- Email: [email protected]
Using a General Internal Medicine Consult Service to Teach Residents and Care for Patients
Using a General Internal Medicine Consult Service to Teach Residents and Care for Patients JAMES B. LEWIS, MD; ROBERT E. MORRISON, MD; ANITA ARNOLD, MD
ABSTRACT: A general medicine consult service can be difficult to manage because house staff are unaccustomed to the consultant role, the required knowledge is new and diverse, and the curriculum may be poorly defined. Within the last 3 decades, perioperative consultation has been more rigorously studied and a more evidence-based method has emerged. The consultative service at the University of Tennessee has developed a systematic approach to medical consultation that pro-
vides efficient, evidence-based patient care along with resident education. The curricular model, which reflects the newly required competencies of the American Board of Internal Medicine and the Residency Review Committee, is transferable to most training settings. KEY INDEXING TERMS: Consultation; Perioperative; Curriculum; Competencies; Assessment. [Am J Med Sci 2003; 326(2):73–78.]
C
Center at Memphis (the MED). The model provides solutions to diverse patient problems, uses a highly organized and structured approach, and has a welldefined, regularly updated curricular content. This model has been updated recently to conform to the new American College of Graduate Medical Education’s core competencies.8 The goals of this article are to outline the structure of a successful medical consultative service, discuss the educational content in light of the new American Board of Internal Medicine (ABIM)-required competencies, and provide a teaching method for preoperative consultation.
onsultative medicine, including preoperative medicine, was taught and practiced in an empiric fashion before the mid-1970s. In 1977, an article by Lee Goldmann and colleagues revolutionized the field.1 This study, largely conducted by internal medicine house staff, established the first multifactorial cardiac risk index for patients undergoing noncardiac procedures. Over the next 10 to 15 years, textbooks and monographs authored by Corman and Bolt, Goldmann, Lubin, Kammerer and Gross, and Merli and Weitz popularized the field.2–7 Bolstered by national workshops and a dramatic increase in journal articles, internal medicine training programs began to incorporate consultative medicine formally into their curricula. In 1987, in concert with these national developments, physicians at 1 of our affiliated hospital centers, Baptist Memorial Hospital, a large community facility, developed a highly successful teaching general internal medicine (GIM) consult service. Within the last 3 years, we have implemented this prototype model into 3 other hospital centers in our program, all within a 2-block radius: The University of Tennessee/Bowld Hospital, the Veterans Administration Medical Center, and The Regional Medical From the University of Tennessee, Memphis, Department of Medicine, Division of General Internal Medicine, Memphis, Tennessee. Submitted July 2, 2002; accepted April 29, 2003. Correspondence: Robert E. Morrison, M.D., University of Tennessee, Department of Medicine, Division of General Internal Medicine, 842 Jefferson Avenue, Room A607, Memphis, TN 38103(E-mail: [email protected]). THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
Structure The GIM consult service is composed of 2 to 3 internal medicine residents and 2 attending general internists, 1 at the University Service (University of Tennessee/Bowld Hospital and the MED) and the other at the Veterans Administration Medical Center. Bedside attending physician rounds at each of the sites lasts 1 to 2 hours daily. One of the consult attending physicians is charged with the didactic content of the rotation and conducts 4 1-hour meetings with all assigned consult residents each week. The consult attending physicians are not assigned ward responsibilities during their months of consult medicine but do carry out all other assigned academic and ambulatory medicine patient care tasks. Consults originate from non–internal medicine services, including orthopedics, obstetrics/gynecology, neurology, psychiatry, neurosurgery, general surgery, plastic surgery, urology, and others. Both 73
Consultative Medicine—Curriculum and Content
private and nonprivate patients are seen, with attending physicians actively role modeling and directly participating in decision-making and patient care. Level of Service An aggressive approach toward generating consults and providing customer satisfaction is necessary, because the consult service is dependent on other medical and nonmedical services. Consults are always seen promptly by the resident and staffed by an attending physician the same day or early the following morning. A consult medicine resident may track anywhere from 4 to 10 patients on any single day. New consultations at a single site may vary from 1 to 8 within a 24-hour period with an average of 1 to 2 consults occurring at night. Senior internal medicine residents cover the service at night and contact the internal medicine attending physician on call when the consult is completed to review the care plan. Recommendations are carefully detailed on the consult form; often, an additional note is entered in the chart. After completion, most consultations are communicated to the requesting service by telephone to provide a maximal level of service and to avoid any misunderstandings or controversy over management. The GIM consult service has no unnecessary or artificial barriers to care and sees patients on the wards, in the emergency department, and in the intensive care units. Patients requiring invasive hemodynamic monitoring and/or ventilator management are referred to the pulmonary/critical care service or trauma intensive care team. If the consulting physician so desires, the GIM consulting team will write orders and take over management of the nonsurgical components of care. The success of this approach is documented at the MED, where this system was instituted on July 1, 2000. At that time the average number of patient consults tracked by the ward teams was about 6. Two years after the initiation of the program, the GIM consult service was tracking an average of 12 to 15 patients per day. Educational Content/Curriculum The consultative medicine rotation has as its overall goal the production of an effective, efficient, knowledgeable internal medicine consultant within a 1-month period. Objectives, including the knowledge, skills, and attitudes required for effective medical consultation, are listed in Appendix 1. Both the new ABIM guidelines on the 6 new competencies and the competency-based curriculum at the University of Rochester provided source materials for our curriculum.9,10 There are 3 primary learning venues: direct patient care, attending physician rounds, and case-based didactic teaching sessions. 74
At the start of the month, each resident and attending physician is referred to an up-to-date, online, 20-article syllabus and given a set of 400 multiple-choice questions. The questions are based largely on the reading material but also incorporate many of the more unusual cases seen by the faculty over the last 15 years and are regularly updated to incorporate good teaching cases seen each year. A listing of textbooks and monographs on consultative medicine is available on the program web site and in the library.11–17 In addition, there are 2 evidencebased online resources, UpToDate (http://www.uptodate.com.) and Physicians Information and Evaluation Resource (PIER; http://pier.acponline.org), which are updated several times each year. UpToDate is available both online and via CD-ROM and features a large set of monographs on medical consultation. PIER is sponsored by the ACP-ASIM and includes a comprehensive module on consultative medicine. UpToDate online requires a subscription and password for use. PIER requires ACP-ASIM membership.18,19 Teaching of residents centers on each patient during attending physician rounds. House staff contact their attending physician promptly after the consultation is completed, and staffing with teaching occurs at that time. The didactic sessions last 1 hour each and are scheduled to permit attendance by all the GIM consult residents. The first 2 sessions are devoted to an overview of preoperative consultation and postoperative care (see Appendix 2). The remaining sessions consist of interactive, Socratic, case-based learning as the consult team reviews the test questions. The questions for each session cover a specific topic such as cardiovascular perioperative evaluation and management, consultation on psychiatric patients, consultation on obstetrical patients, and others. One of the hospital sites has a preoperative clinic, where the outpatient experience strongly complements the inpatient experience. A literature search is performed annually to update the reference list using such search terms as “preoperative,” “perioperative,” and “postoperative complications.” One of the course directors also regularly attends a national course on preoperative and postoperative care. The Society of General Internal Medicine has an interest group on medical consultation and provides a helpful web site for medical educators in this field.18 Test questions are updated and expanded based on current experience. A final examination consisting of 20 case-based questions with multiple-choice answers complements the casebased learning and further encourages residents to master the material. Evaluation Assessment of the success of the curricular objectives is done in 5 ways. First, attending physicians August 2003 Volume 326 Number 2
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complete the standard new ABIM global assessment form, evaluating the 6 new competencies on a 9-point scale. A chart-review audit section has been added to this form to assist in assessing residents’ medical record-keeping. Attending physicians are not required to review a specific number of charts but are asked to assign a 1 to 9 rating based on format, legibility, clinical judgment and diagnostic reasoning, and patient outcomes. Each resident is given a multiple choice, 20-question final examination that measures primarily knowledge but also includes clinical scenarios to test communication skills and professionalism. Residents use 3 evaluation methods to provide feedback about the rotation: a questionnaire immediately after the month ends, a program survey at the end of the year, and a postgraduation survey every 2 years. The ABIM now provides forms for each of these surveys. A comparison of the end-of-year program survey from 2000 to 2002 shows a dramatic rise in the category entitled “Overall Quality of Training.” Using a Likert scale with “1” as poor and “5” as excellent, the overall quality/value of the training in consultative medicine rose from an average of 2.0 in 2000 to 4.1 in 2002. The primary interventions producing this change were the institution of the casebased learning sessions and the system-wide consult service. Residents have commented favorably upon the use of evidence-based medicine, the more positive view they have of non–internal medicine house staff, and the pleasure of using their internal medicine skills over a broad range of problems. Residents who have completed training and are now in practice report the rotation was helpful in hospital consultative work, particularly in the area of perioperative evaluation. Conclusion In summary, the consultative medicine service at the University of Tennessee has been effective in training residents in both perioperative evaluation and management and in general medicine consultation. The course objectives, clinical venues, and assessment methods should be easily reproducible in most house staff training programs whether predominantly public or private. The assessments attest to the success of this model. Appendix 1 Consultative Medicine Rotation Objectives This rotation provides residents with the opportunity to integrate his/her consultative skills in general internal medicine, to acquire skills in risk assessment of surgical patients, and to manage medical problems in the preoperative and postoperative period. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
Patient Care. At the end of this rotation, the resident should be able to: Perform a complete history and physical examination of patients scheduled to undergo an operative procedure or who have been referred by a non– internal medicine service for evaluation. Analyze all available information regarding the patient’s condition obtained through the history and physical examination, chart review, interpretation of laboratory data, and any other available sources. Make informed recommendations to the consulting physician about diagnostic and therapeutic options as well as limitations, advantages, and risks based upon clinical judgment, scientific evidence, available treatment modalities, and patient preference. Manage perioperative and general medicine problems as requested by the consulting physician. Medical Knowledge. Research the medical literature relevant to the cases presented and become more adept at critical appraisal and presentation of this information in an organized manner. Integrate knowledge of pharmacology, including adverse drug reactions and interactions into decisions regarding therapeutic plans. Improve his/her knowledge of the sensitivity, specificity, and predictive value of diagnostic tests in consultative medicine, including the usefulness and validity of diagnostic tests. Improve his/her knowledge in the content areas of all medical subspecialties relevant to consultative medicine in terms of differential diagnosis and principles of management. Practice-Based Learning and Improvement. Evaluate gaps in his/her knowledge, skills, and attitudes about consultative medicine and use evidence-based medicine to fill these gaps. Review unexpected or adverse outcomes to improve subsequent therapeutic decisions and learn to appropriately report such situations (morbidity and mortality review conferences). Develop personal organizational skills that smooth delegation of patient care responsibilities to other caregivers when unable to personally provide care (when away in continuity clinics or during rotational changes). Interpersonal and Communications Skills. Demonstrate effective communication skills with patients and their relatives. Demonstrate effective communication skills with all health care professionals. Demonstrate the ability to communicate effectively in writing in the medical record or other appropriate written follow-up to the consulting physician. Professionalism. Exemplify professional behavior toward patients, relatives, and all other members of the health care team. 75
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Display sensitivity to diversity, including cultural, gender, age, religion, socioeconomic status, and beliefs of patients and other colleagues. Reflect regard for all applicable rules and regulations including confidentiality, scientific integrity, and informed consent. Gain self-awareness about his/her own feelings concerning the ethical issues involved in patient care and how these can impact on his/her ability to provide care or make appropriate recommendations. Demonstrate empathy and compassion in dealing with patients and relatives. Recognize one’s own limitations and to seek help when appropriate. Systems-Based Practice. Demonstrate the ability and willingness to access and use the resources, providers, and systems necessary to provide optimal care. Demonstrate an understanding of the multidisciplinary approach to the provision of patient care. Apply evidence-based, cost-conscious strategies to diagnosis and disease management. Integrate all legal, ethical, sociopolitical, and economic factors affecting the provision of patient care by the physician to his/her patient. Appendix 2 Preoperative Consultative Teaching Method House staff are taught to perform preoperative consultation in a highly organized fashion. In addition to the usual internist’s history and physical examination, housestaff should inquire about anesthesia-related problems in the patient or family members, bleeding problems in patient or family, corticosteroid use within the last year, drugs including herbals that can cause platelet dysfunction, and exercise tolerance (ABCDE). In planning management, house staff are told that a few facts about each internal medicine subspecialty will complete the consultation. The subspecialties of most relevance to the evaluation are cardiology, pulmonary medicine, endocrinology, hematology, hepatology, infectious diseases, nephrology, rheumatology, and neurology. Cardiovascular perioperative evaluation and risk assessment require application of the ACC/AHA guidelines.19 The complete guidelines are listed on both the ACC and AHA web sites (http://www. acc.org and http://www.americanheart.org). -Adrenergic receptor blocker use is revolutionizing perioperative care of the cardiac patient.20 –24 Pulmonary assessment and management are detailed in Smetana’s review25 with a recent multifactorial risk index detailed by Arozullah et al.26 Risk factors include chronic obstructive pulmonary disease, poor general health status, use of general anesthesia, smoking history for more than 20 packyears, and type of surgery. Major knee and hip surgeries and surgery within the chest and/or near 76
the diaphragm increase pulmonary risk. The keys to deep vein thrombosis risk assessment and prophylaxis are outlined in the 2001 Chest review.27 Risk factors for deep vein thrombosis include a history of thrombophlebitis or pulmonary embolism, congestive heart failure, nephrotic syndrome, estrogen therapy, pregnancy, neoplasia, inflammatory bowel disease, dysproteinemia, Behçet syndrome, obesity, types of surgery as noted above, hyperhomocystinemia, immobilization, stroke, paralysis, heparin-induced thrombocytopenia, the antiphospholipid syndrome, paroxysmal nocturnal hemoglobinuria, and the inherited hypercoagulable states. Endocrinological assessment focuses on the diabetic patient and potentially the adrenally suppressed patient. Diabetic perioperative management remains controversial, although several studies support the role of hyperglycemia in causing infectious complications.28 –30 The most recent comprehensive review of diabetic perioperative management is in the Archives of Internal Medicine.31 Metformin must be stopped at the time of surgery because of the risk of lactic acidosis if toxic levels accumulate. The drug may be resumed 3 days later assuming stable renal function. Supplemental steroid dosing in the stressed, adrenally suppressed patient is outlined by Salem et al32 and, more recently, by Coursin and Wood.33 Hematologically, measurement of platelet counts and coagulation tests should be limited to patients who are at risk for bleeding based on history and physical examination. Patients can receive surgery if the phase platelet count is greater than 50,000/L and the international normalized ratio is less than 1.5.34 Exceptions are cardiac and neurologic surgery, where hemostasis is crucial and platelet counts should be more than 100,000/L. Ansell et al35 describe stopping and starting anticoagulation in the patient at risk for thromboembolic events. In chronic liver disease, surgical risk is perhaps best assessed using the Child-Pugh scoring system.36 Acute viral or alcoholic hepatitis patients have a relatively high perioperative mortality, and surgery should be avoided if possible until the patient recovers. The 2 key decisions in infectious disease and perioperative management are the use of antibiotics for wound prophylaxis and for the prevention of endocarditis. It is always wise to verbally discuss antibiotic use with the surgeon to avoid any controversy in the medical record. The presence of a predisposed valvular heart lesion plus surgery involving a mucosal surface (ie, likely to cause a bacteremia) are essential ingredients before committing to endocarditis prophylaxis. Two recent references list recommended wound prophylaxis regimens, and JAMA in 1997 detailed endocarditis prophylaxis.37–39 The patient with chronic renal failure is at risk for bleeding because of thrombasthenia. This risk is August 2003 Volume 326 Number 2
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mitigated if the patient is receiving long-term erythropoietin therapy or has had recent dialysis, ideally the day before surgery. It is prudent to achieve a preoperative serum potassium level of less than 5.5 mEq/L, although studies disagree as to the necessity for this.40,41 From a rheumatologic standpoint, the greatest danger in perioperative management is the rheumatoid arthritic patient with atlantoaxial subluxation. This abnormality can result in spinal cord damage with endotracheal intubation. Flexion and extension cervical spine radiographs should be performed on any rheumatoid patient with long-standing arthritis, neck complaints, or any neurological complaints referable to the spine. Kelly and Conn42 have published a detailed summary of perioperative management of the rheumatic disease patient describing which drugs to stop in the perioperative setting, such as NSAIDS and aspirin, cyclophosphamide, sulfasalazine, leflunomide, etanercept, infliximab, and azathioprine. Finally, any patient with a seizure disorder should have a therapeutic antiepileptic blood level measured before any surgical procedure. References 1. Goldman L, Caldera D, Nussbaum S, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977;297:845–50. 2. Corman LC, Bolt RJ, editors. Medical evaluation of the surgical patient. Med Clin North Am 1979;63:1129 –390. 3. Goldmann DR, Brown FH, Levy WK, et al.Medical care of the surgical patient: a problem-oriented approach to management. Philadelphia: JB Lippincott; 1982. 4. Lubin MF, Walker HK, Smith RS, editors. Medical management of the surgical patient. Boston: Butterworths; 1982. 5. Kammerer WS, Gross RJ, editors. Medical consultation: role of the internist on surgical, obstetric, and psychiatric services. Baltimore: Williams & Wilkins; 1983. 6. Merli GJ, Weitz HH, eds. Preoperative consultation. Med Clin North Am 1987;71:353–590. 7. Merli GJ, Weitz HH, editors. Medical management of the surgical patient. Philadelphia: WB Saunders; 1992. 8. Accreditation Council for Graduate Medical Education outcome project. Competencies and outcome assessment; 2001. Available at: URL: http://www.acgme.org/outcome/assess/ assHome.asp 9. American Board of Internal Medicine. Portfolio for internal medicine residency programs. Evaluating your residents: new competencies, new forms; 2001. Available at: URL: http://www.abim.org/pubs/competencies.pdf. 10. Bordley DR. University of Rochester internal medicine program competency based curriculum; 2001. Available at: URL: http://www.apdim.med.edu/locker/revised_curriculum.pdf. 11. Merli GJ, Weitz HH, editors. Medical management of the surgical patient, 2nd ed. Philadelphia: WB Saunders; 1998. 12. Lubin MF, Walker HK, Smith RB, editors. Medical management of the surgical patient, 3rd ed. Philadelphia: Lippincott; 1995. 13. Gross RJ, Caputo GM, editors. Medical consultation: the internist on surgical, obstetric, and psychiatric services. Baltimore: Williams & Wilkins; 1998. 14. Harrington JT, ed. Consultation in internal medicine, 2nd ed. St. Louis: Mosby Year Book, Inc.; 1996.
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15. Goldmann DR, Brown FH, Guarnieri DM, editors. Perioperative medicine: the medical care of the surgical patient. New York: McGraw-Hill, Health Professions Division; 1994. 16. Merli GJ, Weitz HH, Lubin MF, editors. Postoperative medical complications. Med Clin North Am 2001;85:1101– 328. 17. Cohn SL, ed. Preoperative medical consultation. Med Clin North Am 2003;87:1–301. 18. Society of General Internal Medicine. Interest groups: consultants. Available at: URL: http://www.sgim.org/ interestgroup.cfm#consultant 19. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery-executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2002; 39:542–53. 20. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high risk patients undergoing vascular surgery. N Engl J Med 1999;341:1789 –94. 21. Mangano DT, Layug EL, Wallace A, et al. Effect of atenolol on mortality and cardiovascular mortality after noncardiac surgery. N Engl J Med 1996;335:1713–20. 22. Urban MK, Markowitz SM, Gordon MA, et al. Postoperative prophylactic administration of beta-adrenergic blockers in patients at risk for myocardial ischemia. Anesth Analg 2000;90:1257– 61. 23. Auerbach AD, Goldman L. -Blocker and reduction of cardiac events in noncardiac surgery. JAMA 2002;287:1445–7. 24. Ferguson TB, Coombs LP, Peterson ED. Preoperative beta-blocker use and mortality and morbidity following CABG surgery in North America. JAMA 2002;287:2221–7. 25. Smetana GW. Preoperative pulmonary evaluation. N Engl J Med 1999;340:937– 44. 26. Arozullah AM, Khuri SF, Henderson WG, et al. Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med 2001;135:847–57. 27. Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest 2001;119:132S–75S. 28. Van Den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001;345:1359 – 67. 29. Golden SH, Peart-Vigilance C, Kao WH, et al. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care 1999;22: 1408 –14. 30. Pomposelli JJ, Baxter JK, Babineau TJ, et al. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. JPEN J Parenter Enteral Nutr 1999;22:77– 81. 31. Jacober SJ, Sowers JR. An update on perioperative management of diabetes. Arch Intern Med 1999;159:2405–11. 32. Salem M, Tainsch RE, Brombery J, et al. Perioperative glucocorticoid coverage. Ann Surg 1994;219:416 –25. 33. Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA 2002;287:236 – 40. 34. Kearon C, Hirsch J. Management of anticoagulation before and after elective surgery. N Engl J Med 1997;336:1506 –11. 35. Ansell J, Hirsh J, Dalen J, et al. Managing oral anticoagulant therapy. Chest 2001;119:33S– 8S. 36. Pugh RNH, Murray-Lyon IM, Dawson JL, et al. Transection of the esophagus for bleeding esophageal varices. Brit J Surg 1973;60:646 –9.
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37. Anonymous. Antimicrobial prophylaxis in surgery [published erratum appears in Med Lett Drugs Ther 2001;43: 108]. Med Lett Drugs Ther 2001;43:92–7. 38. Weed HG. Antimicrobial prophylaxis in the surgical patient. Med Clin North Am 2003;87:59 –75. 39. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. JAMA 1997;277:1794 – 801.
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40. Haimov M, Glabman S, Schupak E, et al. General surgery in patients on maintenance hemodialysis. Ann Surg 1974; 179:863–7. 41. Krishman M. Preoperative care of patients with kidney disease. Am Fam Phys 2002;66:1471– 6. 42. Kelley JT, Conn DL. Perioperative management of the rheumatic disease patient. Bull Rheum Dis 2002;51(6):1–7.
August 2003 Volume 326 Number 2
ABSTRACT: A general medicine consult service can be difficult to manage because house staff are unaccustomed to the consultant role, the required knowledge is new and diverse, and the curriculum may be poorly defined. Within the last 3 decades, perioperative consultation has been more rigorously studied and a more evidence-based method has emerged. The consultative service at the University of Tennessee has developed a systematic approach to medical consultation that pro-
vides efficient, evidence-based patient care along with resident education. The curricular model, which reflects the newly required competencies of the American Board of Internal Medicine and the Residency Review Committee, is transferable to most training settings. KEY INDEXING TERMS: Consultation; Perioperative; Curriculum; Competencies; Assessment. [Am J Med Sci 2003; 326(2):73–78.]
C
Center at Memphis (the MED). The model provides solutions to diverse patient problems, uses a highly organized and structured approach, and has a welldefined, regularly updated curricular content. This model has been updated recently to conform to the new American College of Graduate Medical Education’s core competencies.8 The goals of this article are to outline the structure of a successful medical consultative service, discuss the educational content in light of the new American Board of Internal Medicine (ABIM)-required competencies, and provide a teaching method for preoperative consultation.
onsultative medicine, including preoperative medicine, was taught and practiced in an empiric fashion before the mid-1970s. In 1977, an article by Lee Goldmann and colleagues revolutionized the field.1 This study, largely conducted by internal medicine house staff, established the first multifactorial cardiac risk index for patients undergoing noncardiac procedures. Over the next 10 to 15 years, textbooks and monographs authored by Corman and Bolt, Goldmann, Lubin, Kammerer and Gross, and Merli and Weitz popularized the field.2–7 Bolstered by national workshops and a dramatic increase in journal articles, internal medicine training programs began to incorporate consultative medicine formally into their curricula. In 1987, in concert with these national developments, physicians at 1 of our affiliated hospital centers, Baptist Memorial Hospital, a large community facility, developed a highly successful teaching general internal medicine (GIM) consult service. Within the last 3 years, we have implemented this prototype model into 3 other hospital centers in our program, all within a 2-block radius: The University of Tennessee/Bowld Hospital, the Veterans Administration Medical Center, and The Regional Medical From the University of Tennessee, Memphis, Department of Medicine, Division of General Internal Medicine, Memphis, Tennessee. Submitted July 2, 2002; accepted April 29, 2003. Correspondence: Robert E. Morrison, M.D., University of Tennessee, Department of Medicine, Division of General Internal Medicine, 842 Jefferson Avenue, Room A607, Memphis, TN 38103(E-mail: [email protected]). THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
Structure The GIM consult service is composed of 2 to 3 internal medicine residents and 2 attending general internists, 1 at the University Service (University of Tennessee/Bowld Hospital and the MED) and the other at the Veterans Administration Medical Center. Bedside attending physician rounds at each of the sites lasts 1 to 2 hours daily. One of the consult attending physicians is charged with the didactic content of the rotation and conducts 4 1-hour meetings with all assigned consult residents each week. The consult attending physicians are not assigned ward responsibilities during their months of consult medicine but do carry out all other assigned academic and ambulatory medicine patient care tasks. Consults originate from non–internal medicine services, including orthopedics, obstetrics/gynecology, neurology, psychiatry, neurosurgery, general surgery, plastic surgery, urology, and others. Both 73
Consultative Medicine—Curriculum and Content
private and nonprivate patients are seen, with attending physicians actively role modeling and directly participating in decision-making and patient care. Level of Service An aggressive approach toward generating consults and providing customer satisfaction is necessary, because the consult service is dependent on other medical and nonmedical services. Consults are always seen promptly by the resident and staffed by an attending physician the same day or early the following morning. A consult medicine resident may track anywhere from 4 to 10 patients on any single day. New consultations at a single site may vary from 1 to 8 within a 24-hour period with an average of 1 to 2 consults occurring at night. Senior internal medicine residents cover the service at night and contact the internal medicine attending physician on call when the consult is completed to review the care plan. Recommendations are carefully detailed on the consult form; often, an additional note is entered in the chart. After completion, most consultations are communicated to the requesting service by telephone to provide a maximal level of service and to avoid any misunderstandings or controversy over management. The GIM consult service has no unnecessary or artificial barriers to care and sees patients on the wards, in the emergency department, and in the intensive care units. Patients requiring invasive hemodynamic monitoring and/or ventilator management are referred to the pulmonary/critical care service or trauma intensive care team. If the consulting physician so desires, the GIM consulting team will write orders and take over management of the nonsurgical components of care. The success of this approach is documented at the MED, where this system was instituted on July 1, 2000. At that time the average number of patient consults tracked by the ward teams was about 6. Two years after the initiation of the program, the GIM consult service was tracking an average of 12 to 15 patients per day. Educational Content/Curriculum The consultative medicine rotation has as its overall goal the production of an effective, efficient, knowledgeable internal medicine consultant within a 1-month period. Objectives, including the knowledge, skills, and attitudes required for effective medical consultation, are listed in Appendix 1. Both the new ABIM guidelines on the 6 new competencies and the competency-based curriculum at the University of Rochester provided source materials for our curriculum.9,10 There are 3 primary learning venues: direct patient care, attending physician rounds, and case-based didactic teaching sessions. 74
At the start of the month, each resident and attending physician is referred to an up-to-date, online, 20-article syllabus and given a set of 400 multiple-choice questions. The questions are based largely on the reading material but also incorporate many of the more unusual cases seen by the faculty over the last 15 years and are regularly updated to incorporate good teaching cases seen each year. A listing of textbooks and monographs on consultative medicine is available on the program web site and in the library.11–17 In addition, there are 2 evidencebased online resources, UpToDate (http://www.uptodate.com.) and Physicians Information and Evaluation Resource (PIER; http://pier.acponline.org), which are updated several times each year. UpToDate is available both online and via CD-ROM and features a large set of monographs on medical consultation. PIER is sponsored by the ACP-ASIM and includes a comprehensive module on consultative medicine. UpToDate online requires a subscription and password for use. PIER requires ACP-ASIM membership.18,19 Teaching of residents centers on each patient during attending physician rounds. House staff contact their attending physician promptly after the consultation is completed, and staffing with teaching occurs at that time. The didactic sessions last 1 hour each and are scheduled to permit attendance by all the GIM consult residents. The first 2 sessions are devoted to an overview of preoperative consultation and postoperative care (see Appendix 2). The remaining sessions consist of interactive, Socratic, case-based learning as the consult team reviews the test questions. The questions for each session cover a specific topic such as cardiovascular perioperative evaluation and management, consultation on psychiatric patients, consultation on obstetrical patients, and others. One of the hospital sites has a preoperative clinic, where the outpatient experience strongly complements the inpatient experience. A literature search is performed annually to update the reference list using such search terms as “preoperative,” “perioperative,” and “postoperative complications.” One of the course directors also regularly attends a national course on preoperative and postoperative care. The Society of General Internal Medicine has an interest group on medical consultation and provides a helpful web site for medical educators in this field.18 Test questions are updated and expanded based on current experience. A final examination consisting of 20 case-based questions with multiple-choice answers complements the casebased learning and further encourages residents to master the material. Evaluation Assessment of the success of the curricular objectives is done in 5 ways. First, attending physicians August 2003 Volume 326 Number 2
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complete the standard new ABIM global assessment form, evaluating the 6 new competencies on a 9-point scale. A chart-review audit section has been added to this form to assist in assessing residents’ medical record-keeping. Attending physicians are not required to review a specific number of charts but are asked to assign a 1 to 9 rating based on format, legibility, clinical judgment and diagnostic reasoning, and patient outcomes. Each resident is given a multiple choice, 20-question final examination that measures primarily knowledge but also includes clinical scenarios to test communication skills and professionalism. Residents use 3 evaluation methods to provide feedback about the rotation: a questionnaire immediately after the month ends, a program survey at the end of the year, and a postgraduation survey every 2 years. The ABIM now provides forms for each of these surveys. A comparison of the end-of-year program survey from 2000 to 2002 shows a dramatic rise in the category entitled “Overall Quality of Training.” Using a Likert scale with “1” as poor and “5” as excellent, the overall quality/value of the training in consultative medicine rose from an average of 2.0 in 2000 to 4.1 in 2002. The primary interventions producing this change were the institution of the casebased learning sessions and the system-wide consult service. Residents have commented favorably upon the use of evidence-based medicine, the more positive view they have of non–internal medicine house staff, and the pleasure of using their internal medicine skills over a broad range of problems. Residents who have completed training and are now in practice report the rotation was helpful in hospital consultative work, particularly in the area of perioperative evaluation. Conclusion In summary, the consultative medicine service at the University of Tennessee has been effective in training residents in both perioperative evaluation and management and in general medicine consultation. The course objectives, clinical venues, and assessment methods should be easily reproducible in most house staff training programs whether predominantly public or private. The assessments attest to the success of this model. Appendix 1 Consultative Medicine Rotation Objectives This rotation provides residents with the opportunity to integrate his/her consultative skills in general internal medicine, to acquire skills in risk assessment of surgical patients, and to manage medical problems in the preoperative and postoperative period. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
Patient Care. At the end of this rotation, the resident should be able to: Perform a complete history and physical examination of patients scheduled to undergo an operative procedure or who have been referred by a non– internal medicine service for evaluation. Analyze all available information regarding the patient’s condition obtained through the history and physical examination, chart review, interpretation of laboratory data, and any other available sources. Make informed recommendations to the consulting physician about diagnostic and therapeutic options as well as limitations, advantages, and risks based upon clinical judgment, scientific evidence, available treatment modalities, and patient preference. Manage perioperative and general medicine problems as requested by the consulting physician. Medical Knowledge. Research the medical literature relevant to the cases presented and become more adept at critical appraisal and presentation of this information in an organized manner. Integrate knowledge of pharmacology, including adverse drug reactions and interactions into decisions regarding therapeutic plans. Improve his/her knowledge of the sensitivity, specificity, and predictive value of diagnostic tests in consultative medicine, including the usefulness and validity of diagnostic tests. Improve his/her knowledge in the content areas of all medical subspecialties relevant to consultative medicine in terms of differential diagnosis and principles of management. Practice-Based Learning and Improvement. Evaluate gaps in his/her knowledge, skills, and attitudes about consultative medicine and use evidence-based medicine to fill these gaps. Review unexpected or adverse outcomes to improve subsequent therapeutic decisions and learn to appropriately report such situations (morbidity and mortality review conferences). Develop personal organizational skills that smooth delegation of patient care responsibilities to other caregivers when unable to personally provide care (when away in continuity clinics or during rotational changes). Interpersonal and Communications Skills. Demonstrate effective communication skills with patients and their relatives. Demonstrate effective communication skills with all health care professionals. Demonstrate the ability to communicate effectively in writing in the medical record or other appropriate written follow-up to the consulting physician. Professionalism. Exemplify professional behavior toward patients, relatives, and all other members of the health care team. 75
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Display sensitivity to diversity, including cultural, gender, age, religion, socioeconomic status, and beliefs of patients and other colleagues. Reflect regard for all applicable rules and regulations including confidentiality, scientific integrity, and informed consent. Gain self-awareness about his/her own feelings concerning the ethical issues involved in patient care and how these can impact on his/her ability to provide care or make appropriate recommendations. Demonstrate empathy and compassion in dealing with patients and relatives. Recognize one’s own limitations and to seek help when appropriate. Systems-Based Practice. Demonstrate the ability and willingness to access and use the resources, providers, and systems necessary to provide optimal care. Demonstrate an understanding of the multidisciplinary approach to the provision of patient care. Apply evidence-based, cost-conscious strategies to diagnosis and disease management. Integrate all legal, ethical, sociopolitical, and economic factors affecting the provision of patient care by the physician to his/her patient. Appendix 2 Preoperative Consultative Teaching Method House staff are taught to perform preoperative consultation in a highly organized fashion. In addition to the usual internist’s history and physical examination, housestaff should inquire about anesthesia-related problems in the patient or family members, bleeding problems in patient or family, corticosteroid use within the last year, drugs including herbals that can cause platelet dysfunction, and exercise tolerance (ABCDE). In planning management, house staff are told that a few facts about each internal medicine subspecialty will complete the consultation. The subspecialties of most relevance to the evaluation are cardiology, pulmonary medicine, endocrinology, hematology, hepatology, infectious diseases, nephrology, rheumatology, and neurology. Cardiovascular perioperative evaluation and risk assessment require application of the ACC/AHA guidelines.19 The complete guidelines are listed on both the ACC and AHA web sites (http://www. acc.org and http://www.americanheart.org). -Adrenergic receptor blocker use is revolutionizing perioperative care of the cardiac patient.20 –24 Pulmonary assessment and management are detailed in Smetana’s review25 with a recent multifactorial risk index detailed by Arozullah et al.26 Risk factors include chronic obstructive pulmonary disease, poor general health status, use of general anesthesia, smoking history for more than 20 packyears, and type of surgery. Major knee and hip surgeries and surgery within the chest and/or near 76
the diaphragm increase pulmonary risk. The keys to deep vein thrombosis risk assessment and prophylaxis are outlined in the 2001 Chest review.27 Risk factors for deep vein thrombosis include a history of thrombophlebitis or pulmonary embolism, congestive heart failure, nephrotic syndrome, estrogen therapy, pregnancy, neoplasia, inflammatory bowel disease, dysproteinemia, Behçet syndrome, obesity, types of surgery as noted above, hyperhomocystinemia, immobilization, stroke, paralysis, heparin-induced thrombocytopenia, the antiphospholipid syndrome, paroxysmal nocturnal hemoglobinuria, and the inherited hypercoagulable states. Endocrinological assessment focuses on the diabetic patient and potentially the adrenally suppressed patient. Diabetic perioperative management remains controversial, although several studies support the role of hyperglycemia in causing infectious complications.28 –30 The most recent comprehensive review of diabetic perioperative management is in the Archives of Internal Medicine.31 Metformin must be stopped at the time of surgery because of the risk of lactic acidosis if toxic levels accumulate. The drug may be resumed 3 days later assuming stable renal function. Supplemental steroid dosing in the stressed, adrenally suppressed patient is outlined by Salem et al32 and, more recently, by Coursin and Wood.33 Hematologically, measurement of platelet counts and coagulation tests should be limited to patients who are at risk for bleeding based on history and physical examination. Patients can receive surgery if the phase platelet count is greater than 50,000/L and the international normalized ratio is less than 1.5.34 Exceptions are cardiac and neurologic surgery, where hemostasis is crucial and platelet counts should be more than 100,000/L. Ansell et al35 describe stopping and starting anticoagulation in the patient at risk for thromboembolic events. In chronic liver disease, surgical risk is perhaps best assessed using the Child-Pugh scoring system.36 Acute viral or alcoholic hepatitis patients have a relatively high perioperative mortality, and surgery should be avoided if possible until the patient recovers. The 2 key decisions in infectious disease and perioperative management are the use of antibiotics for wound prophylaxis and for the prevention of endocarditis. It is always wise to verbally discuss antibiotic use with the surgeon to avoid any controversy in the medical record. The presence of a predisposed valvular heart lesion plus surgery involving a mucosal surface (ie, likely to cause a bacteremia) are essential ingredients before committing to endocarditis prophylaxis. Two recent references list recommended wound prophylaxis regimens, and JAMA in 1997 detailed endocarditis prophylaxis.37–39 The patient with chronic renal failure is at risk for bleeding because of thrombasthenia. This risk is August 2003 Volume 326 Number 2
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mitigated if the patient is receiving long-term erythropoietin therapy or has had recent dialysis, ideally the day before surgery. It is prudent to achieve a preoperative serum potassium level of less than 5.5 mEq/L, although studies disagree as to the necessity for this.40,41 From a rheumatologic standpoint, the greatest danger in perioperative management is the rheumatoid arthritic patient with atlantoaxial subluxation. This abnormality can result in spinal cord damage with endotracheal intubation. Flexion and extension cervical spine radiographs should be performed on any rheumatoid patient with long-standing arthritis, neck complaints, or any neurological complaints referable to the spine. Kelly and Conn42 have published a detailed summary of perioperative management of the rheumatic disease patient describing which drugs to stop in the perioperative setting, such as NSAIDS and aspirin, cyclophosphamide, sulfasalazine, leflunomide, etanercept, infliximab, and azathioprine. Finally, any patient with a seizure disorder should have a therapeutic antiepileptic blood level measured before any surgical procedure. References 1. Goldman L, Caldera D, Nussbaum S, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977;297:845–50. 2. Corman LC, Bolt RJ, editors. Medical evaluation of the surgical patient. Med Clin North Am 1979;63:1129 –390. 3. Goldmann DR, Brown FH, Levy WK, et al.Medical care of the surgical patient: a problem-oriented approach to management. Philadelphia: JB Lippincott; 1982. 4. Lubin MF, Walker HK, Smith RS, editors. Medical management of the surgical patient. Boston: Butterworths; 1982. 5. Kammerer WS, Gross RJ, editors. Medical consultation: role of the internist on surgical, obstetric, and psychiatric services. Baltimore: Williams & Wilkins; 1983. 6. Merli GJ, Weitz HH, eds. Preoperative consultation. Med Clin North Am 1987;71:353–590. 7. Merli GJ, Weitz HH, editors. Medical management of the surgical patient. Philadelphia: WB Saunders; 1992. 8. Accreditation Council for Graduate Medical Education outcome project. Competencies and outcome assessment; 2001. Available at: URL: http://www.acgme.org/outcome/assess/ assHome.asp 9. American Board of Internal Medicine. Portfolio for internal medicine residency programs. Evaluating your residents: new competencies, new forms; 2001. Available at: URL: http://www.abim.org/pubs/competencies.pdf. 10. Bordley DR. University of Rochester internal medicine program competency based curriculum; 2001. Available at: URL: http://www.apdim.med.edu/locker/revised_curriculum.pdf. 11. Merli GJ, Weitz HH, editors. Medical management of the surgical patient, 2nd ed. Philadelphia: WB Saunders; 1998. 12. Lubin MF, Walker HK, Smith RB, editors. Medical management of the surgical patient, 3rd ed. Philadelphia: Lippincott; 1995. 13. Gross RJ, Caputo GM, editors. Medical consultation: the internist on surgical, obstetric, and psychiatric services. Baltimore: Williams & Wilkins; 1998. 14. Harrington JT, ed. Consultation in internal medicine, 2nd ed. St. Louis: Mosby Year Book, Inc.; 1996.
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15. Goldmann DR, Brown FH, Guarnieri DM, editors. Perioperative medicine: the medical care of the surgical patient. New York: McGraw-Hill, Health Professions Division; 1994. 16. Merli GJ, Weitz HH, Lubin MF, editors. Postoperative medical complications. Med Clin North Am 2001;85:1101– 328. 17. Cohn SL, ed. Preoperative medical consultation. Med Clin North Am 2003;87:1–301. 18. Society of General Internal Medicine. Interest groups: consultants. Available at: URL: http://www.sgim.org/ interestgroup.cfm#consultant 19. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery-executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2002; 39:542–53. 20. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high risk patients undergoing vascular surgery. N Engl J Med 1999;341:1789 –94. 21. Mangano DT, Layug EL, Wallace A, et al. Effect of atenolol on mortality and cardiovascular mortality after noncardiac surgery. N Engl J Med 1996;335:1713–20. 22. Urban MK, Markowitz SM, Gordon MA, et al. Postoperative prophylactic administration of beta-adrenergic blockers in patients at risk for myocardial ischemia. Anesth Analg 2000;90:1257– 61. 23. Auerbach AD, Goldman L. -Blocker and reduction of cardiac events in noncardiac surgery. JAMA 2002;287:1445–7. 24. Ferguson TB, Coombs LP, Peterson ED. Preoperative beta-blocker use and mortality and morbidity following CABG surgery in North America. JAMA 2002;287:2221–7. 25. Smetana GW. Preoperative pulmonary evaluation. N Engl J Med 1999;340:937– 44. 26. Arozullah AM, Khuri SF, Henderson WG, et al. Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med 2001;135:847–57. 27. Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest 2001;119:132S–75S. 28. Van Den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001;345:1359 – 67. 29. Golden SH, Peart-Vigilance C, Kao WH, et al. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care 1999;22: 1408 –14. 30. Pomposelli JJ, Baxter JK, Babineau TJ, et al. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. JPEN J Parenter Enteral Nutr 1999;22:77– 81. 31. Jacober SJ, Sowers JR. An update on perioperative management of diabetes. Arch Intern Med 1999;159:2405–11. 32. Salem M, Tainsch RE, Brombery J, et al. Perioperative glucocorticoid coverage. Ann Surg 1994;219:416 –25. 33. Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA 2002;287:236 – 40. 34. Kearon C, Hirsch J. Management of anticoagulation before and after elective surgery. N Engl J Med 1997;336:1506 –11. 35. Ansell J, Hirsh J, Dalen J, et al. Managing oral anticoagulant therapy. Chest 2001;119:33S– 8S. 36. Pugh RNH, Murray-Lyon IM, Dawson JL, et al. Transection of the esophagus for bleeding esophageal varices. Brit J Surg 1973;60:646 –9.
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37. Anonymous. Antimicrobial prophylaxis in surgery [published erratum appears in Med Lett Drugs Ther 2001;43: 108]. Med Lett Drugs Ther 2001;43:92–7. 38. Weed HG. Antimicrobial prophylaxis in the surgical patient. Med Clin North Am 2003;87:59 –75. 39. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. JAMA 1997;277:1794 – 801.
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40. Haimov M, Glabman S, Schupak E, et al. General surgery in patients on maintenance hemodialysis. Ann Surg 1974; 179:863–7. 41. Krishman M. Preoperative care of patients with kidney disease. Am Fam Phys 2002;66:1471– 6. 42. Kelley JT, Conn DL. Perioperative management of the rheumatic disease patient. Bull Rheum Dis 2002;51(6):1–7.
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