reentry Michelle A. Miller, MD, Derek M. Burnett, MD, Jacinta M. McElligott, MD. Assignment objectives: (a) to summarize the psychosocial and cognitive impact of brain injury, (b) to discuss treatment strategies for visuospatial deficits (c) to summarize community reentry strategies of patients with brain injuries. 28
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement 7. Congenital and Acquired Brain Injury. 4. New Frontiers: Neuroimaging, Neuroprotective Agents, Cognitive-Enhancing Agents, New Technology, and Complementary Medicine Jacinta M. McElligott, MD, Brian D. Greenwald, MD, Thomas K. Watanabe, MD Assignment objectives: (a) To explore the current research and potential clinical applications of medical and technologic advances in neuroprotective agents, cognition- enhancing agents, neuroimaging, virtual reality, robotics, and telemedicine as applicable to brain injury and (b) to identify the evidence to support an expanding use of complementary medicine in brain injury. 8. Congenital and Acquired Brain Injury. 5. Outcomes After Acquired Brain Injury Thomas K. Watanabe, MD, Michelle A. Miller, MD, Jacinta M. McElligott, MD Assignment objectives: (a) To describe variables that affect outcome after acquired brain injury and (b) to identify the outcome tools most appropriate for the patient populations and outcomes to be studied. 9. The Rehabilitation of People with Traumatic Brain Injury. Buck H. Woo, Shanker Nesathurai, eds. Boston Medical. Chapters 1-15. Assignment objectives: (a) identify the epidemiology, pathophysiology and surgical management of traumatic brain injury (b) learn to formulate an initial rehabilitation medicine consultation for a brain injured patient and (c) become familiar with neuropsychological interventions for patients with traumatic brain injuries. Evaluations: Resident’s performance is observed daily by the attending on service during inpatient and outpatient clinical activities. A written evaluation is completed at the end of the resident rotation. At this time, the residents will complete a written evaluation of the rotation and the effectiveness of the attending as a teacher. 29
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement 2. SPINAL CORD INJURY & MUSCULOSKELETAL REHABILITATION Overall Educational Goal: Residents spend four months on the rotation, during which the resident will learn to provide comprehensive, coordinated and family centered care to patients with different level of spinal cord injury and musculoskeletal injuries. Objectives: Patient Care: • Demonstrate the ability to perform a comprehensive musculoskeletal and neurological examination and demonstrate knowledge of the ten key motor muscles, the sensory levels including sacral segments, and the bulbocavernosus reflex. • Become familiar and comfortable using ASIA classification including recognized spinal cord injury syndromes. • Become comfortable discussing with the patient and the family about spinal cord injury and musculoskeletal injury and prognosis. • Be familiar and comfortable managing the following conditions: autonomic dysreflexia, neurogenic bowel/bladder, pulmonary/cardiac/GI complications, DVT prophylaxis, spasticity management, sexual dysfunction, metabolic changes, depression or adjustment disorder, urinary tract infection, skin ulceration, musculoskeletal or neuropathic pain. • Be knowledgeable about the different types of wheelchair seating, positioning, and orthotics to maximize functional activity. • Know and be able to apply key concepts of therapeutic modalities. Medical Knowledge: • Know normal anatomy and function of spinal cord. • Describe the different types of SCI and acute medical management. • Understand the function based upon the level of injury. • Able to formulate comprehensive acute inpatient rehab goals. • Be able to diagnose and quantify spasticity. Understand the benefits and side effects of pharmacologic management for spasticity. • Be knowledgeable regarding autonomic dysreflexia, sexual dysfunction, neurogenic bowel and bladder pathphysiology. • Identify and manage autonomic dysreflexia, neurogenic bowel/ bladder, pulmonary/cardiac/GI complications, MS or neuropathic pain, heterotopic ossification and contractures following SCI. • Describe the risk factors of pressure ulceration, prevention procedures, the international classification, and the principles of dressing for management of ulcerations. • Demonstrate knowledge of pulmonary complications, prevention and management. • Be able to discuss the standard DVT prophylaxis in the setting of SCI and various musculoskeletal conditions. • Correctly identify the management of depression and adjustment disorder with psychological assistance. • Develop a working knowledge of different types of wheelchairs positions and the uses of crutches. 30
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Gain knowledge about vocational rehabilitation and community resources for persons with spinal cord injury and musculoskeletal injuries. Practice-based Learning and Improvement • Review assignments and complete the learning objectives of each assignment. • Review textbook chapters related to the goals and objectives Interpersonal and communication skills: • Effectively exchange information and collaborate with patients and their families • Effectively exchange information with other health professionals. • Demonstrate the ability to write adequately detailed therapy prescriptions based on functional goals for physiatric management. • Demonstrate appropriate interpersonal skills, compassion, and leadership skills in the patient care conference and multidisciplinary team conference. • Prescription writing: write inpatient therapy orders and prescribe home health or outpatient prescriptions that include the following essential elements: diagnosis, parts to be treated, procedures to be used with specifications to techniques and time, special instructions or cautions, home instructions for the patient and number and frequency of treatments. Professionalism: • Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to patients of diverse backgrounds. • Know and be able to apply key concepts of family centered care for patients with a disability. • Perform duties with a professional supportive attitude demonstrating mutual respect for patients, family, rehabilitation team members, and other health professionals. Systems-based practice: • Understand the social and economic impact of medical decisions on patients and society and the need to be the primary advocate for patients’ needs. • Coordinate effectively and efficiently an interdisciplinary team of allied rehabilitation professionals for the maximum benefit of the patient. • Provide documentation in the medical record to support the level of service required for billing purposes. Learning Activities of the Rotation: During this rotation, the residents will: • Be encouraged and expected to ask whenever there is a question. • Participate in inpatient and outpatient team conferences, medical rounds, family conferences and discharge planning conferences. • Observe therapy sessions provided by therapy services (PT, OT, SLP, and RT). • Observe neuropsychological evaluation and counseling session. • Participate in bedside and ad hoc teaching sessions during clinical care. • Review related classic and current journal articles with the attending. 31
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Reading assignments: 1. Martin JH. 1996. Descending projection system and the motor function of the spinal cord. In Neuroanatomy Text Atlas. Appleton and Lange, Stanford CT, p 249-287. Assignment objectives: Know the anatomy and motor function of spinal cord. 2. Bracken MB, Shepard MJ, Holford et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Injury Study. JAMA 1997; 277:1597-1578. 3. Geisler FH, Dorsey FC, Coleman WP. Recovery of motor function after spinal cord injury a randomized, placebo-controlled trial with GM-1 ganglioside. New Engl J. med. 1991; 324-1829-38. Assignment objectives: understand the acute medical management of SCI 4. Spinal Cord Injury Medicine, in Delisa, JA; Gains, BM (eds): Rehabilitation Medicine Principal and Practice. 3rd ed. 1998. pp 1259-91 5. Rehabilitation of Patients with Spinal Cord Injuries; in Braddom,RL (ed). Physical Medicine and Rehabilitation; 1996. pp 1149-1179 Assignment objectives: Gain knowledge of autonomic dysreflexia, neurogenic bladder, spasticity and pressure ulceration evaluation and management, DVT prophylaxis and outcomes of spinal cord dysfunction. Evaluations: Resident’s performance is observed daily by the attending on service during inpatient and outpatient clinical activities. A written evaluation is completed at the end of the resident rotation. At this time, the residents will complete a written evaluation of the rotation and the effectiveness of the attending as a teacher. 32
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement 3. AMPUTEE & GENERAL REHABILITATION Overall Educational Goal: As a result of the resident’s rotation in this discipline, the resident will be able to provide comprehensive, coordinated and family centered care to patients with amputations and co-morbidities including peripheral neuropathy, peripheral vascular disease, trauma, and other conditions resulting in disability. Objectives: Patient Care: a. Demonstrate the ability to perform a general medical and rehabilitation history and physical examination. b. Be able to manage amputee rehabilitation including pre-prosthetic and prosthetic rehabilitation. c. Take an appropriate amputee history. d. Demonstrate the physical examination of the amputee and general rehabilitation patients. e. Demonstrate appropriate stump wrapping technique. f. Understand and identify the common psychological aspects of the person with amputation, including postoperative counseling. g. Demonstrate appropriate evaluation and management of the dysvascular limb and skin ulcers. h. Understand the energy requirements of gait at various levels of traumatic and vascular amputation and implement a pre-prosthetic or prosthetic therapy program for amputees. i. Understand the importance of care of the contralateral limb in diabetic amputees and implement strategies to prevent further amputations. j. Understand phantom sensation and phantom pain. Implement treatment strategies for phantom pain as appropriate. k. Be familiar with prevention and management of common complications of immobility and deconditioning Medical Knowledge: a. Develop a working knowledge of different types of mobility aids, orthotics, prosthetics, and adaptive equipment used to maximize functional independence in patients. b. Be familiar and comfortable managing the following comorbid conditions in amputees: peripheral neuropathy, venous insufficiency, thrombophilia and arterial occlusive disease. c. Review the normal gait cycle. d. Discuss the six determinants of gait. e. Review amputee gait abnormalities, including transtibial and transfemoral amputee gait abnormalities. f. Discuss indications and contraindications for common lower extremity amputation levels. g. Be familiar with principles of amputation surgery. h. Describe advantages and disadvantages of each of the following forms of post-operative wound management: • Soft dressing (e.g Guaze/Kerlix) • Semi-rigid dressing (e.g. Robert-Jones dressing) • Rigid removable dressing (e.g. “stump protector) 33
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Rigid non-removable dressing (like a cast) • Pylon system (e.g. IPOP/IPSF/EPSF) i. Discuss the energy costs of ambulation with prosthetic/orthotic gaits, and with ambulation assists such as crutches or wheelchairs j. Describe available prosthetic/orthotic devices/components for • Partial foot amputee • Syme amputee • Transtibial amputee • Knee disarticulation amputee • Transfemoral amputee • Hip disarticulation amputee k. Describe the rationale/design of the following: • Quadrilateral socket • Ischial containment socket l. Analyze socket fit/pressure distribution for the following: • Partial foot amputee • Syme amputee • Transtibial amputee • Knee disarticulation amputee • Transfemoral amputee • Hip disarticulation amputee m. Analyze gait abnormalities for the following: • Partial foot amputee • Syme amputee • Transtibial amputee • Knee disarticulation amputee • Transfemoral amputee • Hip disarticulation amputee n. Describe available prosthetic/orthotic devices/components for • Partial hand amputee • Wrist disarticulation amputee • Transradial amputee • Elbow disarticulation amputee • Transhumeral amputee • Shoulder disarticulation amputee o. Discuss etiology and management of residual limb pain and phantom limb pain and phantom sensation p. Discuss component selection issues for the geriatric amputee. q. Discuss the dual disability of amputation and hemiparesis. r. Discuss management of the diabetic foot. Practice-based Learning and Improvement: a. Appraise and assimilate medical knowledge to improve amputee patient care. b. Review selected current and classic amputee rehabilitation literature. 34
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Interpersonal and communication skills: a. Effectively exchange information and collaborate with patients and their families. b. Effectively exchange information with other health professionals. c. Demonstrate the ability to write adequately detailed orthotics and prosthetic prescriptions based on functional goals for physiatric management. d. Develop management and leadership skills for the multidisciplinary rehabilitation team. e. Prescription writing: write inpatient therapy orders and prescribe home health or outpatient prescriptions that include the following essential elements: diagnosis, parts to be treated, procedures to be used with specifications to techniques and time, special instructions or cautions, home instructions for the patient and number and frequency of treatments. Professionalism: a. Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to patients of diverse backgrounds. b. Know and be able to apply key concepts of family centered care for patients with a disability. c. Understand the importance of patient confidentiality and protect the patient’s rights. Systems-based practice: a. Understand the social and economic impact of medical decisions on patients and society and the need to be the primary advocate for patients’ needs. 1b. Coordinate effectively and efficiently an interdisciplinary team of allied rehabilitation professionals for the maximum benefit of the patient. 2c. Provide documentation in the medical record to support the level of service required for billing purposes. 3d. Become familiar with independent living services, insurance and Medicare and Medicaid reimbursement for prosthetics according to K-levels. 4 Learning Activities of the Rotation: During this rotation, the residents will: • Be encouraged and expected to ask whenever there is a question. • Participate in inpatient and outpatient team conferences, medical rounds, family conferences and discharge planning conferences. • Observe therapy sessions provided by therapy services. • Observe prosthetic evaluation and fitting. • Participate in bedside and ad hoc teaching sessions during clinical care. • Review related classic and current journal articles with the attending. • Review textbook chapters as assigned. • Review reading assignments as assigned. Reading assignments: 1. Atlas of Amputations and Limb Deficiencies. Surgical, Prosthetic and Rehabilitation Principles 3rd Edition. Smith, Michael and Bowker, eds. American Academy of Orthopedic Surgeons, 2004. Selected chapters as assigned. 35
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement 2. Essentials of Inpatient Rehabilitation, Nesathuri and Blaustein, eds, Boston Medical, 2001. Vascular Rehabilitation, Chapter 6, pages 49-58; 3. Above Knee Amputation. Chapter 7, pages 59-76; Below Knee Amputation, Chapter 8, pages 77-88. 4. Bacharach JM., Rooke TW., Ozmundson PJ, Gloviczki P: Predictive value of transcutaneous oxygen pressure and amputation success by use of supine and elevation measurements. J Vasc Surg 1992; 15(3): 558-563 5. Davis RW: Phantom sensation, phantom pain, and stump pain. Arch Phys Med Rehab 1993; 74: 79-91. 6. Blount WP: Don't throw away the cane. JBJS 1956; 38A: 695-708. 7. Fisher SV, Gullickson G: Energy cost of ambulation in health and disability: A literature review. Arch Phys Med Rehab 1978; 59: 124-133. 8. Inman VT: Conservation of energy in ambulation. Arch Phys Med Rehab 1967; 48: 484-488. 9. Waters, RL, Yakura, JS: The energy expenditure of normal and pathological gait. Crit Rev PM&R 1989; 1(3): 183-209. 10. Varghese G, Hinterbuchner C, Mondall P, Sakuma J: Rehabilitation outcome of patients with dual disability of hemiplegia and amputation. Arch Phys Med Rehab 1978; 59: 121-123. 11. Rehabilitation of Orthopedic and Rheumatologic Disorders. 1. Osteoporosis Assessment, Treatment, and Rehabilitation. Robert J. Kaplan, MD, Andrew N. Vo, MD, Todd P. Stitik, MD, Leonard B. Kamen, DO, Ali A. Bitar, MD, Arch Phys Med Rehab 2005;86(3 Suppl 1):S40-7. Evaluations: Resident’s performance is observed daily by the attending on service during inpatient and outpatient clinical activities. A written evaluation is completed at the mid-point and the end of the resident rotation. At this time, the residents will complete a written evaluation of the rotation and the effectiveness of the attending as a teacher. 36
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement B. PEDIATRIC REHABILITATION Educational Goals: As a result of the resident’s rotation in this discipline, s/he will be able to provide comprehensive, coordinated and family-centered care to children and adolescents with congenital or acquired disabilities. The specific educational goals for the resident on the Pediatric Rehabilitation service are as follows: • Demonstrate the ability to perform a pediatric (re)habilitation history and physical examination. • Develop working knowledge of different types of mobility aids, orthotics, prosthetics and adaptive equipment used to maximize functional independence in children. • Be able to diagnose, quantify and manage spasticity in children with disabilities. • Be familiar and comfortable managing the following conditions: cerebral palsy, spina bifida, spinal cord injury, brachial plexus injury, muscular dystrophy and head injury. • Know and be able to apply key concepts of family-centered care for children with a disability. • Know what constitutes a medical home for children and adolescents with special health care needs. • Be able to develop in all 6 competency areas (see below). Objectives: Acquisition of Six Competencies: Patient Care: Residents will be able to: • Perform an age-appropriate history and physical examination. • Identify patient and family concerns; discuss treatment plan, and (when possible) answers questions to patient and family satisfaction. • Provide patient education, including providing patient and family with appropriate resources to further educate themselves about their condition. • Make appropriate referrals and communicate with other health care providers to optimize care coordination. Medical Knowledge: Residents are expected to: • Demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. • Demonstrate an investigatory and analytic thinking approach to clinical situations. • Know and apply the basic and clinically supportive sciences which are appropriate to pediatric physical medicine and rehabilitation. Practice-Based Learning and Improvement: Residents should be able to: 37
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Understand pediatric rehabilitation as a specialty: appropriate patients for inpatient rehab and the outpatient services. • Apply current literature pertaining to the presenting patient population, especially in regard to standard of care and risk/benefit to patient. • Demonstrate understanding of study design and statistical methods in their appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness. • Analyze practice experience in order to implement practice-based improvement activities systematically. • Identify potential areas that would benefit from further research. • Facilitate the learning of other health care professionals by providing explanations for patient care. Communication: The resident will: • Demonstrate effective listening skills and ability to elicit and provide information using effective non-verbal, explanatory, questioning, summarizing, and relationship-building skills. • Demonstrate the skills necessary to communicate with the non-verbal patient, as well as the acceptable ways to communicate with patients who have aphasia, hearing impairment, and/or visual impairment. • Work effectively with others as a member of a health care team, providing pediatric therapists and others with medical information, indications, contraindications, and precautions of therapies based on co morbidities. • Maintain good communication channels with care managers, social workers, teachers, early interventionists and community health care providers. • Maintain good communication with other hospital pediatric and surgical services. Professionalism: The resident will: • Understand the importance of patient confidentiality and protect the patient’s rights. • Ensure appropriate patient follow-up • Identify and attempt to overcome barriers (cultural, age, gender, economic, education level) that can impede patient and family goals. Systems-Based Care: The resident will: • Identify limitations of inpatient services and show working knowledge of local and regional specialty centers. • Demonstrate knowledge of billing processes, payer mix, balance between patient care and fiscal responsibility. • Effectively provide information to patients, social workers, and families members pertaining to funding, insurance benefits, school services, and vocational rehabilitation. Principal Teaching/Learning Activities: 38
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Direct Collaborative Patient Evaluation Activity is the primary teaching tool for the pediatric rehabilitation service. During inpatient consult rounds and outpatient clinics, the medical student or resident presents each patient to the attending on service. The attending sees every patient with the medical student or resident. For each patient, the attending may ask for demonstration of, or evaluate competency in, any of the six general competency areas. • Perform initial evaluations and re-evaluations on inpatient consultation service. • Provide supervised medical and rehabilitative care for children on the inpatient service. • Provide supervised medical and rehabilitative care for children on the inpatient service. • Dictate or write H&P's, discharge summaries, consults or daily notes (as applicable) on all patients evaluated. • Participate in bedside and ad hoc teaching sessions. • Assist with the supervision and teaching of medical students. • Ask whenever there is a question. • Participate in inpatient and outpatient team conferences, medical rounds, family conferences and discharge planning conferences. • Observe therapy sessions provided by pediatric by pediatric therapy services (PT, OT, and SLP). • Be available for unscheduled calls from the ward or clinic. Additional Educational Activities • Review and discussion of “classic articles” and up-to-date articles as they pertain to the patient population. • Review pertinent questions from recent SAE exams. • Offer credible internet-based resources for review. • Resident is invited to attend any scheduled expert witness depositions provided they receive approval from lawyers involved. Readings/Resources The resident is expected to search for current literature related to his/her patients’ conditions. Some suggested sources are: • Molnar and Alexander, Pediatric Rehabilitation, 3rd Edition • Braddom, Physical Medicine and Rehabilitation • Delisa, Rehabilitation Medicine • MDConsult, Up-To-Date or Medline. • www.TelAbility.org Suggested Reading • Pediatric Rehabilitation, edited by Gabriella Molnar • Physical Therapy for Children, edited by Suzanne Campbell • Occupational Therapy for Children, edited by Pat Nuse Pratt & Anne Stevens Allen • Children with Disabilities: A Medical Primer, edited by Mark Batshaw & Yvonne Perret • Feeding the Disabled Child, edited by Peter Sullivan and Lewis Rosenbloom 39
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Cerebral Palsy: a Complete Guide for Caregiving, edited by Freeman Miller and Steven Bachrach • Living with Spine Bifida: A Guide for Families and Professionals, edited by Adrian Sandler Resident Responsibilities: Perform the following tasks: • Preview records for new and follow-up patients in outpatient clinics. • Record and graph vital signs, weight, height measurements. • New patient history and physical exams – present to attending. • F/U patient history and physical exams – present to attending. • Complete inpatient consult requests, review with attending and relay recommendations to consulting service. • Follow up inpatient consults as necessary. • Answer patient phone calls referred by office staff. • Write prescriptions for medications, equipment, therapy, etc. • Write or call in medication refills (for patients they have followed) • Participate in educational discussions. • Teach medical students and other visitors. • Review and present 2 chapters/week from Pediatric Rehabilitation textbook (see resources section). Attend the following: • Chapter and article review sessions with Attending Physician • All departmental resident educational activities • Neuro-urology – once monthly in urodynamics lab as scheduled Attending Responsibilities: • Schedule time for consult rounds with resident to maximize learning opportunities. • Observe resident’s presentation of patients and offer feedback. • Monitor resident performance of physical exam and give feedback and coaching. • Monitor resident performance of injections and give feedback and coaching. • Review competency-based issues with resident and provide feedback. • Accept feedback regarding teaching and the rotation. • Model evidence-based approach to physiatric management. • Model and foster patient advocacy and humanistic and ethical behavior. • Review mid-rotation and final rotation evaluations. Evaluation: The attending will provide ongoing feedback regarding resident’s performance during the rotation. The resident should feel comfortable discussing issues that arise during the course of 40
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement the rotation. A mid-rotation evaluation form will be completed and reviewed with the resident, addressing strengths and areas, which need improvement in order to achieve competency. The standard rotation evaluation form will be completed at the end of the rotation and reviewed with the resident by the appropriate attending, signed by both, and submitted to the residency coordinator. The resident will fill out a rotation evaluation form to provide feedback about the rotation and the primary attending(s) with whom s/he worked and submit it to the residency coordinator. Individual evaluations will remain anonymous. 41
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement C. ADULT AND GERIATRIC CONSULTATION SERVICES Educational Goals of PM&R Consult Service Rotation: • To learn to perform a comprehensive evaluation of each patient and give recommendations on treatment of conditions pertinent to Physical Medicine and Rehabilitation and any attendant functional deficits. • To recognize acute management of the variety of medical conditions seen on the Consult Service and determine the potential complications, the prognosis, and the potential functional outcomes of each. • To understand recommendations for transfer to an appropriate level rehabilitation setting to address functional issues. • To develop in all of the six general competencies areas. Learning Objectives: Rotation-specific objectives: Residents completing the consultation rotation will: • Be able to perform a history and physical that provides comprehensive medical, social, and functional information about the patient. • Be able to interact effectively with physicians from other medial specialties and other medical personnel. • Be able to prevent common complications of immobility in the acute care setting. • Be able to recommend appropriate medical, therapy, and equipment orders for patients in the acute care setting. • Be able to provide concise, organized, and thorough oral patient presentations. • Be able to determine when a patient is ready for discharge from the inpatient rehabilitation setting to an appropriate discharge destination. • Identify the need to obtain diagnostic studies, laboratory testing or consultation from other medical or surgical services as indicated. • Be able to identify which patients require day rehabilitation, outpatient therapy, home care, or skilled nursing services following dismissal from inpatient rehabilitation. • Be able to develop knowledge of the pathophysiology and the prognosis of the various diagnostic groups seen in the inpatient setting. Acquisition of six competencies: Residents will be able to: Patient Care: • Identify patient and family concerns; begin discussion of inpatient plan, post-hospital plan, and expected functional return. • Provide patient education, including providing patient and family with appropriate resources to further educate themselves about their condition. • Perform focused neurological and musculoskeletal physical exams. 42
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Perform the following aspects of patient care: bowel/bladder programs, wound care, pain management, modalities, fit and recommendation of prosthetics and orthotics, DVT prophylaxis based on diagnosis, and contracture prevention. • Arrange for appropriate follow-up (TBI clinic, Amputee clinic, etc) and any ongoing therapies. Medical Knowledge: • Demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to: • Demonstrate an investigatory and analytic thinking approach to clinical situations. • Know and apply the basic and clinically supportive sciences which are appropriate to physical medicine and rehabilitation. Practice-Based Learning and Improvement: • Understand physiatry as a specialty: identify appropriate patients for inpatient rehab and the outpatient physiatry practice. • Apply current literature pertaining to the presenting patient population especially in regard to standard of care and risk/benefit to patient. Communication: • Demonstrate the skills necessary to communicate with the non-verbal patient, as well as the acceptable ways to communicate with patients who have receptive/expressive aphasia, are visually impaired, and/or are hearing-impaired. • Provide the multidisciplinary team with medical information, indications, contraindications and precautions of therapies based on co morbidities. • Maintain good communication channels with multidisciplinary team members and care managers and social workers. • Maintain good communication with other hospital medical and surgical services. Professionalism: • Understand the importance of patient confidentiality and protect patient’s rights. • Ensure appropriate patient follow-up. • Identify and overcome barriers (cultural, age, gender, economic, education level) that can impede the patient’s goals and recovery. Systems-based care: • Collect and identify information to facilitate the discharge planning process. • Review and recommend length of stay based on diagnosis as well as what resources will be needed at time of discharge. • Identify limitations of inpatient services and show working knowledge of local and regional specialty centers. • Demonstrate knowledge of billing processes, payer mix, balance between patient care and fiscal responsibility, common CPT codes, and CARF criteria. 43
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Effectively provide information to patients, social workers, and families members pertaining to disability funding and ratings, workman’s compensation, insurance benefits, ADA specifications, and job modifications. Principal Teaching/Learning Activities: Direct Collaborative Patient Evaluation Activity is the primary teaching tool for the consult service. During Consult Service Rounds the resident presents each patient to the attending on consult service that day. The attending sees every patient with the resident. For each patient, the attending may ask for demonstration of, or evaluate competency in, any of the six general competency areas. Attending rounds is the more formal didactic teaching component offered on the consult service. Consult topic teaching sessions are in-depth discussions between the attending and resident around issues brought up regarding a specific consult patient. The attending may assign the resident to read and summarize resources and/or recent articles on the topic area; then discussion follows the resident’s presentation. The resident may also read the literature in areas of his/her interest and present this. Topic areas include: • CVA – types, NIH stroke scale, prognosis for recovery • SCI – ASIA scale, neurogenic bowel and bladder management, prognosis for walking, DVT prophylaxis • TBI – Glasgow coma scale, Rancho Los Amigos scale, spasticity management, prognosis for recovery • Miscellaneous neurologic - MS, peripheral neuropathy, myopathy, degenerative neurologic disease – Guillain-Barre & Multiple Sclerosis – etiology, complications, prognosis for recovery • Congenital deformity - CP, myelomeningocele, arthrogryposis • Polyarthropathy - OA or RA with multiple joint involvement – complications of total joint replacement, DVT prophylaxis • Femur or acetabular fracture – complications, prognosis for recovery • AKA - BKA if both or complicating medical condition – pre-prosthetic training, residual limb management, phantom pain • Burns – rehabilitation concepts, wound care, contracture management • Other – deconditioning – complications of immobility; cancer rehabilitation principles. Minimally, read the appropriate chapters in R. Braddom, DeLisa, or other Physical Medicine and Rehabilitation text for each topic Resident Responsibilities: Perform the following tasks: 1. Report to the Consults Service daily, Monday through Friday. 44
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement 2. Perform all initial consults within 24 hours of request and follow-ups based on patient need/request of referring MD/discretion of the attending physician. Trauma referrals in the ICU may be seen after the 24hr window as appropriate. 3. Do a complete chart review, interview and exam, and contact care providers and/or family as needed for necessary information. 4. Review and discuss with referring services or therapists – as indicated 5. Coordinate with Consult Coordinator Nurse – daily to report documentation and recommendations given on new and follow-up consults. 6. Document completely a WEBCIS consult form to facilitate information transfer and billing. 7. Leave a preliminary note in the progress note section of the chart stating: “consult received, evaluation in progress, full note and recommendations to follow” within 24 hours of consult request. 8. Sign-out on Fridays and at end of rotation review with coordinator and appropriate resident regarding patients and plans. Attend the following: 1. Consult rounds – daily with assigned attending as scheduled with attending 2. Attending rounds – as scheduled with attending 3. Referring service discharge planning rounds - Orthopedics, Neurology, Neurosurgery, Trauma – as scheduled and available (Mon. 11:30AM-Neurosurg. Rounds, Tues. 9:30AM-Neuro rounds, Thurs. 9AM-trauma rounds) 4. Educational activities – all PM&R scheduled educational activities Other educational responsibilities • Observe therapy sessions with PT, OT, and SLP as appropriate for patients being followed and review functional status, progress and potential with therapists as required. • Read about the conditions and management of the patients seen. • Ask questions!! Attending Responsibilities: • Schedule time for consult rounds with resident to maximize learning opportunities. • Observe resident’s presentation of patients and offer feedback. • Monitor residents performance of physical exam and give feedback and coaching. • Review competency based issues with resident and provide feedback. • Make assignments for attending round discussions and follow-up. • Accept and encourage feedback regarding teaching and the rotation. • Model evidence-based approach to physiatric management. • Model and foster patient advocacy and humanistic and ethical behavior. • Review mid-rotation and final rotation evaluations. Evaluation: 45
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Resident’s performance is observed daily by the attending on the service during consult service rounds. A written evaluation is completed at the end of the resident's rotation. At that time, the resident will complete a written evaluation of the effectiveness of the attending as a teacher and the rotation as a whole. 46
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement D. ADULT OUTPATIENT REHABILITATION SERVICES EDUCATIONAL GOALS: The educational goals for the resident on the PM&R Outpatient service are as follows: • To learn to perform a comprehensive evaluation of each patient and give recommendations on treatment of conditions pertinent to physical medicine and rehabilitation and any attendant functional deficits. • To recognize acute management of the variety of medical conditions seen in an outpatient PM&R patient population and determine the potential complications, the prognosis, and the potential functional outcomes of each. • To understand recommendations for referral to an appropriate rehabilitation setting and discipline to address functional issues. • To understand and develop recommendations for appropriate ongoing rehabilitation care following dismissal from the inpatient rehabilitation unit. • To develop in all of the six general competencies areas. LEARNING OBJECTIVES: Rotation specific objectives: Residents completing the consultation rotation will: • Be able to perform a history and physical that provides comprehensive medical, social, and functional information about the patient. • Be able to interact effectively with physicians from other medical specialties and other medical personnel. • Be able to recommend appropriate medical, therapy, and equipment orders for patients in the acute outpatient care setting. • Be able to provide concise, organized, and thorough oral patient presentations. • Identify the need to obtain diagnostic studies, laboratory testing or consultation from other medical or surgical services as indicated. • Determine when a patient’s medical acuity requires admittance to an acute hospital setting for medical or surgical issues. • Be able to identify which patients require day rehabilitation, outpatient therapy, home care, or skilled nursing services. • Be able to develop knowledge of the pathophysiology and the prognosis of the various diagnostic groups seen in the outpatient setting. These include but are not limited to conditions of amputation, spine disorders, musculoskeletal extremity disorders, neuropathic disorders, wounds, chronic pain management, post brain injury and spinal cord injury aftercare and long term care and management. • Perform trigger point injections, as well as specific intra-articular and bursal injections. Gain experience and understand basic techniques involved in botox injections, epidurals, fluroscopically-guided procedures, phenol injections, and wound management. Acquisition of six competencies: 47
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Residents will be able to: Patient Care: • Identify patient and family concerns, begin discussion of outpatient plan and expected functional return. • Provide patient education, including providing patient and family with appropriate resources to further educate themselves about their condition. • Perform a fine-tuned physical exam. • Perform the following aspects of patient care: bowel/bladder programs, wound care, pain management modalities, fit and recommendation of orthoses, prescription writing for therapies, modalities, and P&O. Medical Knowledge: • Demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to: • Demonstrate an investigatory and analytic thinking approach to clinical situations. • Know and apply the basic and clinically supportive sciences which are appropriate to physical medicine and rehabilitation. Practice-Based Learning and Improvement: • Understand physiatry as a specialty and learn about the role of outpatient physiatry in the management of the patient population. • Apply current literature pertaining to the presenting patient population, especially in regard to standard of care and risk/benefit to patient, and identify potential areas that would benefit from further research. Communication: • Provide therapists with medical information, indications, contraindications and precautions of therapies based on comorbidities. • Demonstrate the skills necessary to communicate with the non-verbal patient, as well as the acceptable ways to communicate with patients who have receptive/expressive aphasia, are visually-impaired, and/or are hearing-impaired. • Maintain good communication channels with referring physicians, nurses, social workers, care coordinators and other hospital medical and surgical services. • Demonstrate ability to communicate to patients and family members about medical conditions, comorbidities, potential outcomes, complications, and prognosis. Professionalism: • Understand the importance of patient confidentiality and protect the patient’s rights. • Ensure appropriate patient follow-up or referral to other medical specialties. • Identify barriers (cultural, age, gender, economic, education level) that can impede patient’s goals and recovery. Systems-based care: 48
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Identify limitations of inpatient services and show working knowledge of local and regional specialty centers. • Demonstrate knowledge of billing processes, payer mix, balance between patient care and fiscal responsibility, and common CPT codes. • Effectively provide information to patients, social workers, and families members pertaining to disability funding and ratings, workman’s compensation, insurance benefits, ADA specifications, and job modifications. Principal Teaching/Learning Activities: Direct Collaborative Patient Evaluation Activity is the primary teaching tool for the outpatient service. During outpatient clinic the resident presents each patient to the attending on service. The attending sees every patient with the resident. For each patient, the attending may ask for demonstration of, or evaluate competency in, any of the six general competency areas. Additional Educational Activities: • Informal didactic sessions on physiatric issues specific to patient on service • Discussion of “classic articles” and up- to-date articles as they pertain to patient population. • Review pertinent questions from recent SAE exams. • Review labs, imaging studies, and electrodiagnostic results and interpret for the patient population. Readings/Resources: Potential references are limitless given the variety of patients seen on the Consult Service. You are expected to search for current literature related to your patients’ conditions. Some suggested sources are listed: • MDConsult or Medline. On-line sources are most accessible. • Braddom or your another general PM&R text for the Physiatric approach to the variety of problems seen on the outpatient service • Hoppenfeld and Magee for musculoskeletal exam • The 4-minute Neuro Exam for the neuro exam • Principles of Neurology by Adams & Victor is a general Neuorology text. • Primer on the Rheumatologic Diseases • Essentials of Musculoskeletal Care by Snider Resident Responsibilities: Perform the following tasks: • Perform history and physical examination on all patients on day of visit. • Do a complete chart review, interview and exam, and contact care providers and/or family as needed for necessary information. • Injection or treatment procedures commonly encountered in an outpatient PM&R setting. 49
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Review and discuss findings, prognoses, and plans with referring physicians or services. • Dictate an appropriate medical note to document care as well as to facilitate information transfer and billing. • Supervise and teach medical students rotating on the outpatient service. • Arrange for follow up medical and rehabilitation treatment and care. Expectations: • Residents are expected to be in clinic at start time and check in with clinic staff and supervising attending. • All encounter forms with ICD-9 and CPT with codes are to be sent with patient to check out to ensure billing is completed at the end of visit. • Clinic notes must be dictated within 24 hours of visit, if indicated. • Follow up on all labs, x-rays, MRI's etc ordered at clinic cisit and notify patient with results. • Any sample drugs given at clinic must be signed out in log book. Attend the following: • Educational activities – all PM&R scheduled educational activities. • Fluoroscopy guided injection procedures performed by faculty or fellow. Other educational responsibilities: • Observe therapy sessions with PT, OT, and SLP as appropriate for patients being followed and review functional status, progress and potential with therapists as required. • Read about the conditions and management of the patients seen. • Ask questions! Attending Responsibilities: • Schedule time for patient presentation with resident to maximize learning opportunities, • Observe resident’s presentation of patients and offer feedback. • Monitor resident performance of physical exam and give feedback and coaching • Review competency based issues with resident and provide feedback • Make assignments for literature search or further research into specific topics • Accept feedback regarding teaching and the rotation • Model evidence-based approach to physiatric management • Model and foster patient advocacy and humanistic and ethical behavior • Review mid-rotation and final rotation evaluations Evaluation: • The attending will provide ongoing feedback regarding resident performance during the rotation. The resident should feel comfortable discussing issues that arise during the course of the rotation. • A mid-rotation evaluation form will be completed and reviewed with the resident, addressing strengths and areas which need improvement in order to achieve competency. 50
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • The standard rotation evaluation form will be completed at the end of the rotation and reviewed with the resident by the appropriate attending, signed by both, and submitted to the residency coordinator. • The resident will fill out a rotation evaluation form to provide feedback about the rotation and the primary attending(s) with which he/she worked and submit it to the residency coordinator. Individual evaluations will remain anonymous. 51
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement E. ELECTRODIAGNOSTIC MEDICINE (EMG/NCS) Educational Goals The educational goals for the resident on the PM&R EMG/NCS rotation are: • To learn to perform a comprehensive electrodiagnostic evaluation of each patient and provide a concise diagnosis and potential plans for further treatment. • To understand the variety of conditions frequently encountered in electrodiagnostic medicine. • To determine a logical approach of testing for each individual condition. • To understand the electrophysiology of common normal and abnormal findings encountered in EMG/NCS. • To develop an extensive knowledge base of neuromuscular anatomy. • To understand and become familiar with the EMG/NCS apparatus and be able to troubleshoot common errors and problems encountered in EMG/NCS testing. • To develop in all of the six general competencies areas. Learning Objectives Rotation specific objectives: Residents completing the rotation will: 1. Be able to perform a focused history and physical examination that provides necessary medical information about the patient 2. Be able to perform a comprehensive electrodiagnostic evaluation and formulate a clear and concise diagnosis for the patient and referring physician, 3. Be able to recommend treatment to referring physician, if necessary, 4. Be able to interact effectively with physicians from other medial specialties and other medical personnel. Acquisition of six competencies: Residents will be able to: Patient Care: • Identify patient and family concerns associated with the testing process as well as the results. • Provide patient education, including providing patient and family with appropriate resources to further educate themselves about their condition. • Perform a comprehensive electrodiagnostic test. • Arrange for appropriate follow-up, if necessary. Medical Knowledge: • Demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. • Demonstrate an investigatory and analytic thinking approach to clinical situations. 52
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Know and apply the basic and clinically supportive sciences which are appropriate to electrodiagnostic medicine. Practice-Based Learning and Improvement: • Understand physiatry as a specialty and electrodiagnosis as a subspecialty of PM&R. • Apply current literature pertaining to the presenting patient population, especially in regard to standard of care and risk/benefit to patient, and identify potential areas that would benefit from further research. Communication: • Provide concise and timely information on the outcome of the EMG/NCS test to referring parties. • Demonstrate the skills necessary to communicate with the non-verbal patient, as well as the acceptable ways to communicate with patients who have receptive/expressive aphasia, are visually impaired, and/or are hearing-impaired. • Maintain good communication channels with medical staff at the EMG/NCS Lab. Professionalism: • Understand the importance of patient confidentiality and protect this patient’s rights. • Ensure appropriate patient follow-up • Identify barriers (cultural, age, gender, economic, education level) that can impede patient’s ability to undergo testing. Systems-based care: • Demonstrate knowledge of billing processes, payer mix, balance between patient care and fiscal responsibility, common CPT codes, and ICD-9 codes. • Effectively provide information to patients and family members (with HIPAA permission) pertaining to disability funding, insurance benefits, ADA specifications, and job modifications as appropriate. Principal Teaching/Learning Activities: Direct Collaborative Patient Evaluation Activity is the primary teaching tool for the EMG rotation. During EMG testing, the resident presents each patient to the attending on service. The resident will perform any necessary examination of the patient. Depending on the resident’s experience and level of comfort, he/she will observe or perform the test. The attending performs, assists, or supervises every patient with the resident. For each patient, the attending may ask for demonstration of, or evaluate competency in, any of the six general competency areas. Additional Educational Activities: • Informal didactic sessions on electrodiagnostic issues specific to the patient’s condition. • Attend EMG lecture series • Discussion of “classic articles” and up-to-date articles as they pertain to patient population. • Review pertinent questions from recent SAE exams. 53
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Review SEP results and their meaning. Readings/Resources: The resident is expected to search for current literature related to patients’ conditions. Some suggested sources are: • MDConsult or Medline. On-line sources are most accessible. • Braddom or another general PM&R text for the Physiatric approach to the variety of problems seen on the EMG rotation • Hoppenfeld and Magee for musculoskeletal exam • The 4-minute Neuro Exam for the neuro exam • Principles of Neurology by Adams & Victor is a general Neuorology text. • Electrodiagnosis in Diseases of Nerve and Muscle by Kimura • AAEM Mini-monographs • Electrodiagnostic Medicine by Dumitru • Manual of Nerve Conduction Velocity and Clinical Neurophysiology by DeLisa Resident Responsibilities: Perform the following tasks: • Perform history and physical examination on all patients. • Do a complete chart review, interview and exam, and contact care providers and/or family as needed for necessary information. • Initially observe EMG/NCS testing by faculty and become familiar with the equipment, the anatomy, and the electrophysiology. • When experienced with electrodiagnostic evaluation, begin to perform testing under supervision and eventually independently. • Request assistance or ask questions from faculty when necessary. • Dictate an appropriate history and physical. Document and record all test results. Dictate a clear and concise diagnosis after review with faculty. • Provide and explain to patient the results of the test, if necessary. • Supervise and teach junior residents and assist them in EMG/NCS testing. • Observe and experience the use and indications of SEP. Attend the following: • EMG testing in Electrophysiology Lab at UNC Hospitals. • Attend EMG lecture series that occurs every other week. Other educational responsibilities: • Observe SEPs and understand the indications and conditions commonly encountered in testing. • Read about the conditions and management of the patients seen. Attending Responsibilities: 54
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Schedule time for attending teaching sessions with resident to maximize learning opportunities. • Observe resident’s presentation of patients and offer feedback. • Monitor resident performance of electrodiagnostic testing and give feedback and coaching. • Review competency-based issues with resident and provide feedback. • Accept feedback regarding teaching and the rotation. • Model evidence-based approach to physiatric management. • Model and foster patient advocacy and humanistic and ethical behavior. • Review mid-rotation and final rotation evaluations. Evaluation: The attending will provide ongoing feedback regarding resident performance during the rotation. The resident should feel comfortable discussing issues that arise during the course of the rotation. A mid-rotation evaluation form will be completed and reviewed with the resident, addressing strengths and areas, which need improvement in order to achieve competency. The standard PM & R rotation evaluation form will be completed at the end of the rotation and reviewed with the resident by the appropriate attending, signed by both, and submitted to the residency coordinator. In addition, Neurology faculty will also provide his own individual feedback form for the review of the resident. The resident will fill out a rotation evaluation form to provide feedback about the rotation and the primary attending(s) with whom he/she worked and submit it to the residency coordinator. Individual evaluations will remain anonymous. 55
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement EMG/NCS Competency Check List Resident: Date Supervisor Motor NCS Median Ulnar Basic Peroneal Tibial Femoral Radial Supraclavicular Advanced Spinal Accessory Axillary Facial Blink Reflex B-C Reflex Sensory NCS Median Digital Palmar Ulnar Digital Palmar Basic Dorsal Ulnar Cut Superficial Radial Superficial Peroneal Sural Med Antebrachial Cut Lat Antebrachial Cut Post Antebrachial Cut Advanced Med Plantar Lat Plantar Lat Femoral Cutaneous Saphenous 56
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Other NCS F-Waves H-Relfex, Gastrocnemius H-Reflex, Other Median vs. Ulnar D4 Median Vs. Radial D1 Repetative Nerve Stimulation Inching Studies EMG Standard EMG Multi MUP Analysis Interference Pattern Analysis 57
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement F. COMMUNITY AND CARDIAC REHABILITATION Educational Goal: • At the completion of this rotation the resident will be able to prescribe and design specific programs for patient with heart and lung disorders, be familiar with process of geriatric evaluation, apply these techniques to geriatric rehabilitation, and have an understanding of the community-based rehabilitation services. Objectives: • Describe the important indications for cardiopulmonary exercise testing and the techniques used to assess. • Prescribe an exercise program for cardiopulmonary patients. • Design specific therapy programs for patients with heart and lung disorders. • Evaluate the functional status of patients in Geriatric Rehabilitation Clinic. • Identify patients at risk for functional decline. • Formulate a therapy program to restore function. • Be familiar with the following rehabilitative community resources: o North Carolina School for the Blind o Driving School o Rehabilitation in nursing facility o Vocational Rehabilitation Services. Acquisition of six competencies: Patient Care • Perform a complete and comprehensive physiatric history and physical examination. • Perform a history and physical examination that provides guidance in prescribing cardiopulmonary rehabilitation. • Educate and incorporate the patient into planning and decision-making. • Identify the psychosocial impact and how that influences the care of the patient. Medical Knowledge • Incorporate the physiology of disease processes into patient diagnosis and management. • Define the analytic approach to differential diagnosis. Practice-Based Learning and Improvement • Understand the intersection between cardiology and physiatry in the management of cardiopulmonary patients. 58
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Communication • Provide information, education, and treatment plans to patients, family and care providers. • Coordinate care with therapy. • Coordinate care and communicate treatment plans with referring physicians and healthcare providers. Professionalism • Provide the utmost respect and courtesy to patients. • Be responsive to patient needs. Systems-based care • Serve as an advocate to the patient in negotiating the services prescribed in the community. • Educate patients in vocational rehabilitation resources available to them. • Educate low vision patients in community resources available to them. • Educate patients in the process of return to driving following illness or injury. Learning Activities of the Rotation: • The resident will complete a one-month rotation, which includes Cardiac Rehabilitation 3 half days a week, 2 days with Geriatric Evaluation Clinic, and 2 half days a week for community requirements, which consist of : o Attend the North Carolina School of the Blind to learn about services offered to vision impaired patients. o Local Driving School o Local Nursing Facility o Vocational Rehabilitation Counselor Reading/Resources: • Guralnik JM, Ferrucci L, Balfour JL, Wolpato S, Di Iorio A. Progressive versus Catastrophic Loss of the Ability to Walk: Implications for the Prevention of Mobility Loss. JAGS. 2001; 49: 1463-1470. • Chaves PHM, Garrett ES, Fried LP. Predicting the Risk of Mobility Difficulty in older women with screening nomograms. Archives Internal Medicine. 2000; 160: 2525-2533. • Fried LP, Young Y, Rubin G, Bandeen-Roche K, WHAS II Collaborative Research Group. Self-reported preclinical disability identifies older women with early declines in performance and early disease. Journal of Clinical Epidemiology. 2001; 54: 889-901. 59
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Results of a U.S. Consensus Panel of Experts. Archives of Internal Medicine. 2003; 163: 2716-2724. Resident Responsibilities: • Residents should attend each of the above named activities during their rotation. • Complete rotation evaluation • Prescribe exercise program for cardiopulmonary patients • Identify the available resources for vision impaired patients living in the community • Identify and instruct patients in the process of the return to driving program Attending Responsibilities: • Observe resident’s case presentation and provide feedback. • Offer options to the resident to assist in coordination of care. • Review assigned reading assignments with the resident. • Complete and review rotation evaluation. Evaluation: Resident performance will be observed by the attending in charge of the rotations. A written evaluation is completed at the end of the rotation. 60
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement G. ELECTIVE ROTATION (Duration: 2 months) Residents will be given an opportunity to experience two months of elective rotations during their PGY-3 and/or 4 year. Elective rotations will be available within the University of North Carolina Hospitals or affiliates. External electives may be requested but need to be pre-approved through the institutions involved including Office of GME of UNC Hospitals and Program Director. The maximum duration of external electives is 4 weeks in total. Each elective rotation may be taken for a maximum of 4 weeks. Residents must submit requests for elective rotation plans, including learning objectives, goals, areas of ACGME competencies to be addressed, and identify elective rotation faculty supervisor, to the mentor and Program Director for approval one month prior to the start of their elective month. The request must include up to three choices and must specify the length requested for each choice. If the Program Director has not received a written plan for the scheduled elective rotation prior to start of the rotation, the Program Director will assign a rotation for the resident. The resident may take one week of vacation per month of elective rotation. The following electives are available for residents with prior arrangement and approval: • Anesthesiology • Complementary and Alternative Medicine • Hand and foot services • Sports Medicine • Rheumatology • Radiology • Research • Specialty Clinics • Orthotics and Prosthetics • PT/OT/SP 61
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement H. RESEARCH ROTATION Educational Goals: The resident on the Research Rotation will be able: • To appreciate the importance of reading and evaluating the literature as fundamental to medical practice. • To be able to investigate and evaluate their patient care practices. • To be able to evaluate and assimilate scientific evidence. • To be able to improve patient care by practicing evidence-based medicine. • To understand the ethics of human subjects research. • To stimulate residents to become clinician-researchers. Learning Objectives: Residents completing the research rotation/research curriculum/ project will: • Be able to perform a thorough literature review (locate the necessary resources). • Be able to do a critical appraisal of the scientific studies and assimilate the evidence as it relates to his/her research topic/case report. • Be able to pose a meaning research questions based on this assimilation of the evidence. • Be able to apply knowledge of study designs and statistical methods to the appraisal of clinical studies and/or the design and implementation of his/her research project. • Be able to apply the following concepts to reviewing the literature and/or designing a study: • Study designs: Correlational studies; experimental studies; cohort studies • Independent/dependent variables • Controlling variability • Identifying the subject population and methods of obtaining a sample reliability, validity and generalizability • Be able to use information technology to formulate, implement, and manage their research project. Principal Teaching/Learning Activities: • Development and implementation of a research project • Research Lecture Block: The 4 to 6-week didactic teaching component consists of the following topics: -- Science and the Scientific Method -- Basics of designing a study: developing research questions and determining its significance; designing the study; defining the subject population and method for choosing the sample, determining the outcomes measures. -- Researching the literature: performing a literature search -- Critical appraisal Readings/Resources: 62
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Health Sciences Librarians • Hulley, S. B., Cummings, S. R., Browner, W. S., Grady, D., Hearst, N., & Newman, T. B. (2001, 2nd ed.). Designing Clinical Research: An Epidemiologic Approach. New York: Lippincott Williams & Wilkins Publishers. Resident Responsibilities: • Attend Journal Club. • Attend Research Block sessions. • Complete a research project. All residents are required to complete an original research project. This includes activities such as development and implementation of an individual research idea or collaboration with an identified mentor. Case reports are appropriate for this requirement. A case report must demonstrate a thorough review of the literature, a clear explanation of why the case is important, and a statement of the research, which the case could stimulate. Each resident must identify a mentor in the department to advise and supervise his/her progress. • These projects should be of high quality, such that they are at a level worthy of submission for platform or poster presentation at a national meeting. A manuscript must be submitted which should be the quality adequate to submit for publication. All work must be completed prior to graduation. Perform the following tasks: The resident must complete the following according to a time line (see attached sample timeline): • Identify a mentor within the department. • Submit a project proposal. • Complete the human subjects research training and HIPPA training for researchers. • Present proposal at research committee meeting in order to obtain feedback. • Submit final project proposal. • Complete the IRB process. • Demonstrate understanding of the importance of the study or case report, which includes a thorough literature review. • Complete progress reports at designated times. • Complete a manuscript that is adequate to submit for publication. • Present project at a special Departmental Research Symposium. • Submit project for presentation at an appropriate meeting. Associate research director and Faculty Mentor Responsibilities: The faculty responsible for the research rotation will be available to: • Brainstorm research possibilities. • Help design projects. 63
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement • Review and provide feedback on: research proposal, IRB applications, progress reports, abstract submissions, final manuscript, and final presentation. • Monitor performance and provide feedback. Evaluation: The faculty responsible for the research rotation/research curriculum/project will provide on- going feedback to the resident regarding his/her progress and the quality of the project. The resident is expected to function independently, with support from his/her mentor. Therefore, the expectation is that the resident will seek help and advice as he/she progresses through the stages of the project. The resident’s evaluation will reflect the resident’s initiative and follow- through of developing his/her proposal and completing the project. The research evaluation form will be completed at the end of the rotation and reviewed with the resident by the mentor and the faculty member responsible for the research rotation. Both the resident and the responsible faculty member will sign the evaluation and submit it to the residency coordinator. The resident will fill out an evaluation form to provide suggestions for improving the implementation of this segment of the curriculum. 64
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement RESIDENCY PROGRAM REQUIREMENTS FOR SCHOLARLY ACTIVITY Necessity of a research component: Exposure to research is an essential component of a comprehensive training program in Physical Medicine and Rehabilitation. Clinicians need to understand the basics of research methodology and statistics in order to critically evaluate the literature and implement proven therapeutic and diagnostic interventions. In order to deliver the highest level of care, we need physiatrists who will vigorously evaluate unproven but frequently used methods and interventions. With managed care environments, clinical outcomes research and evidenced-based practice are becoming even more important. Goals for Resident Research Requirement: • To gain a greater appreciation for the role of research in the development of PM&R as a medical specialty, and to understand the importance of reading and evaluating the literature. • To instill residents with a working knowledge of research methodology and statistics in order to critically evaluate scientific literature. • To stimulate residents to become clinician-researchers. Completion of scholarly activity: To meet this goal, all residents are encouraged to complete an original research project. This includes activities such as development and implementation of an individual research idea or collaboration with an identified mentor. First author of a case report is appropriate for this requirement. A case report must demonstrate a thorough review of the literature, a clear explanation of why the case is important, and a statement of the research, which the case could stimulate. Each resident must identify a mentor in the department to advise and supervise his/her progress. These projects should be of high quality, such that they are at a level worthy of submission for platform or poster presentation at a national meeting. A manuscript must be generated of the quality to submit for publication. All work must be completed prior to graduation. 65
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Timeline for PMR Research Project DEADLINES 2nd year: April 4 IRB: Rights of Human Subjects Training (submit certificate to Dr. Kowlowitz) 2nd year: May 2 Submit Research question and name of mentor 3rd year: September Submit Project Proposal Contact Dr. Kowlowitz or Dr. Yang to discuss your proposal with members of Research Committee Meeting 3rd year: October 31 Final Proposal submitted ABSOLUTE FINAL (Including draft of IRB submission) DEADLINE 3rd year: November 21 IRB application submitted November - April Sign up for journal club to present your evidence-based literature review 4th year: Sept 18 Progress Report submitted October - January Sign up for Grand Rounds Mini-presentation of your work in progress 4th year: February Draft of Project Report submitted 4th year: April Final Project Report submitted; obtain signature of approval from Director of Research and Residency Program Director Arrange to deliver a practice presentation at a Research Committee Meeting Graduation Presentation to PM&R department 66
    • UNC Dept of Physical Medicine & Rehabilitation Residency Program Manual Supplement Project Proposal (FINAL Submission deadline: DATE) Name: _________________________ Date Submitted: _________________________ Title of Proposal: Mentor: Study question: Rationale/Background: Subjects (if applicable): Methodology: Research project: Include the type of design; study procedures; sequential description of what will be asked of/done to subjects and follow up procedures; assignment of subjects to various arms of the study if applicable; clear operational definitions of all study variables (i.e. independent variable(s): what is being manipulated; dependent variables: outcome measurements) Other project: EBM literature review; developing a best practice guideline based on the evidence; case report including a critical review of the literature; development and piloting of a measurement instrument: Describe the steps you will take (i.e. how you will pick your cases; search words you will use for your literature search; how you will evaluate the articles, etc) Potential Outcomes: Anticipated Problems: Potential strategies to overcome each problem: Resources needed: Equipment: _ Personnel: _______________________________ Statistical Analysis: _ Other: _ Possible budget items needed: 67