UHN/MSH Medical Consult Service
R4 Rotation Objectives
1.   Medical Expert
Enabling Competencies:
  1. Demonstrate expertise in the diagnosis, investigation and management of the general internal
    medicine patient in the perioperative period, in pregnancy, or when under the care of other
    physicians or specialists.  
  2. Demonstrate expertise in the differential diagnosis of patients presenting with undifferentiated
    symptoms or acute illness of unknown etiology.
  3. Demonstrate the ability to maintain up to date knowledge of consultation medicine and apply it to
    the care of patients.
  4. Demonstrate expertise in medical peri-operative care including risk stratification, risk modification
    and post-operative medical management.  
  5. Demonstrate expertise in the management of medical problems of pregnancy, including an
    understanding of the physiological changes in pregnancy, the impact of pregnancy on medical
    disorders and the application of therapeutics in pregnancy.
  6. Recognize drug interactions and side-effects.  
  7. Develop an approach to the following clinical problems of pre and postoperative care:
  • operative cardiovascular risk evaluation using risk indices
  • appropriate use of preoperative diagnostic tests and implementation of guidelines
  • management of medication, anticoagulation, and steroids in the perioperative              
    period        
  • management of diabetes mellitus and hypertension in the perioperative period
  • DVT and endocarditis prophylaxis
  • approach to postoperative cardiac and respiratory complications                                       
  • approach to postoperative delirium
  • approach to postoperative electrolyte abnormalities
  • medical complications of pregnancy, including diabetes, hypertension, thyroid              
  • disease, thromboembolic disease
  1. Apply knowledge and technical expertise in performing the following which may become necessary
    to perform as a general internal medicine consultant on a patient under the care of another
    physician or specialist, interpreting the results and demonstrating an understanding of their
    limitations and complications:
  • central venous catheter insertion;
  • lumbar puncture;
  • peripheral arterial catheter insertion;
  • abdominal paracentesis;
  • endotracheal intubation;
  • thoracentesis;
  • knee joint aspiration;
  • electrocardiographic interpretation.
  1. For any of the following procedural skills, diagnostic and therapeutic, that are sometimes necessary
    to perform when the patient is under the care of another physician or specialist, the trainee will be
    able to describe the indications, the contraindications, the potential complications and the available
    alternatives.  For any given procedure, the trainee will be able to interpret the results. Trainees
    should be able to ensure adequate follow-up is arranged for procedures performed or requested.  
    Acquiring expertise in these procedural skills should be based on the needs of the community
    wherein the trainee is expecting to practice and will vary between trainees. Training in additional
    procedures to those listed may be required depending on future practice location.
  • Ambulatory blood pressure monitoring
  • Exercise stress testing (including nuclear tests)
  • Hemodynamic monitoring
  • Temporary Pacemaker Insertion
  • Ambulatory ECG Monitoring
  • Elective Cardioversion
  • Transthoracic Pacing
  • Echocardiography
  • Chest Tube Insertion
  • Pulmonary Function Testing and Spirometry
  • Overnight oximetry
  • Mechanical Ventilation
  • Endoscopic Procedures (bronchoscopy, gastroscopy, colonscopy and sigmoidoscopy)  
  • Bone Marrow Aspiration and Biopsy
  • Skin Biopsy
  • Joint Aspiration and injection
  • Hemodialysis and peritoneal dialysis
  • Renal Biopsy
  • Thyroid Biopsy
  • Liver Biopsy

2.   Communicator
Enabling Competencies:
  1. Provide clear, concise and timely verbal and written communication to other specialties such as
    surgery, obstetrics, family medicine and/or other subspecialists involved in the care of the patient.
  2. Discuss the risk-benefit of diagnostic and therapeutic options in patients with multi-system illness,
    and/or in the setting of pregnancy and surgery.
  3. Define the role of a consultant versus a primary care giver while involved in the care of surgical
    psychiatric and obstetrical patients.  

3.   Collaborator
Enabling Competencies:
  1. Facilitate the integration of patients with the health care team and the health care community,
    including:
  • Transition from hospital care to the ambulatory care setting.
  • Transition from diagnostic care under a general internist to therapeutic care by another
    subpecialist (example, treatment of newly diagnosed lung cancer).
  1. Facilitate the care of patients through partnerships with the surgical and/or obstetrical team.

4.   Manager
Enabling Competencies:  
  1. Coordinate multiple diagnostic and therapeutic interventions.
  2. Demonstrate understanding of human resource, financial and record keeping issues pertaining to
    running a medical office.
  3. Set priorities and manage time to balance patient care, practice requirements, outside activities and
    personal life.
  4. Demonstrate ability to manage patient care information obtained in both acute and ambulatory care
    settings and ensure appropriate and timely follow-up.
  5. Implement processes to ensure personal practice improvement.
  6. Employ information technology appropriately for patient care.
  7. Appreciate the value of intervention (or not) in patients with terminal disease, and investigate,
    treat as appropriate to such special circumstances.
  8. Participate in systemic quality process evaluation and improvement, such as patient safety
    initiatives.

5.   Health Advocate
Enabling Competencies:
  1. Promote preventive health care (e.g. smoking cessation, treatment of dyslipidemia, hypertension,
    obesity, sedentary lifestyle, and alcoholism) as appropriate to the medical consultation setting.
  2. Implement preventive strategies for example, and including, vaccination, cancer screening and the
    treatment of osteoporosis, as appropriate to the medical consultation setting
  3. Identify and discuss end of life issues and facilitate end of life care.
  4. Promote discussions about end of life care.
  5. Demonstrate ability to promote appropriate and timely care for patients under the care of other
    physicians or specialists.
  6. Facilitate the link between primary care physicians, specialty, and subspecialty medicine to benefit
    the care of patients.
  7. Demonstrate understanding of the principles of evaluation and management of patients with
    potential emerging and epidemic diseases (example SARS).

6.   Scholar
Enabling Competencies:
  1. Demonstrate scholarly activity in one or more of the following categories as it applies to the practice
    of medical consultation:
  • Medical Education (example innovation in medical education).
  • Research (example Medical Education, Clinical Epidemiology, Basic Science, Clinical Research,
    and Clinical Trials).
  • Administration (example Health Care Policy and Economics).
  1. Demonstrate the ability to formulate focused questions related to medical consultation practice, and
    use a variety of search skills and resources to access and appraise appropriate information.  
  2. Demonstrate effective teaching skills in the knowledge areas unique to general internal medicine
    including CME activity, and in the teaching and supervision of junior housestaff and medical
    students.
  3. Implement a personal knowledge management system.

7.   Professional
Enabling Competencies:
  1. Demonstrate a sound understanding of ethical principles and moral values and apply this to the
    management of general internal medicine patients and patients under the care of other physicians
    and specialists during illness and at end of life.
  2. Recognize limitations in skill set and knowledge including knowing when to involve another care
    provider.
  3. Demonstrate an ability to set boundaries consistent with safe and effective patient care.
  4. Participate in finding solutions for the health care needs of society.
  5. Recognize the particular complexities of the ethics of providing patient care as a medical consultant.
R4 Rotation Objectives