Rationale
The intensive care unit (ICU) is a complex and dynamic environment. It has many challenges for its health care providers. Despite literature that indicates care offered by subspecialists trained in critical care medicine (CCM) improves patient outcomes at a lesser cost1,2, most ICUs in the United States are staffed by non-CCM–board certified physicians. This situation is likely to persist or increase due to the projected shortage in the number of intensivists over the next two decades3. Because many of these non–critical care trained providers are internists, CCM training is becoming more and more a priority for many internal medicine residency programs.
Despite this growing need, the education of residents in CCM is challenging. The unpredictability of patients’ illnesses and the schedule of the day in ICUs, residents’ duty hour restrictions, and focus on patient safety and quality of care are some factors that may compromise this achievement. These stresses on the current graduate medical education curriculum may generate conflicts between providing optimal patient care and resident education. Therefore, an efficient, transformative, and updated curriculum of medical education should be established, reviewed and implemented that achieves the dual goals of providing high-quality patient care and excellent resident education.
Although guidelines for CCM training have been published to promote excellence in CCM education4, a well-formed curriculum has not been established5,6. It would be needed to identify current teaching practices, resources, and environments. Many studies have reported suboptimal training of residents in some CCM practices and topics, such as mechanical ventilation7–11 and variation in the amount of efforts devoted to education in acute illness12,13. In addition, methods for teaching residents in the ICU have changed little since the Accreditation Council for Graduate Medical Education (ACGME) instituted duty hour standards and the general competencies14. These deficiencies and apparent lack of progress in CCM medical education may not only affect patient care but may discourage residents from pursuing a career in this field15.
It is hard to find in literature CCM teaching practices and learning environments in internal medicine residency programs. It is also not clear which methods or practices are optimal for resident education in CCM. This curriculum will outline a learning environment within a dynamic and unpredictable day of practice in the Medical ICU (MICU), of Duke University Hospital, for second year Internal Medicine Residents. Medical residents will achieve better learning outcomes, which fulfill their abilities for managing critically-ill patients.
Curriculum Orientation
Duke University has established strong graduate medical education programs. The Internal Medicine Residency Training Program is one of the strong programs in the institution. Clinical rotations in the MICU are considered core rotations during first, second and third year of internal medicine residency training program. All clinical rotations follow the mission, vision and values of the program and the Department of Medicine. The curriculum, in such a dynamic unit, represents the best products of the intellectual practices and studies in this field, the Transactional development of adult cognitive processing and the Transformational development in all aspects of health care on individual level to achieve self-actualization, with integration of the cognitive, social, affective, somatic, aesthetic and spiritual values. I prefer that you not talk about “transmission” which has been debunked by cognitive learning theory. We can’t “give” students new learning.
Mission
Duke Internal Medicine Residency Program trains and educates excellent physicians to provide health care in a comprehensive and an outstanding clinical method. The program will ensure that the resident acquires the essential core clinical skills, confidence, independence and professionalism required for delivering the highest quality of medical care to patients, with diverse types of acute or chronic diseases. It will improve local, national, and global health through clinical excellence, biomedical research, and graduate medical education.
Vision
Duke Internal Medicine Residency Program follows the vision of Duke School of Medicine. The program will educate and train future clinical and scientific leaders by:
· Engaging learners with early, meaningful, and relevant clinical experiences.
· Creating an innovative, transformative curriculum that both individualizes the learning process and ensures competency.
· Allowing learners to investigate in the lab or clinic to advance patient care.
· Addressing health disparities and preventative care in our community and around the world.
· Promoting teamwork, interpersonal communication, and collaboration with others.
Values
Professionalism – a compassion and respect for all people with integrity in all behavior.
Innovation – creativity and problem-solving to conquer current and future challenges.
Excellence – excellence in effective, equitable, high quality and safe patient care.
Scholarship – critical thinking and scientific inquiry to contribute to current knowledge.
Leadership – develop skills of lifelong learning as future leaders.
Teamwork – collaborating with others in the quest for excellence.
Service – every small effort can improve our world.
Diversity – representing and serving all people without prejudice.
Discovery – using clinical problems to guide our investigation in the lab or clinic to improve patient care and quality.
Aim
By the end of this rotation, residents will assess, evaluate and manage critically-ill patients in the medical intensive care setting.
References
Pronovost PJ, Angus DC, Dorman T, etal. Physician staffing patterns and clinical outcomes in critically-ill patients: a systematic review. JAMA. 2002;288(17):2151–2162.
Pronovost PJ, Jenckes MW, Dorman T, et al. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA.1999;281(14):1310–1317.
Angus DC, Kelley MA, Schmitz RJ, et al. Caring for the critically-ill patient: current and projected workforce requirements for care of the critically-ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762–2770.
Dorman T, Angood PB, Angus DC, et al. Guidelines for critical care medicine training and continuing medical education. Crit Care Med. 2004;32(1):263–272.
Barrett H, Bion JF. An international survey of training in adult intensive care medicine. Intensive Care Med. 2005;31(4):553–561.
Shen J, Joynt GM, Critchley LA, et al. Survey of current status of intensive care teaching in English-speaking medical schools. Crit Care Med. 2003;31(1):293–298.
Cox CE, Carson SS, Ely EW, et al. Effectiveness of medical resident education in mechanical ventilation. Am J Respir Crit Care Med. 2003;167(1):32–38.
Hayes CW, Rhee A, Detsky ME, et al. Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents. Crit Care Med. 2007;35(7):1668–1672.
Morgan R, Westmoreland C. Survey of junior hospital doctors’ attitudes to cardiopulmonary resuscitation. Postgrad Med J. 2002;78(921):413–415.
Nadel FM, Lavelle JM, Fein JA, et al. Assessing pediatric senior residents’ training in resuscitation: fund of knowledge, technical skills, and perception of confidence. Pediatr Emerg Care.2000;16(2):73–76.
Scott G, Mulgrew E, Smith T. Cardiopulmonary resuscitation: attitudes and perceptions of junior doctors. Hosp Med. 2003;64(7):425–428.
Hanson CW III, Durbin CG Jr, Maccioli GA, et al. The anesthesiologist in critical care medicine: past, present, and future. Anesthesiology. 2001;95(3):781–788.
Trainor JL, Krug SE. The training of pediatric residents in the care of acutely-ill and injured children. Arch Pediatr Adolesc Med. 2000;154(11):1154–1159.
Chudgar SM, Cox CE, Que LG, et al. Current teaching and evaluation methods in critical care medicine: has the Accreditation Council for Graduate Medical Education affected how we practice and teach in the intensive care unit? Crit Care Med. 2009;37(1):49–60.
Lorin S, Heffner J, Carson S. Attitudes and perceptions of internal medicine residents regarding pulmonary and critical care subspecialty training. Chest. 2005;127(2):630–636.
Updated @July 2015