Department of medicine

Infectious Disease Consult Service

Educational Purpose:

The purpose of the resident rotation on the Infectious Diseases Consult Service is to provide the medical resident with the basic clinical skills necessary for assessment and management of patients with infectious diseases.  The resident will learn to care for a number of infectious syndromes in HIV infected and non-HIV infected patients.  The rotation will also familiarize the resident/student with the appropriate evaluation and treatment of patients with infectious diseases and the appropriate evaluation of patients in whom an infectious etiology is one consideration within a broad differential diagnosis (i.e., undifferentiated fever).  Emphasis is placed upon the use of the history and physical exam to formulate a differential diagnosis and identify risk factors for infectious diseases; this is further refined through the use and interpretation of diagnostic testing, with emphasis on the microbiology laboratory.  The resident/student will learn appropriate treatment plans for situations requiring empiric therapy and organ or pathogen specific therapy.  Preventative and screening measures including public health measures and patient counseling will be emphasized where appropriate.

Goals and Objectives:

PGY-1-

1.  To work up and manage immunocompromised patients, including AIDS patients, infected with viral, bacterial, mycobacterial, or fungal pathogens.

2.  To understand the principles of appropriate antibiotic use.

3.  To learn inpatient evaluation and management of fever of unknown origin.

4.  To understand inpatient diagnosis and management of endocarditis and pericarditis.

5.  To recognize the presentation and treatment of CNS infections including meningitis, encephalitis, and brain abscesses.

6.  To recognize appropriate evaluation and treatment of osteomyelitis.

7.  To recognize the side effects of antiretroviral agents used in treating AIDS.

PGY-2&3-

1.  To work up and manage immunocompromised patients, including AIDS patients, infected with viral, bacterial, mycobacterial, or fungal pathogens.

2.  To understand the principles of appropriate antibiotic use.

3.  To learn inpatient evaluation and management of fever of unknown origin.

4.  To understand diagnosis and management of endocarditis and pericarditis.

5.  To recognize the presentation and treatment of CNS infections including meningitis, encephalitis, and brain abscesses.

6.  To recognize appropriate evaluation and treatment of osteomyelitis.

7.  To recognize the side effects of antiretroviral agents used in treating AIDS.

8.  To supervise interns and medical students as well as facilitate their education and clinical development.

Teaching Methods:

A. New Consultations - Inpatient

The resident/student will initially perform all new infectious diseases consultations; this will usually require 1 to 2 hours per consult, including approximately 20 minutes of reading time in the library on a topic pertinent to the consult. The patient is subsequently seen jointly by the resident/student and the attending. Consultations will not be placed on the chart until signed by the attending.  Emphasis is placed upon a pertinent history and physical with review of laboratory/microbiology findings and radiographic studies. This information is used to answer a question (if stated in the consult request) or to formulate a differential diagnosis which then becomes a starting point for teaching/discussing evaluation and management points of the current and similar clinical situations.

Exceptions to the resident/student seeing all new patients:

1. The consult is STAT or urgent and the resident/student is unavailable.

2. The number of new consultations that day is >3 (>2 for students)

B. Infectious Diseases Outpatient Clinic

The resident/student will participate in one infectious diseases clinic weekly. Both new consults and established patients will be seen. Patients will be presented to the clinic attending.

Infectious Diseases Rotation Curriculum

C. Teaching Rounds

Each new consult seen by the resident/student will form the basis for teaching rounds. The new consult is presented by the resident or student to the entire infectious diseases consult team. The team will then see the patient as a group and review relevant history and/or obtain additional history from the patient and patient record. Pertinent physical findings (positive and negative) will be reviewed at the bedside. This component will be followed by formulation of a differential diagnosis and the development of diagnostic and therapeutic plans. Additional discussion may include pathophysiology, epidemiology, natural history and complications of the infection/pathogen in question.  Residents/students on the infectious diseases consult service average 8 consults per week; presentation and discussion of each case averages 1 hour. In the event that there are no new consults on a given day, the resident/student is assigned to see patients for follow-up visits with ensuing presentation, review and discussion at the bedside.

D. Additional Instruction

Residents and students will receive didactic instruction in clinical pharmacology (3 1 hour sessions/rotation) and microbiology (3 1 hour sessions/rotation).

The Infectious Diseases Division has an additional conference that the residents are expected to attend, “interesting case” conference on Mondays at 1:00 p.m.  In this conference, current infectious disease cases of interest are presented and discussed in detail with the faculty and residents of the Adult and Pediatric Infectious Disease Divisions and Diagnostic Microbiology laboratory.  The resident is expected to present patients at this conference, and may be asked to review the literature and discuss certain aspects of the case.

Mix of Diseases and Pathological Material:

The disease mix is broad, due to the multiple clinical settings to which the resident is exposed during the rotation.  The resident will see patients in all teaching hospitals that serve as training sites for the Internal Medicine Residency Program, as well as in the multi-disciplinary outpatient clinic.

Patient Characteristics:

The ID service consults on a diverse group of adult inpatients of both sexes with a wide variety of infectious diseases.  The variety is representative of the community and of the clinical settings in which they are seen.  Adolescents are occasionally seen, but children and most adolescents are seen the Pediatric Infectious Diseases service.

Types of Clinical Encounters:

AIDS, community and nosocomial pneumonias, endocarditis, pericarditis, meningitis, brain abscesses, osteomyelitis, pyelonephritis, abdominal and hepatic abscessed, and FUO.  Patients are seen in an inpatient setting on a consult service as well as in outpatient clinics.

Procedures and Services:

Common procedures performed on ID inpatients include lumbar punctures, blood cultures, paracentesis, thoracentesis, and occasionally, central venous access.  The resident/student is introduced to techniques used in clinical microbiology, including:  proper handling, staining and interpretation of specimens; bacterial, viral and fungal culture techniques; and performance and interpretation of serologic tests.  The performance of other diagnostic and therapeutic procedures may be available on an irregular basis in both the inpatient and outpatient setting and are to be conducted with an attending physician.

Supervision:

All procedures are supervised by the attending physician and/or fellow.  The upper level resident supervised the 4th year student and the PGY 1 on the service.  The ID fellow provides supervision and support to the upper level resident, and the ID attending supervises the entire team. 

Educational Resources to be Used and Reading Lists:

A reading list compiled from current journal articles will be provided at the beginning of each rotation.  A copy of these articles will be maintained in a binder in the ID Division.  Residents/students are referred to standard textbooks of Internal Medicine and Infectious Diseases and are expected to independently research topics related to patients that they have encountered during the rotation.  Residents/students are encouraged to submit valuable articles they encounter for inclusion in the reading list.  All computers link to the MUSC Library and have online texts and journals.  The conference room library includes current issues of internal medicine and infectious diseases journals, the MMWR, and current internal medicine and infectious diseases textbooks.  An extensive infectious diseases literature file is available in the Infectious Diseases Office.

Method of Evaluation of Resident Competence:

Residents are evaluated monthly on the E*Value system.  The form used allows the attending to assess each core competency individually.  Patient Care is assessed based on direct observation and complete review of all records.  Medical Knowledge is assessed through direct questioning and observation.  Interpersonal Skills and Communication is assessed by observation of interactions with consulting physicians, patients, and families.  The attending physician evaluates Professionalism through direct interaction and observation of the resident.  Systems-Based Practice is evaluated based on interactions with the primary team and the ability to provide medical care in the consultative setting.  Practice-Based Learning is evaluated based on the ability to consult the literature and to improve their performance throughout the rotation.  The residents evaluate the rotation and the attending physician through the E*Value system.  The consult attendings review the rotation evaluations and each attending anonymously receives his or her evaluations. The attending physician meets with the resident at the end of the rotation to discuss performance.  If problems in the resident’s performance become evident early in the rotation, the attending physician will meet with the resident during the rotation as well.

Residents evaluate the rotation and the attending physician on the E*Value system.  Any substandard evaluations go immediately to the Division Director and each attending receives anonymous evaluations annually.  Evaluations of the curriculum are discussed at the monthly faculty meetings. 

 
 
 

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