CORE

MEDICINE
CLERKSHIP
CURRICULUM GUIDE
A RESOURCE FOR TEACHERS AND LEARNERS
Version 3.0
2006

CDIM

SGIM

CLERKSHIP DIRECTORS
IN INTERNAL MEDICINE

SOCIETY OF GENERAL
INTERNAL MEDICINE

CDIM/SGIM
CORE MEDICINE CLERKSHIP
CURRICULUM GUIDE VERSION 3.0 (2006)
UPDATE TASK FORCE
Task Force Leaders
Thomas M. De Fer, MD
Co-Director

Sara B. Fazio, MD
Co-Director

Clerkship Directors in Internal Medicine

Society of General Internal Medicine

Clerkship Director
Washington University School of Medicine
Campus Box 8121
660 S. Euclid Avenue
St. Louis, Missouri 63110
(314) 747-4366
[email protected]

Clerkship Director
Harvard Medical School Beth Israel Deaconess
Medical Center
Shapiro Clinical Center 631 H
Sixth Floor
330 Brookline Avenue
Boston, Massachusetts 02215
(617) 667-1338
[email protected]

Special Advisor
Allan Goroll, MD
Chair, Clerkship Directors Committee
Professor of Medicine
Harvard Medical School
Massachusetts General Hospital
Ambulatory Care Center suite 645
15 Parkman St.
Boston, MA 02114

Task Force Members

Erica Friedman, MD

Dan A. Henry, MD

Associate Dean for Undergraduate Medical

Education
Mount Sinai School of Medicine
One Gustave L. Levy Place
Box 1127
New York, New York 10029
(212) 241-8572
[email protected]

Course Director Multidisciplinary Ambulatory

Experiences and Advanced Inpatient
Experiences
University of Connecticut
School of Medicine
263 Farmington Avenue
Clinical Education AG 069
Farmington, Connecticut 06030
(860) 679-3821
[email protected]

Task Force Members (continued)

Mary Ann Kuzma, MD

James L. Sebastian, MD

Clerkship Director
Drexel University College of Medicine
2900 Queen Lane
Room 221
Philadelphia, Pennsylvania 19129
(215) 991-8526
[email protected]

Director of Student Teaching Programs

Department of Medicine
Medical College of Wisconsin
Froedtert Memorial Lutheran Hospital
Suite 4100
9200 W. Wisconsin Avenue
Milwaukee, Wisconsin 53226
(414) 456-6793
[email protected]

Cynthia H. Ledford, MD
Clerkship Director
Ohio State University College of Medicine
201 Means Hall
1654 Upham Drive
Columbus, Ohio 43221
(614) 293-8589
[email protected]

Kathleen F. Ryan, MD
Clerkship Director
Drexel University College of Medicine
245 N. 15th Street
Mail Stop 427
Philadelphia, Pennsylvania 19102
(215) 762-7296
[email protected]

Glenda Westmoreland, MD
Director of Geriatrics Education
Director, Geriatric Medicine Fellowship
Indiana University School of Medicine
1001 W. 10th Street, OPW-M200
Indianapolis, Indiana 46202
(317) 630-6906
[email protected]

Terry M. Wolpaw, MD
Associate Dean for Curricular Affairs
Case School of Medicine
10900 Euclid Avenue, T402
Cleveland, Ohio 44106-4924
(216) 368-6986
[email protected]

Project Administrators
Nicole V. Baptista

Charles P. Clayton

Policy Associate
Clerkship Directors in Internal Medicine
2501 M Street, NW
Suite 550
Washington, DC 20037
(202) 861-8600
[email protected]

Vice President for Policy

Clerkship Directors in Internal Medicine
2501 M Street, NW
Suite 550
Washington, DC 20037
(202) 861-8600
[email protected]

CDIM/SGIM
CORE MEDICINE CLERKSHIP
CURRICULUM GUIDE VERSION 3.0 (2006)
TABLE OF CONTENTS
VERSION 3.0 TASK FORCE MEMBERS

INTRODUCTION

APPENDIX I: ACGME OUTCOME PROJECT GENERAL COMPETENCIES

19

APPENDIX II: END OF LIFE CARE OBJECTIVES ACROSS THE CURRICULUM

21

APPENDIX III: GENETICS OBJECTIVES ACROSS THE CURRICULUM

23

APPENDIX IV: PROFESSIONALISM ACROSS THE CURRICULUM

27

APPENDIX V: ABBREVIATIONS USED IN THIS DOCUMENT

28

APPENDIX VI: COMPETENCY/TRAINING PROBLEM TEMPLATE

30

APPENDIX VII: VERSION 2.0 UPDATE COMMITTEE MEMBERS

33

APPENDIX VIII: VERSION 1.0 PROJECT PARTICIPANTS

35

GENERAL CLINICAL CORE COMPETENCIES

38

CATEGORY 1
DIAGNOSTIC DECISION MAKING

38

CASE PRESENTATION

40

HISTORY AND PHYSICAL EXAMINATION

44

COMMUNICATION AND
RELATIONSHIPS WITH PATIENTS AND COLLEAGUES

48

INTERPRETATION OF CLINICAL INFORMATION

52

THERAPEUTIC DECISION MAKING

56

BIOETHICS OF CARE

60

SELF-DIRECTED LEARNING

64

PREVENTION

68

CATEGORY 2
COORDINATION OF CARE AND TEAM WORK

72

GERIATRIC CARE

76

BASIC PROCEDURES

80

NUTRITION

82

COMMUNITY HEALTH CARE

86

CATEGORY 3
CONTINUOUS IMPROVEMENT IN SYSTEMS OF MEDICAL CARE

90

OCCUPATIONAL AND ENVIRONMENTAL HEALTH CARE

94

ADVANCED PROCEDURES

96

TRAINING PROBLEMS: HEALTHY PATIENTS

HEALTHY PROMOTION, DISEASE PREVENTION, AND SCREENING

98

TRAINING PROBLEMS: PATIENTS WITH A

SYMPTOM, SIGN, OR ABNORMAL LABORATORY VALUE
ABDOMINAL PAIN

104

ALTERED MENTAL STATUS

110

ANEMIA

114

BACK PAIN

118

CHEST PAIN

122

COUGH

128

DYSPNEA

132

DYSURIA

136

FEVER

140

FLUID, ELECTROLYTE, AND ACID-BASE DISORDERS

144

GASTROINTESTINAL BLEEDING

148

KNEE PAIN

152

RASH

156

UPPER RESPIRATORY COMPLAINTS

162

TRAINING PROBLEMS: PATIENTS PRESENTING WITH A KNOWN CONDITION

ACUTE MYOCARDIAL INFARCTION

166

ACUTE RENAL FAILURE AND CHRONIC KIDNEY DISEASE

170

COMMON CANCERS

174

COPD/OBSTRUCTIVE AIRWAYS DISEASE

180

DIABETES MELLITUS

184

DYSLIPIDEMIAS

189

HEART FAILURE

193

HIV INFECTION

199

HYPERTENSION

205

LIVER DISEASE

211

MAJOR DEPRESSION

217

NOSOCOMIAL INFECTIONS

223

OBESITY

229

PNEUMONIA

233

RHEUMATOLOGIC PROBLEMS

237

SMOKING CESSATION

243

SUBSTANCE ABUSE

247

VENOUS THROMBOEMBOLISM

251

INTRODUCTION
We are pleased to introduce version 3.0 of the CDIM/SGIM Core Medicine Clerkship
Curriculum Guide: A Resource for Teachers and Learners. The guide is a
cooperative project of the Clerkship Directors in Internal Medicine (CDIM) and the
Society of General Internal Medicine (SGIM) and was originally created in 1995 under a
contract with the Division of Medicine of the Health Resources and Services
Administrations Bureau of Health Professions. Version 2.0 was released in 1998. The
editors are indebted to all of the individuals who contributed to these earlier editions of
the guide, in particular Allan Goroll, MD, and Gail Morrison. MD. Version 3.0 is merely
an extension of their initial vision. Most of the original authors will continue to
recognize the essence of their work throughout the guide. The ongoing encouragement,
consultation, and advice of Dr. Goroll have been invaluable to the project.

NEW TO VERSION 3.0:

1.Each learning objective coded by Accreditation Council for Graduate Medical Education
(ACGME) General Competencies: Patient Care (PC), Medical Knowledge (MK),
Practice-Based Learning and Improvement (PLI), Interpersonal and Communication
Skills (CS), Professionalism (P), and Systems-Based Practice (SBP) (Appendix I).
2. Addition of learning objectives regarding End-of Life Care (Appendix II).
3. Addition of learning objectives regarding Genetics (Appendix III).
4. The addition of five new Training Problems: Knee Pain, Obesity, Fever, Rash, and
Upper Respiratory Complaints.
5. Conversion of the Training Problem Joint Pain to Rheumatologic Problems.
6. Conversion of the Training Problem Acute Renal Failure to Acute Renal Failure and
Chronic Kidney Disease.
7. Expansion of learning objectives regarding Professionalism (Appendix IV).
8. All General clinical core competencies and training problems updated for progress in
medical knowledge, trends in health care, and developments in medical education.
9. Addition of references that will be particularly useful to students.
10. Simultaneous release of the updated Pocket Guide.
This update maintains the same structure of the earlier versions, namely:
1. General Clinical Core Competencies
2. Training Problems: Healthy Patients
3. Training Problems: Patients With a Symptom, Sign, or Abnormal
Laboratory Value
4. Training Problems: Patients Presenting with a Known Condition
5. Knowledge, Skills, and Attitudes model

Version 3.0 was inspired by ongoing progress in medical knowledge, trends in health
care, and developments in medical education. Most notable since the release of version
2.0 has been the development and broad application of the ACGME General
Competencies (www.acgme.org/outcome/): Patient Care, Medical Knowledge,
Practice-Based Learning and Improvement, Interpersonal and Communication
Skills, Professionalism, and Systems-Based Practice. Refer to Appendix I for a
detailed account of the ACGME General Competencies. These competencies apply to all
facets of graduate medical education, including residency and fellowship. They have
been quite influential as a new paradigm for medical education as a whole. In fact, it
has been suggested that the learning goals of the core medicine curriculum be framed in
the context of the ACGME competencies to facilitate the transition from student to
resident and to emphasize the continuum of medical education.1
Clearly, a unified approach to medical education encompassing medical school through
residency, fellowship, and perhaps continuing medical education, has strong face validity
and growing support. The ACGME General Competencies across the continuum of
education and sites have been conceptualized as the Association of American Medical
Colleges cube (www.cbil.vcu.edu/cube/), which has subsequently evolved into the
MedEdPORTAL, Providing Online Resources to Advance Learning in Medical
Education (http://services.aamc.org/jsp/mededportal/). This online repository of
educational materials focuses on the continuum of medical education and uses the
ACGME General Competencies as one of the primary indexing tools.
Precedence exists for framing a medical student curriculum in the context of the ACGME
General Competencies, namely the Family Medicine Curriculum Resource (FMCR)
released by the Society of Teachers of Family Medicine in 2004 and funded by the
Health Resources and Services Administration.2 Citing the congruency of the broadbased calls for medical education reform with the ACGME competency structure, the
advisory committee of the FMCR Project made the conspicuous decision to use this
framework for the project from the beginning. The resource includes goals for medical
student education during the preclerkship, family medicine clerkship, and postclerkship
periods organized by the ACGME General Competencies. Members of CDIM served in
a consultative role during the FMCR Project and that process proved informative
regarding the planned curriculum update. In fact, the first discussion of version 3.0
occurred at one of the first FMCR project meetings.

Whelan A, Appel J, Alper EJ, De Fer TM, Dickenson TA, Fazio SB, Friedman E, Kuzma MA, Reddy S.
The future of medical student education in internal medicine. Am J Med. 2004; 116:576-80.
2
Family Medicine Curriculum Resource (FMCR) Project. HRSA Contract (Contract No. 240-00-0107) to
the Society of Teachers of Family Medicine. October, 2004.

One possible approach to the update was a complete reorganization based on the
ACGME General Competencies. Another was to undertake a low-level revision without
reference to the ACGME. Neither approach seemed idealthe first requiring a massive
unfunded effort and ignoring the long-term substantial success of the existing guide
structure, the second neglecting an influential development in medical education. A
middle ground approach was chosen, retaining the original guide structure and crossreferencing individual learning objectives with the ACGME General Competencies.
Every learning objective is coded as: PC (Patient Care), MK (Medical Knowledge), PLI
(Practice-Based Learning and Improvement), CS (Interpersonal and Communication
Skills), P (Professionalism), or SBP (Systems-Based Practice). A few objectives are
tagged with as many as three of these codes, but the vast majority has only one or two.
These tags will eventually serve as one of the primary methods for cataloging an online
form of the curriculum that can be specifically sorted and searched by ACGME General
Competencies.
The CDIM/SGIM General clinical core competencies have much in common with the
ACGME General Competencies. Table 1 is a representation of the substantial overlap
between these two sets of competencies. Assignment of general clinical core
competencies to particular ACGME General Competencies is not intended to imply
exclusivity. It is meant to indicate in which domains the preponderance of learning
objectives exist. As in the original guide, the general clinical core competencies are
assigned a rank order and category. By the end of the core clerkship, medical students
are expected to become more proficient in higher rank/category competencies than lower
rank/category competencies. Those with the lowest rank may result in only rather novice
understanding.
As part of the preparatory work for the update, a survey of the CDIM membership was
conducted at the 2004 CDIM National Meeting. The first portion of the survey asked
respondents to rank the eight existing Category 2 (should be taught in most but not all
cases) and Category 3 (should be taught in some but not all cases) general clinical core
competencies in order of importance (10=highest priority and 1=lowest priority). Two
potential new competencies were included: End-of-Life Care and Genetics. The results
are shown in Table 2.

Table 1.
ACGME General Competencies

2. Case Presentation

3. History and Physical Examination

4. Communication and Relationships
with Patients and Colleagues
5. Interpretation of Clinical
Information
6. Therapeutic Decision Making

7. Bioethics of Care

8. Self-Directed Learning

9. Prevention
10. Coordination of Care and
Teamwork
11. Geriatric Care

12. Basic Procedures

13. Nutrition

14. Community Health Care

15. Continuous Improvement in Systems
of Medical Care
16. Occupational and Environmental
Health Care
17. Advanced Procedures

System-Based Practice

1. Diagnostic Decision Making

Professionalism

Medical Knowledge

Communication Skills

Patient Care

Practice-Based Learning
and Improvement

CDIM/SGIM General Clinical

Core Competencies

X
X

X
X
X
X
X

X
X

(Category 1): Should be taught in all cases, when appropriate.

(Category 2): Should be taught in most but not all cases.
(Category 3): Should be taught in some but not all cases.
Assignment of General Clinical Core Competencies to particular ACGME domains is not intended to imply
exclusivity. It is meant to indicate in which domain(s) the preponderance of learning objectives exists.

Table 2.
CDIM/SGIM General Clinical
Core Competency

Mean Rank

Mode Rank

Median Rank

Coordination of Care and Teamwork

7.74 (+/-2.01)
10
8
Geriatric Care
7.57 (+/-2.02)
10
8
Basic Procedures
7.34 (+/-2.76)
10
8
7.04 (+/-1.76)
6
7
End-of-Life Care
Nutrition
6.12 (+/-2.16)
6
6
Community Health Care
5.35 (+/-2.72)
4
5
Continuous Improvement in Systems of
5.06 (+/-2.63)
5
5
Medical Care
3.67 (+/-2.06)
3
3
Genetics
Occupational and Environmental Health
3.13 (+/-1.88)
2
3
Care
Advanced procedures
2.77 (+/-2.28)
1
2
Respondents (n=106) were asked to rank the listed competencies (including 2 new potential competencies,
End-of-Life Care and Genetics) in order of importance, 10=highest priority and 1=lowest priority.

For the purposes of the survey, it was assumed that all of the Category 1 competencies
(should be taught in all cases, when appropriate) were entirely valid. This decision was
reached by consensus of the CDIM/SGIM Core Medicine Clerkship Curriculum Guide
Version 3.0 Update Task Force. In general, the survey rank order was quite consistent
with the original ordering of these competencies.3 Table 3 shows the original and
updated rank order of all the general clinical core competencies. Figure 1 shows the data
from the original 1994 survey prioritizing the competencies. The potential new
competencies End-of-Life Care4 and Genetics5 were selected as areas of relative
deficiency in the curriculum that could or should be added. Table 4 outlines the
specific questions that were asked about the new competencies.
The survey results suggest some substantiation for the assertion that these competencies
are needed (particularly regarding end-of-life care); however, there was not an
overwhelming mandate for their inclusion. Potential additions to the curriculum were
considered very seriously, bearing in mind the notion of curricular creep and perceived
mandates for coverage during the clerkship. The latter was never envisioned by the
developers nor was absolutely complete coverage of all curricular possibilities. Given
these considerations, it was ultimately decided not to add End-of-Life Care and Genetics
as new freestanding general clinical core competencies. This was in no way intended to
ignore the contemporary importance of these subjects; in fact, objectives regarding these
areas have been woven throughout the existing competencies and training problems (see
Appendix II and Appendix III).

Bass EB, Fortin AH, Morrison G, Willis S, Mumford LM, Goroll AH. Am J Med. 1997;102:564-71.
Liaison Committee on Medical Student Education (LCME) accreditation standard ED-13.
5
Association of American Medical Colleges. Report VI. Contemporary Issues in Medicine: Genetics
Education. Medical School Objectives Project. June, 2004.
4

Table 3.
CDIM/SGIM General Clinical Core
Competencies
Diagnostic Decision Making
Case Presentation
History and Physical Examination
Communication and Relationships with Colleagues
Interpretation of Clinical Information
(previously known as Test Interpretation)
Therapeutic Decision Making
Bioethics of Care
Self-Directed Learning
Prevention
Coordination of Care and Teamwork
Geriatric Care
Basic Procedures
Nutrition
Community Health Care
Continuous Improvement in Systems of Medical Care
Occupational and Environmental Health Care
Advanced Procedures
Category 1: Should be taught in all cases, when appropriate.
Category 2: Should be taught in most but not all cases.
Category 3: Should be taught in some but not all cases.

Version
3.0

Version
2.0/1.0

Category

1
2
3
4

1
2
3
4

1
1
1
1

6
7
8
9
10
11
12
13
14
15
16
17

6
7
8
9
10
12
11
14
13
17
16
15

1
1
1
1
2
2
2
2
2
3
3
3

Figure 1

Prioritization of general competency areas by internal medicine clerkship directors (n=93). Source: Used
with permission from Bass EB, Fortin AH, Morrison G, Willis S, Mumford LM, Goroll AH. Am J Med.
1997;102:564-71.

Table 4.
Question

Mean

Mode

Median

Indicate your level of agreement with the statement

2.73 (+/-1.03)
3
3
Genetics should be added to the list of CDIM/SGIM
General Clinical Core Competencies.*
Indicate your level of agreement with the statement End4.11 (+/-0.85)
4
4
of-Life Care should be added to the list of CDIM/SGIM
General Clinical Core Competencies.*
If Genetics were added to the list of CDIM/SGIM General
2.68 (+/-0.63)
3
3
Clinical Core Competencies, it should be:
If End-of-Life Care were added to the list of CDIM/SGIM
2.13 (+/-0.83)
3
2
General Clinical Core Competencies, it should be:
* 1=Strongly Disagree, 3=Somewhat agree, 5=Strongly Agree.
Category 1: Should be taught in all cases, when appropriate; Category 2: Should be taught in most but not
all cases; Category 3: Should be taught in some but not all cases.

The second portion of the survey asked respondents to select the five (only) potential
topics for new training problems and rank them in order of priority (5=highest priority
and 1=lowest priority). Not selecting an item counted as 0. Again, these topics were
chosen by consensus of the update task force as potential areas that might or should be
covered. The results are presented in Table 5.
Table 5.
Training Problem
1

Mean Rank

ECG Interpretation
2.56 (+/-2.15)
2
Common Musculoskeletal Complaints
1.77 (+/-1.88)
Approach to Weight Loss/Gain3
1.56 (+/-2.02)
Fever4
1.34 (+/-1.88)
5
Common Dermatologic Problems
1.24 (+/-1.76)
Radiograph Interpretation1
1.06 (+/-1.61)
Common Upper Respiratory Complaints6
1.06 (+/-1.68)
7
Chronic Renal Failure
0.98 (+/-1.62)
Common GI Complaints
0.94 (+/-1.57)
Thyroid Disorders
0.84 (+/-1.47)
Dizziness
0.69 (+/-1.28)
Edema
0.62 (+/-1.38)
Womens Health
0.60 (+/-1.33)
Common Ophthalmologic Problems
0.31 (+/-0.92)
Bioterrorism
0.24 (+/-0.82)
Mens Health
0.19 (+/-0.79)
Respondents (n=106) were asked to select the five (only) potential topics for new training problems and
rank them in order of priority (5=highest priority and 1=lowest priority. Not selecting is counted as 0).
1
Incorporated into the existing Competency Interpretation of Clinical Information.
2
Became the new Training Problem Knee Pain.
3
Became the new Training Problem Obesity.
4
Became the new Training Problem Fever.
5
Became the new Training Problem Rash.
6
Became the new Training Problem Common Upper Respiratory Complaints.
7
Incorporated into the existing Training Problem Acute Renal Failure.

As previously noted, the task force was acutely aware of the issues regarding curricular
additions and was committed to limiting the new training problems to only five. It is
worth reiterating that the guide is not now and was never intended to be a full account of
what must be covered during the core clerkship. Rather, the training problems are
examples of how the general clinical core competencies may be covered through
common clinical problems and activities.
Three of the potential topics were easily dealt with: ECG Interpretation, Radiograph
Interpretation, and Chronic Renal Failure. The first two were simply given more specific
coverage in the existing Interpretation of Clinical Information competency. The third
was incorporated into the existing Acute Renal Failure training problem, now called
Acute Renal Failure and Chronic Kidney Disease. Excluding these three, the top five
candidates for new training problems were: Common Musculoskeletal Complaints,6
Approach to Weight Loss/Gain, Fever, Common Dermatologic Problems, and Common
Upper Respiratory Complaints. Each of these was assigned to a primary author on the
task force who began to draft a training problem. Drafts were then passed to another
member of the task force for review and commentary. Near final drafts were reviewed by
the task force at large and also by local experts where necessary. Final drafts were
reviewed by the task force co-directors for consistency of style and format.
From this lengthy process emerged potential topic areas: Knee Pain, Rheumatologic
Problems, Obesity, Fever, Rash, and Upper Respiratory Complaints. Most challenging
was the overlap between the new Common Musculoskeletal Complaints and the existing
Joint Pain; the latter already addressed some systemic rheumatologic diseases. In the
end, Knee Pain proved to be an excellent model for joint pain in general and the then
current Joint Pain was fashioned into a more diagnosis-focused handling of
Rheumatologic Problems. Purposeful overlap still exists between these training
problems. Approach to Weight Loss/Gain evolved into an approach to the epidemic
problem of Obesity. The remaining two were simply name changes to better reflect the
symptom-oriented nature of these training problems.
Near the end of the update process much discussion took place about the addition of other
training problems that ought to be covered by the guide. Unresolved issues included
the original intention of the guide, perceived mandates for coverage, an increase in the
size of the guide to such daunting proportions as to inadvertently diminish its usefulness,
and real holes in the coverage (including but not limited to those listed in Table 3).
Ultimately, the update task force and the CDIM Council came to the consensus that the
original plan to limit curricular additions was the most prudent course.
Another very important matter that arose during the latter stages of the revision was the
treatment of professionalism in the curriculum. From the beginning, objectives
addressing aspects of professionalism were scattered throughout the guide, mostly under
the Attitudes heading. Professionalism was felt to be so fundamental to everyday
teaching, learning, and clinical practice that overtly separating it out as a freestanding
general clinical core competency seemed artificial. On the other hand, professionalism
has become an especially important and visible aspect of medical education and the
6

Association of American Medical Colleges. Report VII. Contemporary Issues in Medicine:

Musculoskeletal Medicine Education. Medical School Objectives Project. September, 2005.

profession itself. The medical literature is replete with data and opinions on the
subject.7,8,9,10 Therefore, we have expanded the coverage of professionalism throughout
the guide. Refer to Appendix IV for a synthesis of the major themes regarding
professionalism across the curriculum.
Revision of the existing general clinical core competencies and training problems
followed a process similar to that outlined above. Each task force member was assigned
several competencies and training problems for a first pass revision. The primary
objectives of the first revision were:
1. Insure that the competency or training problem conforms to the provided template
(Appendix VI).
2. Expand the prerequisites where necessary.
3. Update objectives for new medical knowledge and contemporary issues.
4. Code each learning objective to one or more of the ACGME general
competencies as described above.
5. Add Genetics, End-of-Life Care, and Professionalism objectives where
appropriate.
6. Identify a modest number of references that will be particularly useful to students.
Once the first round of revisions was complete, all were reassigned to a second reviewer
for additional revisions. Task force members were encouraged to enlist the assistance of
local experts when deemed necessary. Finally, each competency and training problem
was reviewed in detail by each of the task force co-directors for consistency and format.
From start to finish the entire revision process was approximately 18 months. All
members of the task force completed their assigned work at their home institutions
without specific remuneration. The editors are enormously grateful to all of the task
force members. Additionally, this project could not have been brought to fruition without
the support and direction of the CDIM staff, in particular Vice President for Policy
Charles P. Clayton and Policy Associate Nicole Baptista.
Thomas M. De Fer, MD
Co-Director
Clerkship Directors in Internal Medicine

Sara B. Fazio, MD
Co-Director
Society of General Internal Medicine

Project Professionalism. American Board of Internal Medicine. 1995.

Embedding Professionalism in Medical Education: Assessment as a Tool for Implementation. Report
from an Invitational Conference Cosponsored by the Association of American Medical Colleges and the
National Board of Medical Examiners. May, 2002.
9
Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is
associated with subsequent disciplinary action by a state medical board. Acad Med. 2004;79:244-9.
10
Whitcomb ME. Medical professionalism: can it be taught? Acad Med. 2005;80:883-4.
8

APPENDIX I
ACGME OUTCOME PROJECT
GENERAL COMPETENCIES
PATIENT CARE
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the
treatment of health problems and the promotion of health. Residents are expected to:
Communicate effectively and demonstrate caring and respectful behaviors when interacting with
patients and their families.
Gather essential and accurate information about their patients.
Make informed decisions about diagnostic and therapeutic interventions based on patient
information and preferences, up-to-date scientific evidence, and clinical judgment.
Develop and carry out patient management plans.
Counsel and educate patients and their families.
Use information technology to support patient care decisions and patient education.
Perform competently all medical and invasive procedures considered essential for the area of
practice.
Provide health care services aimed at preventing health problems or maintaining health.
Work with health care professionals, including those from other disciplines, to provide patientfocused care.

MEDICAL KNOWLEDGE
Residents must 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 their
discipline.

PRACTICE-BASED LEARNING AND IMPROVEMENT

Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate
scientific evidence, and improve their patient care practices. Residents are expected to:
Analyze practice experience and perform practice-based improvement activities using a systematic
methodology.
Locate, appraise, and assimilate evidence from scientific studies related to their patients health
problems.
Obtain and use information about their own population of patients and the larger population from
which their patients are drawn.
Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and
other information on diagnostic and therapeutic effectiveness.
Use information technology to manage information, access online medical information, and
support their own education.
Facilitate the learning of students and other health care professionals.

ACGME Outcome Project

Accreditation Council for Graduate Medical Education
www.acgme.org

INTERPERSONAL AND COMMUNICATION SKILLS

Residents must be able to demonstrate interpersonal and communication skills that result in effective
information exchange and teaming with patients, their patients families, and professional associates.
Residents are expected to:
Create and sustain a therapeutic and ethically sound relationship with patients.
Use effective listening skills and elicit and provide information using effective nonverbal,
explanatory, questioning, and writing skills.
Work effectively with others as a member or leader of a health care team or other professional
group.

PROFESSIONALISM
Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population. Residents are expected to:
Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and
society that supersedes self-interest; accountability to patients, society, and the profession; and a
commitment to excellence and on-going professional development.
Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical
care, confidentiality of patient information, informed consent, and business practices.
Demonstrate sensitivity and responsiveness to patients culture, age, gender, and disabilities.

SYSTEMS-BASED PRACTICE
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health
care and the ability to effectively call on system resources to provide care that is of optimal value.
Residents are expected to:
Understand how their patient care and other professional practices affect other health care
professionals, the health care organization, and the larger society, as well as how these elements of
the system affect their own practice.
Know how types of medical practice and delivery systems differ from one another, including
methods of controlling health care costs and allocating resources.
Practice cost-effective health care and resource allocation that does not compromise quality of
care.
Advocate for quality patient care and assist patients in dealing with system complexities.
Know how to partner with health care managers and health care providers to assess, coordinate,
and improve health care and know how these activities can affect system performance.

ACGME Outcome Project

Accreditation Council for Graduate Medical Education
www.acgme.org

APPENDIX II
END-OF-LIFE CARE OBJECTIVES
ACROSS THE CURRICULUM
GENERAL CLINICAL CORE COMPETENCIES
Rank4) Communication
A. Knowledge
8. Basic techniques for breaking bad news.
B. Skills
8. With guidance and direct supervision, participate in breaking bad news
to patients.
9. With guidance and direct supervision, participate in discussing basic
issues regarding advance directives with patients and their families.
10. With guidance and direct supervision participate in discussing basic
end-of-life issues with patients and their families.
Rank 6) Therapeutic Decision Making
B. Skills
2. Change the therapeutic plan when goals of care change (e.g. a shift
toward palliative care).
Rank 7) Bioethics of Care
A. Knowledge
10. The unique bioethical concerns regarding end-of-life care.
B. Skills
3. Participate in a discussion about advance directives with a patient.
4. Participate in family and interdisciplinary team conferences discussing
end-of-life care and incorporating the patients wishes in that discussion.
Rank 10) Coordination of Care
A. Knowledge
5. The role of the primary care physician in the coordination of care
during key transitions (e.g. outpatient to inpatient, inpatient to skilled
nursing facility, inpatient to hospice, etc.).
Rank 11) Geriatric Care
B. Skill
9. With guidance and direct supervision, participate in discussing basic
issues regarding advance directives with patients and their families.
10. With guidance and direct supervision participate in discussing basic
end-of-life issues with patients and their families.
C. Attitudes and Professional Behaviors
5. Always treat cognitively impaired patients and patients at the end of
their lives with utmost respect and dignity.

TRAINING PROBLEMS
11. Common Cancers
A. Knowledge
7. The similarities and differences between curative and palliative cancer
care.
8. The principles of palliative care and hospice care.
9. Symptoms sometimes seen during end-of-life care and the basic
principles of their management (e.g., pain, dyspnea, nausea and
vomiting, anorexia, fatigue, depression, delirium, constipation).
B. Skills
5. Communication Skills
With guidance and direct supervision, participate in breaking
bad news to patients.
With guidance and direct supervision, participate in discussing
basic issues regarding advanced directives with patients and
their families.
With guidance and direct supervision participate in discussing
basic end-of-life issues with patients and their families.
7. Management Skills
Appropriately assessing and treating pain when necessary with
nonnarctoic and narcotic analgesics.
Anticipating and treating narcotic side effects if necessary.
Adjusting the therapeutic plan when goals of care change (e.g.,
a shift toward palliative care).
Alleviating symptoms sometimes seen during end-of-life care
(e.g., pain, dyspnea, nausea and vomiting, anorexia, fatigue,
depression, delirium, constipation).
Utilizing supportive care or hospice services when appropriate.

APPENDIX III
GENETICS OBJECTIVES
ACROSS THE CURRICULUM
GENERAL CLINICAL CORE COMPETENCIES
Rank1) Diagnostic Decision Making
A. Knowledge
4. The basics of the potential role of genetic information in diagnostic
decision making.
Rank 4) Communication and Relationships with Patient and Colleagues
A. Knowledge
9. Basic tenants of genetic counseling.
Rank 5) Interpretation of Clinical Information
A. Knowledge
8. Describe the basic principles of using genetic information in clinical
decision making.
Rank 6) Therapeutic Decision Making
A. Knowledge
9. The basics of the potential role of genetic information in therapeutic
decision making.
Rank 7) Bioethics of Care
A. Knowledge
9. Bioethical concerns regarding genetic information, privacy issues in
particular.
B. Skills
3. Participate in explaining and obtaining informed consent for genetic
testing.
C. Attitudes
8. Appreciate the psychological impact genetic information may have on
patients.
9) Prevention
A. Knowledge
10. The potential roles and limitations of genetic testing in disease
prevention and early detection.

TRAINING PROBLEMS
4. Anemia
A. Knowledge
7. The genetic basis of some forms of anemia.
B. Skills
5. Communication Skills
Counsel with regard to (a) possible causes, (b) appropriate
further evaluation to establish the diagnosis of an underlying
disease, and (c) the impact on the family (genetic counseling).
16. Acute Myocardial Infarction
A. Knowledge
2. The basic principles of the role of genetics in CAD.
18. Common Cancers
A. Knowledge
5. Genetic considerations of selected cancers (e.g. hereditary
nonpolyposis colon cancer, familial adenomatous polyposis,
BRCA1/BRCA2, HER2, Philadelphia chromosome/BRC-ABL).
19. COPD/Obstructive Airways Disease
A. Knowledge
3. The genetics and role of alpha-1 antitrypsin deficiency in some
patients with emphysema.
20. Diabetes Mellitus
A. Knowledge
4. The basic principles of the role of genetics in diabetes mellitus.
21. Dyslipidemia
A. Knowledge
4. The basic principles of the role of genetics in dyslipidemia,
particularly familial combined hyperlipidemia.
22. Heart Failure
A. Knowledge
2. The basic role of genetics in certain forms of cardiomyopathy.
24. Hypertension
A. Knowledge
2. The basic principles of the role of genetics in hypertension.
25. Liver Disease
A. Knowledge
20. Genetic considerations in liver disease (i.e. hemochromatosis,
Wilsons disease, alpha-1 antitrypsin deficiency, Gilberts syndrome).
26. Major Depression
A. Knowledge
14. The potential role of genetics in depression.

28. Obesity
A. Knowledge
4. The etiology of obesity, including excessive caloric intake, insufficient
energy expenditure leading to low resting metabolic rate, genetic
predisposition, environmental factors affecting weight gain,
psychologic stressors, and lower socioeconomic status.
30. Rheumatologic Problems
A. Knowledge
12. The basic role of genetics in autoimmune disorders.
32. Substance Abuse
A. Knowledge
6. The potential role of genetics in substance abuse vulnerability.
33. Venous Thromboembolism
A. Knowledge
2. Genetic considerations predisposing to venous thrombosis.

APPENDIX IV
PROFESSIONALISM
ACROSS THE CURRICULUM
MAJOR THEMES

Demonstrate a commitment to following the bioethical principles of the medical

profession: autonomy, beneficence, nonmaleficence, truth-telling, and confidentiality.
Demonstrate a commitment to caring for all patients, regardless of the medical
diagnosis, gender, race, socioeconomic status, intellect/level of education, religion,
political affiliation, sexual orientation, ability to pay, or sociocultural background.
View patients as the center of the health care delivery system.
Attend to and advocate for patients interests and needs in a manner appropriate to the
students role.
Identify and respect patients needs and preferences.
Demonstrate respect for patients modesty, feelings, limitations, and sociocultural
background.
Demonstrate respect for patients privacy when dealing with protected health
information and follow Health Information Portability and Accountability Act
(HIPAA) standards.
Encourage patients to share responsibility for health promotion and disease
prevention.
Actively involve patients in their health care whenever possible.
Appreciate the impact diagnostic and therapeutic decisions and diseases have on
patients quality of life, well-being, ability to work, and family.
Respect patients autonomy and informed choices, including the right to refuse
preventive, diagnostic, and therapeutic interventions.
Respond nonjudgmentally to individuals whose sociocultural backgrounds result in
seemingly counterproductive heath care decisions and health-related behaviors.
Respond appropriately to patients who are nonadherent.
Accurately and objectively record and present all data.
Demonstrate ongoing commitment to self-directed learning.
Seek feedback regularly regarding performance and respond appropriately and
productively.
Demonstrate commitment to using risk-benefit, cost-benefit, and evidence-based
considerations in patient care.
Demonstrate a commitment to the utilization of other health care professions and
value their unique contributions to patient care.
Demonstrate teamwork and respect toward all members of the health care team, as
manifested by reliability, responsibility, honesty, helpfulness, selflessness, and
initiative in working with the team.
Appreciate the importance of follow-up on all clinical information and timely
communication of that information to patients and appropriate team members.
Appreciate that medical error prevention and patient safety are the responsibility of
all health care providers and systems and accept the appropriate degree of
responsibility at the medical student level.
Appreciate the importance of ongoing quality improvement in health care.

APPENDIX V
ABBREVIATIONS
USED IN THIS DOCUMENT
ABG arterial blood gases
ACE-I angiotensin converting enzyme inhibitor
ACGME Accreditation Council for Graduate Medical Education
AFB acid-fast bacillus (Mycobacterium tuberculosis)
AIDS acquired immune deficiency syndrome
ALB albumin
Alk Phos alkaline phosphatase
ALT alanine aminotransferase
ANA antinuclear antibody
ARB angiotensin receptor blocker
AST aspartate aminotransferases
BMI body mass index
BUN blood urea nitrogen
CABG coronary artery bypass graphing
CAD coronary artery disease
CBC (with diff) complete blood count (with differential)
CCU coronary care unit
CDC Centers for Disease Control and Prevention
CHF congestive heart failure
CK-MB creatine kinase-MB fraction
COPD chronic obstructive pulmonary disease
Cr creatinine
CS communication skills
CSF cerebrospinal fluid
CT computed tomography
CVA cerebrovascular accident
DM diabetes mellitus
EEG electroencephalogram
ECG/EKG electrocardiogram
ELISA enzyme-linked immunosorbent assay
ESR erythrocyte sedimentation rate
GGT gamma-glutamyl transpeptidase
GLC glucose
H/H hemoglobin and hematocrit
HbA1c hemoglobin A1c, glycosylated hemoglobin
Hepatic function panel ALB, TP, total/direct bilirubin, AST, ALT
HF heart failure
HIPAA Health Information Portability and Accountability Act
HIV human immunodeficiency virus
HDL high density lipoprotein
HMG CoA 3-hydroxy-3-methylgluatryl coenzyme A
INR international normalized ratio
K potassium
KOH potassium hydroxide
KUB kidneys-ureters-bladder single view anteroposterior abdominal film
LDL low density lipoprotein
LP lumbar puncture
MCV mean corpuscular volume
MK medical knowledge
MRI magnetic resonance imaging
Na sodium

NIOSH National Institute of Occupational Safety and Health

NKH nonketotic hyperglycemia
NSAID nonsteroidal anti-inflammatory drugs
OSHA Occupational Safety and Health Administration/Act
P professionalism
PC patient care
PCR polymerase chain reaction
PFTs pulmonary function tests
PLI practice-based learning and improvement
PPD purified protein derivative tuberculin skin test
PSA prostate-specific antigen
PT prothrombin time
PTT partial thromboplastin time
PVD peripheral vascular disease
RF rheumatoid factor
RPR rapid plasma reagin (syphilis serology)
SBP systems-based practice
T3 triiodothyronine
T4 thyroxine
TP total protein
TSH thyroid stimulating hormone
UA urinalysis
URI upper respiratory infection
UTI urinary tract infection
VDRL - venereal disease research laboratory (syphilis serology)

APPENDIX VI
COMPETENCY/TRAINING PROBLEM TEMPLATE
Delete all that are inappropriate or irrelevant
RATIONALE:
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Ability to perform a complete medical history and physical.
Ability to communicate with patients of diverse backgrounds.
Anatomy and physiology of
Pathogenesis and pathophysiology of
Pharmacology of
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. (MK)
2.

(MK)

o
o

(MK)

(MK)

3.
B.

SKILLS: Students should be able to demonstrate specific skills including:

11. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including:
(PC, CS)

12. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
(PC)

13. Differential diagnosis: Students should be able to generate a prioritized

differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology:
(PC, MK)

14. Laboratory interpretation: Students should be able to recommend when to

order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based o the differential diagnosis including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
(PC, MK)

Students should be able to define the indications for and interpret (with
consultation) <<i.e. we do not expect that a student could independently rea
or interpret these tests or labs>> the results of:
(PC, MK)

15. Communication skills: Students should be able to:

Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (PC, CS)
Elicit input and questions from the patient and his or her family about
the management plan. (PC, CS)

16. Basic and advanced procedure skills: Students should be able to:
(PC)

17. Management skills: Students should able to develop an appropriate

evaluation and treatment plan for patients that includes:
(PC, MK)
Determining when to obtain consultation from a <<insert appropriate
specialist>>. (PC, SBP)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

C.

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to <<insert problem>>. (PC, PBL)
Incorporating patient needs and preferences. (PC, P)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for <<insert problem>>. (PBL, P)
2. Recognize the importance of patient needs and preferences when selecting
among diagnostic and therapeutic options for <<insert problem>>. (P)
3. Respond appropriately to patients who are nonadherent to treatment for
<<insert problem>>. (CS, P)
4. Demonstrate ongoing commitment to self-directed learning regarding
<<insert problem>>. (PBL, P)
5. Appreciate the impact <<insert problem>> has on a patients quality of life,
well-being, ability to work, and the family. (P)

6. Recognize the importance of and demonstrate a commitment to the utilization

of other health care professionals in the diagnosis and treatment of <<insert
problem>>. (P, SBP)
D.

REFERENCES:

SGIM/CDIM
CORE MEDICINE CLERKSHIP
CURRICULUM GUIDE VERSION 2.0 (1998)
HRSA CLERKSHIP PROJECT UPDATE
Project Leaders
Allan H. Goroll, MD
Co-Director
Harvard Medical School
Massachusetts General Hospital
Society of General Internal Medicine

Gail Morrison, MD
Co-Director
University of Pennsylvania
School of Medicine
Clerkship Directors in Internal Medicine

Committee Members
Eric B. Bass, MD
Johns Hopkins University
School of Medicine

Alison Whelan, MD
Washington University
School of Medicine

Roger Platt, MD
Mount Sinai
School of Medicine

Maxine A. Papidakis, MD
University of California-San Francisco
School of Medicine

Ardis Olson, MD
Dartmouth-Hitchcock
Medical Center

Ruth-Marie E. Fincher, MD
Medical College of Georgia

Kent J. Sheets, PhD

University of Michigan
School of Medicine

Francine P. Hekelman, PhD, RN

Case Western Reserve University
School of Medicine

Other Consultants
Linda A. Headrick, MD
MetroHealth Medical Center
Dionne Blackman, MD
Johns Hopkins University
School of Medicine
Robert Jablonover, MD
Johns Hopkins University
School of Medicine

SGIM/CDIM
CORE MEDICINE CLERKSHIP
CURRICULUM GUIDE VERSION 1.0 (1995)
HRSA CLERKSHIP PROJECT
Project Leaders
Allan H. Goroll, MD
Co-Director
Society of General Internal Medicine
Harvard Medical School
Massachusetts General Hospital

Gail Morrison, MD
Co-Director
Clerkship Directors in Internal Medicine
University of Pennsylvania
School of Medicine

Key Consultants
Francine Hekelman, PhD, RN
Case Western Reserve University
School of Medicine

Eric B. Bass, MD
Johns Hopkins University
School of Medicine
Laura M. Mumford, MD
Johns Hopkins University
School of Medicine

Special Consultants
Frank Davidoff, MD
Senior Vice President, Education
American College of Physicians

Jack Ende, MD
University of Pennsylvania
School of Medicine

Other Consultants
Connie Parenti, MD
VA Medical Center
Minneapolis, Minnesota

Auguste H. Fortin, MD
Johns Hopkins University
School of Medicine

David C. Parish, MD
Mercer University
School of Medicine

Linda A. Headrick, MD
Case Western Reserve University
School of Medicine

Original project supported by contract 240-93-0029

Division of Medicine, Bureau of Health Professions
Health Resources and Services Administration (HRSA)
Department of Health and Human Services

Advisory Committee
Maxine A. Papadakis, MD
University of California, San Francisco
School of Medicine

Ruth-Marie Fincher, MD
Associate Dean for Curriculum
Medical College of Georgia

Laura M. Mumford, MD
Johns Hopkins University
School of Medicine

Donald G. Kassebaum, MD
Association of American Medical
Colleges

Gail Morrison, MD
Clerkship Directors in Internal Medicine

Allan H. Goroll, MD
Society of General Internal Medicine

Jeffrey M. Engel
American Medical Student Association

Ardis Olson, MD
Ambulatory Pediatric Association

Robert R. Cornwell, DO
Flint Osteopathic Campus

Kent J. Sheets, PhD

Society of Teachers of Family Medicine

GENERAL CLINICAL CORE COMPETENCIES

RANK 1) DIAGNOSTIC DECISION MAKING
RATIONALE:
Physicians are responsible for directing and conducting the diagnostic evaluation of a
broad range of patients, including patients seeking advice on prevention of and screening
for disease and patients with acute and chronic illnesses. In a time of rapidly
proliferating tests, medical students must learn how to design safe, expeditious, and costeffective diagnostic evaluations. This requires well-developed diagnostic decisionmaking skills that incorporate probability-based thinking.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Required course in pathophysiology.
Required course in clinical epidemiology and biostatistics.
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Key history and physical examination findings pertinent to the differential
diagnosis. (MK)
2. Information resources for determining diagnostic options for patients with
common and uncommon medical problems. (MK, PLI)
3. Key factors to consider when selecting from among diagnostic tests, including
pretest probabilities, performance characteristics of tests (sensitivity,
specificity, likelihood ratios), cost, risk, and patient preferences. (MK, P)
4. The basics of the potential role of genetic information in diagnostic decision
making. (MK)
5. Relative cost of diagnostic tests. (MK)
6. How critical pathways or practice guidelines can be used to guide diagnostic
test ordering. (MK)
7. The methods of deductive reasoning, forward thinking, and pattern
recognition in clinical decision making. (MK)

B.

SKILLS: Students should demonstrate specific skills, including:

1. Identifying problems with which a patient presents, appropriately synthesizing
these into logical clinical syndromes. (PC)
2. Identifying which problems are of highest priority. (PC)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

3. Formulating a differential diagnosis based on the findings from the history

and physical examination. (PC)
4. Using probability-based thinking and pattern recognition to identify the most
likely diagnoses. (PC)
5. Using the differential diagnosis to help guide diagnostic test ordering and
sequencing. (PC)
6. Using pretest probabilities and scientific evidence about performance
characteristics of tests (sensitivity, specificity, likelihood ratios) to determine
post-test probabilities according to the predictive value paradigm. (PC)
7. Participating in selecting the diagnostic studies with the greatest likelihood of
providing useful results at a reasonable cost. (PC)
8. Communicating the prioritized differential diagnosis to the patient and his or
her family. (CS)
C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Incorporate the patients perspective into diagnostic decision making. (P)
2. Recognize the importance of patient preferences when selecting among
diagnostic tests. (P)
3. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic tests. (PLI, P)
4. Seek feedback regularly regarding diagnostic decision making and respond
appropriately and productively. (P)
5. Limit the chances of false positive/false negative results by demonstrating
thoughtful test selection. (P)
6. Appreciate the element of uncertainty in diagnostic testing, including the
occurrence and causes of false positive and false negative results. (P)
7. Appreciate the impact uncertainty may have on the patient. (P)
8. Recognize the importance of and demonstrate a commitment to the utilization
of other health care professionals in diagnostic decision making. (P, SBP)

D.

REFERENCES:
Mark, DB. Decision-making in clinical medicine. In Kasper DL, Braunwald
EB, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrisons Principles
of Internal Medicine. 16th ed. New York, NY: McGraw-Hill; 2005:6-13.
Strauss SE, Richardson WS, Glasziou P, Haynes RB. Evidence Based
Medicine: How to Practice and Teach EBM. 3rd ed. New York, NY:
Churchill Livingstone; 2005.
Primer to the Internal Medicine Clerkship
A Guide Produced by the Clerkship Directors in Internal Medicine
Clerkship Directors in Internal Medicine
www.im.org/CDIM/primer.htm
Ferri FF. Differential diagnosis. In Ferri FF, ed. Practical Guide to the Care
of the Medical Patient. 6th ed. St. Louis, MO: Mosby; 2004:39-113.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 2) CASE PRESENTATION
RATIONALE:
Communicating patient care information to colleagues and other health care professionals
is an essential skill regardless of specialty. Internists have traditionally given special
attention to case presentation skills because of the comprehensive nature of patient
evaluations and the various settings in which internal medicine is practiced. Students
should develop facility with different types of case presentations: written and oral, new
patient and follow-up, inpatient and outpatient.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Components of comprehensive and abbreviated case presentations (oral and
written) and settings appropriate for each. (MK)

B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. Prepare legible, comprehensive, and focused new patient workups that include
the following features as clinically appropriate:
Chief complaint. (PC, CS)
Identifying data. (PC, CS)
Concise history of the present illness organized chronologically, with
minimal repetition, omission, or extraneous information, and including
pertinent positives and negatives. (PC, CS)
Past medical history, including relevant details. (PC, CS)
Medications with dosages and frequencies, including herbals,
supplements, and over-the-counter medications. (PC, CS)
Allergies with specific details of the reaction. (PC, CS)
Substance use, including tobacco, alcohol, and illicit drugs. (PC, CS)
Family history. (PC, CS)
Social history. (PC, CS)
Review of symptoms. (PC, CS)
A comprehensive physical examination with detail pertinent to the
patients problem. (PC, CS)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

A succinct, prioritized, and where appropriate complete list of all

problems identified by the history and physical examination. (PC, CS)
A differential diagnosis (appropriate for the students level of training)
for each problem that is neither over-inclusive or under-inclusive,
addresses all reasonable possibilities, pays special attention to
diagnoses that are potentially the most serious or life-threatening, and
is supported by the use of pertinent positives and negatives. (PC, CS)
A diagnostic and treatment plan for each problem (appropriate for the
students level of training). (PC, CS)
2. Orally present a new inpatients or outpatients case in a manner that includes
the following characteristics:
Logically and chronologically develops the history of the present
illness and tells the patients story. (PC, CS)
Summarizes the pertinent positives and negatives. (PC, CS)
Succinctly presents past medical history, family history, social history,
and review of symptoms. (PC, CS)
Includes a logical, organized, and prioritized differential diagnosis.
(PC, CS)

Includes diagnostic and therapeutic plans. (PC, CS)

Can be made briefer when necessary. (PC, CS)
Is presented as much from memory as possible with minimal reference
to memory aids with the exception of highly important dates,
diagnostic tests, laboratory values. (PC, CS)
3. Orally present a follow-up inpatients or outpatients case in a manner that
includes the following characteristics:
Focused and very concise. (PC, CS)
Problem-based. (PC, CS)
Emphasizes pertinent new findings. (PC, CS)
Includes diagnostic and therapeutic plans. (PC, CS)
Can be made briefer when necessary. (PC, CS)
Is presented as much from memory as possible with minimal reference
to memory aids with the exception of highly important dates,
diagnostic tests, laboratory values. (PC, CS)
4. Produce inpatient or outpatient progress notes in a manner that includes the
following characteristics:
Is appropriately titled. (PC, CS)
Includes a brief subjective that addresses new or changed patient
symptoms. (PC, CS)
Provides an accurate and succinct accounting of the objective data
(e.g. vital signs, in/outs, telemetry monitoring, focused physical
examination, laboratory results, and diagnostic tests). (PC, CS)
Includes a prioritized problem list with a concise assessment and plan
for each. (PC, CS)
5. Select the mode of presentation that is most appropriate to the clinical
situation (e.g. written vs. oral, long vs. short, etc.). (PC, CS)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate ongoing commitment to self-directed learning regarding case
presentation skills by regularly seeking feedback on presentations. (PLI, P)
2. Respond appropriately and productively to feedback regarding performance.
(P)

3. Accurately and objectively record and present all data. (P)

4. Demonstrate respect for the patients privacy when dealing with protected
health information and follow Health Information Portability and
Accountability Act (HIPAA) standards. (P)
D.

REFERENCES:
Primer to the Internal Medicine Clerkship
A Guide Produced by the Clerkship Directors in Internal Medicine
Clerkship Directors in Internal Medicine
www.im.org/CDIM/primer.htm
Sobel RK. MSL medicine as a second language. N Engl J Med.
2005;352:1945

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 3) HISTORY TAKING AND PHYSICAL EXAMINATION
RATIONALE:
The ability to obtain an accurate medical history and carefully perform a physical
examination is fundamental to providing comprehensive care to adult patients. In
particular, the internist must be thorough and efficient in obtaining a history and
performing a physical examination with a wide variety of patients, including healthy
adults (both young and old), adults with acute and chronic medical problems, adults with
complex life-threatening diseases, and adults from diverse socioeconomic and cultural
backgrounds. The optimal selection of diagnostic tests, choice of treatment, and use of
subspecialists, as well as the physicians relationship and rapport with patients, all depend
on well-developed history-taking and physical diagnosis skills. These skills, which are
fundamental to effective patient care, should be a primary focus of the students work
during the core clerkship in internal medicine.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Required pre-clinical courses in physical examination and physician-patient
communication (should include instruction in breast, pelvic, rectal, and male genital
exams).
Ability to perform a complete medical history and physical exam on a wide variety of
patients including adolescents and older adults.
Ability to effectively communicate with patients of diverse backgrounds.
Basic skills for obtaining a history related to substance abuse, sexual, occupational,
and mental health.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The significant attributes of a symptom, including: location and radiation,
intensity, quality, temporal sequence (onset, duration, frequency), alleviating
factors, aggravating factors, setting, associated symptoms, functional
impairment, and patients interpretation of symptom. (MK)
2. The four methods of physical examination (inspection, palpation, percussion,
and auscultation), including where and when to use them, their purposes, and
the findings they elicit. (MK)
3. The physiologic mechanisms that explain key findings in the history and
physical exam. (MK)
4. The diagnostic value of the history and physical examination. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. Using language appropriate for each patient. (PC, CS)
2. Using non-verbal techniques to facilitate communication and pursue relevant
inquiry. (PC, CS)
3. Eliciting the patients chief complaint as well as a complete list of the
patients concerns. (PC, CS)
4. Obtaining a patients history in a logical, organized, and thorough manner,
covering the following:
History of present illness. (PC, CS)
past medical history (including usual source of and access to health
care, childhood and adult illnesses, injuries, surgical procedures,
obstetrical history, psychiatric problems, sexual history, and
hospitalizations). (PC, CS)
Preventive health measures. (PC, CS)
Medications with dosages and frequencies, including herbals,
supplements, and over-the-counter medications. (PC, CS)
Allergies with specific details of the reaction. (PC, CS)
Substance use including tobacco, alcohol, and illicit drugs. (PC, CS)
Family history. (PC, CS)
Social history. (PC, CS)
Occupational history. (PC, CS)
Review of symptoms. (PC, CS)
5. Obtaining, whenever necessary, supplemental historical information from
collateral sources, such as significant others or previous physicians. (PC, CS)
6. Demonstrating proper hygienic practices whenever examining a patient. (PC)
7. Positioning the patient and self properly for each part of the physical
examination. (PC)
8. Performing a physical examination for a patient in a logical, organized,
respectful, and thorough manner, including:
The patients general appearance. (PC)
Vital signs. (PC)
Pertinent body regions/organ systems. (PC)
When appropriate breast, pelvic, rectal, male genital exams. (PC)
When appropriate fundoscopic exam. (PC)
When appropriate full neurologic exam. (PC)
9. Adapting the scope and focus of the history and physical exam appropriately
to the medical situation and the time available. (PC)
10. Being observant of the patients modesty as much as possible. (PC, P)

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Appreciate the essential contribution of a pertinent and history and physical
examination to patient care. (P)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

2. Demonstrate ongoing commitment to self-directed learning regarding history

taking and physical examination skills. (PLI, P)
3. Seek feedback regularly regarding history and physical examination skills and
respond appropriately and productively. (P)
4. Recognize the importance of and demonstrate a commitment to the utilization
of other health care professions in obtaining a history and physical
examination (e.g. interpreter services, advanced practice nurses, etc.). (P, SBP)
5. Establish a habit of updating historical information and repeating important
parts of the physical examination during follow-up visits. (P)
6. Demonstrate consideration for the patients modesty, feelings, limitations, and
sociocultural background whenever taking a history and performing a physical
examination. (P)
7. Appreciate that some patients will be very anxious about the physical
examination, particularly the breast, pelvic, rectal, and male genital exams. (P)
D.

REFERENCES:
McGee SR. Evidence-Based Physical Diagnosis. Philadelphia, PA: W. B.
Saunders Company; 2001.
Bickley LS, Szilagyi PG. Bates Guide to Physical Examination and History
Taking. 8th Edition. Philadelphia, PA: Lipincott Williams and Wilkens; 2002.
The Auscultation Assistant
www.med.ucla.edu/wilkes/intro.html
Criley JM. The Physiologic Origin of Heart Sounds and Murmurs: The
Unique Interactive Guide to Cardiac Diagnosis. Philadelphia, PA: Lippincott
Williams and Wilkins; 1997.
Heart Sounds and Cardiac Arrhythmias
Medical Multimedia Laboratories
www.blaufuss.org

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 4) COMMUNICATION AND RELATIONSHIPS WITH
PATIENTS AND COLLEAGUES
RATIONALE:
The physician-patient relationship forms the core of the practice of internal medicine.
Many physicians view it as the most satisfying aspect of their work. The medical
interview and the relationship between physician and patient are important diagnostic and
therapeutic tools. Effective communication skills are needed for a physician to serve as
an effective patient advocate. Communication skills also are needed to address patient
concerns and requests. Proficiency in communicating with patients results in increased
patient and physician satisfaction, increased adherence to therapy, and reduced risk of
malpractice claims. The student on the internal medicine clerkship interacts with a
diverse array of patients, physicians, and other health team members, necessitating
proficiency in communication and interpersonal skills. Students also witness how
diversities of age, gender, race, culture, socioeconomic class, personality, and intellect
require a sensitive and flexible approach. The result of proficiency in communication
and interpersonal skills is increased satisfaction for both doctor and patient.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Required pre-clinical courses in physician-patient communication.
Ability to perform a complete medical history on a wide variety of patients, including
adolescents and older adults.
Ability to communicate with patients of diverse backgrounds.
Basic skills for obtaining a history related to substance abuse and sexual,
occupational, and mental health.
Basic skills for discussing issues relating to advance directives.
Basic skills for breaking bad news.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. How patients and physicians perceptions, preferences, and actions are
affected by cultural and psychosocial factors and how these factors affect the
doctor-patient relationship. (MK, P)
2. The role and contribution of each team member to the care of the patient. (MK,
SBP)

3. The role of psychosocial factors in team interactions. (MK)

4. The role of the physician as patient advocate. (MK)
5. Strategies for establishing positive patient-doctor relationships. (MK)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

6. Patient, physician, and system barriers to successfully negotiated treatment

plans and patient adherence; strategies that may be used to overcome these
barriers. (MK, SBP)
7. Useful strategies when a communicating with patients via an interpreter. (MK)
8. Basic techniques for breaking bad news. (MK)
9. Basic tenants of genetic counseling. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. Demonstrating appropriate listening skills, including verbal and non-verbal
techniques (e.g., restating, probing, clarifying, silence, eye contact, posture,
touch) to communicate empathy and help educate the patient. (CS)
2. Demonstrating effective verbal skills including appropriate use of open- and
closed-ended questions, repetition, facilitation, explanation, and interpretation.
(CS)

3. Determining the information a patient has independently obtained about his or

her problems. (CS)
4. Identifying patients emotional needs. (CS)
5. Respond to empathic opportunities by naming the emotions or feelings
expressed. (CS)
6. Eliciting the patients point of view and concerns about his or her illness and
the medical care he or she is receiving. (CS)
7. Discussing how the health problem affects the patients life. (CS)
8. Determining the extent to which a patient wants to be involved in making
decisions about his or her care. (CS)
9. Providing basic information and an explanation of the diagnosis, prognosis,
and treatment plan. (CS)
10. Responding to patients concerns and expectations. (CS)
11. With guidance and direct supervision, participating in breaking bad news to
patients. (CS)
12. With guidance and direct supervision, participating in discussing basic issues
regarding advance directives with patients and their families. (CS)
13. With guidance and direct supervision, participating in discussing basic end-oflife issues with patients and their families. (CS)
14. Assessing patient commitment and adherence to a treatment plan taking into
account personal and economic circumstances. (CS)
15. Working with a variety of patients, including multi-problem patients, angry
patients, somatizing patients, and substance abuse patients. (CS)
16. Working as an effective member of the patient care team, incorporating skills
in inter-professional communication and collaboration. (CS, SBP)
17. Giving and receiving constructive feedback. (CS)
15. Orally presenting a new inpatients or outpatients case in a manner that
includes the following characteristics:
Logically and chronologically develops the history of the present
illness and tells the patients story. (PC, CS)
Summarizes the pertinent positives and negatives. (PC, CS)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Succinctly presents past medical history, family history, social history,

and review of symptoms. (PC, CS)
includes a logical, organized, and prioritized differential diagnosis (PC,
CS)

Includes diagnostic and therapeutic plans. (PC, CS)

Can be made briefer when necessary. (PC, CS)
Is presented as much from memory as possible with minimal reference
to memory aids with the exception of highly important dates,
diagnostic tests, laboratory values. (PC, CS)
16. Orally presenting a follow-up inpatients or outpatients case in a manner that
includes the following characteristics:
Is focused, very concise, and problem-based. (PC, CS)
Emphasizes pertinent new findings. (PC, CS)
Includes diagnostic and therapeutic plans. (PC, CS)
Can be made briefer when necessary. (PC, CS)
Is presented as much from memory as possible with minimal reference
to memory aids with the exception of highly important dates,
diagnostic tests, and laboratory values. (PC, CS)
17. Demonstrating the ability to make clear and concise presentations about topics
assigned to research. (CS)
18. Demonstrating basic strategies for conflict management and resolution. (CS)
19. Demonstrating basic techniques of communication with non-English speaking
patient via an interpreter. (PC, CS)
C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate ongoing commitment to self-directed learning regarding
effective doctor-patient communication skills. (PLI, P)
2. Seek feedback regularly regarding communication skills and respond
appropriately and productively. (P)
3. take into consideration in each case the patients psychosocial status (P)
4. Demonstrate respect for patients. (P)
5. Involve the patient actively in his or her health care whenever possible. (P)
6. Demonstrate teamwork and respect toward all members of the health care
team, as manifested by reliability, responsibility, honesty, helpfulness,
selflessness, and initiative in working with the team. (SBP, P)
7. Attend to or advocate for the patients interests and needs in a manner
appropriate to the students role. (P)
8. Maintain confidentiality when dealing with protected health information and
follow Health Information Portability and Accountability Act (HIPAA)
guidelines. (P, SBP)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

D.

REFERENCES:
Clinician-Patient Communication to Enhance Health Outcomes. Institute for
Health Care communication, Inc., West Haven, Connecticut, 1998.
www.healthcarecomm.org
Contemporary Issues in Medicine: Communication in Medicine
Medical School Objectives Project, October 1999
Association of American Medical Colleges
www.aamc.org/meded/msop/msop3.pdf
Kurtz S, Silverman J, Draper J. Teaching and Learning Communication Skills
in Medicine. Oxford: Radcliffe Medical Press Ltd; 1998.
Kurtz S, Silverman J, Benson J, Draper J. Marrying content and process in
clinical method teaching: enhancing the Calgary-Cambridge guides. Acad
Med. 2003;78:802-9.
Makoul G. The SEGUE Framework for teaching and assessing
communication skills. Patient Educ Couns. 2001;45:23-34.
Makoul G. Essential elements of communication in medical encounters: the
Kalamazoo consensus statement. Acad Med. 2001;76:390-3.
von Gunten CF, Ferris FD, Emanuel LL. Ensuring competency in end-of-life
care: communication and relational skills. JAMA. 2000;284:3051-7.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 5) INTERPRETATION OF CLINICAL INFORMATION
RATIONALE:
In the routine course of clinical practice, most physicians are required to order and
interpret a wide variety of diagnostic tests and procedures. Determining how these test
results will influence clinical decision making and communicating this information to
patients in a timely and effective manner are core clinical skills that third-year medical
students should possess.
PREREQUISITES:
Prior knowledge, skills and attitudes acquired during the pre-clerkship experience should
include:
Introductory course in clinical pathology and laboratory medicine.
Introductory course in epidemiology and biostatistics.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to:

1. Interpret specific diagnostic tests and procedures that are ordered to evaluate
patients who present with common symptoms and diagnoses encountered in
the practice of internal medicine. (PC, MK)
2. Take into account:
Important differential diagnostic considerations, including potential
diagnostic emergencies. (PC, MK)
Pre-test and post-test likelihood of disease (probabilistic reasoning). (PC,
MK)

Performance characteristics of individual tests. (sensitivity, specificity,

positive and negative predictive value, likelihood ratios). (PC, MK)
3. Define and describe for the tests and procedures listed:
Indications for testing. (PC, MK)
Range of normal variation. (PC, MK)
Critical values that require immediate attention. (PC, MK)
Pathophysiologic implications of abnormal results. (PC, MK)
Relative cost. (MK, SBP)
4. Independently interpret the results of the following laboratory tests:
CBC with diff and blood smear. (PC, MK)
UA. (PC, MK)
Electrolytes. (PC, MK)
BUN/Cr. (PC, MK)
GLC. (PC, MK)
Hepatic function panel. (PC, MK)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Hepatitis serologies. (PC, MK)

Cardiac biomarkers (e.g. myoglobin, CK-MB, and Troponin I/T). (PC,
MK)

Routine coagulation tests (e.g. PT/PTT and INR). (PC, MK)

Thyroid function tests (e.g. T3, T4, and TSH). (PC, MK)
ABG.(PC, MK)
Body fluid cell counts and chemistries. (PC, MK)
5. Independently interpret the results of the following diagnostic procedures:
12-lead ECG. (PC, MK)
Chest radiograph. (PC, MK)
Plain abdominal films (e.g. obstructive series, KUB). (PC, MK)
Pulmonary function tests. (PC, MK)
6. Describe the basic electrophysiologic events that produce the surface ECG.
(MK)

7. Describe how errors in test interpretation can affect clinical outcomes and
costs. (PC, MK)
8. Describe the concept of a threshold as it relates to testing and treatment
decisions. (PC, MK)
9. Describe the basic principles of using genetic information in clinical decision
making. (PC, MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. Interpreting a blood smear, Gram stain, and UA. (PC)
2. Approaching ECG interpretation in a systematic and logical fashion analyzing
the following: rate, rhythm, P wave morphology, PR interval, QRS width,
axis, voltage, QT interval, ST segment morphology, and T wave morphology.
(PC)

3. Recognizing the following on ECG:

Sinus tachycardia, sinus bradycardia, sinus arrhythmia. (PC)
Premature atrial beats, ectopic atrial rhythm/tachycardia, narrow
complex supraventricular tachycardia. (PC)
Multifocal atrial tachycardia, atrial flutter, atrial fibrillation (PC)
First degree, second degree (Mobitz type I and II), and third degree
(complete) heart block. (PC)
Junctional rhythm. (PC)
Premature ventricular beats. (PC)
Typical ventricular tachycardia, ventricular fibrillation. (PC)
Left and right atrial enlargement. (PC)
Left ventricular hypertrophy. (PC)
Left and right bundle branch block, left anterior and posterior
fascicular block. (PC)
The characteristic features of a properly functioning ventricular or dual
chamber pacemaker. (PC)
The delta wave in Wolf-Parkinson-White Syndrome. (PC)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

4.

5.

6.
7.
8.

The classic features of myocardial ischemia and infarction and be able

to localize the findings (i.e. inferior, anterior, lateral, posterior, right
ventricular) and identify the probable culprit vessel. (PC)
The classic features of pulmonary embolism. (PC)
The characteristic effects of hypo- and hyperkalemia. (PC)
Approaching chest radiography interpretation in a systematic and logical
fashion analyzing the following: technique (e.g. view, rotation, exposure),
visible abdomen, soft tissues and bones of the thorax, mediastinum/hila, and
lungs. (PC)
Recognizing the following on chest radiograph:
Rib fracture. (PC)
Cardiomegaly. (PC)
Lobar pneumonia. (PC)
Pleural effusion. (PC)
Pneumothorax. (PC)
Pulmonary nodule. (PC)
Pulmonary edema/congestive heart failure (e.g. cardiomegaly,
pulmonary vascular redistribution, Kerleys B Lines,
interstitial/alveolar edema). (PC)
Hilar lymphadenopathy. (PC)
Mediastinal widening. (PC)
Recording the results of laboratory tests in an organized manner, using flow
sheets when appropriate. (PC)
Estimating the pre-test likelihood of a disease or condition. (PC, MK)
Estimating the post-test probability of disease and stating the clinical
significance of the results of laboratory tests and diagnostic procedures. (PC,
MK)

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for acute MI. (PLI, P, SBP)
2. Regularly seek feedback regarding interpretation of clinical information and
respond appropriately and productively. (P)
3. Recognize the importance of patient preferences when selecting among
diagnostic testing options. (P)
4. Demonstrate ongoing commitment to self-directed learning regarding test
interpretation. (PLI, P)
5. Appreciate the implications of test results before ordering tests. (P)
6. Appreciate the importance of follow-up on all diagnostic tests and procedures
and timely communication of information to patients and appropriate team
members. (P)
7. Demonstrate a commitment to excellence by personally reviewing
radiographs, ECGs, Gram stains, blood smears, etc. to assess the accuracy and
significance of the results. (P)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

D.

REFERENCES:
Jaeschke R, Guyatt G, Sackett DL. Users guides to the medical literature.
III. How to use an article about a diagnostic test. A. Are the results of the
study valid? JAMA. 1994; 271:389-91.
Jaeschke R, Guyatt G, Sackett DL. Users guides to the medical literature.
III. How to use an article about a diagnostic test. B. What are the results and
will they help me in caring for my patients? JAMA. 1994; 271: 703-7.
Dubin D. Rapid Interpretation of EKG's. 5th ed. Tampa, FL: Cover
Publishing Company; 2000.
Goodman LR. Felsons Principles of Chest Roentgenology: A Programmed
Text. 2nd ed. Philadelphia, PA: W. B. Saunders; 1999.
Novelline RA. Squire's Fundamentals of Radiology. 6th ed. Cambridge, MA:
University Press; 2004.
Mark, DB. Decision-making in clinical medicine. In Kasper DL, Braunwald
EB, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrisons Principles
of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005:6-13.
Lab Test Online
www.labtestsonline.org/
RadQuiz: Your Gateway to Radiology Resources
www.radquiz.com
Introduction to Chest Radiology
Department of Radiology
University of Virginia Health Sciences Center
www.med-ed.virginia.edu/courses/rad/cxr/index.html
Ferri FF. Laboratory values and interpretation of results. In Ferri FF, ed.
Practical Guide to the Care of the Medical Patient. 6th ed. St. Louis, MO:
Mosby; 2004:935-976.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 6) THERAPEUTIC DECISION MAKING
RATIONALE:
Internists are responsible for directing and coordinating the therapeutic management of
patients with a wide variety of problems, including critically ill patients with complex
medical problems and the chronically ill. To manage patients effectively, physicians need
basic therapeutic decision-making skills that incorporate both pathophysiologic reasoning
and evidence-based knowledge.
PREREQUISITES:
Introductory coursework in clinical epidemiology and biostatistics.
Introductory coursework in physiology and pathology.
Introductory coursework in pharmacology.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Information resources for determining medical and surgical treatment options
for patients with common and uncommon medical problems. (MK)
2. Key factors to consider in choosing among treatment options, including risk,
cost, evidence about efficacy, and consistency with pathophysiologic reasoning.
(MK)

3. How to use critical pathways and clinical practice guidelines to help guide
therapeutic decision making. (MK)
4. Factors that frequently alter the effects of medications, including drug
interactions and compliance problems. (MK)
5. Factors to consider in selecting a medication from within a class of medications.
(MK)

6. Factors to consider in monitoring a patients response to treatment, including

potential adverse effects. (MK)
7. Various ways that evidence about clinical effectiveness is presented to
clinicians and the potential biases of using absolute or relative risk or number of
patients needed to treat. (MK)
8. Methods of monitoring therapy and how to communicate them in both written
and oral form. (MK)
9. The basics of the potential role of genetic information in therapeutic decision
making. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. Formulating an initial therapeutic plan. (PC)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

2. Changing the therapeutic plan when goals of care change (e.g. a shift toward
palliative care). (PC)
3. Accessing and utilizing, when appropriate, information resources to help
develop an appropriate and timely therapeutic plan. (PC, PLI)
4. Explaining the extent to which the therapeutic plan is based on
pathophysiologic reasoning and scientific evidence of effectiveness. (PC)
5. Beginning to estimate the probability that a therapeutic plan will produce the
desired outcome. (PC)
6. Writing prescriptions and inpatient orders safely and accurately. (PC)
7. Counseling patients about how to take their medications and what to expect
when doing so, including beneficial outcomes and potential adverse effects. (PC,
CS)

8. Monitoring response to therapy. (PC)

9. Recognizing when to seek consultation for additional diagnostic and therapeutic
recommendations. (PC, SBP)
10. Recognizing when to screen for certain conditions based on age and risk factors
and what to do with the results of the screening tests. (PC)
C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased consideration in the selection of therapeutic interventions. (PLI, P)
2. Demonstrate ongoing commitment to self-directed learning regarding
therapeutic interventions. (PLI, P)
3. Seek feedback regularly regarding therapeutic decision making and respond
appropriately and productively. (P)
4. Appreciate the impact therapeutic decisions have on a patients quality of life.
(P)

5. Incorporate the patient in therapeutic decision making, explaining the risks and
benefits of treatment. (CS, P)
6. Respect patients autonomy and informed choices, including the right to refuse
treatment. (P)
7. Demonstrate an understanding of the importance of close follow-up of patients
under active care. (P)
8. Recognize the importance of and demonstrate a commitment to the utilization
of other health care professionals in therapeutic decision making. (P, SBP)
D.

REFERENCES:
Mark, DB. Decision-making in clinical medicine. In Kasper DL, Braunwald
EB, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrisons Principles
of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005:6-13.
Roden DM. Principles of clinical pharmacology. In Kasper DL, Braunwald
EB, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrisons Principles
of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005:13-25.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Users' guides to the medical literature. II. How to use an article about therapy
or prevention. A. Are the results of the study valid? Evidence-Based
Medicine Working Group. JAMA. 1993;270:2598-601.
Users' guides to the medical literature. II. How to use an article about therapy
or prevention. B. What were the results and will they help me in caring for
my patients? Evidence-Based Medicine Working Group. JAMA.
1994;271:59-63.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 7) BIOETHICS OF CARE
RATIONALE:
A basic understanding of ethical principles and their application to patient care is essential
for all physicians. During the internal medicine core clerkship, the student can put into
practice some of the ethical principles learned in the preclinical years, especially by
participating in discussions of informed consent and advance directives. Additionally, the
student learns to recognize ethical dilemmas and respect different perceptions of health,
illness, and health care held by patients of various religious and cultural backgrounds.
PREREQUISITES:
Introductory course on medical ethics providing a basic understanding of ethical principles
and fiduciary relationships and their application in clinical medicine:
Autonomy.
Beneficence.
Nonmaleficence.
Truth-telling.
Confidentiality.
Respect for autonomy (informed choice).
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Basic ethical principles (autonomy, beneficence, nonmaleficence, truthtelling, confidentiality, and autonomy). (MK)
2. The patients right to refuse care. (MK)
3. The unique nature of a fiduciary relationship. (MK)
4. Basic elements of informed consent. (MK)
5. Circumstances under which informed consent is necessary and unnecessary.
(MK)

6. Basic concepts of treatment efficacy, quality of life, and societal demands. (MK)
7. Potential conflicts between individual patient preferences and societal demands.
(MK)

8. The role of the physician in making decisions about the use of expensive or
controversial tests and treatments. (MK)
9. Bioethical concerns regarding genetic information, privacy issues in
particular. (MK)
10. The unique bioethical concerns regarding end-of-life care. (MK)
11. Circumstances when withholding or withdrawing care is acceptable. (MK)
12. The role of federal and state legislation in governing health care. (MK)
13. Circumstances when it may be unavoidable or acceptable to breach the basic
ethical principles. (MK)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. Participating in a discussion about advance directives with a patient. (PC, CS)
2. Participating in obtaining informed consent for a procedure. (PC, CS)
3. Participating in explaining and obtaining informed consent for genetic testing.
(PC, CS)

4. Participating in a preceptors discussion with a patient about a requested

treatment that may not be considered appropriate (e.g., not cost-effective). (PC,
CS)

5. Participating in family and interdisciplinary team conferences discussing endof-life care and incorporating the patients wishes in that discussion. (PC, CS,
SBP)

6. Obtaining additional help from ethics experts in conflict resolution. (PC, SBP)
C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate ongoing commitment to self-directed learning regarding
bioethics. (PLI)
2. Recognize the importance of patient preferences, perspectives, and
perceptions regarding health and illness. (P)
3. Demonstrate a commitment to caring for all patients, regardless of the medical
diagnosis, gender, race, socioeconomic status, intellect/level of education,
religion, political affiliation, sexual orientation, ability to pay, or cultural
background. (P)
4. Recognize the importance of allowing terminally ill patients to die with comfort
and dignity when that is consistent with the wishes of the patient and/or the
patients family. (P)
5. Recognize the potential conflicts between patient expectations and medically
appropriate care. (P)
6. Respond appropriately to patients who are nonadherent to treatment. (P)
7. Demonstrate respect for the patients privacy and confidentiality when dealing
with protected health information and follow HIPAA standards. (P)
8. Appreciate the psychological impact genetic information may have on
patients. (P)

D.

REFERENCES:
Bioethics Resources on the Web
Inter-Institute Bioethics Interest Group
National Institutes of Health
U.S. Department of Health and Human Services
www.nih.gov/sigs/bioethics/
University of Pennsylvania Center for Bioethics
www.bioethics.upenn.edu

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Snyder L, Leffler C, Ethics and Human Rights Committee, American College

of Physicians. Ethics manual: fifth edition. Ann Intern Med. 2005;142:56082.
World Medical Association Ethics Unit
www.wma.net/e/ethicsunit/resources.htm
Ethics in Medicine
University of Washington School of Medicine
eduserv.hscer.washington.edu/bioethics
Program in Ethics In Science and Medicine
University of Texas Southwestern Medical Center
www3.utsouthwestern.edu/ethics/
Virtual Mentor
American Medical Association
www.ama-assn.org/ama/pub/category/3040.html
Bioethics Interest Group
American Medical Student Association
www.amsa.org/bio/index.cfm

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 8) SELF-DIRECTED LEARNING
RATIONALE:
Because of the breadth of the problems encountered in clinical practice, internists face an
extraordinary challenge to keep up with the burgeoning amount of new information
relevant to providing high quality care. Therefore, they must master and practice selfdirected life-long learning, including the ability to access and utilize information systems
and resources efficiently.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Basic library skills, including the ability to perform an electronic literature search.
Critical appraisal skills.
Understanding of basic concepts of biostatistics and clinical epidemiology including:
sensitivity, specificity, positive predictive value, negative predictive value, absolute
risk reduction, relative risk reduction, number needed to treat, likelihood/odds ratios,
and tests of significance.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Key sources for obtaining updated information on issues relevant to the
medical management of adult patients. (MK, PLI)
2. A system for managing information from a variety of sources. (MK, PLI)
3. The concept of the focused clinical question. (MK, PLI)
4. Key questions to ask when critically appraising articles on diagnostic tests:
Was there an independent, blind comparison with a reference (gold)
standard? (MK, PLI)
Was the diagnostic test evaluated in an appropriate spectrum of
patients (like those in whom it would be used in practice)? (MK, PLI)
Was the reference standard applied regardless of the diagnostic test
result? (MK, PLI)
What were the results of the study (e.g. sensitivity, specificity,
likelihood ratios, and/or pre- and post-test probabilities)? (MK, PLI)
5. Key questions to ask when critically appraising articles on medical
therapeutics:
Was the assignment of patients to treatments randomized? (MK, PLI)
Were all patients who entered the trial properly accounted for at the
conclusion of the study and analyzed in the group they were
randomized to? (MK, PLI)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

B.

Were patients and study personnel blind to the treatment? (MK, PLI)
Were the groups similar at the start of the trial? (MK, PLI)
Aside from the experimental intervention, were the groups treated
equally? (MK, PLI)
What were the results of the trial (e.g. relative risk reduction, absolute
risk reduction, and number needed to treat)? (MK, PLI)

SKILLS: Students should be able to demonstrate specific skills, including:

1. Performing a computerized literature search to find articles pertinent to a
focused clinical question. (PLI)
2. Demonstrating critical review skills. (PLI)
3. Reading critically about issues pertinent to their patients. (PLI)
4. assessing the limits of medical knowledge in relation to patient problems (PLI)
5. Using information from consultants critically. (PLI)
6. recognizing when additional information is needed to care for the patient (PLI)
7. Asking colleagues (students, residents, nurses, faculty) for help when needed.
(PLI, SBP)

8. Making use of available instruments to assess ones own knowledge base.

(PLI, P)

9. Summarizing and presenting to colleagues what was learned from consulting

the medical literature. (PLI, CS)
C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate self-directed learning in every case. (PLI, P)
2. Acknowledge gaps in knowledge to both colleagues and patients and request
help. (PLI, P)
3. Seek feedback regularly and respond appropriately and productively. (P)
4. Recognize the value and limitations of other health care professionals when
confronted with a knowledge gap. (PLI, P, SBP)

D.

REFERENCES:
Users' guides to the medical literature. I. How to get started. The EvidenceBased Medicine Working Group. JAMA. 1993;270:2093-5.
Users' guides to the medical literature. II. How to use an article about therapy
or prevention. A. Are the results of the study valid? Evidence-Based
Medicine Working Group. JAMA. 1993;270:2598-601.
Users' guides to the medical literature. II. How to use an article about therapy
or prevention. B. What were the results and will they help me in caring for
my patients? Evidence-Based Medicine Working Group. JAMA.
1994;271:59-63.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Users' guides to the medical literature. III. How to use an article about a
diagnostic test. A. Are the results of the study valid? Evidence-Based
Medicine Working Group. JAMA. 1994;271:389-91.
Users' guides to the medical literature. III. How to use an article about a
diagnostic test. B. What are the results and will they help me in caring for
my patients? The Evidence-Based Medicine Working Group. JAMA.
1994;271:703-7.
Strauss SE, Richardson WS, Glasziou P, Haynes RB. Evidence Based
Medicine: How to Practice and Teach EBM. 3rd ed. New York, NY:
Churchill Livingstone; 2005.
Advancing Education in Practice-Based Learning and Improvement
An Educational Resource from the
ACGME Outcome Project
www.acgme.org/outcome/implement/complete_PBLIBooklet.pdf

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 9) PREVENTION
RATIONALE:
One of the most important responsibilities of primary care physicians is to promote health
and prevent disease in a cost-effective manner. Appropriate care by internists includes
not only recognition and treatment of disease but also the routine incorporation of the
principles of preventive health care into clinical practice. All physicians should be
familiar with the principles of preventive health care to ensure their patients receive
appropriate preventive services.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Introductory course in clinical epidemiology and biostatistics.
Introductory course in health promotion and disease prevention.
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Primary, secondary, and tertiary prevention. (MK)
2. Criteria for determining whether or not a screening test should be incorporated
into the periodic health assessment of adults. (MK)
3. General types of preventive health care issues that should be addressed on a
routine basis in adult patients (i.e., cancer screening; prevention of infectious
diseases, coronary artery disease, osteoporosis, and injuries; and identification
of substance abuse). (MK)
4. Vaccines that have been recommended for routine use in at least some adults
(i.e., influenza, pneumococcal, measles, mumps, rubella, tetanus-diphtheria,
hepatitis). (MK)
5. Indications for endocarditis prophylaxis. (MK)
6. Methods for counseling patients about risk-factor modification, including the
stages of change approach to helping patients change behavior. (MK)
7. Influence of age and clinical status on approach to prevention. (MK)
8. General categories of high-risk patients in whom routine preventative health
care must be modified or enhanced (e.g., family history, travel to an
underdeveloped area, occupational exposures, etc.). (MK)
9. The major areas of controversy in screening. (MK)
10. The potential roles and limitations of genetic testing in disease
prevention/early detection. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. Obtaining a patient history, including a detailed family history, vaccination
history, travel history, sexual history, and occupational exposures. (PC)
2. Identifying patients at high risk for developing diabetes, dyslipidemia,
coronary artery disease, cancer, osteoporosis, influenza, pneumonia, hepatitis,
HIV infection, and tuberculosis by screening for major risk factors. (PC)
3. Obtaining a Pap smear and interpreting its results. (PC)
4. Performing a breast examination. (PC)
5. Instructing patients to perform breast self-examination. (PC, CS)
6. Interpreting the results of a mammogram. (PC)
7. Performing a digital rectal examination. (PC)
8. Interpreting the results of a PSA test and understand its limitations. (PC)
9. Performing a testicular examination. (PC)
10. Interpreting the results of a bone densitometry test. (PC)
11. Interpreting the results of a fasting lipid profile. (PC)
12. Interpreting the results of a fasting glucose test. (PC)
13. Counseling patients about safe-sex practices, smoking cessation, alcohol
abuse, weight loss, healthy diet, exercise, and seat belt use. (PC, CS)
14. place and interpret a PPD. (PC)
15. Locating recently published recommendations as well as original data
regarding measures that should be incorporated into the periodic health
assessment of adults. (PLI)

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Address preventive health care issues as a routine part of their assessment of
patients. (P)
2. Encourage patients to share responsibility for health promotion and disease
prevention. (P)
3. Recognize the importance of patient preferences when recommending
preventive health measures. (P)
4. Understand the patients right to refuse preventive health measures. (P)
5. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection preventive health measures. (PLI, P)
6. Demonstrate ongoing commitment to self-directed learning regarding
preventive health measures. (PLI, P)

D.

REFERENCES:
Pomrehn PR, Davis MV, Chen DW, Barker W. Prevention for the 21st
century: setting the context through undergraduate medical education. Acad
Med. 2000;75(7 Suppl):S5-13.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Guide to Clinical Preventive Services

U.S. Preventative Services Task Force (USPSTF)
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
USPSTF Recommendation: Screening for Cancer
www.ahrq.gov/clinic/cps3dix.htm#cancer
USPSTF Recommendation: Screening for Lipid Disorders
www.ahrq.gov/clinic/ajpmsuppl/lipidrr.htm
USPSTF Recommendation: Screening for High Blood Pressure
www.ahrq/clinic/3rduspstf/highbloodsc/hibloodrr.htm
USPSTF Recommendations Statement: Counseling to prevent tobacco use and
tobacco-caused disease
www.ahrq.gov/clinic/3rduspstf/tobaccoun/tobcounrs.htm
Screening for Prostate Cancer. American College of Physicians. Ann Int Med
1997; 126: 480-484.
Summary of Recommendations for Adult Immunization
Immunization Action Coalition Bulletin
Adapted from the recommendations of the Advisory Commttee on
Immunization Practices (ACIP), August 2005
www.immunize.org/acip
Martin GJ. Screening and prevention of disease. In Kasper DL, Braunwald
EB, Fauci AS, Hauser SL, Longo DL, and Jameson JL eds. Harrisons
Principles of Internal Medicine. 16th ed. New York, NY: McGraw-Hill;
2005:26-28.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 10) COORDINATION OF CARE
RATIONALE:
The task of coordinating a patients care is central to the role of the internist, and involves
communication with the patient and his or her family, colleagues, consultants, nurses,
social workers, and community-based agencies. It is essential for the student to learn that
the physicians responsibility toward the patient does not stop at the end of the office visit
or hospitalization but continues in collaboration with other professionals to ensure that
the patient receives optimal care.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Ability to perform patient-centered interviewing to determine the patients needs and
communicate about diagnostic and therapeutic plans, transitions of care, and end-oflife care.
Ability to identify community resources for care and strategies for coordination of
care.
Health Information Portability and Accountability Act (HIPAA) training to promote
patient privacy.
Required introductory courses in interviewing/physical examination with emphasis on
doctor-patient communication and health care delivery.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe and discuss:

1. The role of consultants and their limits in the care of a patient. (MK, SBP)
2. Key personnel and programs in and out of the hospital that may be able to
contribute to the ongoing care of an individual patient for whom the student
has responsibility (e.g. home health providers, social workers, case
coordinators/managers, community health organizations, etc.). (MK, SBP)
3. The role of the primary care physician in coordinating the comprehensive and
longitudinal patient care plan, including communicating with the patient and
family (directly, telephone, or email) and evaluating patient well-being
through home health and other care providers. (MK, SBP)
4. HIPAA guidelines to promote patient privacy. (MK, SBP)
5. The role of the primary care physician in the coordination of care during key
transitions (e.g. outpatient to inpatient, inpatient to skilled nursing facility,
inpatient to hospice, etc.). (MK, SBP)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

6. The role of clinical nurse specialists, nurse practitioners, physicians assistants,

and other allied health professionals in co-managing patients in the outpatient
and inpatient setting. (MK, SBP)
7. The importance of reconciliation of medications at all transition points of
patient care. (MK, SBP)
8. The rationale for a standardized approach to all hand off communications.
(MK, SBP)

B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. Discussing with the patient and their family ongoing health care needs; using
appropriate language, avoiding jargon, and medical terminology. (PC, CS)
2. Participating in requesting a consultation and identifying the specific question
to be addressed. (PC, CS, .SBP)
3. Participating in the discussion of the consultants recommendations. (PC, CS,
SBP)

4. Participating in developing a coordinated, ongoing care plan in the

community. (PC, SBP)
5. Obtaining a social history that identifies potential limitations in the home
setting which may require an alteration in the medical care plan to protect the
patients welfare. (PC, CS)
6. Reconciling patient medications at key transition points in care. (PC, SBP)
7. Conveying accurately vital patient information at all care hand-off points.
(PC, CS, SBP)

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate teamwork and respect toward all members of the health care
team. (P, SBP)
2. Demonstrate responsibility for patients overall welfare. (P)
3. Participate, whenever possible, in coordination of care and in the provision of
continuity. (P, SBP)

D.

REFERENCES:
Goldman L, Lee, T, Rudd P. Ten commandments of effective consultation.
Arch Intern Med. 1983;143:1753-5.
Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG. Coordinating care across
diseases, settings, and clinicians: a key role for the generalist in practice. Ann
Intern Med. 2005;142:700-708.
Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R.
Continuity of care: a multidisciplinary review. BMJ. 2003;327:1219-21.
Wenger NS, Young R. Quality indicators of continuity and coordination of
care for vulnerable elder persons. Rand Corporation, 2004.
www.rand.org/pubs/working_papers/2004/RAND_WR176.pdf

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Building a Case for Medication Reconciliation

Institute for Safe Medication Practices
www.ismp.org/Newsletters/acutecare/articles/20050421.asp
Reconcile Medications at All Transition Points
Institute for Healthcare Improvement
www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Changes/Reco
ncile+Medications+at+All+Transition+Points.htm
Healthcare Communications Toolkit to Improve Transitions of Care
Department of Defense Patient Safety Program
https://patientsafety.satx.disa.mil/ ContentStore/2005_128%20Handoff%20Toolkit%20FINAL.htm

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 11) GERIATRIC CARE
RATIONALE:
Geriatric patients often have multiple, chronic illnesses which may present with atypical
symptoms. Management strategies need to take into account the effects of aging on
multiple organ systems and socioeconomic factors faced by our elderly society. As the
number of geriatrics patients steadily rises, the internist will devote more time to the care
of these patients.
PREREQUISITES:
Required courses in anatomy, physiology, pathophysiology, physical examination,
and nutrition with attention to specific considerations in the elderly.
Ability to perform a complete medical history and physical.
Ability to communicate with patients of diverse backgrounds.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Functional implications of aging on each major organ system. (MK)
2. Nutritional needs of the elderly and adaptations needed in the presence of
chronic illness. (MK)
3. Key illnesses in the elderly, focusing on their often atypical presentation,
including:
Cardiovascular and cerebrovascular disease. (MK)
Diabetes. (MK)
Urinary tract infection. (MK)
Pneumonia. (MK)
Substance abuse. (MK)
Depression. (MK)
Thyroid disease. (MK)
Fluid and electrolyte disturbances. (MK)
Arthritis. (MK)
Constipation. (MK)
Acute abdomen. (MK)
Depression. (MK)
4. the common geriatric syndromes (i.e. symptoms and conditions common in
the elderly and often multifactorial in origin), including:
Immobility. (MK)
Falls/gait and balance problems. ( MK)
Dizziness. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

5.
6.

7.
8.

B.

Incontinence. (MK)
Weight loss/failure to thrive/malnutrition. (MK)
Sleep disturbance. (MK)
Dementia/delirium. (MK)
Osteoporosis. (MK)
Hearing and visual impairment. (MK)
Pressure ulcers. (MK)
Basic treatment plans for illness in the elderly, with an awareness of the
pharmacokinetic and pharmacodynamic changes seen as we age. (MK)
Principles of screening in the elderly, including immunizations, cardiovascular
risk, cancer, substance abuse, mental illness, osteoporosis, and functional
assessment. (MK)
Factors that contribute to polypharmacy in the elderly. (MK)
Principles of Medicare (including who and what services are covered) and
prescription drug coverage (who and what drugs are covered). (MK, SBP)

SKILLS: Students should be able to demonstrate specific skills, including:

1. Taking a complete and focused history from a geriatric patient with attention
to current symptoms, chronic illnesses, and physical and mental functioning.
(PC, CS)

2. Always obtaining historical information from collateral source, whenever

possible. (PC, CS)
3. Performing a physical examination and functional assessment on an elderly
patient, adapting it to a patient's symptoms, chronic illness, and possible
conditions of frailty, immobility, hearing loss, memory loss, and other
impairments. (PC)
4. Performing a mental status examination to evaluate confusion and/or memory
loss in an elderly patient. (PC)
5. Identifying patients at high risk for falling. (PC)
6. Developing a diagnostic and management plan for patients with the with
symptoms/conditions common in the geriatric population. (PC, MK)
7. Communicating the diagnosis, treatment plan, and subsequent follow-up to
the patient and their family. (PC, CS)
8. Eliciting input and questions from the patient and their family about the
diagnostic and management plan. (PC, CS)
9. With guidance and direct supervision, participating in discussing basic issues
regarding advance directives with patients and their families. (CS)
10. With guidance and direct supervision participating in discussing basic end-oflife issues with patients and their families. (CS)
11. Actively attempting to limit polypharmacy whenever possible. (PC)
12. Participating in an interdisciplinary approach to management and
rehabilitation of elderly patients. (PC, SBP)
13. Determine when to obtain consultation from a geriatric specialist. (PC, SBP)
14. Accessing and using appropriate information systems and resources to help
delineate issues related to the common geriatric syndromes. (PC, PLI)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

15. Incorporating patient needs and preferences. (PC, P)

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Respect the increased risk for iatrogenic complications among elderly patients
by always taking into account risks and monitoring closely for complications.
(P)

2. Demonstrate respect to older patients, particularly those with disabilities, by

making efforts to preserve their dignity and modesty. (P)
3. Always treat cognitively impaired patients and patients at the end of their lives
with utmost respect and dignity. (P)
4. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for the common geriatric syndromes. (PLI, P)
5. Recognize the importance of patient needs and preferences when selecting
among diagnostic and therapeutic options for the common geriatric
syndromes. (P)
6. Demonstrate ongoing commitment to self-directed learning regarding care of
the geriatric patient. (P, PLI)
7. Appreciate the impact the common geriatric syndromes have on a patients
quality of life, well-being, and the family. (P)
8. Recognize the importance of and demonstrate a commitment to the utilization
of other health care professionals in the diagnosis and treatment of geriatric
patients. (P, SBP)
D.

REFERENCES:
The American Geriatrics Society
www.americangeriatrics.org/
Guidelines and Position Statements
www.americangeriatrics.org/products/positionpapers/
Portal of Geriatric Online Education (POGOe)
In association with AAMC MedEdPORTAL
www.pogoe.org
Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J
Med. 2003;348(1):42-9.
Fuller GF. Falls in the elderly. Am Fam Physician. 2000;61:2159-68, 21734.
Miller KE, Zylstra RG, Standridge JB. The geriatric patient: a systematic
approach to maintaining health. Am Fam Physician. 2000;61:1089-104.
Willlams CM. Using medications appropriately in older adults. Am Fam
Physician. 2002;66:1917-24.
Huffman GB. Evaluating and treating unintentional weight loss in the elderly.
Am Fam Physician. 2002;65:640-50.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Sloane PD, Coeytaux RR, Beck RS, Dallara J. Dizziness: state of the science.
Ann Intern Med. 2001;134:823-32.
Cummings JL. Alzheimer's disease. N Engl J Med. 2004;351:56-67.
Lembo A, Camilleri M. Chronic constipation. N Engl J Med.
2003;349:1360-8.
Resnick NM, Dosa D. Geriatric medicine. In Kasper DL, Braunwald EB,
Fauci AS, Hauser SL, Longo DL, Jameson JL eds. Harrisons Principles of
Internal Medicine. 16th ed. New York, NY: McGraw-Hill; 2005:43-53.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 12) BASIC PROCEDURES
RATIONALE:
For many students, the internal medicine clerkship is where the basic procedural skills
required in other clerkships, subinternships, and residencies are learned.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Pertinent anatomic considerations, including venous anatomy of the extremities (for
venipuncture and IV placement), arterial anatomy of the wrist and groin (for blood
gases), vaginal/vulvar anatomy (for urethral catheterization in women as well as pap
smear) and prostate anatomy in men (for prostate exam), rectal anatomy (for digital
rectal exam) and surface anatomy and electrical vector orientation of the heart (for
EKG placement).
The fundamental tenants of informed consent.
Basic training in body substance isolation procedures and sterile technique.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Key indications, contraindications, risks to patients and health care providers,
benefits, and techniques for each of the following basic procedures:
Venipuncture. (MK)
Blood culture. (MK)
ABG. (MK)
ECG. (MK)
Chest radiography. (MK)
Nasogastric tube placement. (MK)
Urethral catheterization. (MK)
Peripheral intravenous catheter insertion. (MK)
Throat culture. (MK)
PAP smear. (MK)
Digital rectal examination. (MK)
Urine dipstick. (MK)
Stool occult blood testing. (MK)
Subcutaneous injection. (MK)
Intramuscular injection. (MK)
Wound culture. (MK)
Dressing change. (MK)
PPD placement. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

2. Alternatives to a given procedure. (MK)

3. The patients experience of the procedure. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. Obtaining informed consent, when necessary, for basic procedures, including
the explanation of the purpose, possible complications, alternative approaches,
and conditions necessary to make the procedure as comfortable, safe, and
interpretable as possible. (PC, CS)
2. Explaining what the patients experience is likely to be in understandable
terms. (CS)
3. Demonstrating step-by-step performance of basic procedures with technical
proficiency. (PC)
4. Demonstrating proper sterile technique and body substance isolation
procedures. (PC)
5. Appropriately documenting, when required, how the procedure was done, any
complications, and results. (CS)

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Appreciate the fear and anxiety many patients have regarding even simple
procedures. (P)
2. Make efforts to maximize patient comfort during a procedure. (P)
3. Appreciate the patients right to refuse procedures. (P)
4. Regularly seek feedback regarding procedural skills and respond appropriately
and productively. (P)

D.

REFERENCES:
Guide to procedures. In Lin GA, Lin TL, Sakurai KA, De Fer TM, eds. The
Washington Manual Internship Survival Guide. 2nd ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2005:178-210.
Chen H, Sonneday CJ, Lillemoe KD eds. Manual of Common Bedside
Surgical Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams and
Wilkins; 2000.
Ferri FF. Procedures and interpretation of results. In Ferri FF, ed. Practical
Guide to the Care of the Medical Patient. 6th ed. St. Louis, MO: Mosby;
2004:903-934.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 13) NUTRITION
RATIONALE:
Despite the importance of nutritional factors in health and illness, physicians frequently
have been criticized for giving these factors inadequate attention. Internists, by virtue of
their dedication to providing comprehensive care to their patients, must assess nutritional
factors on a routine basis. Medical students should be prepared to provide patients with
basic advice regarding ways to optimize their nutritional status. Students also need to
have at least a basic working knowledge of the principles of nutritional assessment and
intervention.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history.
Ability to communicate with patients of diverse backgrounds.
Knowledge of body metabolism, the respective roles of dietary fats, carbohydrates,
and protein, and the need for vitamins and minerals for maintenance of health.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Each student should be able to define, describe, and discuss:

1. The relationship between diet and disease. (MK)
2. Common medical problems that can cause nutritional deficiencies. (MK)
3. Contributions of nutrition to medical problems such as obesity,
hyperlipidemia, diabetes, and hypertension. (MK)
4. How to perform a nutritional assessment and assist the patient in setting goals
for dietary improvement. (MK)
5. Daily caloric, fat, carbohydrate, protein, mineral, and vitamin requirements;
adequacy of diets in providing such requirements; evidence of need for and
potential risks of supplements (e.g. calcium, antioxidants). (MK)
6. Common dietary supplements and their known adverse and beneficial effects
on health. (MK)
7. The consequences of poor nutrition on a critically ill patient, such as poor
wound healing, increased risk of infection, and increased mortality. (MK)
8. Nutritional needs of the elderly and adaptations needed in the presence of
chronic illness. (MK)
9. The indications for enteral and parenteral nutrition. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

B.

SKILLS: Student should be able to demonstrate specific skills, including:

1. Obtaining a nutritional history for all patients, with additional focus on those
with chronic disease (obesity, hyperlipidemia, diabetes mellitus, hypertension,
alcoholism, cancer, COPD, CHF, renal, and GI disease), giving attention to
weight change, appetite, eating habits, digestive problems, dental problems,
physical handicaps, psychiatric problems, socioeconomic factors, alcohol use,
medications, and physical activity. (PC, CS)
2. Identifying physical exam abnormalities that may suggest malnutrition, such
as muscle wasting, decreased adipose stores, as well as stigmata of
vitamin/mineral or protein-calorie malnutrition (e.g. alopecia, ecchymoses,
angular chelosis, glossitis, peripheral neuropathy, edema, etc.). (PC)
3. Calculating a patients body mass index (BMI) and measuring waist
circumference. (PC)
4. Ordering appropriate tests for evaluating a patients nutritional status,
including albumin, prealbumin, serum chemistries and coagulation profile.
(PC)

5. Performing basic nutritional counseling with patients with obesity, diabetes

mellitus, hyperlipidemia, hypertension, heart failure, and coronary artery
disease. (PC, CS)
6. Identifying barriers that prevent a patient from successfully adhering to a
recommended diet. (PC, CS)
7. Determining when to obtain consultation from a dietician. (PC, SBP)
8. Incorporating patient needs and preferences. (PC, P)
C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for malnutrition. (PLI, P)
2. Recognize the importance of patient preferences and cultural factors when
selecting nutritional counseling. (PLI, P)
3. Respond to patients who are non-adherent to recommendations for appropriate
nutritional intake. (CS, P)
4. Demonstrate ongoing commitment to self-directed learning regarding
nutrition. (PLI, P)
5. Appreciate the impact malnutrition has on a patients quality of life, wellbeing, ability to work, and the family. (P)
6. Recognize the importance of involving other healthcare professionals when
appropriate. (P, SBP)

D.

REFERENCES:
Division of Nutrition and Physical Activity
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

U.S. Department of Health and Human Serviced

www.cdc.gov/nccdphp/dnpa/
Dietary Guidelines for Americans
U.S. Department of Agriculture
U.S. Department of Health and Human Services
www.health.gov/dietaryguidelines/
American Dietetic Association
www.eatrigh.org
Food and Nutrition Information Center
U.S. Department of Agriculture
www.nal.usda.gov/fnic/
Dwyer J. Nutritional requirements and dietary assessment. In Kasper DL,
Braunwald EB, Fauci AS, Hauser SL, Longo DL, Jameson JL eds.
Harrisons Principles of Internal Medicine. 16th ed. New York, NY:
McGraw-Hill; 2005:399-403.
Halsted CH. Malnutrition and nutritional assessment. In Kasper DL,
Braunwald EB, Fauci AS, Hauser SL, Longo DL, Jameson JL eds.
Harrisons Principles of Internal Medicine. 16th ed. New York, NY:
McGraw-Hill; 2005:411-415.
Howard L. Enteral and parenteral nutrition therapy. In Kasper DL,
Braunwald EB, Fauci AS, Hauser SL, Longo DL, Jameson JL eds.
Harrisons Principles of Internal Medicine. 16th ed. New York, NY:
McGraw-Hill; 2005:415-422.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 14) COMMUNITY HEALTH CARE
RATIONALE:
The increasing number of physicians practicing under managed care and in communityoriented primary care practices necessitates expanding medical education to prepare
graduates for population-based clinical practice. In a managed care setting, populationbased clinical practice includes the health of an enrolled population. In a communitybased setting, population-based clinical practice includes the health of a population in
addition to the health of the individual patient through concern with resource allocation,
epidemiology, and the care of patients whose needs are not currently met by the health
care system.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Required introductory coursework in health care delivery (with an emphasis on
medical sociology and health care delivery to at risk populations).
Required introductory course in clinical epidemiology and biostatistics.
Required introductory coursework in population health (with an emphasis on
differences between individuals and populations).
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The concepts of rate, incidence, and prevalence to characterize the health of a
population. (MK)
2. How to gather health information about a population. (MK)
3. How disease epidemiology in a community differs from that experienced in an
office or hospital practice. (MK)
4. How health care financing and health care delivery systems affect individual
physicians, patients, and communities. (MK, SBP)
5. How community and individual responses to health problems may be affected
by both individual and community socio-cultural characteristics. (MK)
6. Local government, social service, or community organizations that provide
links between the underserved members of the community and the medical
care systems. (MK, SBP)
7. barriers faced by his or her patients in the community setting. (MK)

B.

SKILLS: Students should be able to demonstrate specific skills, including:

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

1. Defining and describing a population, its demography, culture, socioeconomic

makeup, and health status. (PC)
2. Identifying the unique characteristics of a population that affect the health of
the population and individuals within that population. (PC)
3. Considering how the socio-cultural characteristics of a particular community
may affect that populations attitudes toward health care. (PC)
4. Using, in daily patient care, an understanding of the community and sociocultural context that may affect an individual patients health care decisions
and health-related behaviors. (PC)
5. Identifying patients whose illnesses may put the community at risk. (PC, MK)
6. Incorporating a population-based perspective in analyzing clinical problems.
(PC)

7. Reading critically clinical studies and applying findings to health care

decisions involving real patients and populations of patients. (PC, MK, PLI)
8. Incorporating principles of disease prevention and behavioral change
appropriate for specific populations of patients within a community. (PC, MK)
9. Attempting to develop solutions for barriers to health care delivery (e.g. sociocultural, financial, and system-based) that affect individual patients. (PC, SBP)
10. Functioning effectively as a member of a health care team. (PC, P, SBP)
11. Using, when appropriate, local government, social service, and community
organizations to improve the health of individuals and populations. (PC, SBP)
12. Accessing and utilizing appropriate information systems and resources to help
delineate issues related to population health. (PC, PLI)
C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate respect for cultural and socioeconomic diversity. (P)
2. Show willingness to accept at least partial responsibility for the health of
populations. (P)
3. Respond nonjudgmentally to an individual whose socio-cultural and
community-based background result in seemingly counterproductive heath
care decisions and health-related behaviors. (P)
4. Value the unique contributions of all members of the health care team. (P)
5. Demonstrate ongoing commitment to self-directed learning regarding
population/community health issues. (PLI, P)

D.

REFERENCES:
Contemporary Issues in Medical Education: Quality of Care
Medical Informatics and Population Health, June, 1998
Association of American Medical Colleges
www.aamc.org/meded/msop/msop2.pdf
Population Health Forum
University of Washington
School of Public Health and Community Medicine
depts.washington.edu/eqhlth/index.htm

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Behavioral Risk Factor Surveillance System

Division of Adult and Community Health
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/brfss/index.htm
Healthy People 2010
National Center for Health Statistics
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/nchs/hphome.htm
Rhyne RL, Bogue R, Kukulka G, Fulmer H, eds. Community-Oriented
Primary Care: Health Care for the 21st Century. Washington, DC: American
Public Health Association; 1998.
Strelnick AH. Community-oriented primary care: the state of an art. Arch
Fam Med. 1999;8:550-2.
Fox DM. The relevance of population health to academic medicine. Acad
Med. 2001;76:6-7.
Kindig D, Stoddart G. What is population health?. Am J Public Health.
2003;93:380-3.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 15) CONTINUOUS IMPROVEMENT IN SYSTEMS OF
MEDICAL PRACTICE
RATIONALE:
In the past clinical education had emphasized the role of the physician as an individual
decision maker. Problems with cost and quality of care had usually been attributed to
errors in individual decision making. In recent years, it has become clear that the
individual does not function in isolation but within the context of a health care system
and a health care team whose structure ranges from simple to complex. The way the
system functions is critical to achieving high quality patient care, ensuring patient safety,
reducing sources of errors in medicine, and promoting an environment that respects
disclosure without blame. Furthermore, we have begun to focus on the patient as the
center of the health care delivery system and to assess quality from the perspectives of
the patient and the physician. With the patient as the center of the health care delivery
system, the physician becomes a collaborative partner with other health professionals
who share a common goal of providing safe, accessible, high quality, evidence-based
care.
PREREQUISITES:
Prior knowledge, skills and attitudes acquired during the pre-clerkship experience should
include:
Required introductory course in clinical epidemiology and biostatistics.
Required introductory course in health care delivery.
Required introductory course in bioethics and professionalism.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The concept of systems-based practice. (MK, SBP)
2. How patient care is affected by other professionals, organizations, and society.
(MK, SBP)

3. The principles of clinical quality improvement, including the notion of

variation in practice as a quality issue and the concept of medical care as a
process which can be studied and improved. (MK, SBP)
4. The analysis and improvement of systems to address common quality
problems (e.g., treatment delays, medication errors, failure to use evidencebased diagnostics/treatments, failure to provide preventive care, etc.). (MK,
SBP)

5. Principles of medical record organization in both inpatient and ambulatory

settings. (MK, SBP)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

6. The importance of complete medical documentation in the context of

measuring quality of care, avoiding redundancy, preventing medical errors,
and improving patient safety. (MK, SBP)
7. The need for a multidimensional approach to the assessment of quality,
including the patients perspective of quality. (MK, SBP)
8. The relationship of quality and cost in health care from the standpoint of the
individual, health care systems, and society. (MK, SBP)
9. Major health care safety concerns (e.g., medication errors, wrong-site
procedures, patient misidentification, miscommunication among health care
givers, nosocomial infections, falls, use of restraints, etc.). (MK, SBP)
10. Potential benefits and pitfalls of critical pathways/practice guidelines intended
to improve the quality of care. (MK, SBP)
11. Basic organizational structures and financing streams of the U.S. health care
system. (MK, SBP)
12. The fundamentals of the various type of health insurance (e.g., fee-for-service,
preferred provider organization, health maintenance organization, point-ofservice). (MK, SBP)
13. The fundamentals of Medicare and Medicaid. (MK, SBP)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. Using hospital-based support systems to assist in making clinical decisions
(e.g., antibiotic control program, critical pathways/practice guidelines, etc.).
(PC, PLI, SBP)

2. Recognizing system flaws in the delivery of care (e.g., inability to arrange a

post-discharge appointment within a needed time frame, delays in obtaining
test results, inaccessibility of medical records, etc.). (SBP)
3. Using patient education materials to facilitate patients participation in their
own care. (CS, SBP)
4. Using the medical records system efficiently to produce medical notes that
communicate information clearly. (PC, CS, SBP)
5. Maintaining accurate documentation of preventive health measures. (PC, CS,
SBP)

6. Working collaboratively with other health professionals in the delivery of

quality care. (PC, P, SBP)
7. Assessing the patients needs from the standpoint of the individual, family,
and community. (PC, SBP)
8. Identifying resource available to patients within the health care system. (PC,
SBP)

9. Reporting patient safety concerns and medical errors to the appropriate

individuals. (CS, SBP)
10. Using resources, appropriate information systems, and the tenants of
evidence-based medicine to assess systems-based practice issues. (PLI, SBP)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Recognize the importance of systems, particularly inter-professional
collaboration, in delivering high quality patient care. (P, SBP)
2. Strive to improve the timeliness diagnostic and therapeutic decision making in
order to improve quality of care, increase patient satisfaction, and reduce
health care costs. (PLI, P, SBP)
3. View the patient as the center of the health care delivery system. (P, SBP)
4. Advocate for patients in the health care system. (P, SBP)
5. Appreciate that medical error prevention and patient safety are the
responsibility of all health care providers and systems and accept the
appropriate degree of responsibility at the medical student level. (P, SBP)
6. Appreciate the importance teamwork in delivering high quality care. (P, SBP)
7. Respect other health care professionals as colleagues on a patient-centered
health delivery team and as mutual contributors to high quality patient care.
(P, SBP)

D.

REFERENCES:
GENERAL:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
ahrq.gov
QUALITY OF CARE:
Institute for Healthcare Improvement
www.ihi.org/ihi
Crossing the Quality Chasm: A New Health System for the 21st Century
Committee on Quality Health Care in America
Institute of Medicine
National Academies Press, 2001
National Committee for Quality Assurance
www.ncqa.org
National Guideline Clearing House
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
www.guideline.gov
MEDIAL ERRORS AND PATIENT SAFETY:
To Err Is Human: Building a Safer Health System
Institute of Medicine
www.iom.edu/?id=4117&redirect=0
Patient Safety Network
Agency for Healthcare Research and Quality

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

U.S. Department of Health and Human Services

psnet.ahrq.gov
National Patient Safety Foundation
www.npsf.org
Facts About Patient Safety
Joint Commission on Accreditation of Healthcare Organizations
www.jcaho.org/accredited+organizations/patient+safety/facts+about+pati
ent+safety.htm
HEALTH INSURANCE AND FINANCE:
Understanding Managed Care
Institute for Health Care Studies
Michigan State University
www.ihcs.msu.edu/modules/UMC2003/UMC2003.pdf
The Official U.S. Government Site for People with Medicare
U.S. Department of Health and Human Services
www.medicare.gov
Checkup on Health Insurance Choices
Agency for Healthcare Research and Quality
www.ahrq.gov/consumer/insuranc.htm

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 16) OCCUPATIONAL HEALTH CARE
RATIONALE:
Despite increasing recognition of the health hazards found in living and working
environments, physicians have traditionally received little formal training in the
assessment and management of occupational and environmental health problems.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Required introductory course work in clinical epidemiology and biostatistics.
Required introductory course work in the fundamental principles of public health.
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Each student should be able to define, describe, and discuss :

1. Common environmental diseases that are likely to be encountered by an
internist and the principal etiologic agents associated with them. (MK)
2. Pathogenesis of specific occupational diseases and the types of risks that may
be encountered in the home or at the work site:
Musculoskeletal/ergonomic or repetitive stress disorders (e.g. low
back pain, carpal tunnel syndrome, etc.). (MK)
Work related lung disorders (e.g. occupational asthma, particulate
inhalation, etc.). (MK)
Noise related hearing loss. (MK)
Skin disorders (e.g. latex allergy and other forms of occupational
dermatitis). (MK)
Infectious disease exposure (e.g. hepatitis, HIV, TB, etc.). (MK)
Psychological/stress related disorders (MK)
3. Information sources for determining the risk of specific environmental and
occupational health hazards. (MK)
4. Purpose of Occupational Safety and Health Act (OSHA) regulations and the
function of the National Institute for Occupational Safety and Health.
(NIOSH). (MK, SBP)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. Obtaining an appropriate occupational history on all patients and identifying
those patients whose health may have been adversely affected by their living
conditions or work environment. (PC, CS)
2. Considering the possibility that the patients illness may be related to their
home or work environment. (PC)
3. Providing patients with sound advice on the prevention of occupational and
environmental-related diseases. (PC, CS)
4. Accurately diagnosing and developing a cost-effective basic management plan
for common occupational health problems (e.g. carpal tunnel syndrome,
asthma, asbestosis). (PC, MK, SBP)
5. Determining when to obtain consultation from an environmental and
occupational medicine specialist. (PC, SBP)
6. Accessing and utilizing appropriate information systems and resources to help
delineate issues related to occupational health problems. (PC, PLI)

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be

able to:
1. Demonstrate an understanding that physicians have a duty and professional
responsibility to follow-up on conditions that are suspected of causing
occupational or environmental-related illnesses. (P, SBP)
2. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for occupational health problems. (PLI, P)
3. Recognize the importance of patient needs and preferences when selecting
among diagnostic and therapeutic options for occupational health problems.
(P)

4. Demonstrate ongoing commitment to self-directed learning regarding

occupational health problems. (PLI, P)
5. Appreciate the impact occupational health problems have on a patients
quality of life, well-being, ability to work, and the family. (P)
6. Recognize the importance of and demonstrate a commitment to the utilization
of other health care professionals in the diagnosis and treatment of
occupational health problems. (P, SBP)
D.

REFERENCES:
Occupational Safety and Health Administration
U.S. Department of Labor
www.osha.gov
National Institute for Occupational Safety and Health
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/niosh/homepage.html

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

GENERAL CLINICAL CORE COMPETENCIES

RANK 17) ADVANCED PROCEDURES
RATIONALE:
A number of advanced procedures may be performed by general internists, and
occasionally third-year medical students under their supervision. In either case,
knowledge of the key indications, contraindications, risks, and benefits of these
procedures is essential for high quality patient care. Physicians, regardless of specialty,
must be able to explain to their patients, in understandable terms, what will be
experienced during a procedure.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Pertinent anatomic considerations, including vascular anatomy of the extremities,
wrist/hand, neck, subclavian area and groin.
Pertinent anatomic landmarks important for the safe performance of thoracentesis,
paracentesis, lumbar puncture, and arthrocentesis.
Required introductory course in interviewing and physical examination.
The fundamental tenants of informed consent.
Basic training in body substance isolation procedures and sterile technique.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Key indications, contraindications, risks, benefits, techniques of each of the
following advanced procedures:
Arthrocentesis. (MK)
o Elbow (olecranon bursa). (MK)
o Wrist. (MK)
o Knee. (MK)
o Ankle. (MK)
Central venous catheterization. (MK)
o Internal jugular vein. (MK)
o Subclavian vein. (MK)
o Femoral vein. (MK)
Arterial line placement. (MK)
o Radial artery. (MK)
o Femoral artery. (MK)
Lumbar puncture. (MK)
Thoracentesis. (MK)
Paracentesis. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

2. Potential alternatives to the listed procedures. (MK)

3. The patients probable experience during these procedures. (MK)
4. Indications for and efficacy of intra-articular corticosteroid injections. (MK)
B.

SKILLS: Each student should be able to demonstrate specific skills, including:

1. Participating in obtaining informed consent for advanced procedures,
including the explanation of the purpose, possible complications, alternative
approaches, and conditions necessary to make the procedure as comfortable,
safe, and interpretable as possible. (PC, CS)
2. Explaining the patients probable experience during the procedure in
understandable terms. (PC, CS)
3. Helping to position the patient and make them as comfortable as possible
during the procedure. (PC)
4. Assisting (under supervision, when appropriate) in the performance of the
procedure. (PC)
5. Demonstrating proper sterile technique and body substance isolation
procedures. (PC)
6. Appropriately documenting, when required, how the procedure was done as
well as any complications and results. (CS)
7. Ordering and interpreting appropriate diagnostic tests on fluids removed from
the patient (e.g. synovial fluid, cerebrospinal fluid, pleural fluid, and ascitic
fluid). (PC, MK)

C.

ATTITUDES AND PROFESSIONAL BEHAVIOR: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of procedures to be performed. (PLI, P)
2. Appreciate the fear and anxiety many patients have regarding these
procedures. (P)
3. Make efforts to maximize patient comfort during a procedure. (P)
4. Appreciate the patients right to refuse procedures. (P)
5. Seek feedback regularly regarding procedural skills and respond appropriately
and productively. (P)

D.

REFERENCES:
Guide to procedures. In Lin GA, Lin TL, Sakurai KA, De Fer TM, eds. The
Washington Manual Internship Survival Guide. 2nd ed. Philadelphia, PA:
Lippincott Williams and Wilkins; 2005:178-210.
Chen H, Sonneday CJ, Lillemoe KD eds. Manual of Common Bedside
Surgical Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams and
Wilkins; 2000.
Ferri FF. Procedures and interpretation of results. In Ferri FF, ed. Practical
Guide to the Care of the Medical Patient. 6th ed. St. Louis, MO: Mosby;
2004:903-934.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #1: THE HEALTHY PATIENT: HEALTH

PROMOTION, DISEASE PREVENTION, AND SCREENING
RATIONALE:
The growing appreciation for the contributions of screening, prevention, and health
promotion to health outcomes necessitates that basic clinical education incorporate
advances made in this area. Especially important are those interventions that relate to
prevention of cardiovascular disease, the early detection and treatment of potentially
curable cancers, and to optimizing care for chronic diseases.
PREREQUISITES:
Prior knowledge, skills and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to obtain a patient history that includes a family history and an assessment of
risk factors.
Knowledge of the warning signs of common cancers.
Knowledge of basic criteria and principles of health screening.
Knowledge of clinical epidemiologic concepts as they pertain to estimation of health
risk and quantitative rationale for screening.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The epidemiology and definitions of hypertension, its contribution to
cardiovascular risk, the impact of treatment on risk, and current.
Recommendations for screening. (MK)
2. The epidemiology of hyperlipidemia, its contribution to cardiovascular risk,
the reliability of testing modalities, the impact of treatment on cardiovascular
risk, and current recommendations for screening. (MK)
3. The epidemiology of common cancers, including:
Breast cancer, including the efficacy of available screening modalities,
impact of early treatment on survival, and current recommendations
for screening. (MK)
Common skin cancers, including the warning signs of melanoma and
basal and squamous cell carcinoma. (MK)
Cervical cancer, including the utility of the Pap smear, impact of early
treatment on outcome, and current recommendations for screening.

(MK)

Colorectal cancer, including the utility of available screening

methodologies, the impact of early treatment on outcome, and current
screening recommendations. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Prostate cancer, including the utility of available screening modalities,

impact of early treatment on outcome, and current screening
recommendations. (MK)
4. The risks, benefits, methods, and recommendations for immunizing adults
against hepatitis B, influenza, pneumococcal infection, tetanus/diphtheria, and
mumps/measles/rubella. (MK)
5. Safe sexual practices and risks, benefits, and efficacy of common methods of
contraception. (MK)
6. Efficacy of seat belt use and proper belt application. (MK)
7. Efficacy of exercise and weight loss in prevention of cardiovascular disease
and recommended exercise programs. (MK)
8. The clinical presentations of substance abuse and basic approaches to
prevention and treatment. (MK)
9. The impact of smoking on cardiovascular and cancer risk and basic
approaches to smoking cessation. (MK)
10. Daily caloric, fat, carbohydrate, protein, mineral, and vitamin requirements;
adequacy of diets in providing such requirements; evidence of need for
supplements (e.g. calcium, antioxidants). (MK)
11. The functional status assessment in the geriatric patient and its impact on
assuring the best possible functional state. (MK)
12. Common environmental and occupational hazards. (MK)
13. Controversies and differences that exist in the recommendations for
preventive measures and screening. (MK)
B.

SKILLS: Students should demonstrate specific skills including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, including:
Dietary intake of fats and cholesterol. (PC, CS)
Exercise and activity levels. (PC, CS)
Substance use and its effects, including tobacco, alcohol, and elicit
drugs. (PC, CS)
Psychosocial stresses and environmental risks. (PC, CS)
Specific cancer risks (e.g. family history, exposures, warning
symptoms, preventive efforts). (PC, CS)
Any high-risk sexual practices. (PC, CS)
immunization status appropriate for adults, including:
o Diphtheria/tetanus for all adults. (PC, CS)
o Influenza vaccine and pneumococcal vaccine for the elderly
and those with underlying chronic disease. (PC, CS)
o Rubella for sero-negative women of child-bearing age. (PC, CS)
o Hepatitis B vaccine for medical personnel and other at-risk
populations. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam
with features depending on age/sex/race and medical history of an individual,
including:

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Screening skin examination for signs of malignancy. (PC)

Screening breast examination for a dominant nodule and secondary
signs of malignancy. (PC)
Participation in obtaining a Pap smear. (PC)
Screening rectal examination that includes palpation of the prostate
gland, identification of any nodules, and performance of a stool test for
occult blood. (PC)
Performance of a functional status examination in the geriatric patient.
(PC)

3. Differential diagnosis: Students should be able to generate a prioritized

differential diagnosis using specific history, physical exam, and laboratory
findings identified during the screening examination (PC, MK)
4. Laboratory interpretation: Students should be able to recommend and
interpret laboratory tests for screening purposes, including consideration of
test cost and performance characteristics as well as patient preferences.
Laboratory and other tests may include, when appropriate:
Complete blood count. (PC, MK)
Fasting lipid panel. (PC, MK)
Fasting blood glucose. (PC, MK)
Urinalysis. (PC, MK)
Stool test for occult blood. (PC, MK)
Prostate specific antigen. (PC, MK)
Students should be able to define the indications for and interpret (with
consultation) results of:
Mammography. (PC, MK)
Colonoscopy. (PC, MK)
Pap smear. (PC, MK)
Bone densitometry. (PC, MK)
5. Communication skills: Students should be able to:
Communicate results of the evaluation and counsel for disease
prevention. (PC, CS)
Elicit questions from the patient and his or her family about the plan.
(PC, CS)

6. Basic and advanced procedural skills: Students should be able to:

Perform a urinalysis (dipstick and microscopic). (PC)
Stool occult blood testing. (PC)
Calculate a BMI. (PC)
Perform a functional status examination for elderly patients. (PC)
Administer intramuscular injection of a vaccine. (PC)
Participate in obtaining a Pap smear. (PC)
7. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for healthy patients, including:
Designing an appropriate work-up for any abnormalities noted on the
screening exam. (PC, MK)
Teaching breast self-examinations. (PC, CS)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

counseling for:
o Safe sexual practices. (PC, CS)
o Seatbelt use. (PC, CS)
o Healthy diet. (PC, CS)
o Weight loss. (PC, CS)
o Practical exercise program appropriate to the patient's age, and
current physical condition. (PC, CS)
o Stress management. (PC, CS)
o Alcohol abstinence. (PC, CS)
o Smoking cessation. (PC, CS)
o Cancer screening. (PC, CS)
o Limiting risks of occupational and environmental hazards. (PC,
CS)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to healthy patients. (PC, PLI)
Using a cost-effective approach based for screening. (PC, SBP)
Incorporating patient preferences. (PC, P)
Engaging the patient as an active participant in his/her health care.
(PC,P)

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Recognize the importance of regularly screening all patients followed and of
teaching all patients about preventive measures. (PC, P)
2. Appreciate the necessity of keeping detailed records of screening and health
maintenance measures. (PC, P)
3. Understand that physicians and health care delivery organizations are
frequently judged by their ability to deliver the highest quality screening and
preventive measures. (PLI, P, SBP)
4. Recognize the importance of addressing community sources of health risk.
(PC, P)

5. Respond appropriately to patients who are nonadherent preventive measures.

(CS, P)

6. Respect the patients right to refuse preventive measures and screening. (P)
7. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of screening tests. (PLI, P)
8. Demonstrate ongoing commitment to self-directed learning regarding
prevention and screening. (PLI, P)
9. Recognize the importance and demonstrate a commitment to the utilization of
other healthcare professions in preventative medicine. (P, SBP)
D.

RESOURCES:
USPSTF Recommendation: Screening for Breast Cancer
www.ahcpr.gov/clinic/3rduspstf/breastcancer/brcanrr.htm

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 USPSTF Recommendation: Screening for Cervical Cancer

www.ahrq.gov/clinic/3rduspstf/cervcan/cervcanrr.htm
USPSTF Recommendations Statement: Counseling to prevent tobacco use and
tobacco-caused disease
www.ahrq.gov/clinic/3rduspstf/tobacccoun/tobcounrs.htm
Screening for Prostate Cancer. American College of Physicians. Ann Int Med
1997; 126: 480-484.
Summary of Recommendations for Adult Immunization.
Immunization Action Coalition Bulletin.
Adapted from the recommendations of the Advisory Committee on
Immunization Practices (ACIP), August 2005
www.immunize.org/acip

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #2: ABDOMINAL PAIN

RATIONALE:
Abdominal pain is a common symptom that can be attributed to a wide variety of acute
and chronic disease processes, many of which may represent serious medical problems.
Mastery of the approach to patients with abdominal pain is important to third year
medical students.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Knowledge of gastrointestinal and gynecologic anatomy, physiology, and
pathophysiology.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. three principal types of abdominal pain:
Visceral pain: (MK)
o Poorly localized but site roughly corresponds to dermatome
that innervates the affected organ.
o Characteristics may vary (dull, cramping, burning).
o Frequently accompanied by secondary autonomic effects
(nausea, vomiting, pallor, diaphoresis, restlessness).
o Patient moves around in an attempt to alleviate discomfort.
Somatoparietal or peritoneal pain: (MK)
o More localized and more intense than visceral pain.
o Arises from peritoneal irritation.
o Aggravated by movement (patient attempts to lie still).
Referred pain: (MK)
o Usually well localized but felt in areas remote to affected
organ.
o May be felt in skin or in deeper tissues.
o Results from convergence of visceral afferent neurons with
somatic neurons from different anatomic regions.
2. Relative likelihood of the common causes of abdominal pain based on the
pain pattern and the quadrant in which the pain is located. (MK)
3. Diagnostic discrimination between common causes of abdominal pain based on
history, physical exam, laboratory testing, and imaging procedures. (MK)
4. Symptoms and signs indicative of an acute/surgical abdomen. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

5. The influence of age, gender, menopausal status, and immunocompetency on

the prevalence of different disease processes that may result in abdominal
pain. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an appropriately complete medical history that differentiates among
etiologies of disease, including:
Chronology. (PC, CS)
Location. (PC, CS)
Radiation. (PC, CS)
Character. (PC, CS)
Intensity. (PC, CS)
Duration. (PC, CS)
Aggravating or alleviating factors. (PC, CS)
Associated symptoms. (PC, CS)
Pertinent information about previous abdominal or pelvic surgeries,
chronic medical conditions, sexual activity, medications, and family
history. (PC, CS)
2. Physical exam skills: Students should be able to perform a focused physical
exam in patients who present with abdominal pain in order to:
Establish a preliminary diagnosis of the cause. (PC)
Assess the severity of the patients presenting symptoms and signs.
(PC)

Determine the urgency of implementing diagnostic and treatment

plans. (PC)
The initial physical examination of the patient should include:
A general assessment of the patients appearance, position, and degree
of discomfort. (PC)
Measurement of vital signs, including temperature, pulse, blood
pressure, and, when indicated, orthostatic blood pressure and pulse.
(PC)

Correct order and technique for examining the abdomen. (PC)

Inspection of the abdomen for surgical scars, distension, asymmetry or
cutaneous abnormalities (dilated veins, ecchymoses, etc.). (PC)
Auscultation of the abdomen for abnormal bowel sounds, bruits. (PC)
Percussion of the abdomen for detection of hepatomegaly,
splenomegaly, abdominal masses, or the presence of ascites. (PC)
Palpation of the abdomen for areas of tenderness, signs of peritoneal
inflammation, hepatomegaly, splenomegaly, abnormal masses,
pulsations, or hernias. (PC)
Performance of rectal and pelvic exams (under supervision). (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis of the most important and likely causes of a patients
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

abdominal pain and recognize specific history, physical exam, and laboratory
findings that distinguish between the following diagnoses or conditions:
Appendicitis. (PC, MK)
Cholecystitis (biliary colic). (PC, MK)
Pancreatitis. (PC, MK)
Diverticulitis. (PC, MK)
Peptic ulcer disease including perforation. (PC, MK)
Gastroenteritis. (PC, MK)
Hepatitis. (PC, MK)
Irritable bowel syndrome. (PC, MK)
Small bowel obstruction. (PC, MK)
Acute mesenteric ischemia. (MK, PC)
Inflammatory bowel disease. (PC, MK)
Ruptured abdominal aortic aneurysm. (PC, MK)
Ureteral stones (renal colic). (PC, MK)
Pelvic inflammatory disease. (PC, MK)
Ruptured ectopic pregnancy. (PC, MK)
Abdominal wall pain. (PC, MK)
Referred pain. (PC, MK)
4. Laboratory interpretation: Students should be able to interpret specific
diagnostic tests and procedures that are commonly ordered to evaluate patients
who present with abdominal pain. Test interpretation should take into
account:
Important differential diagnostic considerations including potential
diagnostic emergencies. (PC, MK)
Pre-test and post-test likelihood of disease (probabilistic reasoning). (PC,
MK)

Performance characteristics of individual tests (sensitivity, specificity,

positive and negative predictive value, likelihood ratios). (PC, MK)
Laboratory and diagnostic tests should include, when appropriate:
CBC with differential. (PC, MK)
UA. (PC, MK)
Pregnancy test. (PC, MK)
Stool for occult blood. (PC, MK)
Hepatic function panel. (PC, MK)
Amylase and lipase. (PC, MK)
Abdominal obstructive series. (PC, MK)
Students should be able to define the indications for, and interpret (with
consultation) the results of:
Abdominal ultrasound. (PC, MK)
Abdominal CT scan. (PC, MK)
Paracentesis fluid studies. (PC, MK)
Upper gastrointestinal endoscopy. (PC, MK)
Sigmoidoscopy/colonoscopy. (PC, MK)
Barium contrast studies. (PC, MK)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Radionuclide scan of the hepatobiliary system. (PC, MK)

5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (PC, CS)
Elicit questions from the patient and his or her family about the
management plan. (PC, CS)
Communicate in lay terms the indications, risk/benefits, and expected
outcomes essential to obtaining informed consent for diagnostic and
therapeutic procedures commonly used to evaluate and treat patients
who present with abdominal pain. (PC, CS)
6. Basic and advanced procedural skills: Students should be able to:
Insert a nasogastric tube. (PC)
Perform stool occult blood testing. (PC)
Assist in performing a paracentesis after explaining the procedure to
the patient. (PC, CS)
7. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients that includes:
Recognizing the role of narcotic analgesics and empiric antibiotics in
treating selected patients who present with acute abdominal pain. (PC, MK)
Determining when to consult a gastroenterologist or a surgeon. (PC,

SBP)

Involving a surgeon as soon as possible when a patient is identified as

having an acute abdomen. (PC, SBP)
Selecting various tests and procedures commonly used to diagnose
patients who present with symptoms of abdominal pain. ( PC, MK)
Recommending basic initial management plans for the various causes
of abdominal pain listed in the differential diagnosis. (PC, MK)
Considering the potential value of addressing psychosocial issues in
the management of chronic abdominal pain. (PC, MK)
Accessing and utilizing appropriate information systems and resources
to help delineate issues related to abdominal pain. (PC, PLI)
Using a cost-effective approach based on the differential diagnosis.

Incorporating patient preferences. (PC, P)

(PC, SBP)

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for abdominal pain. (PLI, P)
2. Recognize the importance of patient needs and preferences when selecting
among diagnostic and therapeutic options for abdominal pain. (P)
3. Recognize the importance and demonstrate a commitment to the utilization of
other healthcare professions in the treatment of abdominal pain. (P, SBP)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

D.

REFERENCES:
Silen W. Copes Early Diagnosis of the Acute Abdomen. 20th ed. New York:
Oxford University Press; 2000.
Wagner JM, McKinney WP, Carpenter JL. The rational clinical exam. Does
this patient have appendicitis? JAMA. 1996;276:1589-94.
Lederle F, Simel D. The rational clinical exam. Does this patient have an
abdominal aortic aneurysm? JAMA. 1999;281:77-82.
Trowbridge RL, Rutkowski NK, Shojania KG. The rational clinical exam.
Does this patient have acute cholecystitis? JAMA. 2003;289: 80-86.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #3: ALTERED MENTAL STATUS

RATIONALE:
The diagnosis and management of altered mental status requires a working knowledge of
all areas of internal medicine, so varied are the etiologies and corresponding treatment
strategies. Internists must master an approach to the problem as they are often the first
physicians to see such patients.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Ability to perform a complete medical history and physical.
Ability to communicate with patients of diverse backgrounds.
Basic course work in physiology, pathophysiology, and neuroanatomy.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The differentiation of delirium, dementia, and depression. (MK)
2. The pathophysiology, symptoms, and signs of the most common and most
serious causes of altered mental status, including:
Metabolic causes (e.g. hyper/hyponatremia, hyper/hypoglycemia,
hypercalcemia, hyper/hypothyroidism, hypoxia/hypercapnea, B12
deficiency, hepatic encephalopathy, uremic encephalopathy,
drug/alcohol intoxication/withdrawal, and Wernickes
encephalopathy). (MK)
Structural lesions (e.g. primary or metastatic tumor, intracranial
hemorrhage, subdural hematoma). (MK)
Vascular (e.g. cerebrovascular accident, transient ischemic attack,
cerebral vasculitis). (MK)
Infectious etiologies (e.g. encephalitis, meningitis, urosepsis,
endocarditis, pneumonia, cellulites). (MK)
Seizures/ post-ictal state. (MK)
Hypertensive encephalopathy. (MK)
Low perfusion states (e.g. arrhythmias, MI, shock, acute blood loss,
severe dehydration). (MK)
Miscellaneous causes (e.g. fecal impaction, postoperative state, sleep
deprivation, urinary retention). (MK)
3. The importance of thoroughly reviewing prescription medications over-thecounter drugs, and supplements and inquiring about substance abuse. (MK)
4. The risk factors for developing altered mental status, including:
Dementia. (MK)
Advanced age. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Substance abuse. (MK)

Comorbid physical problems such as sleep deprivation, immobility,
dehydration, pain, and sensory impairment. (MK)
ICU admission. (MK)
5. The diagnostic evaluation of altered mental status. (MK)
6. Indications, contraindications, and complications of lumbar puncture. (MK)
7. Principles of management of the common causes of altered mental status. (MK)
8. nonpharmacologic measures to reduce agitation and aggression, including:
Avoiding the use of physical restraints whenever possible. (MK)
Using reorientation techniques. (MK)
Assuring the patient has their devices to correct sensory deficits. (MK)
Promoting normal sleep and day/night awareness. (MK)
Preventing dehydration and electrolyte disturbances. (MK)
Avoiding medications which may worsen delirium whenever possible
(e.g. anticholinergics, benzodiazepines, etc.). (MK)
9. The risks of using physical restraints. (MK)
10. The risk and benefits of using low-dose high potency antipsychotics for
delirium associated agitation and aggression. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history that differentiates among etiologies
of altered mental status including eliciting appropriate information from
patients and their families regarding the onset, progression, associated
symptoms, and level of physical and mental disability. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Complete neurologic examination. (PC)
Mental status examination. (PC)
Fundoscopic examination. (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology for altered mental status. (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences. Laboratory and diagnostic tests should include, when
appropriate:
CBC with differential. (PC, MK)
Electrolytes, BUN/Cr, GLC, hepatic function panel, Ca. (PC, MK)
ABG. (PC, MK)
Toxicology screen. (PC, MK)
VDRL. (PC, MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Vitamin B12 and thiamine measurements. (PC, MK)

Thyroid function tests. (PC, MK)
Urinalysis and urine culture. (PC, MK)
Blood cultures. (PC, MK)
Cerebrospinal fluid analysis (color, opening pressure, chemistries, cell
counts, staining, cultures, cytology, cryptococcal antigen, VDRL). (PC,
MK)

Students should be able to define the indications for and interpret (with
consultation) the results of:
Cranial CT. (PC, MK)
Cranial MRI. (PC, MK)
Electroencephalogram. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (PC, CS)
Elicit questions from the patient and his or her family about the
management plan. (PC, CS)
When the patient is unable to communicate, obtain a history from a
collateral source such as a family member or other health care proxy.
(PC, CS)

6. Basic and advanced procedural skills: Students should be able to:

Obtain an ABG. (PC)
Assist in performing a lumbar puncture after explaining the procedure
to the patient. (PC, CS)
7. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
Recognizing that altered mental status in a older inpatient is a medical
emergency and requires that the patient be evaluated immediately. (PC,

MK)

Writing appropriate fluid and replacement orders for patients with

common electrolyte and metabolic disturbances. (PC, MK)
Writing appropriate antibiotic orders for the treatment of common
infectious etiologies. (PC, MK)
Ordering appropriate nonpharmacologic and pharmacologic
interventions for patients with acute altered mental status with
accompanying agitation and aggression. (PC, MK)
Determining when to obtain consultation from a neurologist or
neurosurgeon. (PC, SBP)
Utilizing hospital and community resources for patients with
permanent or disabling conditions to help assist their transfer back to
the community or rehabilitation facility. (PC, SBP)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to altered mental status. (PC, PLI)
Incorporating patient preferences. (PC, P)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Appreciate the familys concern and at times despair arising from a loved
ones development of altered mental status. (CS, P)
2. Appreciate the patients distress and emotional response to that may
accompany circumstances of altered mental status. (CS,P)
3. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for altered mental status. (PLI, P)
4. Recognize the importance of patient preferences when selecting among
diagnostic and therapeutic options for altered mental status. (P)
5. Demonstrate ongoing commitment to self-directed learning regarding altered
mental status. (PLI, P)
6. Appreciate the impact altered mental status has on a patients quality of life,
well-being, ability to work, and the family. (P)
7. Recognize the importance of and demonstrate a commitment to the utilization
of other healthcare professionals in the diagnosis and treatment of altered
mental status. (P, SBP)

D.

REFERENCES:
Ropper AH. (2005). Acute confusional states and coma. In Kasper DL,
Braunwald EB, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds.
Harrisons Principles of Internal Medicine. 16th ed. New York, NY:
McGraw-Hill; 2005:1624-31.
Gleason OC. Delirium. Am Fam Physician. 2003;67:1027-34.
Brown TM, Boyle MF. Delirium. BMJ. 2002;325:644-7.
Meagher DJ. Delirium: optimizing management. BMJ. 2001;322:144-9.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #4: ANEMIA

RATIONALE:
Anemia is a common finding, often identified incidentally in asymptomatic patients. It
can be a manifestation of a serious underlying disease. Distinguishing among the many
disorders that cause anemia, not all of which require treatment, is an important training
problem for third year medical students.
PREREQUISITES:
Prior knowledge, skills and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Knowledge of pathogenesis and pathophysiology of anemia.
Knowledge of the basic biochemistry and pathophysiology of the blood and bone
marrow.
Knowledge of the pharmacology of medications that can cause anemia as well as
those used to treat it.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Classification of anemia based on red cell size:
Microcytic:
o Iron deficiency. (MK)
o Thalassemic disorders. (MK)
o Sideroblastic anemia. (MK)
Normocytic:
o Acute blood loss. (MK)
o Hemolysis. (MK)
o Anemia of chronic disease (e.g. infection, inflammation,
malignancy). (MK)
o Chronic renal insufficiency/erythropoietin deficiency. (MK)
o Bone marrow suppression (e.g. bone marrow invasion, aplastic
anemia).
o Hypothyroidism. (MK)
o Testosterone deficiency. (MK)
o Early presentation of microcytic or macrocytic anemia (e.g.
early iron deficiency anemia). (MK)
o Combined presentation of microcytic and macrocytic anemias.

(MK)

Macrocytic:
o Ethanol abuse. (MK)
o B12 deficiency. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

2.
3.

4.
5.
6.
7.
8.
B.

o Folate deficiency. (MK)

o Drug-induced. (MK)
o Reticulcytosis. (MK)
o Liver disease. (MK)
o Myelodysplastic syndromes. (MK)
o Hypothyroidism. (MK)
Morphological characteristics, pathophysiology, and relative prevalence of
each of the causes of anemia. (MK)
The meaning and utility of various components of the hemogram (e.g.
hemoglobin, hematocrit, mean corpuscular volume, and random distribution
width). (MK)
The classification of anemia into hypoproliferative and hyperproliferative
categories and the utility of the reticulocyte count/index. (MK)
The potential usefulness of the white blood cell count and red blood cell count
when attempting to determine the cause of anemia. (MK)
The diagnostic utility of the various tests for iron deficiency (e.g. serum iron,
total iron binding capacity, transferrin saturation, ferritin). (MK)
The genetic basis of some forms of anemia. (MK)
Indications, contraindications, and complications of blood transfusion. (MK)

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including:
Constitutional and systemic symptoms (e.g. fatigue, weight loss). (PC,
CS)

History of gastrointestinal bleeding or risk factors for it. (PC, CS)

Abdominal pain. (PC, CS)
Prior history of anemia or other blood diseases. (PC, CS)
Medications. (PC, CS)
Diet. (PC, CS)
Alcohol use. (PC, CS)
Menstrual history. (PC, CS)
Family history of anemia or other blood diseases. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Pallor (e.g. palms, conjunctiva, nail beds). (PC)
Mouth (e.g. glossitis, cheilosis). (PC)
Hyperdynamic precordium, systolic flow murmur. (PC)
Lymph nodes. (PC)
spleen. (PC)
Obtain stool for occult blood testing. (PC)
Nervous system. (PC)
3. Differential diagnosis: Students should be able to generate a list of the most
important and most common causes of anemia, recognizing specific history,
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

physical exam, and laboratory findings that suggest a specific etiology. (PC,
MK)

4. Laboratory interpretation: Students should be able to recommend when to

order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
Hemoglobin and hematocrit. (PC, MK)
Red cell indices (e.g. mean corpuscular volume and random
distribution width). (PC, MK)
White blood cell and platelet count. (PC, MK)
Reticulocyte count. (PC, MK)
Iron studies (serum iron, TIBC, ferritin, transferrin). (PC, MK)
Serum B12 and folate. (PC, MK)
Haptoglobin. (PC, MK)
Lactic dehydrogenase. (LDH) (PC, MK)
Hemoglobin electrophoresis. (PC, MK)
blood smear. (PC, MK)
Students should be able to define the indications for and interpret (with
consultation) results of:
Bone marrow biopsy. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to patients. (PC, CS)
Elicit questions from the patient about the management plan. (PC, CS)
Counsel with regard to (a) possible causes, (b) appropriate further
evaluation to establish the diagnosis of an underlying disease, and (c)
the impact on the family (genetic counseling). (PC, CS)
6. Basic procedural skills: Students should be able to perform and interpret:
Stool occult blood testing. (PC)
7. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients that includes:
Evaluating for underlying disease processes, given that anemia is not a
disease per se, but rather a common finding that requires further
delineation in order to identify the underlying cause. (PC, MK)
Prescribing indicated replacement therapy, including iron, vitamin
B12, and folic acid. (PC, MK)
Determining when to obtain consultation from a hematologist. (PC,
SBP)

Using a cost-effective approach based on the differential diagnosis.

(PC, SBP)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to anemia. (PC, PLI)
Incorporating patient preferences. (PC, P)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for anemia. (PLI, P)
2. Respond appropriately to patients who are non-adherent to treatment for
anemia. (CS, P)
3. Demonstrate ongoing commitment to self-directed learning regarding anemia.
(PLI, P)

4. Appreciate the impact anemia has on a patients quality of life, well-being,

ability to work, and the family. (P)
5. Recognize the importance of and demonstrate a commitment to the utilization
of other healthcare professions in the treatment of anemia. (P, SBP)
D.

REFERENCES:
Sheth TN. Choudhry NK. Bowes M. Detsky AS. The relation of conjunctival
pallor to the presence of anemia. J Gen Intern Med. 1997;12:102-6.
Guyatt, G H. Oxman, A D. Ali, M. Willan, A. McIlroy, W. Patterson, C.
Laboratory diagnosis of iron-deficiency anemia: an overview. J Gen Intern
Med. 1992;7:145-53.
Kis AM. Carnes M. Detecting iron deficiency in anemic patients with
concomitant medical problems. J Gen Intern Med. 1998; 13:455-61.
Bain BJ. Diagnosis from the blood smear. N Engl Journal Med.
2005;353:498-507.
Weiss G. Goodnough LT. Anemia of chronic disease. N Engl J Med.
2005;352:1011-23.
Hoffbrand V. Provan D. ABC of clinical haematology: macrocytic anaemias.
BMJ. 1997;314:430-3.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #5: BACK PAIN

RATIONALE:
Back pain is one of the most commonly encountered problems in the outpatient, primary
care internal medicine setting. It has an important differential diagnosis, and the initial
decision-making must be made on the basis of clinical findings. As such, it is an
excellent training condition for teaching decision-making based on careful collection and
interpretation of basic clinical data. There is emerging data on test utility, especially as
regards expensive spinal imaging, which facilitates teaching rational, cost-effective test
ordering. Moreover, its requirement for skillful management, patient education, and
support facilitate the teaching of these competencies.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Ability to perform a complete medical history and physical.
Ability to communicate with patients of diverse backgrounds.
Anatomy and physiology of bony, soft tissue, vascular, and of the spine.
Pathogenesis and pathophysiology of muscular strain, osteoarthritis, spinal stenosis,
osteoporosis, disc degeneration, and spinal metastases.
Pharmacology of non-narcotic and narcotic analgesics, nonsteroidal anti-inflammatory
drugs, muscle relaxants.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The symptoms, signs, and typical clinical course of the various causes of back
pain including:
Ligamentous/muscle strain (nonspecific musculoskeletal back pain).
(MK)

Degenerative arthritis (spondylosis). (MK)

Disc herniation. (MK)
spinal stenosis. (MK)
Vertebral compression fracture. (MK)
Traumatic fracture. (MK)
Sacroileitis. (MK)
Spinal metastases. (MK)
Spinal epidural abscess. (MK)
Cauda equina syndrome. (MK)
2. The role of diagnostic studies in the evaluation of the back pain there
indications, limitations, cost:
Plain radiography. (MK)
CT. (MK)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

MRI. (MK)
Myelogram. (MK)
Electrodiagnosis (i.e. electromyography and nerve conduction studies).
(MK)

3.

4.
5.
6.
B.

Bone densitometry. (MK)

Response to therapy of the various etiologies, with understanding of the roles
of:
Bed rest. (MK)
Exercise. (MK)
Analgesia. (MK)
NSAIDs. (MK)
heat/ice. (MK)
Ultrasound. (MK)
Spinal manipulation. (MK)
Surgical interventions. (MK)
Risk factor for and means of limiting disability and chronicity. (MK)
Fear avoidance behaviors. (MK)
Pain related behaviors with regard to chronic narcotic use. (MK)

SKILLS: Students should be able to demonstrate specific skills including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including:
Cancer history. (PC, CS)
Weight loss. (PC, CS)
Fever. (PC, CS)
Recent infection. (PC, CS)
Intravenous drug use. (PC, CS)
Steroid use. (PC, CS)
Trauma. (PC, CS)
Rapidly progressive focal numbness and/or weakness. (PC, CS)
Bowel/bladder dysfunction. (PC, CS)
Saddle anesthesia. (PC, CS)
Symptoms of systemic rheumatologic conditions. (PC, CS)
Anatomic abnormalities (e.g. kyphosis, scoliosis). (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Examination of the spine. (PC)
Neurologic examination of the lower extremities. (PC)
Straight leg raising test. (PC)
Testing for saddle anesthesia. (PC)
Assessment of rectal tone. (PC)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

3. Differential diagnosis: Students should be able to generate a prioritized

differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology for back pain (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
ESR. (PC, MK)
CBC. (PC, MK)
Serum Alk Phos. (PC, MK)
Students should be able to define the indications for and interpret (with
consultation) the results of:
Plain spinal radiography. (PC, MK)
Spinal CT. (PC, MK)
Spinal MRI. (PC, MK)
Radionuclide bone scan. (PC, MK)
Bone densitometry. (PC, MK)
Electrodiagnostic tests. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to patients. (PC, CS)
Explain the importance of active participation in the treatment plan.
(PC, CS)

Elicit questions from the patient and their family about the
management plan. (PC, CS)
6. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
Patient education about the typical course of back pain. (PC, MK)
Methods to prevent the development of chronic back pain. (PC, MK)
Proper use of analgesics, NSAIDs, muscle relaxants, and local
heat/ice. (PC, MK)
Teaching back hygiene measures, exercises, and proper lifting and
standing ergonomics. (PC, MK)
Counseling patients about lifestyle modifications including weight
loss. (PC, MK)
the potential role of chiropractic, acupuncture, and massage (PC, MK)
Determining when to obtain consultation from an appropriate back
pain specialist. (PC, SBP)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to back pain. (PC, PLI)
Incorporating patient preferences. (PC, P)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for back pain. (PLI, P)
2. Recognize the importance of patient preferences when selecting among
diagnostic and therapeutic options for back pain. (P)
3. Appreciate the importance of active patient involvement in the treatment of
back pain. (P)
4. respond appropriately to patients who are nonadherent to treatment for back
pain. (CS, P)
5. respond appropriately to patients with chronic back pain (P)
6. Demonstrate ongoing commitment to self-directed learning regarding back
pain. (PLI, P)
7. Appreciate the impact back pain has on a patients quality of life, well-being,
ability to work, and the family. (P)
8. Recognize the importance of and demonstrate a commitment to the utilization
of other healthcare professionals in the treatment of back pain. (P, SBP)

D.

REFERENCES:
Carragee EJ. Persistent low back pain. N Engl J Med. 2005;352:1891-8.
Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344:363-70.
Atlas SJ, Deyo RA. Evaluating and managing acute low back pain in the
primary care setting. J Gen Intern Med. 2001;16:120-31.
Deyo RA. Diagnostic evaluation of LBP: reaching a specific diagnosis is
often impossible. Arch Intern Med. 2002;162:1444-7; discussion 1447-8.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #6: CHEST PAIN

RATIONALE:
Chest pain is a common and important presenting symptom for a variety of disorders,
some of which may be life-threatening emergencies. The ability to distinguish chest pain
caused by an acute coronary syndrome (unstable angina or acute myocardial infarction)
from other cardiac, gastrointestinal, pulmonary, musculoskeletal or psychogenic
etiologies is an important training problem for third-year medical students.
PREREQUISITES:
Prior knowledge, skills and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate appropriately with patients of diverse backgrounds, including
the elderly patient.
Knowledge of the anatomy of the heart, chest and abdomen.
Understanding of the epidemiology of heart disease.
Knowledge of the pathogenesis and pathophysiology of cardiovascular disease.
Knowledge of the pharmacology of cardiovascular drugs.
Ability to perform a cardiovascular risk assessment and understand issues related to
primary and secondary prevention of cardiovascular disease.
Ability to understand the impact of illness on individuals and their families.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe and discuss:

1.

Symptoms and signs of chest pain that may be due to an acute coronary syndrome
such as unstable angina or acute myocardial infarction. (MK)
Symptoms and signs of chest pain that are characteristic of angina pectoris. (MK)
Symptoms and signs of chest pain due to other cardiac causes such as:
Atypical or variant angina (coronary vasospasm, Prinzmetal angina).

2.
3.

(MK)

4.

5.

Cocaine-induced chest pain. (MK)

Pericarditis. (MK)
Aortic dissection. (MK)
Valvular heart disease (aortic stenosis, mitral valve prolapse). (MK)
Non-ischemic cardiomyopathy. (MK)
Syndrome X. (MK)
Symptoms and signs of chest pain due to gastrointestinal disorders such as:
Esophageal disease (GERD, esophagitis, esophageal dysmotility). (MK)
Biliary disease (cholecystitis, cholangitis). (MK)
Peptic ulcer disease. (MK)
Pancreatitis. (MK)
Symptoms and signs of chest pain due to pulmonary disorders such as:

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

6.

7.

8.

9.

Pneumonia. (MK)
Spontaneous pneumothorax. (MK)
Pleurisy. (MK)
Pulmonary embolism. (MK)
Pulmonary hypertension/cor pulmonale. (MK)
Symptoms and signs of chest pain due to musculoskeletal causes such as:
Costochondritis. (MK)
Rib fracture. (MK)
Myofascial pain syndromes. (MK)
Muscular strain. (MK)
Herpes zoster. (MK)
Symptoms and signs of chest pain due to psychogenic causes such as:
Panic disorders. (MK)
Hyperventilation. (MK)
Somatoform disorders. (MK)
Factors that may be responsible for provoking or exacerbating symptoms of
ischemic chest pain by:
Increasing myocardial oxygen demand.
o Tachycardia or tachyarrhythmia. (MK)
o Hypertension. (MK)
o Increased wall stress (aortic stenosis, cardiomyopathy). (MK)
o Hyperthyroidism. (MK)
Decreasing myocardial oxygen supply.
o Anemia. (MK)
o Hypoxemia. (MK)
Risk factors for the development of coronary heart disease:
Age and gender. (MK)
Family history of sudden death or premature CAD. (MK)
Personal history of peripheral vascular or cerebrovascular disease.

10.

(MK)

Smoking. (MK)
Lipid abnormalities (includes dietary history of saturated fat and
cholesterol). (MK)
Diabetes mellitus. (MK)
Hypertension. (MK)
Obesity. (MK)
Sedentary lifestyle. (MK)
Cocaine use. (MK)
Estrogen use. (MK)
Chronic inflammation. (MK)
Physiologic basis and/or scientific evidence supporting each type of treatment,
intervention or procedure commonly used in the management of patients who
present with chest pain. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

11.

Role of a critical pathway or practice guideline in delivering high quality, costeffective care for patients presenting with symptoms of chest pain in the
outpatient clinic, emergency room or hospital. (MK, PC, SBP)

B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an appropriately complete medical history that differentiates among
the common etiologies of chest pain.
The initial medical history should allow students to categorize the
patients symptoms as angina pectoris, atypical angina or non-cardiac
chest pain. (PC, CS)
Specifically, the medical history of a patient with chest pain should
contain information about those clinical characteristics that are typical
of angina pectoris:
o Substernal location. (PC, CS)
o Precipitated by exertion. (PC, CS)
o Relieved by rest or nitroglycerin. (PC, CS)
o Onset, duration, severity, radiation, presence or absence of
associated symptoms (such as dyspnea, diaphoresis or
lightheadedness). (PC, CS)
The history of a patient with chest pain should also contain
information about:
o Risk factors for coronary heart disease. (PC, CS)
o Previous history of ischemic heart disease or valvular heart
disease (rheumatic fever, cardiac murmurs). (PC, CS)
o Previous history of peripheral vascular disease or
cerebrovascular disease. (PC, CS)
Students should be able to use the medical history to assess the
functional status of patients who present with ischemic chest pain. (PC,
CS)

2. Physical exam skills: Students should be able to perform a focused physical

exam that includes the following elements:
Accurate measurement of arterial blood pressure and recognition of
the typical blood pressure findings that occur in patients with aortic
stenosis, aortic insufficiency, and pulsus paradoxus. (PC)
Assessment of major arterial pulses for abnormalities, including bruits.
(PC)

Assessment of the neck veins for jugular venous distention and, when
necessary, evaluation for abdominal jugular reflux. (PC)
Assessment of the conjunctiva and optic fundus. (PC)
Assessment of the extremities to ascertain skin condition, including
color, temperature and the presence of edema, xanthomas, cyanosis
and clubbing. (PC)
Assessment of the lungs for crackles, rhonchi, rubs and decreased
breath sounds. (PC)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Inspection and palpation of the anterior chest to identify right and left
sided heaves, lifts, and thrills. (PC)
Auscultation of the heart to determine rhythm, intensity of heart
sounds, splitting of S2 and the presence of rubs, gallops (S3, S4,
summation) or extra heart sounds (e.g. clicks). (PC)
Auscultation of the heart to detect the presence of heart murmurs.
When a heart murmur is present, students should be able to:
o Identify timing (systolic vs. diastolic, holosystolic vs. ejection).
(PC)

o Describe pitch, location and pattern of radiation. (PC)

o Gauge significance (innocent vs. pathologic, sclerosis vs.
stenosis). (PC)
Assessment of the abdomen to determine the presence of epigastric or
right upper quadrant tenderness, hepatomegaly, abnormal pulsations or
bruits. (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis and recognize specific history, physical exam, and
laboratory findings that suggest a diagnosis of myocardial ischemia rather
than a non-ischemic cause of chest pain (GI, pulmonary, musculoskeletal,
psychogenic or undetermined). (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Test interpretation should take into account:
Important differential diagnostic considerations including the must
not miss diagnoses. (PC, MK)
Pre-test and post-test likelihood of disease (probabilistic reasoning). (PC,
MK)

Performance characteristics of individual tests (sensitivity, specificity,

positive and negative predictive value, likelihood ratios). (PC, MK)
Laboratory and diagnostic tests should include, when appropriate:
Cardiac biomarkers indicative of myocardial necrosis. (PC, MK)
12-lead ECG. (PC, MK)
Chest radiograph. (PC, MK)
ABG. (PC, MK)
Students should be able to define the indications for, and interpret (with
consultation) the results of the following diagnostic tests and procedures:
Echocardiogram (transthoracic and transesophageal). (PC, MK)
Exercise stress test. (PC, MK)
Stress thallium (myocardial perfusion scan). (PC, MK)
Dobutamine stress echocardiography. (PC, MK)
Coronary angiography. (PC, MK)
Electron beam CT scan (for coronary calcification). (PC, MK)
Ventilation/perfusion lung (V/Q) scan. (PC, MK)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Pulmonary embolism protocol CT scan. (PC, MK)

Pulmonary angiography. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, prognosis and treatment plan to patients
and their families. (PC, CS)
As appropriate for age and gender, educate patients about risk factors
for cardiovascular disease. (PC, CS)
Counsel patients or facilitate the provision of counseling related to:
o Smoking cessation. (PC, CS)
o Reduction of dietary saturated fats and cholesterol. (PC, CS)
o Restriction of dietary sodium intake. (PC, CS)
o Weight reduction. (PC, CS)
o Increased physical activity. (PC, CS)
6. Basic procedural skills: Students should be able to:
Perform a 12-lead ECG. (PC)
7. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients that includes:
Identification of the indications, contraindications, mechanisms of
action, adverse reactions, significant interactions, and relative costs of
the following medications:
o Anti-platelet agents (aspirin, clopidogrel). (PC, MK)
o Nitroglycerin and long-acting nitrates. (PC, MK)
o Beta-blockers. (PC, MK)
o Angiotensin-converting enzyme inhibitors. (PC, MK)
o Calcium channel blockers. (PC, MK)
o Antithrombotic therapy (heparin, warfarin). (PC, MK)
o Glycoprotein IIb/IIIa inhibitors. (PC, MK)
o Lipid-lowering agents. (PC, MK)
Identification of the indications, contraindications, complications,
long-term outcomes and relative costs associated with the following
treatment modalities for ischemic heart disease:
o Thrombolytic therapy. (PC, MK)
o Percutaneous coronary intervention (with or without stenting).
(PC, MK)

o Coronary artery bypass graft surgery (CABG). (PC, MK)

Determining when to consult a cardiologist or other subspecialist in
the management of patients with chest pain. (PC, SBP)
Description of how the diagnosis and treatment of chest pain in special
populations may differ (e.g. very elderly, associated co-morbidities).
(PC, MK)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to chest pain. (PC, PLI)
Incorporating patient preferences. (PC, P)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Understand the emotional impact of a diagnosis of coronary artery disease and
its potential effect on lifestyle (work performance, sexual functioning, etc).
(PC, P)

2. Respond appropriately to patient who are nonadherent to lifestyle

modifications. (CS, P)
2. Recognize the importance of early detection and modification of risk factors
that may contribute to the development of atherosclerosis. (PC, P)
3. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for chest pain. (PLI, P)
4. Demonstrate ongoing commitment to self-directed learning regarding chest
pain. (PLI, P)
5. Recognize the importance and demonstrate a commitment to the utilization of
other healthcare professions in the treatment of chest pain. (P, SBP)
D.

REFERENCES:
ACC/AHA 2002 guideline update for the management of patients with
chronic stable angina--summary article: a report of the American College of
Cardiology/American Heart Association Task Force on practice guidelines
(Committee on the Management of Patients With Chronic Stable Angina). J
Am Coll Cardiol. 2003;41:159-68.
http://www.acc.org/clinical/guidelines/stable/stable_clean.pdf
Panju AA, Hemmeigarn BR, Guyatt GH, Simel DL. Is this patient having a
myocardial infarction? JAMA. 1998;280:1256-63.
Klompas M. Does this patient have an acute thoracic aortic dissection?
JAMA. 2002;287:2262-72.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #7: COUGH

RATIONALE:
Cough is one of the most common symptoms with which a patient will present in the
outpatient setting. There are several common etiologies for cough of which a third year
medical student should be aware, as well as more clinically concerning etiologies. A
proper understanding of the pathophysiology, diagnosis, and treatment of cough is an
important learning objective.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Knowledge of respiratory anatomy, physiology and pathophysiology.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe and discuss:

1. The criteria used to classify a cough (e.g. acute vs. chronic, productive vs.
non-productive). (MK)
2. Symptoms, signs, pathophysiology, differential diagnosis, and typical clinical
course of the most common causes cough:
Acute cough:
o Viral tracheitis. (MK)
o Acute bronchitis. (MK)
o Pneumonia. (MK)
Chronic cough:
o Gastroesophageal reflux. (MK)
o Post-nasal drip. (MK)
o Asthma/reactive airways disease. (MK)
o Angiotensin converting enzyme inhibitors. (MK)
o Post-infectious. (MK)
o Infectious (pertussis, tuberculosis). (MK)
o Chronic bronchitis. (MK)
o Bronchiectasis. (MK)
o Pleural effusion. (MK)
o Lung cancer. (MK)
o Congestive heart failure. (MK)

B.

SKILLS: Students should be able to demonstrate specific skills, including:

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

1. History-taking skills: Students should be able to obtain, document, and

present an age-appropriate medical history that differentiates among the
etiologies of disease, including:
Onset. (PC, CS)
Duration. (PC, CS)
Exacerbating/relieving factors. (PC, CS)
Associated symptoms (fever, chills, weight loss). (PC, CS)
Presence or absence of hemoptysis. (PC, CS)
Tobacco history. (PC, CS)
Relevant past medical history. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Accurately determining respiratory rate and level of respiratory
distress. (PC)
Recognizing the pharyngeal signs of post nasal drip. (PC)
Identifying rales, rhonchi, and wheezes. (PC)
Recognizing signs of pulmonary consolidation. (PC)
3. Differential diagnosis: Students should be able to generate a prioritorized
differential diagnosis recognizing history, physical exam, and laboratory
findings that suggest a specific etiology of cough. (PC, MK)
4. Laboratory interpretations: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
Chest radiograph. (PC, MK)
Pleural fluid cell count and chemistries. (PC, MK)
PFTs. (PC, MK)
Sputum Gram stain and sputum acid-fast stain. (PC, MK)
Sputum culture and sensitivities. (PC, MK)
Students should be able to define the indications for and interpret (with
consultation) results of:
Barium swallow. (PC, MK)
Upper endoscopy. (PC, MK)
Sputum cytology. (PC, MK)
Chest CT scan. (PC, MK)
5. Communication skills: Students should be able to:
Counsel and educate patients about environmental contributors to their
disease, pneumococcal and influenza immunizations, and smoking
cessation. (PC, CS)
Communicate the diagnosis, prognosis, and treatment plan, and
subsequent follow-up to the patient and his or her family. (PC, CS)
Elicit input and questions from the patient and his or her family about
the management plan. (PC, CS)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

6. Management skills: Students should be able to develop an appropriate

evaluation and treatment plan for patients that includes:
Describing the indications, contraindications, mechanisms of action,
adverse reactions, significant interactions, and relative costs of the
various treatments, interventions, or procedures commonly used to
diagnose and treat patients who present with symptoms of cough. (PC,
MK, SBP)

C.

Determining when to obtain consultation from a pulmonologist,

allergist, otolaryngologist, or gastroenterologist. (PC, SBP)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to patients with chronic cough. (PC, PLI)
Incorporating patient needs and preferences. (PC, P)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for cough. (PLI, P)
2. Respond appropriately to patients who are non-adherent to treatment for
cough and smoking cessation. (CS, P)
3. Demonstrate ongoing commitment to self-directed learning regarding
diagnosis and management of cough. (PLI, P)
4. Appreciate the impact that an acute or chronic cough has on a patients quality
of life, well-being, ability to work, and the family. (P)
5. Recognize the importance and demonstrate a commitment to the utilization of
other healthcare professions in the treatment of cough. (P, SBP)
6. REFERENCES:
Currie GP, Gray RD, McKay J. Chronic cough. BMJ. 2003;326:261.
Irwin RS, Madison JM. The persistently troublesome cough. Am J Respir
Crit Care Med. 2002;165:1469-74.
Jones HC, Chang SI. Clinical Inquires. What is the best approach to the
evaluation and treatment of chronic cough? J Fam Pract. 2001;50:748-9.
Irwin RS, Madison MJ. Primary care: the diagnosis and treatment of cough.
N Engl J Med. 2000;343:1715-21.
Irwin RS, Boulet LP, Cloutier MM, et al. Managing cough as a defense
mechanism and as a symptom. Consensus panel report of the American
College of Chest Physicians. Chest. 1998;114:133S-181S.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #8: DYSPNEA

RATIONALE:
Shortness of breath or dyspnea is one of the most common patient complaints
encountered in internal medicine. It has a very large number of etiologic possibilities
some benign but many potentially life-threatening. Because of the latter, a systematic
approach to dyspnea is crucial.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Ability to perform a complete medical history and physical.
Ability to communicate with patients of diverse backgrounds.
Anatomy, physiology, and pathophysiology of the pulmonary, cardiac, neurologic, and
musculoskeletal systems.
Physiology of acid-base homeostasis.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Major organ systems/pathologic states causing dyspnea and their
pathophysiology, including:
Cardiac. (MK)
Pulmonary. (MK)
Anemia/hypovolemia. (MK)
Acid-base disorders and other metabolic derangements (MK)
Neuromuscular weakness. (MK)
Central neurologic derangements. (MK)
2. The symptoms, signs, and laboratory values associated with respiratory failure
and ventilatory failure. (MK)
3. The alveolar-arterial oxygen gradient and the pathophysiologic states that can
alter it. (MK)
4. The potential risks of relying too heavily on pulse oximetry as the sole
indicator of arterial oxygen content. (MK)
5. The common causes of acute dyspnea, their pathophysiology, symptoms, and
signs, including:
Pulmonary edema. (MK)
Pulmonary embolism. (MK)
Pneumonia. (MK)
Acute exacerbation of COPD. (MK)
Asthma. (MK)
Cardiac ischemia. (MK)
Pneumothorax. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Anxiety. (MK)
6. The common causes of chronic dyspnea their pathophysiology, symptoms,
and signs, including:
Congestive heart failure. (MK)
COPD. (MK)
Pulmonary parenchymal disease. (MK)
Pulmonary vascular disease. (MK)
Anemia. (MK)
Neuromuscular weakness. (MK)
7. Basic treatment options for the common causes of acute and chronic dyspnea.
(MK)

8. The utility of supplemental oxygen therapy and the potential dangers of overly
aggressive oxygen supplementation in some pathophysiologic states. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including:
Quantity, quality, severity, duration, ameliorating/exacerbating factors
of the dyspnea. (PC, CS)
Associated symptoms such as fevers, chills, sweats, orthopnea,
paroxysmal nocturnal dyspnea, wheezing, edema, chest pain, cough,
sputum production, hemoptysis, palpitations, nausea, anxiety,
dizziness, orthostasis, weakness. (PC, CS)
History of pulmonary, cardiac, neuromuscular/neurologic, renal,
hepatic, and coagulopathic disorders. (PC, CS)
Risk factors for deep vein thrombosis/pulmonary embolism. (PC, CS)
Ingestion of drugs and toxic substances, administration of IV fluids.
(PC, CS)

smoking and environmental exposures. (PC, CS)

2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Accurately determining respiratory rate and level of respiratory
distress. (PC)
Assessing the use of accessory muscles for breathing. (PC)
Accurately measuring pulsus paradox. (PC)
Identifying bronchial breath sounds, rales, rhonchi, wheezes, and
subcutaneous emphysema. (PC)
Identifying signs of pulmonary consolidation and hyperresonance. (PC)
Identifying signs of pleural effusion. (PC)
Identifying signs of elevated central venous pressure. (PC)
Identifying signs of hypovolemia. (PC)
Identifying S3 gallop, edema, and pallor. (PC)
Identifying signs of deep vein thrombosis. (PC)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

3. Differential diagnosis: Students should be able to generate a prioritized

differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology of dyspnea (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
CBC. (PC, MK)
Electrolytes, BUN/Cr, GLC. (PC, MK)
Pulse oximitry. (PC, MK)
ABG. (PC, MK)
Chest radiograph. (PC, MK)
12-lead ECG. (PC, MK)
Pulmonary function tests. (PC, MK)
Students should be able to define the indications for and interpret (with
consultation) the results of:
Ventilation perfusion scintigraphy. (PC, MK)
Chest CT. (PC, MK)
Venous Doppler studies. (PC, MK)
Cardiac stress test. (PC, MK)
Echocardiography. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (PC, CS)
Elicit questions from the patient and his or her family about the
management plan. (PC, CS)
Counsel and educate patients about environmental contributors to their
disease. (PC, CS)
Counsel patients nonjudgmentally about smoking cessation. (PC, CS)
6. Basic and advanced procedural skills: Students should be able to:
Obtain an ABG. (PC)
7. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
A rapid triage approach to the acutely dyspneic patient. (PC, MK)
An appropriate assessment of the patients oxygenation status. (PC, MK)
Appropriate oxygen supplementation as indicated. (PC, MK)
Management plans for pulmonary edema/congestive heart failure,
pneumonia, COPD, asthma, pulmonary embolism, cardiac ischemia,
hypovolemia, anemia, and pneumothorax. (PC, MK)
Determining when to obtain consultation from an appropriate
specialist. (PC, SBP)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

C.

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to dyspnea. (PC, PLI)
Incorporating patient preferences. (PC, P)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for dyspnea. (PLI, P)
2. Recognize the importance of patient preferences when selecting among
diagnostic and therapeutic options for dyspnea. (P)
3. Demonstrate ongoing commitment to self-directed learning regarding
dyspnea. (PLI, P)
4. Appreciate the impact dyspnea has/have on a patients quality of life, wellbeing, ability to work, and the family. (P)
5. Recognize the importance of and demonstrate a commitment to the utilization
of other healthcare professionals in the diagnosis and treatment of dyspnea. (P,
SBP)

6. Show understanding for the difficulties patients face with smoking cessation.
(P)

D.

REFERENCES:
Ingram RH and Braunwald E. (2005). Dyspnea and pulmonary edema. In
Kasper DL, Braunwald EB, Fauci AS, Hauser SL, Longo DL, Jameson JL,
eds. Harrisons Principles of Internal Medicine. 16th ed. New York, NY:
McGraw-Hill; 2005:201-5.
Zoorob RJ. Campbell JS. Acute dyspnea in the office. Am Fam Physician.
2003;68:1803-10.
Fedullo PF. Tapson VF. Clinical practice. The evaluation of suspected
pulmonary embolism. N Engl J Med. 2003;349:1247-56.
Manning HL. Schwartzstein RM. Pathophysiology of dyspnea. N Engl J
Med. 1995;333:1547-53.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #9: DYSURIA

RATIONALE:
Dysuria is a very common presentation in the outpatient setting. Given the amount of
health care dollars that are spent on antibiotic treatment of urinary tract infections as well
as the emergence of resistance, it is important for third year medical students to have a
working knowledge of how to approach the patient with this complaint, and how to
differentiate patients with cystitis from other common causes of dysuria.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Knowledge of genitourinary anatomy, physiology and pathophysiology.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Presenting signs and symptoms of the common causes of dysuria, including:
Cystitis. (MK)
Urethritis, gonococcal and non-gonococcal (e.g. chlamydia,
trichomonas, HSV). (MK)
Pyelonephritis. (MK)
Acute and chronic prostatitis. (MK)
Epididymitis. (MK)
Vaginitis (yeast, bacterial vaginosis, trichomonas, atrophic, irritant).
(MK)

Interstitial cystitis. (MK)

2. Symptoms and signs of pyelonephritis and how to distinguish an upper from a
lower UTI. (MK)
3. Common bacteria that cause UTI. (MK)
4. Aspects of pathogenesis that affect UTI, including gender, sexual activity,
diabetes, anatomic anomalies, instrumentation, and use of an indwelling
catheter. (MK)
5. Indications for pursuing further work up for patients with UTI. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate history that differentiates among etiologies of
dysuria, including:
Timing, frequency, severity, and location of dysuria. (PC, CS)
Fever, chills, sweats. (PC, CS)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Frequency, urgency, hesitancy, incomplete voiding. (PC, CS)

Back, abdominal, and groin pain. (PC, CS)
History of nephrolithiasis. (PC, CS)
Hematuria. (PC, CS)
Vaginal or penile discharge. (PC, CS)
Penile skin lesions. (PC, CS)
Sexual activity. (PC, CS)
History of sexual transmitted diseases. (PC, CS)
Dyspareunia. (PC, CS)
Scrotal, testicular, and perineal pain. (PC, CS)
Use of topical hygiene products. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Percussion and palpation of the bladder to accurately recognize
distention and tenderness. (PC)
Palpation over the kidneys to elicit flank tenderness. (PC)
Palpation of the abdomen to elicit tenderness. (PC)
Palpation and massage of the male prostate to obtain discharge. (PC)
Accurate recognition of perineal or vaginal atrophy and inflammation.
(PC)

Techniques of the pelvic examination to assess for causes of vaginitis.

(PC)

3. Differential diagnosis: Students should be able to generate a differential

diagnosis recognizing specific history, physical exam, and laboratory findings
that suggest a specific etiology of dysuria. (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
Urinalysis interpretation including cells and casts, urine dipstick and
Gram stain when appropriate. (PC, MK)
Urine culture. (PC, MK)
Gram stain and culture of urethral or cervical discharge. (PC, MK)
KOH stain and normal saline wet prep of vaginal discharge. (PC, MK)
Urinary or cervical PCR to test for gonorrhea and Chlamydia. (PC, MK)
KUB radiograph. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (PC, CS)
Elicit input and questions from the patient and his or her family about
the management plan. (PC, CS)
Counsel patients about safe sexual activity. (PC, CS)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Explain the risk of recurrent UTI and counsel regarding preventative

measures. (PC, CS)
6. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients that includes:
Selecting appropriate empiric antibiotic therapy for cystitis,
pyelonephritis or urethritis prior to culture results. (PC, MK)
Counseling patients on symptomatic therapies for acute cystitis. (PC,
MK)

Selecting the appropriate duration of therapy for cystitis and

pyelonephritis. (PC, MK)
Evaluating and managing patients with recurrent urinary tract
infections including prophylaxis. (PC, MK)
Choosing appropriate treatment for vaginitis depending on results of
evaluation. (PC, MK)
Understanding the treatment of prostatitis based on probable
organisms and age. (PC, MK)
Determining when to obtain consultation from a urologist or
gynecologist. (PC, MK)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

C.

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to dysuria. (PC, PLI)
Incorporating patient preferences. (PC, P)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for dysuria. (PLI, P)
2. Recognize the importance of patient needs and preferences when selecting
among diagnostic and therapeutic options for dysuria. (P)
3. Demonstrate ongoing commitment to self-directed learning regarding dysuria.
(PLI, P)

4. Recognize the importance of and demonstrate a commitment to the utilization

of other healthcare professionals in the treatment of dysuria. (P, SBP)
D.

REFERENCES:
Bremnor JD, Sadovsky R. Evaluation of dysuria in adults. Am Fam
Physician. 2002;65:1589-96.
Bent S, Nallamothu BK, Simel DL, et al. Does this woman have an acute
uncomplicated urinary tract infection? JAMA. 2002;287:2701-10.
Owen MK, Clenney TL. Management of vaginitis. Am Fam Physician.
2004;70:2125-32.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Fihn SD. Clinical practice. Acute uncomplicated urinary tract infection in

women. N Engl J Med. 2003;349:259-66.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #10: FEVER

RATIONALE:
Because fever can have many infectious or noninfectious causes, patients with fever
should be stratified by host susceptibility factors and evaluated in a systematic manner. A
rational approach to patients with fever will help clinicians recognize presentations that
need immediate attention, limit unnecessary diagnostic testing in less seriously ill
patients, and help inform therapeutic decision making.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Physiology and pathophysiology of thermoregulation and the immune response.
Pharmacology of antipyretics.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Physiology of the acute febrile response, including the:
Beneficial and detrimental effects of fever upon the host. (MK)
The differences in clinical manifestations between immunocompetent
and immunocompromised patients. (MK)
2. Risk factors and co-morbidities that are important in determining the host
response to infection (e.g. neutropenia, asplenia, cirrhosis, alcoholism,
diabetes, corticosteroid use, malnutrition, T cell dysfunction) (MK)
3. Etiology of fever in special populations, including patients with a history of:
Neutropenia due to cancer-related myelosuppression. (MK)
HIV disease. (MK)
Intravenous drug abuse. (MK)
Recent international travel or immigration. (MK)
Concomitant skin rash and lymphadenopathy. (MK)
4. Pathophysiology and clinical presentation of patients with sepsis syndromes.
(MK)

5. common causes of prolonged fever without apparent source, including:

FUO in a normal host. (MK)
Nosocomial FUO. (MK)
Neutropenic FUO. (MK)
FUO associated with HIV disease. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

1. History-taking skills: Students should be able to obtain, document, and

present an age-appropriate medical history that differentiates among etiologies
of disease, including:
Chronology, duration and pattern of fever. (PC, CS)
Associated symptoms. (PC, CS)
Immune status and baseline co-morbidities. (PC, CS)
Immunization status. (PC, CS)
Relevant history of exposures. (PC, CS)
Occupational, travel, family, and sexual history. (PC, CS)
Medication history, including use of over-the-counter and illicit drugs.
(PC, CS)

2. Physical exam skills: Students should be able to perform a complete physical

exam to determine the severity of disease and establish a preliminary
hypothesis about the cause of fever. (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology:
Infection. (PC, MK)
Rheumatologic disease/inflammatory disorder. (PC, MK)
Malignancy. (PC, MK)
Drug reaction. (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
CBC with differential. (PC, MK)
UA with exam of urinary sediment. (PC, MK)
Chest radiography. (PC, MK)
Blood cultures. (PC, MK)
Urine cultures. (PC, MK)
Sputum Gram stain and cultures. (PC, MK)
Sputum AFB stain and culture. (PC, MK)
ESR and/or specific rheumatologic tests. (PC, MK)
PPD. (PC, MK)
Cerebrospinal fluid analysis (color, opening pressure, chemistries, cell
counts, staining, cultures, cytology, cryptococcal antigen, VDRL). (PC,
MK)

Chemistries, Gram stain, and culture of abnormal fluid collections

(e.g. pleural effusion, ascites, abscesses). (PC, MK)
Stool culture of enteric pathogens. (PC, MK)
Stool Clostridium difficile toxin assay. (PC, MK)
Stains and cultures from the throat, urethra, anus, cervix, vagina. (PC,
MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 HIV ELISA and western blot. (PC, MK)

Students should be able to define the indications for and interpret (with
consultation) the results of:
CT imaging. (PC, MK)
Echocardiography. (PC, MK)
Tissue biopsy. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
o patients. (PC, CS)
Elicit questions from the patient and their family about the
management plan. (PC, CS)
6. Basic and advanced procedural skills: Students should be able to:
Obtain blood, wound, and throat cultures. (PC)
Place and interpret a PPD. (PC)
7. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
Developing an appropriate evaluation plan for patients with fever
including ordering and interpreting appropriate laboratory and
radiographic studies. (PC)
Assessing the severity of presentation based on the history, host
factors, physical exam and laboratory results and recognizing
presentations that need immediate attention. (PC)
Developing an appropriate treatment plan for patients with fever
including the selection of an initial, empiric treatment regimen for
neutropenic patients with fever and/or patients with life threatening
sepsis. (PC)
Determining when to obtain consultation from an appropriate
specialist. (PC, SBP)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

C.

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to fever. (PC, PLI)
Incorporating patient preferences. (PC, P)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for fever. (P, PLI)
2. Appreciate the impact fever has on a patients quality of life, well-being,
ability to work, and family; recognize the emotional impact of differential
diagnosis. (P)
3. Recognize the importance of and demonstrate a commitment to the utilization
of other healthcare professions in the diagnosis and treatment of fever. (P, SBP)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

D.

REFERENCES:
Dinarello CA, Gelfand JA. (2005). Fever and hyperthermia. In Kasper DL,
Braunwald EB, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds.
Harrisons Principles of Internal Medicine. 16th ed. New York, NY:
McGraw-Hill; 2005:104-8.
Kaye ET, Kaye KM. (2005). Fever and rash. In Kasper DL, Braunwald EB,
Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrisons Principles of
Internal Medicine. 16th ed. New York, NY: McGraw-Hill; 2005:108-16.
Gelfand JA, Callahan MV. (2005). Fever of unknown origin. In Kasper DL,
Braunwald EB, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds.
Harrisons Principles of Internal Medicine. 16th ed. New York, NY:
McGraw-Hill; 2005:116-21.
Roth AR, Basello GM. Approach to the adult patient with fever of unknown
origin. Am Fam Physician. 2003;68:2223-8.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #11: FLUID, ELECTROLYTE AND

ACID-BASE DISORDERS
RATIONALE:
Many disease processes can cause serious disturbances in the fluid, electrolyte and acidbase status of patients. Clinicians must be prepared to identify and correct these
disturbances as efficiently as possible, thus making it an important training problem for
third year medical students.
PREREQUISITES:
Prior knowledge, skills and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Knowledge of pathogenesis and pathophysiology of fluid, electrolyte and acid-base
disorders.
Knowledge of medications that can cause alterations in fluid and electrolyte status as
well as disturbance of acid-base status.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe and discuss:

1. The pathophysiology of:
Hypo- and hypervolemia. (MK)
Hypo- and hypernatremia. (MK)
Hypo- and hyperkalemia. (MK)
Hypo- and hypercalcemia. (MK)
Simple and mixed acid-base disorders. (MK)
Hypo- and hyperphosphatemia. (MK)
Hypo- and hypermagnesemia. (MK)
Respiratory acidosis and alkalosis. (MK)
Metabolic acidosis and alkalosis. (MK)
2. Presenting symptoms and signs of the above disorders. (MK)
3. The importance of total body water and its distribution. (MK)
4. The differential diagnosis of hypo- and hypernatremia in the setting of volume
depletion, euvolemia, and hypervolemia. (MK)
5. How to distinguish hyponatremia from pseudohyponatremia. (MK)
6. How to identify spurious hyperkalemia or acidosis-related hyperkalemia. (MK)
7. Risks of too rapid or delayed therapy for hyponatremia. (MK)
8. The most common causes of respiratory acidosis, respiratory alkalosis,
metabolic acidosis and metabolic alkalosis. (MK)
9. How to calculate the anion gap and explain its relevance to determining the
cause of a metabolic acidosis. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

10. Changes in total body water distribution that occur with aging. (MK)
11. How altered mental status can contribute to electrolyte disorders. (MK)
12. Tests to use in the evaluation of fluid, electrolyte, and acid-base disorders.
(MK)

13. Indications for obtaining an ABG. (MK)

14. The types of fluid preparations to use in the treatment of fluid and electrolyte
disorders. (MK)
B.

SKILLS: Students should demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history that differentiates among etiologies
of disease, including:
Eliciting appropriate information from patients with volume overload,
including recent weight gain, edema or ascites, symptoms of heart
failure, dietary sodium intake, changes in medications, noncompliance
and intravenous fluid regimens. (PC, CS)
Eliciting appropriate information from patients with volume depletion,
including recent weight loss, thirst, gastrointestinal losses, urinary
losses, oral intake, insensible losses, and intravenous fluid regimens.
(PC, CS)

Eliciting appropriate information from patients with electrolyte

problems, including use of diuretics and other medications,
gastrointestinal losses, and history of relevant medical conditions (e.g.,
heart failure, liver disease, renal disease, pulmonary disease, central
nervous system disease, and malignancy). (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Measurement of orthostatic vital signs. (PC)
Identification of signs of volume overload including peripheral edema,
pulmonary edema, ascites, edema. (PC)
Identification of signs of volume depletion including tachycardia,
orthostatic hypotension, dry mucous membranes, poor skin turgor. (PC)
Identification of signs of sodium disorders including lethargy,
weakness, encephalopathy, delirium, seizures. (PC)
Identification of signs of potassium disorders including weakness,
fatigue, constipation, ileus, cramping, tetany, hypo- or hyperreflexia.
(PC)

Identification of signs of calcium disorders including cramping, tetany,

Chvosteks and Trousseaus sign, seizures, anorexia, constipation,
polyuria, hypo- or hyperreflexia, stupor, coma. (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history, physical exam, and
laboratory findings that distinguish between:
Hypo- and hypervolemia. (PC, MK)
Hypo- and hypernatremia. (PC, MK)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

4.

5.

6.

7.

Hypo- and hyperkalemia. (PC, MK)

Hypo- and hypercalcemia. (PC, MK)
Hypo- and hyperphosphatemia. (PC, MK)
Hypo- and hypermagnesemia. (PC, MK)
Respiratory acidosis and alkalosis. (PC, MK)
Metabolic acidosis and alkalosis. (PC, MK)
Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
Serum electrolytes, BUN/Cr. (PC, MK)
Anion gap. (PC, MK)
ABG. (PC, MK)
Serum and urine osmolality. (PC, MK)
Urinary sodium. (PC, MK)
Fractional excretion of sodium. (PC, MK)
ECG findings in hyper- and hypokalemia. (PC, MK)
Communication skills: Students should be able to:
Explain to a patient and his or her family why intravenous fluids are
needed. (PC, CS)
Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (PC, CS)
Elicit input and questions from the patient and their family about the
management plan. (PC, CS)
Basic and advanced procedural skills: Students should be able to:
Insert a peripheral intravenous catheter. (PC)
Obtain an ABG. (PC)
Assist in the insertion of a central venous catheter. (PC)
Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients that includes:
Writing appropriate fluid orders for the treatment of hypo- and
hypervolemia, hypo- and hypernatremia, hypo- and hyperkalemia,
hypo- and hypercalcemia. (PC, MK)
Writing appropriate orders for replacing sodium, potassium, calcium,
phosphates, and magnesium. (PC, MK)
Writing appropriate orders for correcting hyperkalemia,
hypercalcemia, hyperphosphatemia and hypermagnesemia. (PC, MK)
Calculating the water deficit that needs to be corrected to treat
hypernatremia. (PC, MK)
Identifying indications for administration of bicarbonate. (PC, MK)
Determining when to obtain consultation from a nephrologist. (PC, SBP)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

C.

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to fluid, electrolyte, and acid-base
disorders. (PC SBP)
Incorporating patient preferences. (PC, P)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for problems related to fluid, electrolyte and acid-base disorders.
(PLI, P)

2. Demonstrate ongoing commitment to self-directed learning regarding fluid,

electrolyte and acid-based disorders. (PLI, P)
3. Recognize the importance and demonstrate a commitment to the utilization of
other healthcare professions in the treatment of problems related to fluid,
electrolyte and acid-base disorders. (P, SBP)
D.

REFERENCES:
Singer GG, Brenner BM. Fluid and Electrolyte Disturbances. In Kasper DL,
Braunwald EB, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds.
Harrisons Principles of Internal Medicine. 16th ed. New York, NY:
McGraw-Hill; 2005:252-63.
DuBose TD. (2005). Acidosis and Alkalosis. In Kasper DL, Braunwald EB,
Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrisons Principles of
Internal Medicine. 16th ed. New York, NY: McGraw-Hill; 2005:263-71.
Preston RA. Acid-Base, Fluids, and Electrolytes Made Ridiculously Simple.
Miami, FL: MedMaster Incorporated; 2002.
Adrogue HJ. Madias NE. Hyponatremia. N Engl J Med. 2000;342:1581-9.
Adrogue HJ. Madias NE. Hypernatremia. N Engl J Med. 2000;342:1493-9.
Stewart AF. Clinical practice: Hypercalcemia associated with cancer. N
Engl J Med. 2005;352:373-9.
Carroll MF. Schade DS. A practical approach to hypercalcemia. Am Fam
Physician. 2003;67:1959-66.
Gennari FJ. Hypokalemia. N Engl J Med. 1998;339:451-8.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #12: GASTROINTESTINAL BLEEDING

RATIONALE:
Gastrointestinal bleeding is a common disorder which can be life-threatening if not
properly diagnosed and treated. Knowledge of etiology, risk factors, approach, and
management is integral to internal medicine training.
Prerequisites:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Anatomy, physiology, and pathophysiology of the gastrointestinal tract.
Pharmacology of non-steroidal anti-inflammatory medication (a major contributing
factor in etiology of gastrointestinal bleeding) as well as proton pump inhibitors and
other agents used in the acute setting for treatment of gastrointestinal bleeding.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1.

4.
5.
6.

The common causes for and symptoms of upper and lower gastrointestinal
blood loss, including:
Esophagitis/esophageal erosions. (MK)
Mallory Weiss tear. (MK)
Peptic and duodenal ulcer disease. (MK)
Esophageal/gastric varices. (MK)
Erosive gastritis. (MK)
Arteriovenous malformations. (MK)
Gastrointestinal tumors, benign and malignant. (MK)
Diverticulosis. (MK)
Ischemic colitis. (MK)
Hemorrhoids. (MK)
Anal fissures. (MK)
The distinguishing features of upper versus lower GI bleeding (MK)
The indications for inpatient versus outpatient evaluation and treatment (MK)
The principles of stabilization and treatment of acute massive GI blood loss.
(MK)

7.

The role of contributing factors in GI bleeding such as H. pylori infection;

NSAIDs, alcohol, cigarette use, coagulopathies; and chronic liver disease.
(MK)

B.

SKILLS: Students should demonstrate specific skills, including:

PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

1. History-taking skills: Students should be able to obtain, document, and

present an age-appropriate history that differentiates among etiologies of
disease, including:
Features that distinguish upper from lower GI bleeding. (PC, CS)
Quantification of degree of blood loss. (PC, CS)
Chronology and duration of bleeding. (PC, CS)
Associated symptoms. (PC, CS)
Relevant past medical history. (PC, CS)
Medication history, including use of tobacco and alcohol. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical
examination to establish the diagnosis and severity of disease, including:
Postural blood pressure and pulse. (PC, MK)
Abdominal palpation for organomegaly, masses, and tenderness. (PC,
MK)

3.

4.

5.

6.

7.

Search for stigmata of chronic liver disease. (PC, CS)

Anal and rectal examination. (PC, CS)
Differential diagnosis: Students should be able to generate a differential
diagnosis recognizing specific history and physical examination findings that
suggest a specific etiology for GI bleeding. (PC, MK)
Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
Stool and gastric fluid tests for occult blood. (MK, PC)
CBC. (MK, PC)
PT/PTT. (MK, PC)
Hepatic function panel. (MK, PC)
Tests for Helicobacter pylori. (MK, PC)
Students should be able to define the indications for and interpret (with
consultation) results of:
Esophagogastroduodenoscopy (EGD). (MK, PC)
Colonoscopy. (MK, PC)
Barium studies of the gastrointestinal tract. (MK, PC)
Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to patients. (PC, CS)
Elicit questions from the patient and his or her family about the
management plan. (PC, CS)
Basic and advanced procedural skills: Students should be able to:
Start an IV line using a large bore (i.e. 18 gauge) needle. (MK, PC)
Perform a stool or emesis occult blood testing. (MK, PC)
Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients that includes:

PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

C.

Establishing adequate venous access. (PC, MK)

Administering crystalloid fluid resuscitation. (PC, MK)
Ordering blood and blood product transfusion. (PC, MK)
Determining when to obtain consultation from a gastroenterologist or a
general surgeon. (PC, MK)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to gastrointestinal bleeding. (PC, PLI)
Incorporating patient preferences. (PC,P)
Outlining long-term management when appropriate (e.g. Helicobacter
pylori eradication, antacid, H-2 blocker or proton pump inhibitor
therapy, smoking /alcohol cessation, NSAID restriction, and dietary
modification. (MK, CS)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for gastrointestinal bleeding. (PLI, P)
2. Respond appropriately to patients who are nonadherent to treatment for
gastrointestinal bleeding. (CS, P)
3. Demonstrate ongoing commitment to self-directed learning regarding
gastrointestinal bleeding. (PLI, P)
4. Appreciate the impact gastrointestinal bleeding has on a patients quality of
life, well-being, ability to work, and the family. (P)
5. Recognize the importance and demonstrate a commitment to the utilization of
other health care professions in the treatment of gastrointestinal bleeding. (P,
SBP)

D.

RESOURCES:
Fallah, MA, Prakash, C, Edmundowicz, S. Acute gastrointestinal bleeding.
Med Clin North Am. 2000;84:1183-208.
Laine L. (2005). Gastrointestinal bleeding. In Kasper DL, Braunwald EB,
Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrisons Principles of
Internal Medicine. 16th ed. New York, NY: McGraw-Hill; 2005:235-8.
Del Valle J. (2005). Peptic ulcer disease and related disorders. In Kasper
DL, Braunwald EB, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds.
Harrisons Principles of Internal Medicine. 16th ed. New York, NY:
McGraw-Hill; 2005:1746-62.
Gearhart SL, Bulkley G. (2005). Common diseases of the colon and
anorectum and mesenteric vascular insufficiency. In Kasper DL, Braunwald
EB, Fauci AS, Hauser SL, Longo DL, Jameson JL, eds. Harrisons Principles
of Internal Medicine. 16th ed. New York, NY: McGraw-Hill; 2005:1795-803.

PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Mitchell SH, Schaefer DC. A new view of occult and obscure gastrointestinal
bleeding. Am Fam Physician. 2004;69:875-81.

PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #13: KNEE PAIN

RATIONALE:
Musculoskeletal complaints are some of the most common problems for which patients
seek medical attention, and the knee is the single most common joint pain. Many of these
problems can be effectively tackled in the primary care setting without need for
consultation. The principles presented in this training problem can be readily applied to
other joint pains.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Anatomy and physiology of the musculoskeletal system.
Pharmacology of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs),
topical medications (capsaicin and lidocaine) and glucocorticoids.
Basic bone radiograph interpretation.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. A systematic approach to joint pain based on an understanding of
pathophysiology to classify potential causes. (MK)
2. The effect of the time course of symptoms on the potential causes of joint pain
(acute vs. subacute vs. chronic). (MK)
3. The difference between and pathophysiology of arthralgia vs. arthritis and
mechanical vs. inflammatory joint pain. (MK)
4. The distinguishing features of intra-articular and periarticular complaints
(joint pain vs. bursitis and tendonitis). (MK)
5. The effect of the features of joint involvement on the potential causes of joint
pain (monoarticular vs. oligoarticular vs. polyarticular, symmetric vs.
asymmetric, axial and/or appendicular, small vs. large joints, additive vs.
migratory vs. intermittent). (MK)
6. Indications for performing an arthrocentesis and the results of synovial fluid
analysis. (MK)
7. The utility of describing the relative location of knee pain (anterior, medial,
lateral, posterior). (MK)
8. The relative frequency of the various causes of knee pain. (MK)
9. The differential diagnosis, pathophysiology, and typical presentations of the
common intra-articular causes of knee pain:
Osteoarthritis. (MK)
Inflammatory arthropathies. (MK)
Crystalline arthropathies. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Septic arthritis. (MK)

Patellofemoral pain syndrome. (MK)
Cruciate ligament tear. (MK)
Meniscal damage. (MK)
10. The differential diagnosis, pathophysiology, and typical presentations of the
common periarticular causes of knee pain:
Collateral ligament sprain/tear. (MK)
Ileotibial band syndrome. (MK)
Prepatellar bursitis. (MK)
Popliteal (Baker) cyst. (MK)
11. basic symptomatic treatment for knee pain, including:
Relative rest. (MK)
Ice/heat. (MK)
Compression. (MK)
Elevation. (MK)
Acetaminophen. (MK)
Nonsteroidal anti-inflammatory drugs. (MK)
Glucosamine and chondroitin sulfate. (MK)
Physical therapy. (MK)
Assistive devices. (MK)
Topical analgesics. (MK)
Corticosteroid injection. (MK)
12. Indications for and efficacy of intra-articular corticosteroid injections. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history that differentiates among etiologies
of disease, including:
Delineation of the specific features of the pain. (PC, CS)
Presence of stiffness, swelling, warmth, redness. (PC, CS)
Symptoms of instability, locking, clicking/popping, and weakness. (PC,
CS)

History of trauma, new activities, repetitive motion. (PC, CS)

Impact on the patients ability to carry out activities of daily living.
(PC, CS)

2. Physical exam skills: Students should be able to perform a physical exam to

establish the diagnosis and severity of disease, including:
Examination of the knee, including:
o Inspection. (PC)
o Palpation. (PC)
o Range of motion. (PC)
o Gait assessment. (PC)
o Evaluation for effusion. (PC)
o Assessment of ligamentous and cartilaginous stability. (PC)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

3. Differential diagnosis: Students should be able to generate a prioritized

differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology for knee pain. (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
Synovial fluid analysis. (PC, MK)
Students should be able to define the indications for and interpret (with
consultation) the results of:
Plain radiographs of the knee. (PC, MK)
CT and MRI of the knee. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to patients. (PC, CS)
Elicit questions from the patient and his or her family about the
management plan. (PC, CS)
6. Basic and advanced procedure skills: Students should be able to:
Assist in the performance of an arthrocentesis and intra-articular
corticosteroid injection. (PC)
7. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
Determining when to perform an arthrocentesis. (PC, MK)
Prescribing simple, nonmedicinal symptomatic measures such as rest,
ice/heat, compression, and elevation. (PC, MK)
Prescribing physical therapy and assistive devices (PC, MK)
Prescribing exercise. (PC, MK)
Counseling patients regarding weight loss. (PC, MK)
Prescribing non-narcotic analgesics and anti-inflammatory agents. (PC,

MK)

Determining when to prescribe narcotic analgesics. (PC, MK)

Determining when to prescribe intra-articular corticosteroid injection.
(PC, MK)

Determining when to obtain consultation from an orthopedic surgeon

and rheumatologist. (PC, MK)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to knee pain. (PC, PLI)
Incorporating patient preferences. (PC, P)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for knee pain. (PLI, P)
2. Recognize the importance of patient preferences when selecting among
diagnostic and therapeutic options for knee pain. (P)
3. Respond appropriately to patients who are nonadherent to treatment for knee
pain. (CS, P)
4. Appreciate the impact chronic knee pain has on a patients quality of life,
psychological well-being, ability to work, and the family. (P)
5. Recognize the importance of and demonstrate a commitment to the utilization
of other health care professions in the treatment of knee pain. (P, SBP)
6. Appreciate the difficulty patients with limited mobility have in achieving
weight loss. (P)
7. Demonstrate an appropriate attitude in managing patients with chronic pain.
(P)

D.

REFERENCES:
Cush JJ, Lipsky PE. (2005). Approach to articular and musculoskeletal
disorders. In Kasper DL, Braunwald EB, Fauci AS, Hauser SL, Longo DL,
Jameson JL, eds. Harrisons Principles of Internal Medicine. 16th ed. New
York, NY: McGraw-Hill; 2005:2029-36.
Brandt KD. (2005). Osteoarthritis. In Kasper DL, Braunwald EB, Fauci AS,
Hauser SL, Longo DL, Jameson JL, eds. Harrisons Principles of Internal
Medicine. 16th ed. New York, NY: McGraw-Hill; 2005:2036-45.
Principles of diagnosis and management: Pattern recognition in arthritis. In
Klippel JH, Dieppe PA, Ferri FF, eds. Primary Care Rheumatology. St.
Louis, MO: Mosby; 1999:11-7.
Regional pain and monoarticular disorders: Pain in the knee. (1999). In
Klippel JH, Dieppe PA, Ferri FF, eds. Primary Care Rheumatology. St.
Louis, MO: Mosby; 1999:99-107.
DeHaven KE. Knee and lower leg. In Greene WB, ed. Essentials of
Musculoskeletal Care. 2nd ed. Rosemont, IL: American Academy of
Orthopedic Surgeons; 2001:341-405.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #14: RASH

RATIONALE:
Rash is an extremely common complaint. It may be the manifestation of a primary
cutaneous disorder or secondary to a systemic condition. Internists see many patients
with both and, therefore, must be acquainted with the diagnosis and management.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Anatomy, physiology, and pathophysiology of the skin.
Pharmacology of glucocorticoids, antifungals, antibiotics, benzoyl peroxide, salicylic
acid, and retinoids and derivatives.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. the standard nomenclature used to describe rashes (macule, patch, papule,
nodule, plaque, vesicle, pustule, bulla, cyst, wheal, telangiectasia, petechia,
purpura, erosion, ulcer). (MK)
2. the morphologic features used to describe potentially malignant skin lesions
(Asymmetry, Border, Color, Diameter, Dynamic i.e. changing, Elevation, and
Enlargement, ABCDE). (MK)
3. The significance of focal, organ-based, and constitutional signs and symptoms
in the context of a rash (e.g. rash and fever, rash and arthritis, rash and renal
failure). (MK)
4. The differential diagnosis, pathophysiology, and typical presentations of the
common causes of eczematous dermatoses:
Atopic dermatitis. (MK)
Contact dermatitis. (MK)
Stasis dermatitis. (MK)
Seborrheic dermatitis. (MK)
5. The differential diagnosis, pathophysiology, and typical presentations of the
common causes of maculopapular eruptions:
viral exanthems. (MK)
bacterial exanthems. (MK)
erythema multiforme. (MK)
6. The differential diagnosis, pathophysiology, and typical presentations of the
common causes of papulosquamous dermatoses:
Psoriasis. (MK)
Pityriasis rosea. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

7. The differential diagnosis, pathophysiology, and typical presentations of the

common causes of cutaneous infections:
Impetigo. (MK)
Cellulitis. (MK)
Folliculitis. (MK)
Dermatophytosis (tinea corporis, tinea capitis, tinea cruris, tinea pedis,
onychomycosis). (MK)
Tinea versicolor. (MK)
Candidiasis. (MK)
Condylomata. (MK)
Herpes zoster. (MK)
8. The prevention of community acquisition of Methicillin-resistant
Staphylococcus aureus (MRSA), including good hygiene practices:
Keeping hands clean by washing thoroughly with soap and water or
using an alcohol-based sanitizer. (MK)
Keeping cuts and scrapes clean and covered with a bandage until
healed. (MK)
Avoiding contact with other peoples wounds or bandages. (MK)
Avoiding sharing personal items such as towels and razors. (MK)
9. The differential diagnosis, pathophysiology, and typical presentations of the
common causes of pustular diseases:
Acne. (MK)
Rosacea. (MK)
10. The differential diagnosis, pathophysiology, and typical presentations of the
common causes of cutaneous ulcers.
Venous insufficiency. (MK)
Peripheral arterial disease. (MK)
Neuropathic. (MK)
11. The significance of palpable purpura and other cutaneous findings of
vasculitis. (MK)
12. The differential diagnosis, pathophysiology, and typical presentations of the
common causes of urticaria and angioedema. (MK)
13. The differential diagnosis, pathophysiology, and typical presentations of drug
eruptions. (MK)
14. The differential diagnosis, pathophysiology, and typical presentations of the
common causes of benign neoplasms and hyperplasias:
Seborrheic keratosis. (MK)
Epidermoid cyst. (MK)
15. The differential diagnosis, pathophysiology, and typical presentations of the
common causes of premalignant lesions and malignancies:
Actinic keratosis. (MK)
Basal cell carcinoma. (MK)
Squamous cell carcinoma. (MK)
Malignant melanoma. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

16. The differential diagnosis, pathophysiology, and typical presentations of the

cutaneous manifestations of sexually transmitted diseases.
Syphilis. (MK)
Disseminated gonorrhea infection. (MK)
Human papilloma virus. (MK)
Herpes simplex virus. (MK)
17. The differential diagnosis, pathophysiology, and typical presentations of the
cutaneous manifestations of internal/systemic diseases. (MK)
18. The general indications for skin biopsy. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history that differentiates among etiologies
of disease, including:
Evolution (site of onset, manner of spread, duration). (PC, CS)
Symptoms associated with the rash (pruritis, pain, photosensitivity,
malaise, fever, arthralgias). (PC, CS)
Past medical history of systemic diseases known to have cutaneous
manifestation. (PC, CS)
Sexual history. (PC, CS)
Medication usage and allergies. (PC, CS)
Skin care product usage. (PC, CS)
Chemical skin exposure. (PC, CS)
Sun exposure. (PC, CS)
Travel history. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease including:
Description of the type of primary skin lesion (macule, patch, papule,
nodule, plaque, vesicle, pustule, bulla, cyst, wheal, telangiectasia,
petechia, purpura, erosion, ulcer). (PC)
Description of the shape, margination, color, arrangement, and
distribution of the individual lesions. (PC)
Describe potentially malignant lesions in terms of Asymmetry, Border,
Color, Diameter, Elevation, and Enlargement (ABCDE). (PC)
Presence of exudates: dry (crust) or wet (weeping) exudates. (PC)
Presence of scale or lichenification. (PC)
Palpation of lesions for consistency, alteration of temperature,
mobility, and tenderness. (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology for a rash. (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

consideration of test cost and performance characteristics as well as patient

preferences.
Laboratory and diagnostic tests should include, when appropriate:
KOH preparation. (PC, MK)
CBC with differential. (PC, MK)
RPR and VDRL. (PC, MK)
Bacterial culture. (PC, MK)
Students should be able to define the indications for and interpret (with
consultation) the significance of the results of:
Skin biopsy. (PC, MK)
5. Communication skills: Students should be able to:
Explain the dangers of excess sun exposure. (PC, CS)
Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (PC, CS)
Elicit questions from the patient and his or her family about the
management plan. (PC, CS)
Counsel patients regarding the prevention of community acquisition of
MRSA. (PC, CS)
6. Basic and advanced procedural skills: Students should be able to:
Perform a skin scraping and KOH preparation. (PC)
7. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
Determining when to perform a skin scraping and KOH preparation.
(MK, PC)

Determining when to obtain tests appropriate for the diagnosis of

systemic medical conditions suspected as the cause of rash. (MK, PC)
Prescribing a simple hypoallergenic skin care regimen. (MK, PC)
Prescribing appropriate moisturizing/emollient treatment. (MK, PC)
Discussing the importance of and prescribing sunscreen use. (PC, MK,
CS)

Prescribing appropriate treatment for eczematous dermatoses, mild

psoriasis, common cutaneous skin infections, acne, rosacea, venous
stasis dermatitis and ulcers, and common drug eruptions. (PC, MK)
Determining when to obtain a consultation from a dermatologist. (PC)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to common dermatologic complaints.
(PC, PLI)

C.

Incorporating patient preferences. (PC, P)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for rashes. (PLI, P)
2. Recognize the importance of patient preferences when selecting among
diagnostic and therapeutic options for rashes. (P)
3. Appreciate the impact rashes have on a patients quality of life, well-being,
ability to work, and the family. (P)
D.

REFERENCES:
Drage LA. Life-threatening rashes: dermatologic signs of four infectious
diseases. Mayo Clin Proc. 199;74:68-72.
Williams HC. Clinical practice. Atopic dermatitis. N Engl J Med.
2005;352:2314-24.
Abbasi NR. Shaw HM. Rigel DS. Friedman RJ. McCarthy WH. Osman I.
Kopf AW. Polsky D. Early diagnosis of cutaneous melanoma: revisiting the
ABCD criteria. JAMA. 2004;292:2771-6.
James WD. Clinical practice. Acne. N Engl J Med. 2005;352:1463-72.
Wolff K, Johnson AJ, Suurmond R. Fitzpatricks Color Atlas & Synopsis of
Clinical Dermatology. 4th ed. New York, NY; 2005.
American Academy of Dermatology
Medical Student Core Curriculum
www.aad.org/professionals/Residents/MedStudCoreCurr/MedStudCoreC
urr.htm
Community-Associated MRSA
Division of Healthcare Quality Promotion
National Center for Infectious Diseases
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #15: UPPER RESPIRATORY COMPLAINTS

RATIONALE:
Upper respiratory tract infections (URIs) are some of the most common problems for
which patients seek medical attention. Many patients inappropriately receive antibiotic
therapy for these mostly viral infections.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Anatomy and physiology of the upper airway, Eustachian tubes, and sinuses.
Anatomy and physiology of the respiratory system.
Pathogenesis and pathophysiology of upper respiratory tract diseases.
Microbial pathogens associated with upper respiratory tract infections.
Pharmacology of antibiotics.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. A rational approach to the common URIs: nasal congestion, rhinorrhea, facial
pain/tenderness, cough, sputum production, sore throat, and ear pain. (MK)
2. Common constitutional symptoms that accompany URIs: generalized
weakness, fatigue, malaise, headache, mild myalgias, and modest fever. (MK)
3. The microbiology of URIs, highlighting the relative frequencies of viral and
bacterial etiologies. (MK)
4. The most common microbiologic agents that cause the common URIs. (MK)
5. The pathophysiology and typical clinical presentation of the common URIs:
Common cold. (MK)
Acute bronchitis. (MK)
Pharyngitis. (MK)
Acute sinusitis. (MK)
Otitis media. (MK)
6. The pathophysiologic similarities between the common cold and acute
sinusitis. (MK)
7. The clinical features and microbiology of acute compared to chronic sinusitis.
(MK)

8. The pathophysiology and symptomatology of allergic rhinitis and the clinical

features that may help differentiate it from the common cold and acute
sinusitis. (MK)
9. The clinical features that may help differentiate the common URIs from
influenza. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

10. The pathophysiology and clinical features of acute compared to chronic

bronchitis. (MK)
11. The pathophysiology and clinical features of acute bronchitis compared to
pneumonia. (MK)
12. The pathophysiology and clinical features of otitis media and Eustachian tube
malfunction. (MK)
13. The signs and symptoms that may help distinguish viral from bacterial
pharyngitis. (MK)
14. Symptomatic treatment for URIs and the major side effects/contraindications
for these treatments, including:
Decongestants. (MK)
Non-selective antihistamines. (MK)
Mucolytics. (MK)
Cough suppressants. (MK)
Pain relievers/fever reducers. (MK)
15. The general role of antibiotics in the treatment of URIs and specific evidencebased indications for them. (MK)
16. The basic elements of the treatment of allergic rhinitis. (MK)
17. The use of antiviral agents in the prophylaxis and treatment of influenza. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including:
The predominant symptom (nasal congestion/rhinorrhea, purulent
nasal discharge with facial pain/tenderness, sore throat, cough with or
without sputum, sore throat or ear pain). (PC, CS)
Constitutional symptoms. (PC, CS)
Symptoms of potential pneumonia. (PC, CS)
History of or symptoms of serious cardiopulmonary diseases (e.g.
asthma, chronic obstructive pulmonary disease, congestive heart
failure) that may alter the treatment plan. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Examination of the nasal cavity, pharynx, and sinuses. (PC)
Otoscopic examination. (PC)
Evaluation of the head and neck for lymphadenopathy. (PC)
Auscultation of the lungs to distinguish pulmonary consolidation,
pleural effusion, pulmonary congestion, and chronic obstructive
pulmonary disease. (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology of upper respiratory complaints:
Common cold. (PC, MK)
Acute sinusitis. (PC, MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

4.

5.

6.
7.

Chronic sinusitis. (PC, MK)

Allergic rhinitis. (PC, MK)
Pharyngitis. (PC, MK)
Otitis media. (PC, MK)
Otitis externa. (PC, MK)
Acute bronchitis. (PC, MK)
Chronic bronchitis. (PC, MK)
Influenza. (PC, MK)
Pneumonia. (PC, MK)
Infectious mononucleosis. (PC, MK)
Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences
Laboratory and diagnostic tests should include, when appropriate:
CBC with differential. (PC)
Rapid strep test. (PC)
Throat culture. (PC)
Chest radiograph. (PC)
PFTs. (PC)
Monospot/heterophile antibody. (PC)
Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (CS)
Elicit questions from the patient and his or her family about the
management plan. (CS)
Explain the microbiologic origin of most URIs and why antibiotics are
generally ineffective. (CS)
Explain the importance of antimicrobial resistance. (CS)
Basic and advanced procedure skills:
Throat culture. (PC)
Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
Determining when to obtain a chest radiograph. (PC, MK)
Determining when to prescribe antibiotics. (PC, MK)
Selecting the most appropriate antibiotic for acute bacterial sinusitis,
streptococcal pharyngitis, and bacterial otitis media. (PC, MK)
Prescribing symptomatic treatments. (PC, MK)
Determining when to obtain consultation from an allergist,
otolaryngologist, or pulmonologist. (PC, SBP)
Using a cost-effective approach based on the differential diagnosis.

(PC, SBP)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to URIs. (PC, PLI)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice


C.

Incorporating patient preferences. (PC, P)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for common URI complaints. (P, PLI)
2. Appreciate the impact common URI complaints have on a patients quality of
life, well-being, ability to work, and the family. (P)
3. Discuss the patients perspective regarding the use of antibiotics for URIs. (CS,
P)

4. Discuss the role physicians play in the over-prescribing of antibiotics for

URIs. (P)
5. Discuss the importance of antimicrobial resistance from the point of view of
the individual and society at large. (P)
D.

REFERENCES:
Arroll B, Kenealy T. Antibiotics for the common cold and acute purulent
rhinitis. Cochrane Database Syst Rev. 2005;(3):CD000247.
Bisno AL. Acute pharyngitis. N Engl J Med. 2001;344:205-11.
Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane
Database Syst Rev. 2004;(2):CD000023.
Metlay JP, Kapoor WN, Fine MJ. Does this patient have community-acquired
pneumonia? Diagnosing pneumonia by history and physical examination.
JAMA. 1997;278:1440-5.
Smucny J, Fahey T, Becker L, et al. Antibiotics for acute bronchitis.
Cochrane Database Syst Rev. 2004;(4):CD000245.
Snow V, Mottur-Pilson C, Gonzales R, et al. Principles of appropriate
antibiotic use for treatment of acute bronchitis in adults. Ann Intern Med.
2001;134:518-20.
Guidelines for the Control of Pertussis Outbreaks
National Immunization Program
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/nip/publications/pertussis/guide.htm
Get Smart. Know When Antibiotics Work
National Campaign for Appropriate Antibiotic Use
Division of Bacterial and Mycotic Diseases
National Center for Infectious Diseases
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/drugresistance/community/

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #16: ACUTE MYOCARDIAL INFARCTION

RATIONALE:
Cardiovascular disease is the number one killer of Americans. Many associated risk
factors are quite modifiable. Proper urgent management of acute myocardial infarctions
significantly reduces mortality.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Ability to perform a complete medical history and physical.
Ability to communicate with patients of diverse backgrounds.
Anatomy and physiology of the heart and coronary vessels.
Risk factors for and pathogenesis/pathophysiology of atherosclerosis.
Pharmacology of aspirin, morphine, nitroglycerine, heparin, antiplatelet agents,
thrombolytic agents, beta-blockers, angiotensin converting enzyme inhibitors (ACE-I),
angiotensin II receptor blockers (ARB), and HMG-CoA reductase inhibitors.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The primary and secondary prevention of ischemic heart disease through the
reduction of cardiovascular risk factors (e.g. controlling hypertension and
dyslipidemia, aggressive diabetes management, avoiding tobacco, and aspirin
prophylaxis). (MK)
2. The basic principles of the role of genetics in CAD. (MK)
3. Pathogenesis, signs, and symptoms of the acute coronary syndromes:
Unstable angina. (MK)
Non-ST-elevation myocardial infarction (NSTEMI). (MK)
ST-elevation myocardial infarction (STEMI). (MK)
4. Atypical presentations of cardiac ischemia/infraction. (MK)
5. The typical clinical course of the acute coronary syndromes. (MK)
6. ECG findings and macromolecular markers (myoglobin, CK-MB, Troponin-I,
Troponin-T) of acute ischemia/MI. (MK)
7. The utility of echocardiography in acute MI. (MK)
8. The importance of monitoring for and immediate treatment of ventricular
fibrillation in acute MI. (MK)
9. Therapeutic options for acute MI and how they may differ for NSTEMI and
STEMI, including:
Aspirin. (MK)
Morphine. (MK)
Nitroglycerine. (MK)
Oxygen. (MK)
Heparin. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Antiplatelet agents (glycoprotein IIb/IIIa inhibitors). (MK)

Beta-blockers. (MK)
ACE-I/ARB. (MK)
HMG-CoA reductase inhibitors. (MK)
Thrombolytic agents. (MK)
Emergent cardiac catheterization with percutaneous coronary
intervention. (MK)
10. Pathogenesis, signs, and symptoms of the complications of acute MI,
including arrhythmias, reduced ventricular function, cardiogenic shock,
pericarditis, papillary muscle dysfunction/rupture, acute valvular dysfunction,
and cardiac free wall rupture. (MK)
11. The general approach to the evaluation and treatment of ventricular
tachycardia and fibrillation. (MK)
12. The importance of post-MI risk stratification, including the burden of residual
coronary disease and assessment of left ventricular function. (MK)
13. Basic principles of cardiac rehabilitation. (MK)
14. Indications for coronary artery bypass grafting (CABG). (MK)
15. The Centers for Medicare & Medicaid Services (CMS) and the Joint
Commission on the Accreditation of Healthcare Organizations (JCAHO)
quality measures for acute MI treatment. (MK, PLI, SBP)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history that differentiates among etiologies
of disease, including:
Cardiac risk factors. (PC, CS)
Location, duration, intensity, exacerbating/ameliorating factors,
radiation of chest pain. (PC, CS)
Symptoms associated with chest pain (e.g. nausea, emesis, dyspnea,
diaphoresis, palpitations, dizziness, syncope, heartburn belching, etc.).
(PC, CS)

2. Physical exam skills: Students should be able to perform a physical exam to

establish the diagnosis and severity of disease including:
Recognition of dyspnea and anxiety. (PC)
Accurate measurement of vital signs. (PC)
Examination of the heart and vascular system. (PC)
Examination of the lungs. (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology of chest pain:
Stable angina. (PC, MK)
Coronary vasospasm. (PC, MK)
Unstable angina. (PC, MK)
Acute MI. (PC, MK)
Pericarditis. (PC, MK)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Aortic dissection. (PC, MK)

Pulmonary embolism. (PC, MK)
Other noncardiac causes of chest pain. (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences
Laboratory and diagnostic tests should include, when appropriate:
ECG. (PC, MK)
Chest radiograph. (PC, MK)
Macromolecular markers (myoglobin, CK-MB, Troponin-I, TroponinT). (PC, MK)
Students should be able to define the indications for and interpret (with
consultation) the results of:
Echocardiogram. (PC, MK)
Cardiac stress testing. (PC, MK)
Coronary angiography. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to patients. (PC, CS)
Elicit questions from the patient and his or her family about the
diagnostic and management plan. (PC, CS)
Educate patients about modifying cardiac risk factors. (PC, CS)
6. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
Medical management of acute MI. (PC, MK)
CCU monitoring. (PC, MK)
Indications for and complications of thrombolytic therapy, cardiac
catheterization with percutaneous coronary intervention, and CABG.

(PC, MK)

Proper pre-discharge risk stratification. (PC, MK)

Secondary risk factor modification. (PC, MK)
Determining when to obtain consultation from a cardiologist and
cardiothoracic surgeon. (PC, SBP)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to acute MI. (PC, PLI)
Incorporating patient preferences. (PC, P)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate a commitment to meeting national quality standards for the care
of patient with acute MI. (P, PLI, SBP)
2. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for acute MI. (PLI, P)
3. Recognize the importance of patient preferences when selecting among
diagnostic and therapeutic options for acute MI. (P)
4. Demonstrate ongoing commitment to self-directed learning regarding acute
MI. (PLI, P)
5. Appreciate the impact acute MI has on a patients quality of life, well-being,
ability to work, and the family. (P)
6. Recognize the importance of and demonstrate a commitment to the utilization
of other healthcare professionals in the treatment of acute MI. (P, SBP)

D.

REFERENCES:
ACC/AHA 2002 guideline update for the management of patients with
chronic stable angina--summary article: a report of the American College of
Cardiology/American Heart Association Task Force on practice guidelines
(Committee on the Management of Patients with Chronic Stable Angina). J
Am Coll Cardiol 2003; 41:159-68.
www.acc.org/clinical/topic/topic.htm#guidelines
ACC/AHA 2002 guideline update for the management of patients with
unstable angina and non-ST-segment elevation myocardial infarction-summary article: a report of the American College of Cardiology/American
Heart Association task force on practice guidelines (Committee on the
Management of Patients With Unstable Angina). J Am Coll Cardiol.
2002;40:1366-74.
www.acc.org/clinical/topic/topic.htm#guidelines
ACC/AHA guidelines for the management of patients with ST-elevation
myocardial infarction--executive summary. A report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to revise the 1999 guidelines for the management of
patients with acute myocardial infarction). J Am Coll Cardiol. 2004;44:671719.
Erratum in: J Am Coll Cardiol. 2005;45(8):1376.
www.acc.org/clinical/topic/topic.htm#guidelines
AHA/ACC Scientific Statement: AHA/ACC guidelines for preventing heart
attack and death in patients with atherosclerotic cardiovascular disease: 2001
update: A statement for healthcare professionals from the American Heart
Association and the American College of Cardiology. Circulation.
2001;25:1577-9.
www.acc.org/clinical/topic/topic.htm#guidelines

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #17: ACUTE RENAL FAILURE AND

CHRONIC KIDNEY DISEASE
RATIONALE:
Renal disease is a common problem in internal medicine and may manifest with
symptoms referable to the kidney as well as other systems. Patients who go on to endstage renal disease have high morbidity and mortality, despite advances in dialysis
treatment. Thus, an understanding of chronic kidney disease is useful to all physicians.
A rational approach to patients with suspected or known acute renal failure allows
students and clinicians to quickly assess the etiology and initiate treatment without
unnecessary delay in an effort to prevent the development of chronic kidney disease.
PREREQUISITES:
Prior knowledge, skills and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Knowledge of pathogenesis and pathophysiology of acute renal failure and the
development of chronic kidney disease.
Understanding of drugs that can have adverse effect on renal function.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe and discuss:

1. The distinction between the three major pathophysiologic etiologies for acute
renal failure (ARF):
Decreased renal perfusion (prerenal). (MK)
Intrinsic renal disease (renal). (MK)
Acute renal obstruction (postrenal). (MK)
2. The pathophysiology of the major etiologies of prerenal ARF, including:
Hypovolemia. (MK)
Decreased cardiac output. (MK)
Systemic vasodilation. (MK)
Renal vasoconstriction. (MK)
3. The pathophysiology of the major etiologies of intrinsic renal ARF,
including:
Vascular lesions. (MK)
Glomerular lesions. (MK)
interstitial nephritis. (MK)
Intra-tubule deposition/obstruction. (MK)
Acute tubular necrosis (ATN). (MK)
4. The pathophysiology of the major etiologies of postrenal ARF, including:

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Urethral (e.g. tumors, calculi, clot, sloughed papillae, retroperitoneal

fibrosis, lymphadenopathy). (MK)
Bladder neck (e.g. tumors, calculi, prostatic hypertrophy or carcinoma,
neurogenic). (MK)
Urethral (e.g. stricture, tumors, obstructed indwelling catheters). (MK)
5. The pathophysiology and clinical findings of uremia. (MK)
6. The natural history, initial evaluation and treatment, and complications of
ARF. (MK)
7. The most common etiologies of chronic kidney disease (CKD):
DM. (MK)
Hypertension. (MK)
Glomerulonephritis. (MK)
Polycystic kidney disease. (MK)
Autoimmune diseases (e.g. systemic lupus erythematosus). (MK)
The staging scheme for CKD. (MK)
8. The significance for proteinuria in CKD. (MK)
9. The use of ACE-Is and ARBs in the management of CKD. (MK)
10. The importance of secondary hyperparathyroidism in CKD. (MK)
11. The pathophysiology of anemia in CKD. (MK)
12. The value of glycemic and hypertension control in limiting the progression of
CKD. (MK)
13. The value of CAD risk factor modification in patients with CKD, particularly
those treated with dialysis. (MK)
14. The basic principles of renal replacement therapy (e.g., hemodialysis and
peritoneal dialysis) as well as the complications. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate history that distinguishes among the three major
reasons for ARF (pre-renal, renal, post-renal), including the predisposing
conditions, nephrotoxic drugs or agents, and systemic disease and the major
causes of CKD. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical
examination to establish the diagnosis and severity of disease, including:
The determination of a patients volume status through estimation of
the central venous pressure using the height of jugular venous
distention and measurement of pulse and blood pressure in the
lying/standing position. (PC)
Palpation and percussion of the bladder to recognize bladder
distention. (PC)
Palpation of the prostate. (PC)
Determination of the presence of pulmonary edema, peripheral edema,
ascites, and signs of heart failure. (PC)
Findings consistent with uremia. (PC)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Examination for evidence of systemic disease, including but not

limited to: skin, joints, and nails. (PC)
3. Differential diagnosis: Students should be able to generate a differential
diagnosis for a patient with ARF or CKD recognizing specific history,
physical exam, and laboratory findings that suggest a specific etiology. (PC,
MK)

4. Laboratory interpretation: Students should be able to recommend when to

order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences. Laboratory and diagnostic tests should include, when appropriate:
Serum electrolytes, BUN/Cr, calcium, phosphorus. (PC, MK)
Urine sodium. (PC, MK)
Serum and urine osmolality. (PC, MK)
Anion gap. (PC, MK)
ABG (PC, MK)
Serum BUN to Cr ratio. (PC, MK)
CBC, ferritin. (PC, MK)
Performing and interpreting a urinalysis, including microscopic
examination for casts, red blood cells, white blood cells, and crystals.
(PC, MK)

Calculating fractional excretion of sodium and appreciate its

usefulness in distinguishing between pre-renal and intrinsic renal
disease. (PC, MK)
Calculating creatinine clearance using the Cockcroft-Gault or MDRD
(modification of diet in renal disease study) equations. (PC, MK)
Serum parathyroid hormone level. (PC, MK)
ECG findings in hyperkalemia. (PC, MK)
Students should be able to define the indications for and interpret (with
consultation) results of:
Renal ultrasonography. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (PC, CS)
Elicit questions from the patient and his or her family about the
management plan. (PC, CS)
Counsel patients regarding a renal diet. (PC, CS)
6. Basic and advanced procedure skills: Students should be able to:
Insert a peripheral intravenous catheter. (PC)
Place a urinary catheter. (PC)
Obtain an ABG. (PC)
7. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients, including:
Designing an appropriate management plan for initial management of
ARF, including volume management, dietary recommendations, drug
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

dosage alterations, electrolyte monitoring, and indications for dialysis.

(PC, MK)

Developing a management plan to effectively treat HTN and DM. (PC,

Recommending treatment with phosphate binders, calcium

replacement, and vitamin D replacement. (PC, MK)
Recommending treatment for dyslipidemia. (PC, MK)
Recommending treatment for anemia secondary to CKD. (PC, MK)
Recommending acute treatment for hyperkalemia. (PC, MK)
Determining when to obtain consultation from a nephrologist. (PC, MK)
Using a cost-effective approach based on the differential diagnosis.

MK)

C.

(PC, SBP)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to renal failure. (PC, PLI)
Incorporating patient preferences. (PC, P)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for ARF and CKD. (PLI, P)
2. Respond appropriately to patients who are nonadherent to treatment for renal
failure. (CS, P)
3. Demonstrate ongoing commitment to self-directed learning regarding renal
failure. (PLI, P)
4. Appreciate the impact renal failure has on a patients quality of life, wellbeing, ability to work, and the family. (P)
5. Recognize the importance and demonstrate a commitment to the utilization of
other healthcare professions in the treatment of renal failure. (P, SBP)

D.

REFERENCES:
Lamiere N, Van Breson W, Vanholder R. Acute renal failure. Lancet.
2005;365:417-30.
Singri N, Ahya SN, Levin ML. Acute renal failure. JAMA. 2003;289:74751.
Schrier RW, Wang W, Poole B, Mitra A. Acute renal failure: definitions,
diagnosis, pathogenesis, and therapy. J Clin Invest. 2004;114:5-14.
Esson ML, Schrier RW. Diagnosis and treatment of acute tubular necrosis.
Ann Intern Med. 2002;137:744-52.
Levey AS. Clinical practice. Nondiabetic kidney disease. N Engl J Med.
2002;347:1505-11.
Palmer BF. Renal dysfunction complicating the treatment of hypertension. N
Engl J Med. 2002;347:1256-61.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #18: COMMON CANCERS

RATIONALE:
A skillful initial workup for suspected cancer is an essential part of effective primary care
practice. Developing a logical and practical diagnostic approach to the more common
cancers (e.g. skin, colorectal, lung, breast, cervical, and prostate) is an excellent means of
honing basic history-taking, physical examination, and communication skills and learning
how to use diagnostic studies in a cost effective manner. Encountering patients in whom
cancer is a diagnostic possibility will stimulate learning of the important clinical
presentations and natural histories of these life-threatening conditions. Focusing on
cancer diagnosis helps to concentrate the students learning and avoids premature
immersion in the often very technical and specialized issues of cancer treatment.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Anatomy, physiology, and pathophysiology of common cancers.
Basic knowledge of the common symptoms and signs of the most common cancers.
Knowledge of basic concepts of clinical epidemiology pertinent to test selection and
interpretation (e.g. sensitivity, specificity, positive predictive value, negative
predictive value).
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Primary prevention measures for common cancers. (MK)
2. Current screening recommendations for skin, colorectal, lung, breast, cervical,
and prostate cancer. (MK)
3. Principle clinical presentations, clinical courses, complications, and causes of
death for the most common cancers (e.g. skin, colorectal, lung, breast,
cervical, and prostate). (MK)
4. Basic methods of initial evaluation, including the sensitivity and specificity of
basic diagnostic studies and indication for their use, including:
Indications for skin biopsy in a patient with a suspicious skin lesion.
(MK)

Indications for colonoscopy in individuals a risk for colon cancer. (MK)

Indications for breast biopsy in a patient with a breast nodule or
abnormal screening mammogram. (MK)
Indications for a lymph node biopsy in a patent with suspicious
lymphadenopathy. (MK)
Initial cost-effective workups for: isolated pleural effusion, pulmonary
nodule, liver nodule, prostate nodule, elevated prostate-specific
antigen, testicular nodule, stool test positive for occult blood, abnormal

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Problem-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Pap smear, and other findings suggestive of gastrointestinal and

urogenital cancers. (MK)
5. Genetic considerations of selected cancers (e.g. hereditary nonpolyposis colon
cancer, familial adenomatous polyposis, BRCA1/BRCA2, HER2,
Philadelphia chromosome/BRC-ABL). (MK)
6. The role of human papilloma virus in cervical cancer. (MK)
7. The similarities and differences between curative and palliative cancer care.
(MK)

8. The principles of palliative care and hospice care. (MK)

9. Symptoms sometimes seen during end-of-life care and the basic principles of
their management (e.g., pain, dyspnea, nausea and vomiting, anorexia, fatigue,
depression, delirium, constipation). (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including:
Unintentional weight loss, fever, bone pain. (PC, CS)
Sun exposure history, abnormal skin lesions. (PC, CS)
Blood in the stool, alterations in bowel movements, abdominal pain,
abdominal mass. (PC, CS)
Smoking, cough, hemoptysis, chest pain, dyspnea. (PC, CS)
Breast nodules and secondary signs of breast cancer. (PC, CS)
Abnormal vaginal bleeding. (PC, CS)
Abnormal urinary symptoms. (PC, CS)
Lymphadenopathy. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Skin examination. (PC)
Digital rectal examination. (PC)
Breast examination. (PC)
Lymph node examination. (PC)
Male genital examination and prostate examination. (PC)
Pelvic examination and Pap smear. (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology for:
Unintentional weight loss. (PC, MK)
Fever. (PC, MK)
Abnormal skin lesions. (PC, MK)
Occult blood positive stool. (PC, MK)
Colorectal mass. (PC, MK)
Chronic cough, hemoptysis, pulmonary nodule, and pleural effusion.
(PC, MK)

Breast mass. (PC, MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Problem-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

4.

5.

6.

7.

Abnormal Pap smear. (PC, MK)

Abdominal or pelvic mass. (PC, MK)
Prostate nodule and elevated prostate specific antigen. (PC, MK)
Lymphadenopathy. (PC, MK)
Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
CBC. (PC)
Electrolytes, BUN/Cr, Ca, hepatic function panel. (PC)
Stool occult blood testing. (PC)
PSA. (PC)
Students should be able to define the indications for and interpret (with
consultation) the significance of the results of:
Skin biopsy. (PC)
Mammogram. (PC)
Breast biopsy. (PC)
Colon/rectal biopsy. (PC)
Lung biopsy. (PC)
Pap smear. (PC)
Prostate biopsy. (PC)
Lymph node biopsy. (PC)
Communication skills: Students should be able to:
Communicate the diagnostic plan and subsequent follow-up to
patients. (PC, CS)
Elicit questions from the patient and his or her family about the
management plan. (PC, CS)
With guidance and direct supervision, participate in breaking bad news
to patients. (PC, CS)
With guidance and direct supervision, participate in discussing basic
issues regarding advance directives with the patient and his or her
family. (PC, CS)
With guidance and direct supervision participate in discussing basic
end-of-life issues with the patient and his or her family. (PC, CS)
Basic and advanced procedure skills: Students should be able to:
Cervical Pap smear. (PC)
Stool occult blood testing. (PC)
Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
Initial work-up of the symptom, sign, or abnormal laboratory value
suspected to be due to cancer. (PC)
Provision of support and information for the patient. (PC)
Coordination of care for workup. (PC, SBP)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Problem-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Determining when to obtain consultation from appropriate specialists.

(PC, SBP)

A cost-effective approach based on the differential diagnosis. (PC, SBP)

Accessing and utilizing appropriate information systems and resources
to help delineate issues related to common cancers. (PC, PLI)
Incorporating patient needs and preferences. (PC, P)
Appropriately assessing and treating pain when necessary with
nonnarctoic and narcotic analgesics. (PC)
Anticipating and treating narcotic side effects if necessary. (PC)
Adjusting the therapeutic plan when goals of care change (e.g., a shift
toward palliative care). (PC)
Alleviation of symptoms sometimes seen during end of life care (e.g.,
pain, dyspnea, nausea and vomiting, anorexia, fatigue, depression,
delirium, constipation). (PC)
Utilizing supportive care or hospice service when appropriate. (PC,
SBP)

C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Appreciate the uncertainty and fear patients experience when cancer is a
significant diagnostic possibility. (P)
2. Respect the patients right to refuse cancer screening. (P)
3. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for common cancers. (PLI, P)
4. Recognize the importance of patient preferences when selecting among
diagnostic options for common cancers. (P)
5. Demonstrate ongoing commitment to self-directed learning regarding
common cancers. (PLI, P)
6. Appreciate the impact common cancers have on a patients quality of life,
well-being, ability to work, and the family. (P)
7. Recognize the importance of and demonstrate a commitment to the utilization
of other healthcare professions in the workup and treatment of common
cancers. (P, SBP)

D.

REFERENCES:
National Cancer Institute
National Institutes of Health
www.cancer.gov
Guide to Clinical Preventive Services
U.S. Preventative Services Task Force (USPSTF)
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
www.ahrq.gov/clinic/cps3dix.htm#cancer

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Problem-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 American Cancer Society

www.cancer.org
NCCN Clinical Practice Guidelines in Oncology
National Comprehensive Cancer Network
www.nccn.org/professionals/physician_gls/default.asp

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Problem-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #19: COPD/OBSTRUCTIVE AIRWAYS

DISEASE
RATIONALE:
The chronic obstructive pulmonary diseases (chronic bronchitis and emphysema) are
important causes of morbidity and mortality and are a major cause of total disability,
second only to coronary artery disease. Cigarette smoking plays a major role in the
progression of the disease, with survival rates lower among patients who continue to
smoke cigarettes. The severity and debilitation of these disorders make them an
important training problem for all third year medical students. The number of new cases
of asthma is dramatically increasing. Most cases with appropriate treatment can have
minimal symptoms.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Ability to perform a complete medical history and physical.
Ability to communicate with patients of diverse backgrounds.
Normal structure and function of the heart and lungs and how these are altered in
respiratory system diseases.
Pathogenesis and pathophysiology of pulmonary diseases.
Pharmacology of bronchodilators, corticosteroids, and antibiotics.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The epidemiology, risk factors, symptoms, signs, and typical clinical course of
the common forms of COPD, including chronic bronchitis and emphysema.
(MK)

2. Common causes of acute exacerbations of COPD (AECOPD), including:

Acute infectious bronchitis. (MK)
Pneumonia. (MK)
Pulmonary edema. (MK)
Poor air quality (e.g. ozone, pollutants, tobacco smoke). (MK)
Occupational exposures. (MK)
Medical noncompliance. (MK)
3. The etiology, pathogenesis, evaluation, and management of hypoxemia and
hypercapnia. (MK)
4. The genetics and role of alpha-1 antitrypsin deficiency in some patients with
emphysema. (MK)
5. The epidemiology, risk factors, symptoms, signs, and typical clinical course of
asthma. (MK)
6. Allergic and non-allergic factors that may precipitate bronchospasm and
exacerbate asthma, including:
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Grass and tree pollen. (MK)

Animal dander. (MK)
Cockroaches. (MK)
Dust mites. (MK)
Allergic rhinitis/post-nasal drip. (MK)
Acute/chronic infectious sinusitis. (MK)
Acute infectious bronchitis. (MK)
Pneumonia. (MK)
Pulmonary edema. (MK)
Exercise. (MK)
Anxiety/stress. (MK)
Poor air quality (e.g. ozone, pollutants, tobacco smoke). (MK)
Occupational exposures. (MK)
Medical noncompliance. (MK)
7. Therapies for COPD and asthma, including:
Beta-agonist bronchodilators. (MK)
Anticholinergic bronchodilators. (MK)
Leukotriene inhibitors. (MK)
Mast cell stabilizers. (MK)
Theophylline. (MK)
Inhaled corticosteroids. (MK)
Systemic corticosteroids. (MK)
Antimicrobial agents. (MK)
Supplemental oxygen. (MK)
Immunotherapy. (MK)
8. The indications for and the efficacy of influenza and pneumococcal vaccines.
(MK)

B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease including:
Existence, duration, and severity of dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, cough, sputum production, wheezing, fever, chills,
sweats, chest pain, hemoptysis. (PC, CS)
Smoking history and passive exposure to tobacco smoke. (PC, CS)
Occupational history. (PC, CS)
Family history of pulmonary problems. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease including:
Accurately determining respiratory rate and level of respiratory
distress. (PC)
Assessing the use of accessory muscles for breathing. (PC)
Identifying bronchial breath sounds, rales, rhonchi, and wheezes. (PC)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Identifying signs of pulmonary consolidation, pleural effusion, and

pneumothorax. (PC)
Identifying the signs of pulmonary hyperresonance/hyperexpansion.
(PC)

3. Differential diagnosis: Students should be able to generate a prioritized

differential diagnosis recognizing specific history and physical exam findings
that suggest a diagnosis of chronic bronchitis, emphysema, asthma, or other
conditions with similar findings.
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
Pulse oximitry. (PC, MK)
ABG. (PC, MK)
Chest radiograph. (PC, MK)
Pulmonary function tests. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (PC, CS)
Elicit questions from the patient and his or her family about the
management plan. (PC, CS)
Counsel patients about smoking cessation. (PC, CS)
Counsel patients about the performance of home peak flow
monitoring. (PC, CS)
Counsel patients about environmental controls. (PC, CS)
Encourage asthma patients to be involved in their own disease
management and counsel them about an asthma action plan. (PC, CS)
6. Basic and advanced procedure skills: Students should be able to:
Obtain an ABG. (PC)
7. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
The use of bronchodilators and inhaled corticosteroids. (PC, MK)
The key components of the care of patients admitted with acute
exacerbations of COPD and asthma. (PC, MK)
Using systemic corticosteroids appropriately. (PC, MK)
Judicious use of antimicrobial agents. (PC, MK)
The principles of oxygen therapy. (PC, MK)
Determining when to obtain consultation from a pulmonologist or
allergist/immunologist. (PC, SBP)
Smoking cessation strategies. (PC)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

C.

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to COPD and asthma. (PC, PLI)
Incorporating patient preferences. (PC, P)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for COPD and asthma. (PLI, P)
2. Recognize the importance of patient preferences when selecting among
diagnostic and therapeutic options for COPD and asthma (P)
3. Respond appropriately to patients who are nonadherent to treatment for COPD
and asthma. (CS, P)
4. Appreciate the impact of working, living, and environmental conditions on the
development and progression of respiratory tract disease; demonstrate
understanding that patients are often unable to change these factors on their
own. (P)
5. Demonstrate ongoing commitment to self-directed learning regarding COPD
and asthma. (PLI, P)
6. Appreciate the impact COPD and asthma have on a patients quality of life,
well-being, ability to work, and the family. (P)
7. Recognize the importance of and demonstrate a commitment to the utilization
of other healthcare professionals in the diagnosis and treatment of COPD and
asthma. (P, SBP)
8. Appreciate the importance of antimicrobial resistance. (P)
9. Show understanding for the difficulties patients face with smoking cessation.
(P)

D.

REFERENCES:
National Heart Lung and Blood Institute/World Health Organization Global
Initiative for Chronic Obstructive Lung Disease
Diagnosis, management, and prevention of chronic obstructive pulmonary
disease
www.goldcopd.com
National Institutes of Health, National Heart, Lung, and Blood Institute
National Asthma Education and Prevention Program
Practical Guide for the Diagnosis and Management of Asthma
NIH Publication 97-4074. Bethesda, MD. 2003.
http://www.nhlbi.nih.gov/health/indexpro.htm
Celli BR, MacNee W. Standards for the diagnosis and treatment of patients
with COPD: a summary of the ATS/ERS position paper. Eur Respir J
2004;23:932-46.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #20: DIABETES MELLITUS

RATIONALE:
Diabetes mellitus is an increasingly prevalent illness in the United States. It is estimated
that five to nine percent of American adults are diabetic with the illness appearing at
earlier ages in some populations. It is a leading cause of disability and death. Over 130
billion health care dollars are spent on diabetes annually. All internists must identify
those at risk and institute appropriate management to ameliorate the potentially fatal
complications of this illness.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Ability to perform a complete medical history and physical.
Ability to communicate with patients of diverse backgrounds.
Pathogenesis and pathophysiology of type I and II diabetes mellitus, diabetic
ketoacidosis, nonketotic hyperglycemia.
Effects of insulin on glucose and fat metabolism.
Pharmacology of insulin, sulfonylureas, metformin, thiazolidinediones, and glucose
absorption inhibitors.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Diagnostic criteria for impaired fasting glucose and impaired glucose
tolerance. (MK)
2. Diagnostic criteria for type I and type II diabetes mellitus, based on a history,
physical examination, and laboratory testing. (MK)
3. Pathophysiology, risk factors, and epidemiology of type I and type II diabetes
mellitus. (MK)
4. The basic principles of the role of genetics in diabetes mellitus. (MK)
5. Presenting symptoms and signs of type I and type II diabetes mellitus. (MK)
6. Presenting symptoms and signs of diabetic ketoacidosis (DKA) and
nonketotic hyperglycemic (NKH). (MK)
7. Pathophysiology for the abnormal laboratory values in DKA and NKH
including plasma sodium, potassium, and bicarbonate. (MK)
8. Precipitants of DKA and NKH. (MK)
9. Major causes of morbidity and mortality in diabetes mellitus (coronary artery
disease, peripheral vascular disease, hypoglycemia, DKA, NKH coma,
retinopathy, neuropathyperipheral and autonomic, nephropathy, foot
disorders, infections). (MK)
10. Laboratory tests needed to screen, diagnose, and follow diabetic patients
including: glucose, electrolytes, blood urea nitrogen/creatinine, fasting lipid

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

profile, HgA1c, urine microalbumin/creatinine ratio, urine dipstick for protein.

(MK)

10. Non-pharmacologic and pharmacologic (drugs and side effects) treatment of

diabetes mellitus to maintain acceptable levels of glycemic control, prevent
target organ disease, and other associated complications. (MK)
11. The specific components of the American Diabetes Association (ADA)
dietary recommendations for type I and type II diabetes mellitus. (MK)
12. Basic management of diabetic ketoacidosis and nonketotic hyperglycemic
states, including the similarities and differences in fluid and electrolyte
replacement. (MK)
13. Basic management of blood glucoses in the hospitalized patient. (MK)
14. The Somogyi effect and the Dawn phenomenon and the implications of each
in diabetes pharmacologic management. (MK)
15. The fundamental aspects of the American Diabetes Association (ADA)
clinical practice recommendations and how they encourage high quality
diabetes care. (MK, PLI, SBP)
16. Basic management of hypertension and hyperlipidemia in the diabetic patient.
(MK)

B.

SKILLS: Students should be able to demonstrate specific skills including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including:
Weight changes. (PC, CS)
Hypo- or hyperglycemic symptoms. (PC, CS)
Medication history (adherence, side effects, other medications). (PC,
CS)

Home glucose monitoring results. (PC, CS)

Target organ disease complications (cardiovascular, foot,
gastrointestinal, infectious, neurological, sexual, skin, urinary, or
vision symptoms). (PC, CS)
Diet history (total caloric intake, intake of sugar-containing foods,
intake of saturated fat and cholesterol, physical activity level, timing of
meals). (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Skin examination for diabetic dermopathy, furuncles/carbuncles,
candidiasis, necrobiosis lipoidica diabeticorum, dermatophytosis, and
acanthosis nigricans. (PC)
Fundoscopic exam. (PC)
Arterial pulses. (PC)
Peripheral nerves (e.g. monofilament testing). (PC)
Examination of the feet for corns, calluses, and ulcerations. (PC)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

In patients with DKA or NKH evaluate for mental status alterations,

Kussmauls respirations, fruity breath, and signs of volume depletion.
(PC)

3. Differential diagnosis: Students should be able to generate a prioritized

differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology for:
Hyperglycemia. (PC, MK)
Hypoglycemia. (PC, MK)
Anion gap acidosis. (PC, MK)
Ketosis. (PC, MK)
Hyperosmolality. (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences
Laboratory and diagnostic tests should include, when appropriate:
Fasting serum GLC. (PC, MK)
Electrolytes, BUN/Cr. (PC, MK)
Serum and urine ketones. (PC, MK)
Serum and urine osmolality. (PC, MK)
HbA1c. (PC, MK)
Fasting lipid profile. (PC, MK)
UA. (PC, MK)
Urine microalbumin/creatinine ratio. (PC, MK)
24-hour urine for protein and creatinine clearance. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to patients. (PC, CS)
Elicit questions from the patient and their family about the
management plan. (PC, CS)
Counsel patients appropriately on dietary measures, exercise,
medication adherence, proper foot care, and prevention of other target
organ disease. (PC, CS)
6. Basic and advanced procedural skills: Students should be able to:
Finger-stick capillary blood glucose determination. (PC)
Obtain an ABG. (PC)
7. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
Writing appropriate fluid and insulin orders and outline critical steps
for the treatment of DKA and DKH. (PC, MK)
Counseling patients regarding basic features of ADA diabetic diet
recommendations. (PC, CS)
Instructing patients in home blood glucose monitoring. (PC, CS)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Counseling patients on behavior changes (smoking cessation,

medication adherence, poor glycemic control, obesity, hypertension,
dyslipidemia, and infection) to avoid the complications of diabetes.
(PC, CS)

C.

Counseling patients regarding basic foot care. (PC, CS)

Determining when to institute diet therapy, oral hypoglycemic agents,
and insulin therapy. (PC, MK)
Calculating an appropriate insulin dose for a diabetic patient. (PC, MK)
Using community resources (ADA, hospital and community-based
education programs) to aid the patient in understanding and managing
his or her illness. (PC, SBP)
Determining when to obtain consultation from an endocrinologist,
nephrologist, ophthalmologist, podiatrist, and dietician. (PC, SBP)
Accessing and utilizing appropriate information systems and resources
to help delineate issues related to diabetes mellitus. (PC, PLI)
Incorporating patient preferences. (PC)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate a commitment to meeting ADA clinical practice
recommendations to insure quality diabetes care. (PLI, P, SBP)
2. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for diabetes mellitus. (PLI, P)
3. Recognize the importance of patient preferences when selecting among
diagnostic and therapeutic options for diabetes mellitus. (P)
4. Respond appropriately to patients who are nonadherent to treatment for
diabetes mellitus. (CS, P)
5. Demonstrate ongoing commitment to self-directed learning regarding diabetes
mellitus. (PLI, P)
6. Appreciate the impact diabetes mellitus has on a patients quality of life, wellbeing, ability to work, and the family. (P)
7. Recognize the importance of and demonstrate a commitment to the utilization
of other healthcare professionals in the treatment of diabetes mellitus. (P, SBP)

D.

REFERENCES:
The Diabetes Control and Complication Trail Research Group. The effect of
intensive treatment of diabetes on the development and progression of longterm complications in insulin-dependent diabetes mellitus. N Engl JMed.
1993;329:977-86.
UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose
control with sulphonylureas or insulin compared with conventional treatment
and risk of complications in patients with type 2 diabetes (UKPDS 33).
Lancet. 1998;352:837-53.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Clinical Practice Recommendations

American Diabetes Association
www.diabetes.org/for-health-professionals-and-scientists/cpr.jsp
Kitabchi AE. Wall BM. Management of diabetic ketoacidosis. Am Fam
Physician. 1999;60:455-64.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #21: DYSLIPIDEMIA

RATIONALE:
Dyslipidemia is a common, important, and treatable cardiovascular risk factor. Its
pathophysiology is increasingly understood, diagnostic tests are readily available, and
treatment modalities range from diet and exercise to a multitude of pharmacotherapies.
Competency in the evaluation and management of this problem helps develop skills in
rational test selection, patient education, and design of cost-effective treatment strategies.
It also draws attention to the importance of community health education and nutrition.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Ability to perform a complete medical history and physical.
Ability to communicate with patients of diverse backgrounds.
Anatomy and physiology of the vascular system.
Basic cholesterol and lipoprotein metabolism.
Pathogenesis and pathophysiology of atherosclerosis.
Pharmacology of bile acid sequestrants (resins), nicotinic acid, fibric acid derivatives,
HMG-CoA reductase inhibitors (statins), and cholesterol absorption inhibitors
(ezetimibe).
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The contribution of lipoproteins to atherogenesis and CAD risk, including the
importance of elevations in total cholesterol, LDL cholesterol, ratio of total to
HDL cholesterol, and Lipoprotein a. (MK)
2. The classification and etiologies of primary dyslipidemias. (MK)
3. Etiologies and underlying pathophysiology of secondary dyslipidemias. (MK)
4. The basic principles of the role of genetics in dyslipidemia, particularly
familial combined hyperlipidemia. (MK)
5. Screening recommendations for dyslipidemias in American adults. (MK)
6. The importance of identifying and treating asymptomatic patients at high risk
for CAD as aggressively as those with symptomatic disease. (MK)
7. The available diagnostic studies and their use, particularly determinations of
HDL, LDL, and total cholesterol, as well as the need to test for other
cardiovascular risk factors. (MK)
8. The current National Cholesterol Education Program (NCEP, ATP III)
guidelines for risk factor assessment, diagnosis and management of
dyslipidemias, including goal LDL cholesterol, goal non-HDL cholesterol,
and the concept of coronary artery disease equivalent based on risk factors for
coronary artery disease. (MK, PLI, SBP)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

9. Basic management of the common dyslipidemias, including diet, fiber,

exercise, and risk/benefits/cost of drug therapy (statins, fibrates, ezetimide,
nicotinic acid, resins). (MK)
10. Diagnosis and implications of the metabolic syndrome. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease including:
Prior patient or family history of dyslipidemia. (PC, CS)
Other coronary risk factors. (PC, CS)
Family history of early cardiovascular disease. (PC, CS)
Dietary fat, saturated fat, fiber, cholesterol, and refined carbohydrate
intake. (PC, CS)
Exercise habits. (PC, CS)
Alcohol use. (PC, CS)
Past history of established CAD, cerebral vascular disease, and other
vascular disease. (PC, CS)
Presence of symptoms of angina and peripheral vascular disease. (PC,
CS)

History of renal, hepatic, or myopathic disease. (PC, CS)

2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Blood pressure elevation. (PC)
Xanthomata. (PC)
Atherosclerotic fundoscopic changes. (PC)
Carotid or femoral bruits. (PC, CS)
Diminished peripheral pulses. (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam findings
that suggest primary or secondary causes of dyslipidemia. (PC, CS)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
Fasting lipid profile. (PC, MK)
TSH (PC, MK)
Fasting GLC, electrolytes, BUN/Cr. (PC, MK)
Hepatic function panel. (PC, MK)
CK. (PC, MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

5. Communication skills: Students should be able to:

Communicate the diagnosis, treatment plan, and subsequent follow-up
to patients. (PC, CS)
Elicit questions from the patient and his or her family about the
management plan. (PC, CS)
Counsel patients about dietary measures to reduce cholesterol and
saturated fats. (PC, CS)
Counsel patients about ways to increase exercise. (PC, CS)
Counsel patients about other modifiable cardiovascular risk factors.
(PC, CS)

6. Management skills: Students should able to develop an appropriate

evaluation and treatment plan for patients that includes:
An individual treatment plan that follows the NCEP ATP III
guidelines. (PC, MK)
Lifestyle modification (diet, exercise). (PC, MK)
Appropriate pharmacologic interventions, including bile acid
sequestrants (resins), nicotinic acid, fibric acid derivatives, HMG-CoA
reductase inhibitors (statins), and cholesterol absorption inhibitors
(ezetimibe). (PC, MK)
Monitoring for adherence and side effects due to pharmacologic
management. (PC, MK)
Laboratory response to therapy. (PC, MK)
Identifying barriers that prevent patients from adhering to
recommended dietary, exercise, and pharmacologic plans. (PC, MK)
Determining when to obtain consultation from an endocrinologist, or
dietician. (PC, SBP)
Using a cost-effective approach based on the differential diagnosis.

C.

(PC, SBP)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to dyslipidemia. (PC, PLI)
Incorporating patient preferences. (PC)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate a commitment to meeting NCEP ATP III guidelines to insure
quality care of patients with dyslipidemia. (PLI, P, SBP)
2. Appreciate the importance of encouraging patients to assume responsibility
for modifying their diet and increasing their exercise level. (P, CS)
3. Appreciate the difficulties and frustrations that patients and health care
providers face with recommended dietary changes. (P)
4. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for dyslipidemia. (PLI, P)
5. Recognize the importance of patient preferences when selecting among
diagnostic and therapeutic options for dyslipidemia. (P)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

6. Respond appropriately to patients who are nonadherent to treatment for

dyslipidemia. (CS, P)
7. Demonstrate ongoing commitment to self-directed learning regarding
dyslipidemia. (PLI, P)
8. Recognize the importance of and demonstrate a commitment to the utilization
of other healthcare professionals in the treatment of dyslipidemia. (P, SBP)
D.

REFERENCES:
National Institutes of Health, National Heart, Lung, and Blood Institute
National Cholesterol Education Program
Clinical Practice Guidelines for Cholesterol Management in Adults (ATP III)
www.nhlbi.nih.gov/about/ncep
Grundy SM, Cleeman JI, Merz CN, et al; National Heart, Lung, and Blood
Institute; American College of Cardiology Foundation; American Heart
Association. Implications of recent clinical trials for the National Cholesterol
Education Program Adult Treatment Panel III guidelines. Circulation.
2004;110:227-39.
Ashen MD, Blumenthal RS. Clinical practice. Low HDL cholesterol levels.
N Engl J Med. 2005;353:1252-60.
Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. N
Engl J Med. 2005;352:1685-95.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #22: HEART FAILURE

RATIONALE:
Chronic heart failure (HF) is one of the most common cardiac problems encountered in
clinical practice. Identification and correction of treatable underlying causes, control of
precipitating factors and judicious use of multi-drug regimens for individuals with HF are
important issues for third-year medical students.
PREREQUISITES:
Prior knowledge, skills and attitudes acquired during the pre-clerkship years should
include:
Knowledge of the structure and function of the heart and lungs.
Understanding of the epidemiology of heart disease.
Knowledge of the atherogenesis and pathophysiology of cardiovascular disease.
Knowledge of the pharmacology of cardiovascular drugs.
Ability to communicate appropriately with all types of patients including the elderly
and those with diverse backgrounds.
Ability to perform a complete medical history and physical exam.
Ability to perform a cardiovascular risk assessment and understand issues related to
primary and secondary prevention of cardiovascular disease.
Ability to understand the impact of illness on individuals and their families and, when
appropriate, to address issues related to end-of-life care.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Types of processes and most common disease entities that cause HF (i.e.
ischemic, valvular, hypertrophic, infiltrative, inflammatory, etc.). (MK)
2. The basic role of genetics in certain forms of cardiomyopathy. (MK)
3. Staging system for heart failure:
Stage A: high risk for HF but no structural heart disease is present.
(MK)

Stage B: structural heart disease is present but never any symptoms.

(MK)

3.
4.
5.
6.

Stage C: past or current symptoms associated with structural heart

disease. (MK)
Stage D: end-stage disease with requirements for specialized
treatment. (MK)
Types of processes that cause systolic vs. diastolic dysfunction. (MK)
Symptoms and signs of left-sided vs. right-sided heart failure. (MK)
Compensatory mechanisms of heart failure including cardiac remodeling and
activation of endogenous neurohormonal systems. (MK)
Factors leading to symptomatic exacerbation of HF, including ischemia,
arrhythmias, hypoxemia, anemia, fever, hypertension, thyroid disorders, non-

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

compliance with medications and dietary restrictions and use of nonsteroidal

anti-inflammatory drugs. (MK)
7. Importance of age, gender and ethnicity on the prevalence and prognosis of
HF. (MK)
8. Physiological basis and scientific evidence supporting each type of treatment,
intervention, or procedure commonly used in the management of patients who
present with HF. (MK)
9. The general approach to the evaluation and treatment of atrial fibrillation (MK)
10. Role of critical pathways or practice guidelines in delivering high-quality, cost
effective care for patients presenting with new or recurrent heart failure. (PC, SBP)
11. The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission
on the Accreditation of Healthcare Organizations (JCAHO) quality measures for
HF treatment. (MK, PLI, SBP)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, including:
Differentiating between various etiologies of heart failure (answers the
question: Why is the patient in heart failure?). (PC, CS)
Identifying clinical factors responsible for symptomatic exacerbation
(answers the question: Why is the patient worse now?). (PC, CS)
Exercise intolerance (fatigue, dyspnea on exertion). (PC, CS)
Fluid retention (peripheral edema, dyspnea). (PC, CS)
Changes in sleep pattern (orthopnea, paroxysmal nocturnal dyspnea
[PND], nocturia). (PC, CS)
Assessing the functional capacity of patients with HF (walking
distance, New York Heart classification). (PC, CS)
Cardiac risk factors. (PC, CS)
2. Physical exam skills: Students should be able to perform a focused physical
exam to help establish the diagnosis of HF and estimate its severity:
Measurement of vital signs including weight and respiratory
rate/pattern. (PC)
Accurate measurement of arterial blood pressure and recognition of
the typical blood pressure findings that occur in patients with aortic
stenosis, aortic insufficiency and pulsus paradoxus. (PC)
Assessment of major arterial pulses for abnormalities, including bruits.

(PC)

Assessment of the neck veins for jugular venous distention and, when
necessary, evaluation for abdominal jugular reflux. (PC)
Assessment of the conjunctiva and optic fundus. (PC)
Assessment of the extremities to ascertain for skin conditions,
including color, temperature and the presence of edema, cyanosis or
clubbing. (PC)
Assessment of the lungs for crackles, rhonchi and decreased breath
sounds. (PC)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Inspection and palpation of the anterior chest to identify right and left
sided heaves, lifts and thrills. (PC)
Auscultation of the heart to determine rhythm, intensity of heart
sounds, splitting of S2 and the presence of rubs, gallops (S3, S4,
summation) or extra heart sounds (e.g. clicks). (PC)
Auscultation of the heart to detect the presence of heart murmurs;
when a murmur is present, students should be able to:
o Identify timing (systolic vs. diastolic, holosystolic vs. ejection).
(PC)

o Describe pitch, location and pattern of radiation. (PC)

o Gauge significance (innocent vs. pathologic, sclerosis vs.
stenosis). (PC)
Assessment of the abdomen to determine the presence of
hepatomegaly, ascites, abnormal pulsations and bruits. (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis and recognize specific history, physical exam and/or
laboratory findings that:
Help support or refute a clinical diagnosis of heart failure. (PC, MK)
Distinguish between various underlying etiologies of HF, including
disease processes that primarily affect:
o Pericardium (constrictive pericarditis, pericardial tamponade).
(PC, MK)

o Endocardium (valvular [congenital, acquired], endocarditis).

(PC, MK)

o Myocardium (hypertrophic, restrictive, congestive). (PC, MK)

4. Laboratory interpretation: Students should be able interpret specific
diagnostic tests and procedures that are commonly ordered to evaluate patients
who present with heart failure. Test interpretation should take into account:
Laboratory and diagnostic tests should include, when appropriate:
12-lead ECG. (PC, MK)
Chest radiograph. (PC, MK)
B-type natriuretic peptide. (PC, MK)
Students should be able to define the indications for, and interpret (with
consultation) the results of the following diagnostic tests and procedures:
Echocardiography. (PC, MK)
Treadmill and nuclear exercise testing. (PC, MK)
Radionuclide ventriculogram. (PC, MK)
Cardiac. (PC, MK)
Coronary angiography. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, prognosis and treatment plan to the
patient and his or her family. (PC, CS)
Elicit questions from the patient and his or her family about the
management plan. (PC, CS)
Educate patients about cardiovascular risk factors. (PC, CS)
Council patients regarding a sodium-restricted diet. (PC, CS)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Address palliative care and end-of-life issues with patients who have
intractable symptoms associated with end-stage heart failure. (PC, CS,
P)

6. Basic and advanced procedural skills: students should be able to:

Perform a 12-lead ECG. (PC)
Obtain an ABG. (PC)
7. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients that includes:
Recognize the importance of early detection and treatment of risk
factors that may lead to the development of heart failure. (PC)
Identifying the indications, contraindications, mechanisms of action,
adverse reactions, significant interactions, and relative costs of the
following treatments/interventions:
o Non-pharmacological management. (PC, MK)
- Sodium restriction. (PC, MK)
- Physical activity and limitations. (PC, MK)
o Pharmacological management (recommended for routine use).
(PC, MK)

Diuretics. (PC, MK)

ACE-I/ARB. (PC, MK)
Beta-blockers. (PC, MK)
Aldosterone antagonists (spironolactone, eplerenone).
(PC, MK)

- digoxin. (PC, MK)

o Interventions considered for use in selected patients. (PC, MK)
- Hydralazine and isosorbide dinitrate. (PC, MK)
- Angoitensin receptor blockers. (PC, MK)
- Calcium channel blockers. (PC, MK)
- Anti-arrhythmic agents. (PC, MK)
- Anticoagulants/anti a thrombotic agents. (PC, MK)
o other modalities(PC, MK)
- Coronary revascularization. (PC, MK)
- Synchronized biventricular pacing. (PC, MK)
- Implantable cardiac defibrillators. (PC, MK)
Developing a timely and appropriate evaluation and treatment plan for
patients with heart failure due to diastolic dysfunction, including:
o Control of physiologic factors (blood pressure, heart rate). (PC,
MK)

o Reduction in central blood volume by judicious use of

diuretics. (PC, MK)
o Alleviation of myocardial ischemia. (PC, MK)
o Use of calcium channel blockers. (PC, MK)
Describing use of other agents and interventions that may be useful in
treating patients with refractory, end-stage heart failure:
o Intravenous vasodilators. (PC, MK)
o Intravenous positive inotropic agents. (PC, MK)
o Infusion of B-type natriuretic peptide (nesiritide). (PC, MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

o Ventricular assist devices. (PC, MK)

o Heart transplantation. (PC, MK)
Defining and describing how the diagnosis and treatment of HF in special
populations may differ (e.g. very elderly, associated co-morbidities). (PC,
MK)

Demonstrating how critical pathways or practice guidelines in

ambulatory or hospitalized patients with HF can be used to guide
diagnostic test ordering and medical decision making. (PC, PLI, SBP)
Determining when to consult a cardiologist. (PC, SBP)
Identifying when palliative care may be appropriate for patients with
refractory symptoms associated with end-stage disease. (PC)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

C.

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to HF. (PC, PLI)
Incorporating patient preferences. (PC)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for HF. (PLI, P)
2. Recognize the significant morbidity and mortality associated with HF (P)
3. Recognize the impact of lifestyle limitations caused by HF. (P)
4. Respond appropriately to patients who are non-adherent to treatment for HF.
(CS, P)

5. Demonstrate ongoing commitment to self-directed learning regarding heart

failure. (PLI, P)
6. Recognize the importance and demonstrate a commitment to the utilization of
other healthcare professions in the treatment of heart failure. (P, SBP)
7. Appreciate the importance of and demonstrate a commitment to meeting
national health care quality measures for the treatment of HF. (PLI, P, SBP)
D.

REFERENCES:
ACC/AHA 2005 guideline update for the diagnosis and management of
chronic heart failure in the adult: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Update the 2001 Guidelines for the Evaluation and
Management of Heart Failure). J Am Coll Cardiol. 2005;46:1116-43.
http://www.acc.org/clinical/guidelines/failure/update/index.pdf
Cook DJ, Simel DL. Does this patient have abnormal central venous
pressure? JAMA. 1996; 275: 630-634.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Wang CS. FitzGerald JM. Schulzer M. Mak E. Ayas NT. Does this dyspneic
patient in the emergency department have congestive heart failure? JAMA.
2005;294:1944-56.
Doust JA. Glasziou PP. Pietrzak E. Dobson AJ. A systematic review of the
diagnostic accuracy of natriuretic peptides for heart failure. Arch Intern Med.
2004;164:1978-84.
Yan AT. Yan RT. Liu PP. Narrative review: pharmacotherapy for chronic
heart failure: evidence from recent clinical trials. Ann Intern Med.
2005;142(2):132-45.
Aurigemma GP. Gaasch WH. Clinical practice. Diastolic heart failure. N
Engl J Med. 2004;351:1097-105.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #23: HIV INFECTION

RATIONALE:
HIV infection and AIDS represent one of the most difficult challenges in clinical
medicine today. An HIV specialist (usually an infectious diseases physician) cares for
the vast majority of patients with HIV infection and AIDS. Given that there is no proven
cure, this remains an important training problem for third year medical students. The
enormous and continuously evolving complexities of antiretroviral treatment are
generally beyond the level of the third year medical student and for that matter most
general internists. Rather, an approach to HIV infection, AIDS, and its most common
and serious complications are stressed.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Ability to perform a complete medical history and physical.
Ability to communicate with patients of diverse backgrounds.
Knowledge of the worldwide epidemiology, biology, and immunology of HIV.
Microbiology of common opportunistic organisms.
Pharmacology of antimicrobial agents and antiretrovirals.
Understanding of universal precautions.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Symptoms and signs of acute HIV seroconversion. (MK)
2. CDC AIDS case definition. (MK)
3. Specific tests for HIV (e.g. HIV ELISA, confirmatory western blot,
quantitative PCR) and their operating characteristics. (MK)
4. Relationship of CD4 lymphocyte count to opportunistic infections as well as
relationship between CD4 lymphocyte count and viral load to overall disease
progression. (MK)
5. The basic principles of highly active antiretroviral therapy (HAART),
including the different classes of antiviral medications and their use, as well as
common side effects and drug-drug interactions. (MK)
6. Basics of post-exposure prophylaxis. (MK)
7. The marked importance of antiretroviral medication adherence and the
potential consequences of erratic or poor adherence. (MK)
8. Vaccination recommendation for patients infected with HIV. (MK)
9. Indications for and utility and risks of prophylaxis of HIV-related
opportunistic infections. (MK)
10. Pathogenesis, symptoms, signs, typical clinical course, and management of
HIV-related opportunistic infections with a recognition of which are most
common:

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Pneumocystis jiroveci. (MK)

Candidiasis (oral, esophageal, vaginal). (MK)
Cryptococcus neoformans. (MK)
Cryptosporidium parvum. (MK)
Cytomegalovirus infection (gastrointestinal, neurologic, retinal). (MK)
Varicella-zoster virus. (MK)
Isospora belli. (MK)
Microsporidiosis. (MK)
Mycobacterium avium complex. (MK)
Mycobacterium tuberculosis. (MK)
Toxoplasma gondii. (MK)
11. Symptoms and signs of the following HIV-related malignancies:
Kaposis sarcoma. (MK)
Non-Hodgkins lymphoma. (MK)
Cervical carcinoma. (MK)
12. Common skin and oral manifestations of HIV infection and AIDS:
Molluscum contagiosum. (MK)
Cryptococcus neoformans. (MK)
Viral warts. (MK)
Lipodystrophy. (MK)
Herpes zoster. (MK)
Seborrhoeic dermatitis. (MK)
Buccal candidiasis. (MK)
Oral hairy leukoplakia. (MK)
13. Safe sex practices. (MK)
14. The importance of proper ongoing dental care. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history that differentiates among etiologies
of disease, including:
HIV infection risk factors. (PC, CS)
Sexual contacts. (PC, CS)
Parenteral exposure to infected blood by needle sharing or transfusion.
(PC, CS)

Occupational exposures. (PC, CS)

Other sexually transmitted diseases. (PC, CS)
Tuberculosis exposure. (PC, CS)
Prior HIV serology results, CD4 lymphocyte count and viral load. (PC,
CS)

Prior HIV-related opportunistic infections. (PC, CS)

Current/prior antiretroviral medications and their side effects. (PC, CS)
Fever, sweats, anorexia, unintentional weight loss, rash/skin lesions,
lymphadenopathy. (PC, CS)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Cough, sputum production, dyspnea, chest pain. (PC, CS)

Headache, altered mental status, psychiatric complaints. (PC, CS)
Odynophagia, dysphagia. (PC, CS)
Vaginal discharge, history of cervical dysplasia or neoplasia. (PC, CS)
Diarrhea. (PC, CS)
Visual changes. (PC, CS)
A dietary history to determine caloric intake. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
General appearance regarding atrophy/wasting/cachexia. (PC)
Complete neurologic examination. (PC)
Mental status examination. (PC)
Fundoscopic examination. (PC)
Lymph node examination. (PC)
Skin and oral examination. (PC)
Pelvic and male genital examination. (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology in an potentially or known HIV-infected
patient for the following:
Fever. (PC, MK)
Unintentional weight loss/wasting/cachexia. (PC, MK)
Lymphadenopathy. (PC, MK)
Rash and skin lesions. (PC, MK)
Cough, sputum production, dyspnea, abnormal chest radiography. (PC,
MK)

Diarrhea, odynophagia, dysphagia. (PC, MK)

Altered mental status and psychiatric changes. (PC, MK)
Headache. (PC, MK)
Oral lesions. (PC, MK)
Visual/retinal abnormalities. (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
Specific tests for HIV (e.g. HIV ELISA, confirmatory western blot,
quantitative PCR). (PC, MK)
CD4 lymphocyte count. (PC, MK)
CBC with differential. (PC, MK)
Sputum staining and cultures. (PC, MK)
Blood cultures. (PC, MK)
Cerebrospinal fluid analysis (color, opening pressure, chemistries, cell
counts, staining, cultures, cytology, cryptococcal antigen, VDRL,
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Ebstein Barr virus, cytomegalovirus, toxoplasmosis, JC virus). (PC,

MK)

Stool for ova and parasites, cryptosporium, isospora, microsporidia,

cytomegalovirus antigen. (PC, MK)
Chest radiograph. (PC, MK)
Students should be able to define the indications for and interpret (with
consultation) the results of:
Chest CT. (PC, MK)
Cranial CT. (PC, MK)
Cranial MRI. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (PC, CS)
Elicit input and questions from the patient and his or her family about
the management plan. (PC, CS)
counsel and educate patients about HIV exposure prevention (PC, CS)
Counsel an exposed patient about seroconversion rates and, in
appropriate situations, the availability of post-exposure prophylaxis.

(PC, CS)

Counsel and educate patients about complications of HIV drug

therapy, drug-drug interactions, and the marked importance of
adherence. (PC, CS)
6. Basic and advanced procedural skills: Students should be able to:
Obtain blood cultures. (PC)
Obtain an ABG. (PC)
Place and interpret a PPD. (PC)
Assist in performing a lumbar puncture after explaining the procedure
to the patient. (PC)
7. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
Ordering appropriate laboratory tests. (PC, MK)
Advising patients regarding HIV transmission prevention. (PC, MK)
Insuring antiretroviral adherence. (PC, MK)
Following parameters of disease progression/activity. (e.g. CD4
lymphocyte count, viral load). (PC, MK)
Monitoring for the development of side effects from antiretroviral
treatment and drug-drug interactions. (PC, MK)
Insuring the administration of appropriate vaccinations. (PC, MK)
Assessing PPD status. (PC, MK)
Prescribing and monitoring appropriate opportunist infection
prophylaxis. (PC, MK)
Ordering nutritional supplements to manage and prevent malnutrition.

(PC, MK)

Assisting in the procurement of proper and ongoing dental care. (PC,

MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

C.

Identifying and recommending community health care resources

available for the care of AIDS patients. (PC, SBP)
Determining when to obtain consultation from an infectious diseases
specialist. (PC, SBP)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to HIV infection and AIDS. (PC, PLI)
Incorporating patient need and preferences. (PC)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Appreciate the bioethical, social, and legal issues concerning patient
confidentiality of HIV infection. (PC, CS)
2. Demonstrate a nonjudgmental attitude regarding the mode of HIV acquisition.
(P)

3. Appreciate the sometimes severe social stigma of HIV infection and AIDS. (P)
4. Show respect of alternative lifestyles. (P)
5. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for HIV infection and AIDS. (PLI, P)
6. Recognize the importance of patient needs and preferences when selecting
among diagnostic and therapeutic options for patients with HIV infection or
AIDS. (P)
7. Respond appropriately to patients who are nonadherent to antiretroviral
treatment. (CS, P)
8. Demonstrate ongoing commitment to self-directed learning regarding HIV
infection and AIDS. (PLI, P)
9. Appreciate the impact HIV infection and AIDS have on a patients quality of
life, well-being, ability to work, and the family. (P)
10. Recognize the importance of and demonstrate a commitment to the utilization
of other health care professionals in the diagnosis and treatment of HIV
infection and AIDS. (P, SBP)
D.

REFERENCES:
Guidelines for preventing Opportunistic Infections Among HIV-Infected
Persons-2002. Recommendations of the U.S. Public Health Service and the
Infectious Diseases Society of America. MMWR 51(RR-08);1-60.
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/mmwr/PDF/RR/RR5108.pdf
Guidelines for Using Antiretroviral Agents Among HIV-Infected Adults and
Adolescents-2002. Recommendations of the Panel on Clinical Practices for
Treatment of HIV. MMWR 51(RR-07);1-64.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services
www.cdc.gov/mmwr/PDF/RR/RR5107
Aberg JA, Gallant JE, Anderson J, Oleske JM, Libman H, Currier JS, Stone
VE, Kaplan, JE. Primary care guideline for the management of persons
infected with human immunodeficiency virus: recommendation of the HIV
Medicine Association of the Infectious Diseases Society of America. Clin
Infect Dis. 2004;39:609-29.
www.journals.uchicago.edu/CID/journal/issues/v39n5/34135/34135.web.p
df
www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=5625
AIDSinfo
National Institutes of Health
U.S. Department of Health and Human Services
www.aidsinfo.nih.gov
Divisions of HIV/AIDS Prevention
National Center for HIV, STD and TB Prevention
Centers for Disease Control and Prevention U.S.
Department of Health and Human Services
www.cdc.gov/hiv/dhap.htm
Hammer SM. Management of newly diagnosed HIV infection. N Engl J
Med. 2005;353:1702-10.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #24: HYPERTENSION

RATIONALE:
As many as 50 million Americans have elevated blood pressure (systolic pressure 140
mmHg or greater and/or diastolic blood pressure 90 mmHg or greater) or are taking
antihypertensive medication. Nonfatal and fatal cardiovascular disease (CVD)
including coronary heart disease (CHD), peripheral vascular disease, stroke and renal
diseaseall increase progressively with higher levels of both systolic (SBP) and diastolic
(DBP) blood pressure levels. These relationships are strong, continuous, independent,
predictive and etiologically significant, and indicate that reduction of blood pressure
reduces these risks.
PREREQUISITES:
Prior knowledge, skills and attitudes acquired during the pre-clinical years should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Knowledge of the pathogenesis and pathophysiology of hypertension.
Knowledge of the epidemiology and risk factors for hypertension.
Understanding of the pharmacologic management of acute and chronic hypertension.
Understanding the behavioral issues by sex, race, culture, and age that relate to the
management and treatment of hypertension.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe and discuss:

1. The etiologies and relative prevalence of primary and secondary hypertension.
(MK)

2. The basic principles of the role of genetics in hypertension. (MK)

3. The definition of hypertensive urgency and emergency, citing examples of
both. (MK)
4. The difference between essential (primary) and secondary hypertension. (MK)
5. Symptoms and signs of the following disorders associated with secondary
hypertension:
Renovascular hypertension. (MK)
Renal failure. (MK)
Polycystic kidney disease. (MK)
Cushings disease or syndrome. (MK)
Hyperaldosteronism. (MK)
Hyperthyroidism. (MK)
Hypercalcemia. (MK)
Medication, alcohol, and illicit drug use. (MK)
Coarctation of the aorta. (MK)
Sleep apnea. (MK)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

6. The manifestations of target-organ disease due to hypertension. (MK)

7. Classification of blood pressure (SBP and DBP for all age 18 or older). (MK)
8. Basic approaches to the pharmacological management of acute and chronic
hypertension, including the physiologic basis and scientific evidence
supporting these approaches, and causes for lack of responsiveness to therapy.
(MK)

9. Prevention strategies for reducing hypertension (including lifestyle factors,

such as dietary intake of sodium, weight, and exercise level), and explain the
physiologic basis and/or scientific evidence supporting each strategy. (MK)
10. Steps in management of patients with a hypertensive emergency. (MK)
11. Factors that contribute to non-adherence with antihypertensive medications.
(MK)

B.

SKILLS: Students should demonstrate specific skills including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history that differentiates among etiologies
of disease, including:
Duration and levels of elevated blood pressure. (PC, CS)
History of symptoms of cardiovascular, cerebrovascular, peripheral
vascular or renal disease; diabetes; dyslipidemia; or gout. (PC, CS)
History of symptoms suggesting secondary hypertension. (PC, CS)
History of weight gain, leisure-time physical activities, and smoking or
other tobacco use. (PC, CS)
Family history of high blood pressure, premature CHD, stroke, CVD,
diabetes mellitus and dyslipidemia. (PC, CS)
Psychosocial and environmental factors that may elevate blood
pressure (family situation, employment status, working conditions,
education level). (PC, CS)
Dietary assessment, including sodium intake and intake of saturated fat
and cholesterol. (PC, CS)
Results and side effects of previous antihypertensive therapy. (PC, CS)
use of commonly prescribed, over-the -counter, and illicit medications
that may raise blood pressure or interfere with the effectiveness of
antihypertensive medications. (PC, CS)
Alcohol intake. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Blood pressure measurements to detect and confirm the presence of
high blood pressure. (PC)
Examination of the fundus for arteriolar narrowing, arteriovenous
nicking, hemorrhages, exudates, or papilledema. (PC)
Neck for carotid bruits, distended veins, or an enlarged thyroid gland.
((PC)
Heart for increased rate, increased size, precordial heave, clicks,
murmurs, arrhythmias, and third (S3) and fourth (S4) sounds. (PC)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

3.

4.

5.

6.

7.

Abdomen for bruits, enlarged kidneys, masses, and abnormal aortic

pulsation. (PC)
Extremities for diminished, delayed, or absent peripheral arterial
pulsations, bruits, and edema. (PC)
Peripheral pulses specifically femoral arterial pulses. (PC)
Body habitus, looking for changes associated with secondary
hypertension. (PC)
Peripheral and central nervous system for ischemic changes. (PC)
Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history, physical exam, and
laboratory findings that suggest a specific etiology of hypertension. (PC, MK)
Laboratory interpretation: Students should be able to recommend and
interpret diagnostic and laboratory tests, both prior to and after initiating
treatment based on the differential diagnosis, including consideration of test
cost and performance characteristics as well as patient preferences.
Laboratory and diagnostic tests should include, when appropriate:
UA. (PC, MK)
CBC. (PC, MK)
Blood glucose (fasting if possible). (PC, MK)
Electrolytes, BUN/Cr. (PC, MK)
Uric acid. (PC, MK)
Fasting lipid profile. (PC, MK)
ECG. (PC, MK)
Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan and prognosis of the
disease to the patient and his or her family, taking into account the
patients knowledge of hypertension and his or her preferences
regarding treatment options. (PC, CS)
Elicit questions from the patient and his or her family about the
management plan. (PC, CS)
Educate patients about hypertension risk factors, taking into account:
o Demographics. (PC, CS)
o Concomitant diseases and therapies. (PC, CS)
o Quality of life. (PC, CS)
o Physiologic and biochemical measurements. (PC, CS)
o Economic considerations. (PC, CS)
Basic and advanced procedural skills: Students should be able to perform:
UA (dipstick and microscopic). (PC)
12-lead ECG. (PC)
Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients that includes:
Treating acute and chronic hypertension. (PC, MK)
Treating primary (essential) hypertension versus secondary
hypertension. (PC, MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Using a cost-effective approach based on the differential diagnosis.

(PC, SBP)

C.

Prescribing preventative strategies to diminish hypertension,

including:
o Weight reduction. (PC, MK)
o Moderation of alcohol intake. (PC, MK)
o Regular physical activity. (PC, MK)
o Reduction of sodium intake. (PC, MK)
o Increase in potassium intake. (PC, MK)
o Smoking cessation. (PC, MK)
Accessing and utilizing appropriate information systems and resources
to help delineate issues related to hypertension. (PC, PLI)
Incorporating patient preferences. (PC)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Appreciate the importance of patient preferences and adherence with
management plans for those with hypertension. (P)
2. Recognize the responsibility of the physician with regard to non-adherence.
(P)

3. Respond appropriately to patients who are non-adherent to treatment for

hypertension. (CS, P)
4. Appreciate how preventative strategies may diminish need for medications. (P)
5. Appreciate the importance of side effects of medications and their impact on
quality of life and adherence (including those side effects to which the
geriatric population may be more prone) and demonstrate a commitment to
limiting the whenever possible. (P)
6. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for hypertension. (PLI, P)
7. Demonstrate ongoing commitment to self-directed learning regarding
hypertension. (PLI, P)
8. Appreciate the impact hypertension has on a patients quality of life, wellbeing, ability to work, and the family. (P)
9. Recognize the importance and demonstrate a commitment to the utilization of
other healthcare professions in the treatment of hypertension. (P, SBP)
D.

REFERENCES:
Chobanian, AV, Bakris, GL, Black, HR, et al. The seventh report of the joint
national committee on prevention, detection, evaluation, and treatment of high
blood pressure: the JNC 7 report. JAMA. 2003; 289:2560-72.
www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm
Major cardiovascular events in hypertensive patients randomized to doxazosin
vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

heart attack trial (ALLHAT). ALLHAT Collaborative Research Group.

JAMA. 2000;283:1967-75.
ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research
Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart
Attack Trial. Major outcomes in high-risk hypertensive patients randomized
to angiotensin-converting enzyme inhibitor or calcium channel blocker vs
diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent
Heart Attack Trial (ALLHAT). JAMA. 2002;288:2981-97.
Davis BR, Furberg CD, Wright JT Jr, Cutler JA, Whelton P. ALLHAT
Collaborative Research Group. ALLHAT: setting the record straight. Ann
Intern Med. 2004;141:39-46.
Eisenberg MJ, Brox A, Bestawros AN. Calcium channel blockers: an update.
Am J Med. 2004;116:35-43.
Wing LM, Reid CM, Ryan P, et al. Second Australian National Blood
Pressure Study Group. A comparison of outcomes with angiotensinconverting--enzyme inhibitors and diuretics for hypertension in the elderly. N
Engl J Med. 2003;348:583-92.
Agodoa LY, Appel L, Bakris GL, et al. African American Study of Kidney
Disease and Hypertension (AASK) Study Group. Effect of ramipril vs
amlodipine on renal outcomes in hypertensive nephrosclerosis: a randomized
controlled trial. JAMA. 2001;285:2719-28.
Brenner BM, Cooper ME, de Zeeuw D, et al. RENAAL Study Investigators.
Effects of losartan on renal and cardiovascular outcomes in patients with type
2 diabetes and nephropathy. N Engl J Med. 2001;345:861-9.
Lewis EJ, Hunsicker LG, Clarke WR, et al. Collaborative Study Group.
Renoprotective effect of the angiotensin-receptor antagonist irbesartan in
patients with nephropathy due to type 2 diabetes. N Engl J Med.
2001;345:851-60.
Tuomilehto J, Rastenyte D, Birkenhager WH, et al. Effects of calciumchannel blockade in older patients with diabetes and systolic hypertension.
Systolic Hypertension in Europe Trial Investigators. N Engl J Med.
1999;340:677-84.
Anonymous. Tight blood pressure control and risk of macrovascular and
microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective
Diabetes Study Group. BMJ. 1998;317:703-13.
Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an
angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in
high-risk patients. The Heart Outcomes Prevention Evaluation Study
Investigators. N Engl J Med. 2000;342:145-53.
Dahlof B, Devereux RB, Kjeldsen SE, et al. LIFE Study Group.
Cardiovascular morbidity and mortality in the Losartan Intervention For
Endpoint reduction in hypertension study (LIFE): a randomised trial against
atenolol. Lancet. 2002;359:995-1003.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #25: LIVER DISEASE

RATIONALE:
The causes of hepatobiliary disease are many and can be quite overwhelming to the
internal medicine clerk. A thorough understanding of a systematic approach to
hyperbilirubinemia/jaundice is by far preferable to random knowledge of highly specific
etiologies. The liver responds pathologically to injury in characteristic ways and
knowledge of these patterns can also be very useful in differential diagnosis. Several
etiologies of liver disease such as acute/chronic viral hepatitis and alcohol-induced liver
disease are sufficiently common as to require specific attention. In addition, many liver
diseases can result in cirrhosis and its complications and, therefore, understanding this
end-stage development is important.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Ability to perform a complete medical history and physical.
Ability to communicate with patients of diverse backgrounds.
Anatomy, physiology, and pathophysiology of the hepatobiliary system.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The biochemical/physiologic/mechanistic approach to hyperbilirubinemia,
including:
Increased production. (MK)
Decreased hepatocyte uptake. (MK)
Decreased conjugation. (MK)
Decreased excretion from the hepatocyte. (MK)
Decreased small duct transport (intrahepatic cholestasis). (MK)
Decreased large duct transport (extrahepatic cholestasis, obstructive
jaundice). (MK)
2. The biochemistry and common causes of unconjugated and conjugated
hyperbilirubinemia. (MK)
3. The use of serum markers of liver injury (e.g. AST, ALT, GGT, Alk Phos)
and function (e.g. bilirubin, ALB, PT/INR) in the diagnostic evaluation of
hepatobiliary disease. (MK)
4. The clinical significance of asymptomatic, isolated elevation of AST, ALT,
GGT, and/or Alk Phos. (MK)
5. The common pathologic patterns of liver disease and their common causes,
including:
Steatosis (fatty liver). (MK)
Hepatitis. (MK)
Cirrhosis. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Infiltrative. (MK)
Intrahepatic cholestasis. (MK)
Extrahepatic cholestasis (obstructive jaundice). (MK)
6. The epidemiology, symptoms, signs, typical clinical course, and prevention of
viral hepatitis. (MK)
7. The distinctions between acute and chronic hepatitis. (MK)
8. The indications for and efficacy of hepatitis A and B vaccinations. (MK)
9. The common causes and clinical significance of hepatic steatosis and
steatohepatis. (MK)
10. The epidemiology, symptoms, signs, and typical clinical course of
autoimmune liver diseases such as autoimmune hepatitis, primary biliary
cirrhosis, and primary sclerosing cholangitis. (MK)
11. The epidemiology, symptoms, signs, and typical clinical course of cirrhosis.
(MK)

12. The pathophysiologic manifestations, symptoms, signs, and complications of

alcohol-induced liver disease. (MK)
13. The symptoms, signs, and complications of portal hypertension. (MK)
14. The pathophysiology and common causes of ascites. (MK)
15. The pathophysiologic manifestations, symptoms, and signs of spontaneous
bacterial peritonitis. (MK)
16. The basic pathophysiology, symptoms, signs, typical clinical course, and
precipitants of hepatic encephalopathy. (MK)
17. The basic pathophysiology, symptoms, signs, and typical clinical course of the
hepatorenal syndrome. (MK)
18. The analysis of ascitic fluid and its use in the diagnostic evaluation of liver
disease. (MK)
19. Common causes of drug-induced liver injury. (MK)
20. Genetic considerations in liver disease (i.e. hemochromatosis, Wilsons
disease, alpha-1 antitrypsin deficiency, Gilberts syndrome). (MK)
21. The epidemiology, pathophysiology, symptoms, signs, and typical clinical
course of cholelithiasis and cholecystitis. (MK)
22. The clinical syndrome of ascending cholangitis including its common
causes and typical clinical course. (MK)
23. The indications for and risks of paracentesis and liver biopsy. (MK)
24. The indications for and utility of hepatobiliary imaging studies, including:
Ultrasound. (MK)
Nuclear medicine studies. (MK)
CT. (MK)
MRI. (MK)
Magnetic resonance cholangiopancreatography (MRCP). (MK)
Endoscopic retrograde cholangiopancreatography (ERCP). (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including:
Jaundice, discolored urine, pruritis, light-colored stool, unintentional
weight loss, fever, nausea, emesis, diarrhea, altered mental status,
abdominal pain, increased abdominal girth, edema, rectal bleeding,
hematemesis. (PC, CS)
DM. (PC, CS)
Alcohol use. (PC, CS)
Prescription, over-the-counter, and illicit drug use. (PC, CS)
Transfusions and other sources of potential blood-born pathogen
exposure. (PC, CS)
Consumption of uncooked shellfish and other food items potentially
contaminated with fecal matter. (PC, CS)
Sexual history. (PC, CS)
Vaccination history. (PC, CS)
Family history of liver diseases. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Jaundice. (PC)
Complete abdominal examination including findings consistent with
ascites (e.g. bulging flanks, shifting dullness, fluid wave). (PC)
Findings compatible with chronic alcohol use and portal hypertension
(e.g. palmar erythema, spider angiomas, gynecomastia, testicular
atrophy, Dupuytrens contracture, muscle wasting, splenomegaly,
ascites, edema, caput medusa, hemorrhoids). (PC)
Findings compatible with hepatic (portosystemic) encephalopathy (e.g.
disturbances of consciousness and behavior, fluctuating neurologic
signs, asterixis). (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology of liver disease. (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
CBC. (PC, MK)
Electrolytes, BUN/Cr, GLC. (PC, MK)
ALB, TP, total bilirubin, direct bilirubin, PT/INR, AST, ALT, Alk
Phos. (PC, MK)
Hepatitis serology. (PC, MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Ascitic fluid ALB, amylase, cell counts, staining, cultures, and the
serum-ascites albumin gradient (SAAG). (PC, MK)
Students should be able to define the indications for and interpret (with
consultation) the results of:
Ultrasound. (PC, MK)
Nuclear medicine studies. (PC, MK)
CT. (PC, MK)
MRI. (PC, MK)
Magnetic resonance cholangiopancreatography (MRCP). (PC, MK)
Endoscopic retrograde cholangiopancreatography (ERCP). (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (PC, CS)
Elicit input and questions from the patient and his or her family about
the management plan. (PC, CS)
Discuss the avoidance of known hepatotoxins. (PC, CS)
Counsel patients regarding alcohol abstinence. (PC, CS)
Discuss the importance of hepatitis A and B vaccinations for
nonimmune patients. (PC, CS)
6. Basic and advanced procedural skills: Students should be able to:
Assist in performing a paracentesis after explaining the procedure to
the patient. (PC)
7. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
The diagnostic evaluation of asymptomatic, isolated elevation of the
transaminases and/or Alk Phos. (PC, MK)
The diagnostic evaluation of patients with jaundice and unconjugated
or conjugated hyperbilirubinemia. (PC, MK)
The basic management of steatosis, hepatitis, cirrhosis, intra- and extra
hepatic cholestasis, acute cholecystitis, ascites, portal hypertension,
spontaneous bacterial peritonitis, and hepatic encephalopathy. (PC, MK)
Determining when to obtain consultation from a gastroenterologist,
hepatologist, or biliary surgeon. (PC, SBP)
Using a cost-effective approach based on the differential diagnosis.

C.

(PC, SBP)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to liver disease. (PC, PLI)
Incorporating patient preferences. (PC)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for liver disease. (PLI, P)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

2. Recognize the importance of patient needs and preferences when selecting

among diagnostic and therapeutic options for liver disease. (P)
3. Respond appropriately to patients who are nonadherent to treatment for liver
disease. (CS, P)
4. Demonstrate ongoing commitment to self-directed learning regarding liver
disease. (PLI, P)
5. Appreciate the impact liver disease has on a patients quality of life, wellbeing, ability to work, and the family. (P)
6. Recognize the importance of and demonstrate a commitment to the utilization
of other healthcare professionals in the diagnosis and treatment of liver
disease. (P, SBP)
7. Discuss the public health role physicians play in the prevention of viral
hepatitis. (P, SBP)
8. Appreciate the difficulties patient face with alcohol abstinence. (P)
D.

REFERENCES:
Viral Hepatitis
National Center for Infectious Diseases
Center for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/ncidod/diseases/hepatits/index.htm
Practice Guidelines
American Association for the Study of Liver Diseases
www.aasld.org
National Institute on Alcohol Abuse and Alcoholism
National Institutes of Health
U.S. Department of Health and Human Services
www.niaaa.nih.gov
Pratt DS, Kaplan MM. Evaluation of abnormal liver-enzyme results in
asymptomatic patients. N Engl J Med. 2000;342:1266-71.
Angulo P. Nonalcoholic fatty liver disease. N Engl J Med. 2002;346:122131.
Trowbridge RL, Rutkowski NK, Shojania. Does this patient have acute
cholecystitis? JAMA. 2003;289:80-6.
Indar AA, Beckingham IJ. Acute cholecystitis. BMJ. 2002;325:639-43.
Krige JE, Bechingham IJ. ABC of diseases of liver, pancreas, and biliary
system. Portal hypertension-1: varices. BMJ. 2001;322:348-51.
Krige JE, Bechingham IJ. ABC of diseases of liver, pancreas, and biliary
system. Portal hypertension-2. Ascites, encephalopathy, and other
conditions. BMJ. 2001;322:416-8.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #26: MAJOR DEPRESSION

RATIONALE:
Major depression is a very common problem in adults, resulting in significant morbidity
and mortality. Most often the primary care provider is the first health care professional to
see a depressed patient. Frequently, the initial presentation is associated with somatic
complaints that bring the patient to the physician. Major depression is also a relatively
common accompaniment to serious medical conditions. There is significant evidence
that primary care physicians commonly fail to diagnose major depression. With
relatively recent improvements in available treatment, it is even more important for
internists to screen for major depression and to know the common presenting symptoms.
The internist should also be familiar with available therapeutic options and be prepared to
treat selected patients, including those who decline consultation with a mental health
professional.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Ability to perform a complete medical history and physical.
Ability to communicate with patients of diverse backgrounds.
Neurochemistry of major depression.
Pharmacology of the major classes of antidepressants.
Basic understanding of the efficacy of psychotherapy, antidepressants, and
electroconvulsive therapy.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The epidemiology of major depression in the general population and the
impact of major illness on the prevalence of major depression (e.g. stroke,
heart disease, DM, cancer, Parkinsons disease, HIV/AIDS). (MK)
2. The impact of major depression on the outcome of medical illness. (MK)
3. The American Psychiatric Associations Diagnostic and Statistical Manual 4th
edition (DSM-IV) diagnostic criteria for major depression. (MK)
4. Common psychological symptoms and signs of major depression (e.g. low
mood/affect, anxiety, irritability/anger, disinterest, anhedonia, decreased
libido, guilt, poor self-esteem, poor concentration, rumination, helplessness,
hopelessness, thoughts of death and suicide, somatic complaints). (MK)
5. Common neurovegetative symptoms and signs of major depression (e.g.
appetite disturbance, decreased energy, psychomotor retardation or agitation,
sleep disturbance). (MK)
6. Common somatic complaints that accompany depressive disorders and the
potential for the occurrence of these symptoms without obvious psychological
symptoms (e.g. fatigue, weakness, myalgias, arthralgias, headache, nausea,

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

dyspnea, palpitations, chest pain/discomfort, lightheadedness/dizziness, bowel

movement alterations). (MK)
7. The distinguishing features of major depression with psychotic features,
bipolar disorder, dementia, and delirium. (MK)
8. The differential diagnosis of major depression, including:
Other psychiatric disorders. (MK)
Drug-induced (e.g. corticosteroids, cimetidine, metoclopramide,
clonidine, etc.). (MK)
Drug withdrawal (e.g. amphetamine, cocaine). (MK)
Infection (e.g. tertiary syphilis). (MK)
Endocrine/metabolic (e.g. hypo/hyperthyroidism, Cushings,
Addisons). (MK)
Collagen vascular diseases (e.g. lupus, fibromyalgia). (MK)
Neurologic (e.g. stoke, multiple sclerosis, Parkinsons disease, head
trauma, complex partial seizures). (MK)
Nutritional (e.g. B12, folate, niacin, thiamine deficiencies). (MK)
Neoplastic (e.g. pancreatic cancer, disseminated carcinomatosis). (MK)
9. US Preventive Services Task Force (USPSTF) depression screening
recommendations. (MK)
10. The risks of untreated major depression. (MK)
11. Assessment of the risk of suicide. (MK)
12. The demographics and risk factors for completed suicide. (MK)
13. The potential link between major depression and substance abuse. (MK)
14. The potential role of genetics in depression.(MK)
15. Indications and efficacy of the basic therapeutic options for major depression,
including:
Psychotherapy (cognitive behavioral therapy or interpersonal
psychotherapy). (MK)
Pharmacotherapy. (MK)
Electroconvulsive therapy. (MK)
16. The side effects of the major classes of antidepressants and common
interaction with other medications. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease including:
Eliciting the symptoms of major depression. (PC, CS)
Determining the presence or absence of underlying dementia, anxiety
disorders, adverse drug effects, and grief in any patient suspected of
having major depression. (PC, CS)
Obtaining a complete drug history (including illicit drugs). (PC, CS)
Identifying chronic diseases that are associated with increased risk of
major depression. (PC, CS)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

2. Physical exam skills: Students should be able to perform a physical exam to

establish the diagnosis and severity of disease, including:
A complete neurologic examination. (PC)
A complete mental status exam. (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology for major depression (psychiatric and
nonpsychiatric). (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
Blood and urine drug screening. (PC, MK)
Thyroid function tests. (PC, MK)
Serum RPR and VDRL. (PC, MK)
B12, folate, and thiamine levels. (PC, MK)
Students should be able to define the indications for and interpret (with
consultation) the results of:
Cranial CT. (PC, MK)
Cranial MRI. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (PC, CS)
Elicit input and questions from the patient and his or her family about
the management plan. (PC, CS)
Demonstrate effective listening skills and empathy. (PC, CS)
Advise the patient of the delay in therapeutic benefit from
antidepressant medications. (PC, CS)
6. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
An appreciation of the fact that major depression is not generally a
diagnosis of exclusion and that ruling out all other possible medical
causes is typically not necessary. (PC, MK)
Making an accurate diagnosis of major depression. (PC, MK)
Assessing for the risk of suicide. (PC, MK)
Recommending psychotherapy (cognitive behavioral therapy or
interpersonal psychotherapy). (PC, MK)
Selecting appropriate initial pharmacologic therapy considering
efficacy, side effects, and potential drug-drug interactions. (PC, MK,
SBP)

Identifying barriers to major depression treatment. (PC, SBP)

Anticipating potential resistance to seeing a psychiatrist and
antidepressant treatment. (PC)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

C.

Planning appropriate follow-up. (PC, MK)

Recognizing success or failure of initial treatment and making
appropriate adjustments. (PC, MK)
Determining when to obtain consultation from a psychiatrist,
psychologist, or other mental health professional. (PC, SBP)
Using a cost-effective approach to treatment. (PC, SBP)
Accessing and utilizing appropriate information systems and resources
to help delineate issues related to major depression. (PC, PLI)
Incorporating patient needs and preferences. (PC)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Recognize major depression as an important and potentially life-threatening
disease. (P)
2. Appreciate the social stigma of psychiatric diagnoses and the ways nonpsychiatric physicians may inadvertently contribute to this. (P)
3. Appreciated the reluctance of some patients to see a psychiatrist. (P)
4. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for major depression. (PLI, P)
5. Recognize the importance of patient needs and preferences when selecting
among diagnostic and therapeutic options for major depression. (P)
6. Respond appropriately to patients who are nonadherent to treatment for major
depression. (CS, P)
7. Demonstrate ongoing commitment to self-directed learning regarding major
depression. (PLI, P)
8. Appreciate the impact major depression has on a patients quality of life, wellbeing, ability to work, and the family. (P)
9. Recognize the importance of and demonstrate a commitment to the utilization
of other health care professionals in the diagnosis and treatment of major
depression. (P, SBP)

D.

REFERENCES:
Depression
National Institute of Mental Health
National Institutes of Health
U.S. Department of Health and Human Services
www.nimh.nih.gov/publicat//defresssion.cfm
Practice Guidelines
American Psychiatric Association
www.psych.org/psych_pract/treatg/pg/prac_guide.cfm
The National Association on Mental Illness
www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPa

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

ge/TaggedPageDisplay.cfm&TPLID=54&ContentID=26414
Mann JJ. The medical management of depression. N Engl J Med.
2005;353:1819-34.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #27: NOSOCOMIAL INFECTIONS

RATIONALE:
Nosocomial infections have been occurring since the inception of the hospital. Despite
many advances the incidence is still roughly five percent of all acute care hospitalizations
or about two million cases a year. Nosocomial infections are estimated to approximately
double the morbidity and mortality rates of any person admitted to the hospital. Directly
attributable deaths can total up to 88,000 per year with the expenditure of many millions
of excess health care dollars. Preventing nosocomial infections is the responsibility of
every heath care worker, including physicians, house officers, medical students, nurses,
technicians, administrators, etc. Also considered here are occupational exposures for
which health care workers are at risk.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Ability to perform a complete medical history and physical.
Ability to communicate with patients of diverse backgrounds.
Basic training in body substance isolation procedures.
Microbiology and pathophysiology of the common nosocomial organisms, including
Staphylococcus aureus (methicillin sensitive and resistant), Staphylococcus
epidermidis, Enterococcus species (vancomycin sensitive and resistant), Pseudomonas
aeruginosa and other nosocomial gram-negative bacilli, Clostridium difficile, and
Candida species.
The pharmacology of antimicrobial agents.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The epidemiology and significance of nosocomial infections in the United
States. (MK)
2. The general clinical risk factors for nosocomial infection. including:
Immunocompromise. (MK)
Immunosuppressive drugs. (MK)
Extremes of age. (MK)
Compromise of the skin and mucosal surfaces secondary to:
o Drugs. (MK)
o Irradiation. (MK)
o Trauma. (MK)
o Invasive diagnostic and therapeutic procedures. (MK)
o Invasive indwelling devises (e.g. intravenous catheter, bladder
catheter, endotracheal tube, etc.). (MK)
3. The major routes of nosocomial infection transmission, including:
Contact. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Droplet. (MK)
Airborne. (MK)
Common vehicle. (MK)
4. The epidemiology, pathophysiology, microbiology, symptoms, signs, typical
clinical course, and preventive strategies for the most common nosocomial
infections, including:
Urinary tract infection. (MK)
Pneumonia. (MK)
Surgical site infection. (MK)
Intravascular devised-related bloodstream infections. (MK)
Skin infections. (MK)
Health care associated diarrhea. (MK)
5. Empiric antibiotic therapy for the most common nosocomial infections. (MK)
6. The epidemiology, pathophysiology, microbiology, symptoms, signs, typical
clinical course, and preventive strategies for colonization or infection with the
following organisms:
Vancomycin-resistant enterococci. (MK)
Clostridium difficile. (MK)
Methicillin-resistant Staphylococcus aureus. (MRSA) (MK)
Multidrug-resistant Gram-negative bacteria. (MK)
7. The crucial importance of judicious antibiotic use. (MK)
8. The effect of widespread use of broad spectrum anti-microbial agents on
endogenous body flora and the hospital microbial flora. (MK)
9. The types of isolation procedures and their indications:
Standard. (MK)
Airborne. (MK)
Contact. (MK)
Droplet. (MK)
10. The Centers for Disease Control and Prevention (CDC) guidelines for hand
hygiene. (MK)
11. Preventive strategies for needlestick and sharps injuries intended to reduce the
transmission of bloodborne pathogens (hepatitis B, hepatitis C, and HIV).
(MK)

12. Local hospital post-exposure (i.e. after an eye/mucous membrane splash,

needlestick or other sharps injury) protocols for prompt reporting, evaluation,
counseling, treatment, and follow-up. (MK, SBP)
13. The indications, efficacy, and side effects of post-exposure prophylaxis for
hepatitis B and HIV/AIDS. (MK)
14. negative-pressure ventilation isolation for known or suspected tuberculosis
patients (MK)
15. National Institute for Occupational Safety and Health (NIOSH) approved
personal respiratory protective equipment (i.e. N95 respirator) use for the
prevention of transmission of Mycobacterium tuberculosis to health care
workers. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease in the organ systems likely to be involved with
nosocomial infection. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical
examination of skin, vascular access sites, lungs, abdomen, wounds, and
catheter and drain sites and recognize signs of local or systemic infection (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis of the likely sites and organisms involved, recognizing
specific history and physical exam findings that suggest a specific etiology.
(PC, MK)

4. Laboratory interpretation: Students should be able to recommend when to

order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based o the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
Urinalysis and culture and sensitivities. (PC, MK)
Sputum Gram stain and culture and sensitivities. (PC, MK)
Chest radiograph. (PC, MK)
Wound cultures and sensitivities. (PC, MK)
Clostridium difficile toxin assay. (PC, MK)
Hepatitis serologies. (PC, MK)
HIV ELISA and western blot. (PC, MK)
Sputum AFB staining and culture. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (PC, CS)
Elicit input and questions from the patient and his or her family about
the management plan. (PC, CS)
Explain the necessity for isolation procedures. (PC, CS)
Counsel patients about the need for judicious antibiotic usage and the
potential patient-specific and public health risks of not doing so. (PC,
CS)

6. Basic and advanced procedural skills: Students should be able to:

Obtain blood cultures. (PC)
Place and interpret a PPD. (PC)
Demonstrate proper sterile technique for invasive procedures. (PC)
7. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
Assessing a hospitalized patient who develops a new fever 48 or more
hours after admission. (PC, MK)
Developing a plan for the evaluation and treatment of hospital
acquired infection. (PC, MK)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Demonstrating appropriate choice of antimicrobial drugs which

considers mechanisms of action, spectrum of activity,
pharmacokinetics, drug interactions, and adverse reactions. (PC, MK)
Recognizing when indwelling intravascular and urinary collection
devices should be removed. (PC, MK)
Requesting appropriate isolation measures to protect other patients and
health care workers. (PC, SBP)
Determining when to obtain consultation from an infectious diseases
specialist. (PC, SBP)
Contacting hospital infection control experts when appropriate. (SBP)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

C.

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to nosocomial infections. (PC, PLI)
Incorporating patient needs and preferences. (PC)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Serve as a role model to all other health care providers by strictly following all
infection control measures including hand hygiene and all isolation
procedures. (P, SBP)
2. Appreciate the role physicians play in the inappropriate prescribing of
antimicrobial agents and the public health ramifications. (P, SBP)
3. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for nosocomial infections. (PLI, P)
4. Recognize the importance of patient needs and preferences when selecting
among diagnostic and therapeutic options for nosocomial infections. (P)
5. Demonstrate ongoing commitment to self-directed learning regarding
nosocomial infections. (PLI, P)
6. Appreciate the impact nosocomial infections have on a patients quality of
life, well-being, ability to work, and the family. (P)
7. Recognize the importance of and demonstrate a commitment to the utilization
of other health care professionals in the diagnosis, treatment, and prevention
of nosocomial infections. (P, SBP)

D.

REFERENCES:
Infection Control Guidelines
Division of Healthcare Quality Promotion
National Center for Infectious Diseases
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/ncidod/hip/default.htm

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Vancomycin-Resistant Enterococci
Division of Healthcare Quality Promotion
National Center for Infectious Diseases
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/ncidod/hip/ARESIST/vre.htm
Pautanen SM, Simor AE. Clostridium difficile associated diarrhea in adults.
Can Med Assoc J. 2004;171:51-8.
www.cmaj.ca/cgi/reprint/171/1/51
Healthcare-Associated MRSA
Division of Healthcare Quality Promotion
National Center for Infectious Diseases
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/ncidod/dhqp/ar_mrsa.html

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #28: OBESITY

RATIONALE:
Obesity and overweight are recognized as ever growing epidemics in the United States.
These conditions have been correlated with the development of medical conditions such
as diabetes, hypertension, heart disease, and osteoarthritis. Mastery of the approach to
patients who are not at an ideal body weight is important to general internists because
they often deal with the sequelae of the comorbid illnesses.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Psychology associated with addictive behavior.
Anatomy, physiology, and pathophysiology of the gastrointestinal tract and digestion.
Pharmacology of the available drugs used to treat obesity.
Nutrition and caloric requirements.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The etiology of obesity including excessive caloric intake, insufficient energy
expenditure leading to low resting metabolic rate, genetic predisposition,
environmental factors affecting weight gain, psychologic stressors, and lower
socioeconomic status. (MK)
2. The definition and classification of overweight and obese using BMI. (MK)
3. The health implications that being overweight or obese may have on the
patient. (MK)
4. How daily caloric requirements are calculated and the caloric deficit required
to achieve a five to 10 percent weight reduction in six to 12 months. (MK)
5. The principles of behavior modification. (MK)
6. How to develop an exercise program and assist the patient in setting goals for
weight loss. (MK)
7. Treatment options, including nonpharmacologic and pharmacologic treatment,
behavioral therapy and surgical intervention. (MK)

B.

SKILLS: Students should be able to demonstrate specific skills including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, including:
Reviewing the patients weight history from childhood. (PC, CS)
Assessing the risk factors for obesity related conditions. (PC, CS)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Assessing the patients motivation for losing weight. (PC, CS)

Reviewing the patients past experience with losing weight and
determining barriers encountered in prior attempts. (PC, CS)
Reviewing the patients activity level and diet. (PC, CS)
Obtaining an assessment of tobacco and drug use especially noting if
the patient is in the process of stopping either. (PC, CS)
Obtaining a family history focusing on weight related issues and
comorbid illnesses associated with obesity. (PC, CS)
Obtaining a focused review of systems including signs and symptoms
of secondary causes of obesity such as Cushings syndrome,
hypothyroidism, and hypogonadism. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Calculation of degree of obesity from the patients height and weight
by calculating BMI. (PC)
Noting the presence of abdominal obesity based on waist-to-hip
circumference. (PC)
Assessing the signs of vascular disease including hypertension, carotid
bruits, abdominal aortic size, blood pressure and peripheral pulses.

(PC)

Assessing for signs of endocrine abnormalities, including: striae,

peripheral neuropathy, depressed tendon reflexes, bruising, and signs
of dyslipidemia (e.g. xanthomas and xanthalasma). (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology of primary and secondary obesity. (MK, PC)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
Serum GLC. (PC, MK)
TSH. (PC, MK)
Lipid profile. (PC, MK)
HbA1c. (PC, MK)
BUN/Cr. (PC, MK)
Urine microalbumin. (PC, MK)
ECG. (PC, MK)
24-hour urinary cortisol (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to patients. (PC, CS)
Elicit questions from the patient and his or her family about the
management plan. (PC, CS)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Adapt to the patients life-style and preferences, with emphasis on the

patients role in treatment and maximizing compliance. (PC, CS)
Assist the patient in understanding that attainment of ideal body
weight may not necessarily be a realistic goal and that health benefits
may be achieved with losses of five to 10 percent body weight. (PC, CS)
6. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
Determining when to obtain consultation from an endocrinologist,
dietician, or obesity management specialist. (PC, SBP)
Developing reasonable weight loss goals with the patient. (PC, MK)
Developing a dietary plan. (PC, MK)
Developing a prescription for physical activity. (PC, MK)
Identifying indications for pharmacotherapy. (PC, MK)
Identifying indications for bariatric surgery. (PC, MK)
Accessing and utilizing appropriate information systems and resources
to help delineate issues related to obesity. (PC, PLI)
Incorporating patient preferences in the treatment plan. (PC)
C.

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for obesity. (PLI, P)
2. Respond appropriately to patients who are nonadherent to treatment for
obesity. (CS, P)
3. Demonstrate ongoing commitment to self-directed learning regarding obesity.
(PLI, P)

4. Appreciate the impact obesity has on a patients quality of life, well-being,

ability to work, and family. (P)
5. Recognize the importance of and demonstrate a commitment to the utilization
of other healthcare professions in the treatment of obesity. (P, SBP)
D.

REFERENCES:
Overweight and Obesity
National Center for Chronic Disease Prevention and Health Promotion
Center for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/nccdphp/dnpa/obesity
Aim for a Healthy Weight
National Heart, Lung, and Blood Institute Obesity Education Initiative
National Institutes of Health
U.S. Department of Health and Human Services
www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.htm

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Screening for Obesity in Adults

Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
www.ahrq.gov/clinic/uspstf/uspsobes.htm
Tsai AG, Wadden TA. Systematic review: an evaluation of major commercial
weight loss programs in the United States. Ann Intern Med. 2005;152-56-66.
Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic
review and meta-analysis. JAMA. 2004;292:1724-37.
Li Z, Maglione M, Tu W, et al. Meta-analysis: pharmacologic treatment of
obesity. Ann Intern Med. 2005;142:532-46.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #29: PNEUMONIA

RATIONALE:
Pneumonia continues to be a major public health issue, a leading reason for
hospitalization, and a significant cause of mortality. Not only that, it is an important
complication of admission for other causes. Many different specialties encounter
pneumonia in the course of practice, the internist most particularly.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clinical experience should
include:
Ability to perform a complete medical history and physical.
Ability to communicate with patients of diverse backgrounds.
Anatomy and physiology of the pulmonary system.
Pathogenesis and pathophysiology of pneumonia.
Microbiology of the common pneumonia pathogens.
Pharmacology of antimicrobial agents.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The epidemiology, pathophysiology, symptoms, signs, and typical clinical
course of community-acquired, nosocomial, and aspiration pneumonia and
pneumonia in the immunocompromised host. (MK)
2. The conceptualization of typical and atypical pneumonia and its
limitations. (MK)
3. Common pneumonia pathogens (viral, bacterial, mycobacterial, and fungal) in
immunocompetent and immunocompromised hosts). (MK)
4. Identify patients who are at risk for impaired immunity. (MK)
5. Indications for hospitalization and ICU admission of patient with pneumonia.
(MK)

6. The radiographic findings of the various types of pneumonia. (MK)

7. The antimicrobial treatments (e.g. antiviral, antibacterial, antimycobacterial,
and antifungal) for community-acquired, nosocomial, and aspiration
pneumonia, and pneumonia in the immunocompromised host. (MK)
8. The implications of antimicrobial resistance. (MK)
9. The pathogenesis, symptoms, and signs of the complications of acute bacterial
pneumonia including: bacteremia, sepsis, parapneumonic effusion, empyema,
meningitis, and metastatic microabscesses. (MK)
10. The indications for and complications of chest tube placement. (MK)
11. The indications for and efficacy of influenza and pneumococcal vaccinations.
(MK)

12. The indications and procedures for respiratory isolation. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

13. The Centers for Medicare & Medicaid Services (CMS) and the Joint
Commission on the Accreditation of Healthcare Organizations (JCAHO)
quality measures for community-acquired pneumonia treatment. (MK, PLI, SBP)
B.

SKILLS: Students should be able to demonstrate specific skills including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history that differentiates among etiologies
of disease, including:
The presence and quantification of fever, chills, sweats, cough,
sputum, hemoptysis, dyspnea, and chest pain. (PC, CS)
Historical features consistent with potential immunocompromise. (PC,
CS)

potential tuberculosis exposure (PC, CS)

2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Accurately determining respiratory rate and level of respiratory
distress. (PC)
Identifying bronchial breath sounds, rales, rhonchi, and wheezes. (PC)
Identifying signs of pulmonary consolidation. (PC)
Identifying signs of pleural effusion. (PC)
Identifying signs of the complications of pneumonia. (PC)
3. Differential diagnosis: Students should be able to generate a prioritized
differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology of pneumonia and other possible diagnoses,
including:
Common cold. (PC, MK)
Acute bronchitis. (PC, MK)
Influenza. (PC, MK)
Acute exacerbation of COPD. (PC, MK)
Asthma exacerbation. (PC, MK)
CHF. (PC, MK)
Pulmonary embolism. (PC, MK)
Aspiration. (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
CBC. (PC, MK)
Blood cultures. (PC, MK)
ABG. (PC, MK)
Pleural fluid chemistry, cell counts, staining, and culture. (PC, MK)
Chest radiograph. (PC, MK)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Students should be able to define the indications for and interpret (with
consultation) the results of:
Chest CT. (PC, MK)
5. Communication skills: Students should be able to:

Communicate the diagnosis, treatment plan, prognosis, and

subsequent follow-up to the patient and his or her family. (PC, CS)

Elicit questions from the patient and his or her family about the
management plan. (PC, CS)

Educate the patient about pneumococcal and influenza

immunizations. (PC, CS)

Educate the patient about the importance of smoking cessation. (PC,

CS)

6. Basic and advanced procedural skills: Students should be able to:

Place and interpret a tuberculin skin test (PPD). (PC)
Obtain blood cultures. (PC)
Obtain an ABG. (PC)
7. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
Selecting an appropriate empiric antibiotic regimen for communityacquired, nosocomial, immunocompromised-host, and aspiration
pneumonia, taking into account pertinent patient features. (PC, MK)
Adjusting antimicrobial treatment according to the sputum staining
and culture results. (PC, MK)
Recognizing the complications of pneumonia. (PC, MK)
Determining when to obtain consultation from a pulmonologist or
infectious diseases specialist. (PC, SBP)
Using a cost-effective approach based on the differential diagnosis.

C.

(PC, SBP)

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to pneumonia. (PC, PLI)
Incorporating patient preferences. (PC)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for the various types of pneumonia. (PLI, P)
2. Recognize the importance of patient preferences when selecting among
diagnostic and therapeutic options for pneumonia. (P)
3. Demonstrate ongoing commitment to self-directed learning regarding
pneumonia. (PLI, P)
4. Appreciate the impact pneumonia has on a patients quality of life, well-being,
ability to work, and the family. (P)
5. Recognize the importance of and demonstrate a commitment to the utilization
of other healthcare professionals in the treatment of pneumonia. (P, SBP)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

6. Appreciate the importance of antimicrobial resistance. (P)

7. Appreciate the public health role of the physician when treating certain types
of pneumonia (e.g. tuberculosis). (P)
8. Appreciate the importance of and demonstrate a commitment to meeting
national health care quality measures for the treatment of acute MI. (P, SBP,
PLI)

D.

REFERENCES:
Improving Treatment Decisions for Patients with Community-Acquired
Pneumonia
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
www.ahrq.gov/clinic/pneumonia/pneumonria.htm
Ramsdell J, Narsavage GL, Fink JB. Management of community-acquired
pneumonia in the home: an American College of Chest Physicians clinical
position statement. Chest. 2005;127:1752-63.
www.guideline.gov/summary/summary.aspx?ss=15&doc_id=7325&nbr=4
348
Influenza
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/flu/
Prevention of Pneumococcal Disease: Recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR 46(RR-08);1-24.
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/mmwr/PDF/RR/RR4608.pdf
Prevention and Control of Influenza: Recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR 50(RR-04);1-46.
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
www.cdc.gov/mmwr/PDF/RR/RR5004

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #30: RHEUMATOLOGIC PROBLEMS

RATIONALE:
Rheumatologic diseases are an important part of the practice of internal medicine. This
includes problems referring to specific joints as well as patients with systemic symptoms
that are sometimes difficult to unify into a single diagnosis.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Anatomy, physiology, and pathophysiology of the musculoskeletal system.
Basic course work in immunology.
Pharmacology of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs),
glucocorticoids, disease-modifying antirheumatic drugs (DMARDs), drugs use in the
treatment of gout.
Basic bone radiograph interpretation.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. A systematic approach to joint pain based on an understanding of
pathophysiology to classify potential causes. (MK)
2. The effect of the time course of symptoms on the potential causes of joint pain
(acute vs. subacute vs. chronic). (MK)
3. The difference between and pathophysiology of arthralgia vs. arthritis and
mechanical vs. inflammatory joint pain. (MK)
4. The distinguishing features of intra-articular and periarticular complaints
(joint pain vs. bursitis and tendonitis). (MK)
5. The effect of the features of joint involvement on the potential causes of joint
pain (monoarticular vs. oligoarticular vs. polyarticular, symmetric vs.
asymmetric, axial and/or appendicular, small vs. large joints, additive vs.
migratory vs. intermittent). (MK)
6. Indications for performing an arthrocentesis and the results of synovial fluid
analysis. (MK)
7. The pathophysiology and common signs and symptoms of:
Osteoarthritis. (MK)
Crystalline arthropathies. (MK)
Septic arthritis. (MK)
8. Indications for and effectiveness of intra-articular steroid injections. (MK)
9. Treatment options for gout (e.g. colchicine, NSAIDs, steroids, uricosurics,
xanthine oxidase inhibitors). (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

10. The pathophysiology and common signs and symptoms of common

periarticular disorders:
Sprain/stain. (MK)
Tendonitis. (MK)
Bursitis. (MK)
11. The basic pathophysiology of autoimmunity and autoimmune diseases. (MK)
12. The basic role of genetics in autoimmune disorders. (MK)
13. Typical clinical scenarios when systemic rheumatologic disorders should be
considered:
Diffuse aches and pains. (MK)
Generalized weakness/fatigue. (MK)
Myalgias with or without weakness. (MK)
Arthritis with systemic signs (e.g. fever, weight loss). (MK)
Arthritis with disorders of other systems (e.g. rash, cardiopulmonary
symptoms, gastrointestinal symptoms, eye disease, renal disease,
neurologic symptoms). (MK)
13. the common signs and symptoms of and diagnostic approach to:
Rheumatoid arthritis. (MK)
Spondyloarthropathies (reactive arthritis/Reiters syndrome,
ankylosing spondylitis, psoriatic arthritis). (MK)
Systemic lupus erythematosus. (MK)
Systemic sclerosis. (MK)
Raynauds syndrome/phenomenon. (MK)
Sjgrens syndrome. (MK)
Temporal arteritis and polymyalgia rheumatica. (MK)
Other systemic vasculitides. (MK)
Polymyositis and dermatomyositis. (MK)
Fibromyalgia. (MK)
B.

SKILLS: Students should be able to demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history that differentiates among etiologies
of disease, including:
Eliciting features of joint complaints:
o Pain. (PC, CS)
o Stiffness. (PC, CS)
o Location. (PC, CS)
o Mode of onset. (PC, CS)
o Duration. (PC, CS)
o Severity. (PC, CS)
o Exacerbating and alleviating factors. (PC, CS)
o Warmth, redness, and tenderness. (PC, CS)
o Associated nonarticular symptoms. (PC, CS)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Determining when in the course of acute arthritis it is necessary to

obtain a sexual history. (PC, CS)
Determining the impact of rheumatologic complaints on a patient's
activities of daily living. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
A systematic examination of all joints identifying the following
abnormal findings:
o Erythema, warmth, tenderness, and swelling. (PC)
o Effusion. (PC)
o Crepitus. (PC)
o Altered range of motion. (PC)
o Ulnar deviation. (PC)
o Synovial thickening. (PC)
o Joint alignment deformities (e.g. varus and valgus). (PC)
o Podagra. (PC)
Muscular bulk, strength, and tenderness. (PC)
Examination of the skin identifying the following abnormal findings:
o Rheumatoid and tophaceous nodules. (PC)
o Alopecia. (PC)
o Malar rash. (PC)
o Sclerodactyly. (PC)
o Telangiectasias. (PC)
o Raynauds phenomenon. (PC)
o Psoriasis. (PC)
o Cutaneous manifestations of vasculitis (e.g. palpable purpura).
(PC)

3. Differential diagnosis: Students should be able to generate a prioritized

differential diagnosis recognizing specific history and physical exam findings
that suggest a specific etiology:
Osteoarthritis. (PC, MK)
Crystalline arthropathies. (PC, MK)
Septic arthritis. (PC, MK)
Rheumatoid arthritis. (PC, MK)
Spondyloarthropathies (reactive arthritis/Reiters syndrome,
ankylosing spondylitis, psoriatic arthritis). (PC, MK)
Systemic lupus erythematosus. (PC, MK)
Systemic sclerosis. (PC, MK)
Raynauds syndrome/phenomenon. (PC, MK)
Sjrgrens syndrome. (PC, MK)
Temporal arteritis and polymyalgia rheumatica. (PC, MK)
Other systemic vasculitides. (PC, MK)
Polymyositis and dermatomyositis. (PC, MK)
Fibromyalgia. (PC, MK)
4. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

to and after initiating treatment based on the differential diagnosis, including

consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
CBC with differential. (PC, MK)
Synovial fluid analysis (Gram stain, culture, crystal exam, cell count
with differential, and glucose). (PC, MK)
Uric acid. (PC, MK)
ESR. (PC, MK)
Rheumatoid factor (RF). (PC, MK)
Antinuclear antibody test (ANA) and anti-DNA test. (PC, MK)
Students should be able to define the indications for and interpret (with
consultation) the results of:
Plain radiographs of the shoulder, elbow, wrist, hand, hip, knee, ankle,
and foot. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to patients. (PC, CS)
Elicit questions from the patient about the management plan. (PC, CS)
6. Basic and advanced procedure skills: Students should be able to:
Assist in the performance of an arthrocentesis and intra-articular
corticosteroid injection. (PC)
7. Management skills: Students should able to develop an appropriate
evaluation and treatment plan for patients that includes:
Selecting appropriate medications for the relief of joint pain. (PC, MK)
Prescribing acute and preventative treatment for crystalline
arthropathies. (PC, MK)
Prescribing basic treatment options for septic arthritis. (PC, MK)
Prescribing basic treatment options for systemic rheumatologic
conditions. (PC, MK)
Determining when to obtain consultation from a rheumatologist and
orthopedic surgeon. (PC, SBP)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

C.

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to rheumatologic problems. (PC, PLI)
Incorporating patient preferences. (PC)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection diagnostic and therapeutic interventions
for rheumatologic problems. (PLI, P)
2. Recognize the importance of patient preferences when selecting among
diagnostic and therapeutic options for rheumatologic problems. (P)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

3. Respond appropriately to patients who are nonadherent to treatment for

rheumatologic problems. (CS, P)
4. Demonstrate ongoing commitment to self-directed learning regarding
rheumatologic problems. (PLI, P)
5. Appreciate the impact rheumatologic problems have on a patients quality of
life, well-being, ability to work, and the family. (P)
6. Recognize the importance of and demonstrate a commitment to the utilization
of other healthcare professions in the treatment of rheumatologic problems. (P,
SBP)

D.

REFERENCES:
Evaluation of the patient history and physical examination, laboratory
assessment, arthrocentesis and synovial fluid analysis. In Schumacher HR,
Klippel JH, Koopman WJ, eds. Primer on the Rheumatic Diseases. 12th Ed.
Atlanta, GA: Arthritis Foundation; 2001.
Management Guidelines
American College of Rheumatology
www.rheumatology.org/publications/guidelines/index.asp
Arthritis Foundation
www.arthritis.org
National Institute of Arthritis and Musculoskeletal and Skin Diseases
National Institutes of Health
U.S. Department of Health and Human Services
www.niams.nih.gov

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #31: SMOKING CESSATION

RATIONALE:
Smoking is a major public health issue because it causes or aggravates many serious
illnesses. Effective intervention strategies for chronic smokers have been developed
using principals of behavioral counseling. These principals are applicable to other risky
health behaviors. Health behavior risk assessment and intervention is now expected of
physicians as part of the comprehensive care of adults. Selecting and performing an
appropriate smoking cessation intervention is an important training problem for the third
year medical student.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Knowledge of the anatomy, physiology, and pathophysiology of the cardiopulmonary system.
Knowledge of the pharmacology of addictive drugs.
Knowledge of the risks of smoking, passive smoke, and smokeless tobacco.
Appreciation of the reasons for or against discontinuing smoking.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. The pharmacologic effects of nicotine. (MK)
2. Nicotine withdrawal symptoms. (MK)
3. Intervention strategies physicians can use for those patients willing and not
willing to quit. (MK)
4. The stages of change, including:
Precontemplation. (MK)
Contemplation. (MK)
Preparation. (MK)
Action. (MK)
Maintenance. (MK)
5. The five As of smoking cessation:
Ask. (MK)
Advise. (MK)
Assess. (MK)
Assist. (MK)
Arrange. (MK)
6. The five Rs of smoking cessation:
Relevance. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Risks. (MK)
Rewards. (MK)
Roadblocks. (MK)
Repetition. (MK)
7. The common barriers preventing patients from undertaking smoking
cessation. (MK)
8. The principles of at least one theory of behavior modification. (MK)
9. Common medical diseases associated with chronic smoking and the effects of
stopping on future risk. (MK)
10. The indications for nicotine replacement therapy, pharmacotherapy (i.e.
bupropion) or both. (MK)
11. The association between smoking cessation and weight gain. (MK)
12. The fact that tobacco dependence is considered a chronic relapsing disorder.
(MK)

13. The Centers for Medicare & Medicaid Services (CMS) and the Joint
Commission on the Accreditation of Healthcare Organizations (JCAHO)
quality measures for smoking cessation advice (i.e. all smoking patients
admitted with pneumonia, HF, or an acute MI are given smoking cessation
advice or counseling during hospital stay). (MK, PLI, SBP)
B.

SKILLS: Students should demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, including:
Ask the patient if he or she uses tobacco. (PC, CS)
Determine the length and magnitude of tobacco use. (PC, CS)
Ask if the patient is interested in stopping.
Ask about the patients past experiences with smoking cessation. (PC,
CS)

Ask relevant questions regarding the symptoms of diseases associated

with long-term smoking (e.g. CAD, COPD, PVD, CVA, lung cancer).
(PC, CS)

2. Physical exam skills: Students should be able to perform a physical exam to

establish the diagnosis and severity of disease, including:
Identification of nicotine stains. (PC)
Identification of lesions with malignant potential on the lips and in the
oral cavity. (PC)
Identification of chest findings consistent with chronic obstructive
lung disease and lung cancer. (PC)
Examination of the heart and vascular system. (PC)
3. Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 Complete blood count to detect erythrocytosis. (PC, MK)

Lipid profile to aid in cardiovascular stratification. (PC, MK)
4. Communication skills: Students should be able to:
Ask every patient if he or she uses tobacco. (PC, CS)
Advise every patient who smokes to stop in a nonjudgmental manner.
(PC, CS)

Assess the patients willingness to make attempt to quit. (PC, CS)

Assist those who are willing to make a quit attempt through
counseling. (PC, CS)
Respond positively and non-judgmentally to the patients excuses or
concerns about cessation. (PC, CS)
Get the patient to commit to a specific action plan that can lead to
complete cessation. (PC, CS)
For those unwilling to quit, use of 5 Rs to motivate the patient:
o Relevance. (PC, CS)
o Risks. (PC, CS)
o Rewards. (PC, CS)
o Roadblocks. (PC, CS)
o Repetition. (PC, CS)
5. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patient, including:
Designing an intervention that matches the stage of behavior change
demonstrated by the patient. (PC, CS)
Explaining how to use nicotine patch, nasal spray or inhaler, and/or
bupropion therapy. (PC, CS)
Negotiating a follow-up plan with the patient. (PC, CS)
Encouraging the patient to increase physical activity to lessen weight
gain, if medically appropriate. (PC, CS)
Accessing and utilizing appropriate information systems and resources
to help delineate issues/resources related to aiding smoking cessation.
(PC, PLI)

C.

Incorporating patient preferences. (PC)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Student should be able

to:
1. Demonstrate a commitment to meeting national quality standards for smoking
cessation. (P, PLI, SBP)
2. Maintain a non-judgmental attitude at all times regarding smoking cessation.
(P)

3. Demonstrate a commitment to deliver a non-judgmental "stop smoking"

message to every patient who smokes. (P)
4. Promote problem-solving by the patient. (P)
5. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for smoking cessation. (PLI, P)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

6. Respond appropriately to patients who are non-adherent to treatment for

smoking cessation. (P)
7. Demonstrate ongoing commitment to self-directed learning regarding
smoking cessation. (PLI, P)
8. Appreciate the impact smoking cessation has on a patients quality of life,
well-being, ability to work, and the family. (P)
9. Recognize the importance and demonstrate a commitment to the utilization of
other healthcare professions in the treatment of smoking cessation. (P, SBP)
D.

RESOURCES:
Public Health Service
Department of Health and Human Services
Tobacco Cessation Guideline
www.surgeongeneral.gov/tobacco/default.htm
Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement
therapy for smoking cessation. Cochrane Database of Syst Rev.
2004;(3):CD000146.
Schroeder SA. What to do with a patient who smokes. JAMA.
2005;294:482-7.
Talwar A, Jain M, Vijayan VK. Pharmacotherapy of tobacco dependence.
Med Clin North Am. 2004;88:1517-34.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #32: SUBSTANCE ABUSE

RATIONALE:
Substance abuse is a prevalent problem that intersects with patient care on a variety of
different levels and in patients from every socio-economic status. Being able to
recognize it, counsel patients appropriately, and devise an appropriate treatment plan is
integral to the practice of internal medicine.
PREREQUISITES:
Prior knowledge, skills, and attitudes acquired during the pre-clerkship experiences
should include:
Ability to perform a complete medical history and physical exam.
Ability to communicate with patients of diverse backgrounds.
Knowledge of drug and alcohol metabolism and physiology.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe, and discuss:

1. Presenting signs and symptoms of abuse of the following substances:
Alcohol. (MK)
Opioids. (MK)
Cocaine. (MK)
Amphetamines.(MK)
Hallucinogens. (MK)
Barbiturates. (MK)
Marijuana. (MK)
Anabolic steroids. (MK)
Benzodiazepines. (MK)
2. Signs, symptoms, risk factors for, and major causes of morbidity and mortality
secondary to alcohol and drug abuse, intoxication, overdose, and withdrawal.
(MK)

3. Diagnostic criteria for substance abuse, dependency and addiction. (MK)

4. Questions in the CAGE questionnaire:
Cut down. (MK)
Annoyed/angry. (MK)
Guilty. (MK)
Eye opener. (MK)
5. Health benefits of substance abuse cessation. (MK)
6. The potential role of genetics in substance abuse vulnerability. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

B.

SKILLS: Students should demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document, and
present an age-appropriate medical history, that differentiates among
etiologies of disease, including:
Social history that is elicited in a nonjudgmental, supportive manner,
using appropriate questioning (e.g. CAGE questions, etc.). (PC, CS)
Use of injection drugs and shared needles. (PC, CS)
Relevant medication history. (PC, CS)
Immune status. (PC, CS)
Family history of substance abuse. (PC, CS)
Lifestyle factors that will influence patients access to illicit substances
and interfere with ability to enable effective treatment. (PC, CS)
Screening for depression and other psychiatric disease. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical exam to
establish the diagnosis and severity of disease, including:
Accurate recognition of signs that may indicate intoxication or
withdrawal (e.g. behavioral or speech changes, changes in pupil size,
conjunctival or nasal injection, tachycardia, sweating, piloerection,
yawning, unsteady gait, etc.). (PC, MK)
Examination of the nose for septal perforation as complication of
cocaine use. (PC, MK)
Examination of the skin for track marks or signs of needle use. (PC,
MK)

Identification of stigmata of secondary disease states (e.g. cirrhosis

splenomegaly, gynecomastia, telangiectasias, caput medusa, etc.) (PC,
MK)

Assessing for signs of endocarditis (e.g., fever, murmur, rash, etc). (PC,
MK)

Obtaining full mental status examination. (PC, MK)

3. Differential diagnosis: Students should be able to generate a differential
diagnosis recognizing history, physical exam and/or laboratory findings to
determine the diagnosis of abuse of drugs or alcohol and their sequelae. (PC,
MK)

4. Laboratory interpretation: Students should be able to recommend when to

order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, when appropriate:
Blood alcohol level. (PC, MK)
Urine and serum toxicology screens. (PC, MK)
Hepatic function panel. (PC, MK)
Amylase and lipase levels. (PC, MK)
Tests for HIV, hepatitis B and hepatitis C. (PC, MK)
ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 CBC. (PC, MK)

Blood cultures. (PC, MK)
5. Communication skills: Students should be able to:
Communicate the evaluation, treatment plan, and subsequent follow up
to the patient and his or her family in a non-judgmental manner. (PC,
CS)

Elicit questions from the patient and his or her family about the disease
process and management plan. (PC, CS)
Counsel patients regarding cessation and available community referral
resources. (PC, CS, SBP)
6. Management skills: Students should be able to develop an appropriate
evaluation and treatment plan that includes:
Assessing the patients motivation for achieving sobriety/abstinence.

C.

(PC, MK)

Understanding the principles of acute management of drug/alcohol

intoxication and withdrawal versus long-term treatment planning. (MK,
PC)

Using Clinical Institute Withdrawal Assessment for Alcohol. (CIWAAr) scale in acute alcohol withdrawal to prevent seizures or delirium
tremens (MK, PC)
Recommending appropriate use of benzodiazepines for alcohol
withdrawal. (MK, PC)
Determining when to obtain consultation from a psychiatrist. (PC, SBP)
Accessing and utilizing appropriate information systems and resources
to help delineate issues related to substance abuse. (PC, PLI)
Incorporating patient preferences and understanding limitations of
treatment. (PC)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for substance abuse. (PLI, P)
2. Respond appropriately to patients who are non-adherent to treatment for
substance abuse. (CS, P)
3. Demonstrate ongoing commitment to self-directed learning regarding
substance abuse. (PLI, P)
4. Appreciate the impact substance abuse has on a patients as well as a familys
quality of life, well-being, and ability to work. (P)
5. Recognize the importance and demonstrate a commitment to the utilization of
other healthcare professions in the treatment of substance abuse. (P, SBP)

D.

REFERENCES:

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

 U.S. Preventive Services Task Force. Screening and behavioral counseling

interventions in primary care to reduce alcohol misuse recommendation
statement. Ann Intern Med. 2004;140:554-6.
Kosten TR, O'Connor PG. Management of drug and alcohol withdrawal. N
Engl J Med. 2003;348:1786-95.
Mersy DJ. Recognition of alcohol and substance abuse. Am Fam Physician.
2003;67:1529-32.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

TRAINING PROBLEM #33: VENOUS THROMBOEMBOLISM

RATIONALE:
Venous thromboembolic disease (DVT and PE) is a very common problem in internal
medicine and one that can have devastating consequences if not appropriately diagnosed
and treated. Diagnosis of DVT and PE can be especially challenging. Prophylactic
measures are very effective but do not eliminate the risk.
PREREQUISITES:
Prior knowledge, skills and attitudes acquired during the pre-clerkship experience should
include:
Ability to perform a complete medical history and physical exam (with particular
attention to the cardiac, pulmonary, and venous systems).
Ability to communicate with patients of diverse backgrounds.
Knowledge of the anatomy, physiology, and pathophysiology of the cardiac,
pulmonary, and venous systems.
Physiology and pathophysiology of the hemostatic system.
Pharmacology of antithrombotic agents.
SPECIFIC LEARNING OBJECTIVES:
A.

KNOWLEDGE: Students should be able to define, describe and discuss:

1. Risk factors for developing DVT, including:
Prior history of DVT/PE. (MK)
Immobility/hospitalization. (MK)
Increasing age. (MK)
Obesity. (MK)
Trauma. (MK)
Smoking. (MK)
Surgery. (MK)
Cancer. (MK)
Acute MI. (MK)
Stroke and neurologic trauma. (MK)
Coagulopathy. (MK)
Pregnancy. (MK)
Oral estrogens. (MK)
2. Genetic considerations predisposing to venous thrombosis. (MK)
3. The symptoms and signs of DVT and PE. (MK)
4. The differential diagnosis of DVT including the many causes of unilateral leg
pain and swelling:
Venous stasis and the postphlebitic syndrome. (MK)
Lymphedema. (MK)
Cellulitis. (MK)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

5.

6.

7.
8.
9.

B.

Superficial thrombophlebitis. (MK)

Ruptured popliteal cyst. (MK)
Musculoskeletal injury. (MK)
Arterial occlusive disorders. (MK)
The differential diagnosis of PE including the many causes of chest pain and
dyspnea:
MI/unstable angina. (MK)
Congestive heart failure. (MK)
Pericarditis. (MK)
Pneumonia/bronchitis/COPD exacerbation. (MK)
Asthma. (MK)
Pulmonary hypertension. (MK)
Pneumothorax. (MK)
Musculoskeletal pain (e.g. rib fracture, costochondritis). (MK)
Treatment modalities for DVT/PE, including:
Unfractionated heparin. (MK)
Low-molecular-weight heparin. (MK)
Warfarin. (MK)
Thrombolytics. (MK)
The risks, benefits, and indications for inferior vena cava filters. (MK)
The long-term sequelae of DVT and PE. (MK)
Methods of DVT/PE prophylaxis, their indications and efficacy, including:
Ambulation. (MK)
Graded compression stockings. (MK)
Pneumatic compression devices. (MK)
Unfractionated heparin. (MK)
Low-molecular-weight heparin. (MK)
Warfarin. (MK)

SKILLS: Students should demonstrate specific skills, including:

1. History-taking skills: Students should be able to obtain, document and
present an age-appropriate medical history that suggests the diagnosis of DVT
or PE, including:
The presence or absence of known risk factors. (PC, CS)
Presence or absence of leg pain, swelling, warmth, discoloration, and
palpable cord. (PC, CS)
The presence or absence of dyspnea, chest pain, palpitations, cough,
hemoptysis. (PC, CS)
2. Physical exam skills: Students should be able to perform a physical
examination to establish the diagnosis and severity of disease, including:
Assessment of vital signs (i.e. hypotension, tachycardia, tachypnea,
fever) and general appearance (i.e. degree of respiratory distress,
anxiety). (PC)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

3.

4.

5.

6.

7.

Accurate identification of leg swelling, erythema, warmth, and

tenderness. (PC)
Inspection for signs of lower extremity trauma, arthritis, or joint
effusion. (PC)
Identification of pleural friction rubs, wheezes, rales, rhonchi, and
signs of pneumothorax. (PC)
Differential diagnosis: Students should be able to generate a differential
diagnosis for a patient suspected of having DVT/PE, recognizing specific
history, physical examination and laboratory findings which suggest DVT/PE,
including the disease states noted above. (PC, MK)
Laboratory interpretation: Students should be able to recommend when to
order diagnostic and laboratory tests and be able to interpret them, both prior
to and after initiating treatment based on the differential diagnosis, including
consideration of test cost and performance characteristics as well as patient
preferences.
Laboratory and diagnostic tests should include, where appropriate:
Pulse oximetry. (PC, MK)
12-lead ECG. (PC, MK)
Chest radiograph. (PC, MK)
ABG. (PC, MK)
D-dimer. (PC, MK)
Students should be able to define the indications for and interpret (with
consultation) the results of:
Duplex venous ultrasonography. (PC, MK)
Ventilation perfusion (V/Q) scan. (PC, MK)
CT angiography. (PC, MK)
Pulmonary angiography. (PC, MK)
Echocardiography. (PC, MK)
Communication skills: Students should be able to:
Communicate the diagnosis, treatment plan, and subsequent follow-up
to the patient and his or her family. (PC, CS)
Elicit questions from the patient and his or her family about the
management plan. (PC, CS)
Basic and advanced procedural skills: Students should be able to:
Perform a 12-lead ECG. (PC)
Obtain an ABG. (PC)
Management skills: Students should be able to develop an appropriate
evaluation and treatment plan for patients that includes:
Outlining the acute and long-term treatment of isolated calf vein
phlebitis, superficial thrombophlebitis, DVT, and thromboembolism,
including appropriate use and monitoring of heparin and warfarin. (MK,
PC)

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice

Understanding the indications for placement of inferior vena cava

filter, indications and complications of thrombolytic therapy, as well
as indications for performing a hypercoaguability work-up. (PC, MK)
Determining when to obtain consultation from a pulmonologist or
interventional radiologist. (PC, MK)
Using a cost-effective approach based on the differential diagnosis.
(PC, SBP)

C.

Accessing and utilizing appropriate information systems and resources

to help delineate issues related to venous thromboembolism. (PC, PLI)
Incorporating patient preferences. (PC)

ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able

to:
1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic
interventions for venous thromboembolic disease. (PLI, P)
2. Respond appropriately to patients who are non-adherent to treatment for
venous thromboembolic disease. (CS, P)
3. Demonstrate ongoing commitment to self-directed learning regarding venous
thromboembolic disease. (PLI, P)
4. Appreciate the impact venous thromboembolic disease has on a patients
quality of life, well-being, ability to work, and the family. (P)
5. Recognize the importance and demonstrate a commitment to the utilization of
other healthcare professions in the treatment of venous thromboembolic
disease. (P, SBP)

D.

REFERENCES:
American College of Chest Physicians. The seventh ACCP conference on
antithrombotic and thrombolytic therapy: evidence-based guidelines. Chest.
2004;126(Number 3 Supplement)
www.chestjournal.org/content/vol126/3_suppl
Spyropoulos AC. Emerging strategies in the prevention of venous
thromboembolism in hospitalized medical patients. Chest. 2005;128:958-69.
Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, Biel RK,
Bharadia V, Kalra NK. D-dimer for the exclusion of acute venous thrombosis
and pulmonary embolism: a systematic review. Ann Intern Med.
2004;140:589-602.
Bates SM, Ginsberg JS. Clinical practice. Treatment of deep-vein
thrombosis. N Engl J Med. 2004;351:268-77.
Fedullo PF. Tapson VF. Clinical practice. The evaluation of suspected
pulmonary embolism. N Engl J Med. 2003;349:1247-56.

ACGME Competencies:
PC = Patient Care
MK = Medical Knowledge
PLI = Practice-Based Learning and Improvement

CS = Communication Skills
P = Professionalism
SBP = Systems-Based Practice