IM Oncology Inpatient Curriculum

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IM Oncology Inpatient Curriculum

  1. 1. University of Kansas Medical Center Internal Medicine Residency Curriculum Medical Oncology In-Patient Rotation Revised 12/2006 The Residency Review Committee requires that the resident and attending have a face-to-face meeting at the beginning of the rotation to review the learning objectives. Section Chief, Hematology/Oncology: Stephen Williamson, M.D. Educational Purpose for Rotation: The inpatient medical oncology service provides for the acute care and palliative management of cancer patients admitted from the outpatient oncology service, transferred from other in patient services, and accepted from multiple out-of-hospital referral sources. This patient population provides house staff the opportunity to further expand their generic clinical skills in the acute care of critically ill patients at an accelerated pace, under close attending staff supervision, and to learn principles of management more uniquely associated with the care of cancer patients. The knowledge base and skills required to manage the complications of malignancy and its treatment are emphasized. In addition, principles of diagnosis and treatment employed in the management of various malignancies are reviewed. Teaching Methods: • Required attendance at Medicine Department meetings: daily morning report sessions, daily noon resident core conferences, weekly grand rounds, and morbidity and mortality conference • Weekly tumor board (in depth discussion of individual case presentations, including review of pathology materials, review of radiologic studies, discussion of staging, and detailed consideration of therapeutic options) • Weekly oncology journal club (presentation of current oncology or oncology related articles, followed by critical review by staff oncologists and fellows) • Monthly conference for treatment protocol review (case presentations for discussion of available, applicable protocols for therapy) • Didactic lectures 2-3 times per week on oncology or oncology related topics • Daily 30-45 min. small group discussions of active diagnostic and therapeutic problems on service, often conducted in a problem based learning approach • Mini presentations by medical students and residents of selected topics related to assigned patient Clinical Experience and Level of Resident Supervision:
  2. 2. House staff responsibilities: 1. Call rotation --- Residents on the inpatient team will alternate evening “short” call, from 5 to 8 pm on weekdays. In general, each intern will take short call two nights per week, and the senior resident will cover the remaining evening. In addition, interns on the team can expect to take two 24- hour “long” weekend calls per month, typically a Saturday and a Sunday. 2. Oncology service --- a. Residents are responsible for admission histories and physical examinations on all patients, presentation of all new admissions on rounds, and maintaining daily progress notes on all patients. b. Residents are expected to give short presentations on subjects pertinent to active patients on service throughout the rotation. c. All residents will participate in one ½ day oncology clinic per week. 3. General medicine clinic --- all residents will continue to be responsible for attending their one ½ day medicine clinic each week while on the oncology in patient service. Residents will be closely supervised by the inpatient oncology attending in all aspects of patient care. Each patient will be seen with the attending on a daily basis, and all new patients will be discussed with the attending to ensure that appropriate diagnostic and therapeutic care plans are in place. Patients admitted in the evening should be checked out with either the service attending or the oncology fellow on call. Competency-Based Educational Goals and Objectives by Level of Training: Medical Knowledge: Learning objectives in medical knowledge for residents at all levels of training: 1. Principles of palliative care a. Pain management, including dosing, scheduling and routes of administration of pain medications b. Appropriate employment of sedation and antidepressant medications c. Employment of hospice programs d. Awareness of ethical issues surrounding end-of-life care e. Communication skills with terminally ill patients and their families 2. Employment of blood components, and recognition of and appropriate intervention in associated untoward effects, including hemolytic transfusion reaction; avoidance of wasting 3. Principles of chemotherapy, including specific side effects and their management
  3. 3. 4. Neurologic complications associated with malignant disease and its treatment 5. Management of oncologic emergencies, other than neurologic - SVC obstruction, cardiac tamponade, and acute tumor lysis syndrome 6. Management of the febrile granulocytopenic patient 7. Approach to hyponatremia in the oncology patient, including the diagnosis of SIADH and its management 8. Management of hypercalcemia 9. Basic principles of blood coagulation 10. Hypercoagulable states --- diagnosis and management, including the diagnosis and treatment of complicating pulmonary embolism 11. Signs, symptoms, diagnostic evaluation/staging and stage- determined therapy for common cancers • PGY-1: o Use written and electronic reference and literature sources to learn about patients' general medical diseases. o Demonstrate growth in knowledge of oncology over the course of the rotation. o Be able to apply knowledge to patient care to begin to formulate a care plan. o Demonstrate of understanding of pathophysiologic mechanisms • PGY-2: All of the above, and: o Be aware of indications, contraindications and risks of commonly used medications and procedures in inpatient oncology. o Demonstrate knowledge of epidemiologic and social-behavioral sciences. o Apply the basic, clinical, epidemiologic and social behavioral science knowledge to the care of the patient o Successfully complete the required Internet-based training module for the rotation. • PGY-3: All of the above, and: o Demonstrate an investigatory and analytic approach to clinical situations. • Methods of Evaluation: • Summative evaluation by attending physician • Internet-based training module completion and performance • A “take home” quiz, with questions covering the above learning objectives for all levels of training, will be given to each resident at the beginning of the rotation to ensure the resident’s awareness of areas of knowledge in which competency will be expected by the end of the rotation.
  4. 4. Patient Care: • PGY-1: o Recognize limits in clinical experience and know when to ask for help. o Understand and weigh alternatives for diagnosis and treatment of common oncologic conditions. o Efficient, skillful performance of history and physical examination o Contribute to development and completion of management plans. o Recognize deterioration in clinical condition in a hospitalized oncology patient and take appropriate initial diagnostic and therapeutic steps. o Be able to establish appropriate differential diagnosis and to pursue appropriate diagnostic workup and initial treatment • PGY-2: All of the above, and: o Understand and weigh alternatives for diagnosis and treatment of less common oncologic conditions. o Apply diagnostic procedures and therapies appropriately. o Elicit subtle findings on physical examination. o Obtain a precise, logical and efficient history. o Interpret results of procedures properly. o Be able to manage multiple problems at once. o Develop and carry out management plans. o Triage patients to appropriate level of care. • PGY-3: All of the above, and: o Reason well in ambiguous situations. o Spend time appropriate to the complexity of the problem. o Anticipate potential deterioration in clinical condition and take diagnostic and therapeutic steps. • Evaluation Methods: Observed patient interaction and feedback (mini- CEX), attending evaluation Professionalism: • PGY-1: o Display a compassionate, thoughtful approach to patients and their families o Display professional and appropriate dress and behavior o Participate in harmonious, productive interaction with peers o Demonstrate collegial, respectful interaction with nursing and paramedical personnel, but with willingness to accept a leadership role when appropriate o Demonstrate intellectually honest, enthusiastic interaction with attending staff, exhibiting a willingness to learn
  5. 5. o Acknowledge errors and work to minimize them. • PGY-2: All of the above, and: o Display initiative and leadership. o Be able to delegate responsibility to others. • PGY-3: All of the above, and: o Demonstrate commitment to on-going professional development. • Evaluation Methods: Attending evaluation, based on direct observation as well as solicited feedback from other team members, including care coordinator, social worker, and unit 42 floor nurses when appropriate. Systems-Based Practice: • PGY-1: o Be a patient advocate. o Advocate for high quality patient care and assist vulnerable hospitalized patients in dealing with system complexity. o Demonstrate ability to adapt to change. • PGY-2: All of the above, and: o Apply knowledge of how to partner with hospital-based health care team members, consultants, and outpatient oncologists to assess, coordinate and improve patient care. o Use systematic approaches to reduce errors. o Participate in developing ways to improve systems of practice and health management. • PGY-3: All of the above, and: o Provide cost effective care. o Understand how individual practices affect other health care professionals, organizations and society. o Demonstrate knowledge of types of medical practice and delivery systems, including hospice services. o Practice effective allocation of health care resources that does not compromise the quality of care. • Evaluation Methods: Attending evaluation, care coordinator evaluation Practice-Based Learning and Improvement: • PGY-1: o Understand his or her limitations of knowledge. o Show willingness to learn from mistakes. o Be self motivated to acquire knowledge. o Accept feedback and develops self-improvement plans. • PGY-2: All of the above, and: o Undertake self-evaluation with insight and initiative. o Facilitate the learning of students and other health care professionals.
  6. 6. o Be able to access and apply multiple sources of information to practice evidence-based patient care. • PGY-3: All of the above, and: o Analyze personal practice patterns systematically, and look for ways to improve. • Evaluation Methods: Attending evaluation Interpersonal and Communication Skills: • PGY-1: o Write pertinent and organized progress notes. o Dictate timely, concise, and cohesive discharge summaries. o Use effective listening, narrative and non-verbal skills to elicit and provide information. o Work effectively as a member of the health care team. o Create and sustain therapeutic and ethically sound relationships with patients and families. • PGY-2: All of the above, and: o Provide appropriate education and counseling to patients, families and colleagues. o Be able to discuss end of life care with patient/families with skill and compassion. o Work effectively as a leader of the health care team. • PGY-3: All of the above, and: o Be able to communicate with consultants and referring physicians with confidence and clarity. • Evaluation Methods: Attending and peer evaluations, mini-CEX Suggested resources: 1. Resident packet with selected handouts, textbook (The American Cancer Society’s Clinical Oncology), and selected articles. 2. Perry MC, ed. The Chemotherapy Source Book, 2nd ed. Baltimore: Williams and Wilkins, 1997. 3. Chu E, DeVita V. Physicians’ Cancer Chemotherapy Drug Manual. Sudberry, MA: Jones and Bartlett, 2001. 4. The EPEC Project (Education of Physicians on End-of-life Care), American Medical Society. 5. Snyder L, Quill TE, ed. Physician’s Guide to End-of-Life Care, Philadelphia: American College of Physicians – American Society of Internal medicine.
  7. 7. 6. Haskell CM, ed. Cancer Treatment, 5th ed. Philadelphia: W.B. Saunders Co., 2001. 7. DeVita V, Hellman S, Rosenberg SA, ed. Cancer – Principles and practice of Oncology, Philadelphia: Lippincott Williams and Wilkins, 2001.
  8. 8. Fast Facts, a project of the National Residency End-of-Life Curriculum Project, funded by the Robert Wood Johnson Foundation, are distributed by e-mail every two weeks. The complete collection of Fast Facts is available for downloading at HREF="http://www.eperc.mcw.edu/" MACROBUTTON HtmlResAnchor www.eperc.mcw.edu. FAST FACT AND CONCEPTS #69 END-OF-LIFE EDUCATION PROJECT PSEUDOADDICTION David E. Weissman, MD The term Pseudoaddiction was first used in 1989 to describe an iatrogenic syndrome resulting from poorly treated pain. The index case was a 17y/o man with leukemia, pneumonia and chest wall pain. The patient displayed behaviors (moaning, grimacing, increasing requests for analgesics) wrongly interpreted by the medical physicians and nurses as indicators of addiction, rather than of inadequately treated pain. Put simply, Pseudoaddiction is something that we do to patients, through our fears and mis-understanding of pain, pain treatment and addiction. Diagnostic Features • Behaviors that suggest to the health care provider the possibility of psychological dependence (addiction):  Moaning or other physical behaviors in which the patient is trying to demonstrate to the provider that they are in pain;  Clock-watching or repeated requests for medication prior to the prescribed interval;  Pain complaints that seem “excessive” to the given pain stimulus; • Inadequately prescribed and titrated opioid analgesics; typically the use of an opioid of inadequate potency (e.g. 50 mg of meperidine) and/or at an excessive dosing interval (e.g. oral morphine q6 hours prn). Anytime there is a suggestion, because of escalating pain behaviors, that a patient on opioids may be “addicted”, Pseudoaddiction should be ruled-out. Perform a complete pain assessment and review the recent analgesic history: • Is this a pain syndrome that typically responds to opioids? • Is the current opioid dose, route and schedule appropriate? If so, has a reasonable attempt at dose escalation been made? • Is there any past medical history to suggest a substance abuse disorder? Complete a comprehensive addiction assessment if such a disorder is suspected. • Pseudoaddiction improves with the provision of adequate analgesia, including opioids. In contrast, addiction gets worse when analgesia, including opioids, is administered. Management If you believe the current problem is Pseudoaddiction, there are two key management steps: 1) 1. Establish trust—a primary issue in most cases is the loss of trust between the patient and the health care providers. The physician and nursing staff should meet to discuss how they will restore a trusting therapeutic relationship; outside assistance from a pain or palliative care service may be helpful. Plan to meet with the patient and openly discuss the events leading up to the current problem; engage the patient in the decision process about the current and future use of analgesics. 2) 2. Prescribe opioids at pharmacologically appropriate doses and schedules; aggressively dose escalate until analgesia is achieved or toxicities develop (see FF # 18, 20, 36). Frequently re-evaluate progress in pain management and ask for consultation assistance..
  9. 9. References Weissman DE and Haddox JD. Opioid pseudoaddiction. Pain 1989 36:363-366. Kowal N. What is the issue? Pseudoaddiction or undertreatment of pain. Nursing Economics 1999; 17:348- 349. Sees KL and Clark HW. Opioid use in the treatment of chronic pain: assessment of addiction. J Pain Symptom Manage 1993; 8:257-264. Copyright and Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Fast Facts and Concepts #69 Pseudoaddiction. Weissman DE. June 2002. End- of-Life Physician Education Resource Center www.eperc.mcw.edu. Please e-mail suggested future topics for Fast Facts; Let us know how you used this material—send an e-mail describing the educational format and the learner reaction. Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.
  10. 10. Review of Goals and Objectives with Resident Block ______ Rotation_________________________________ Resident statement: The above goals and objectives were reviewed with me at the beginning of my rotation, and I understand the expectations for the rotation and how I will be evaluated. Resident Signature: ______________________________________________________ Printed Name: ______________________________________________________ Date: ______________________________________________________ Staff Signature: ______________________________________________________ I have discussed with my staff my need for a Mini-CEX during this block. 

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