RESIDENCY TRAINING

CURRICULUM
FOR
INTERNAL MEDICINE
2010
[Draft Copy]

DEPARTMENT OF MEDICINE
Bangabandhu Sheikh Mujib
Medical University
Dhaka, Bangladesh
 Contents
Items Page No.
1. Introduction
1.1 About Internal Medicine
1.2 The Modern-Day Physician
1.3The Science and ART of Medicine
1.4The competency-based curriculum
2. Mission statement
3. General objectives
4. Educational Objectives
5. Teaching and Learning Methods
6. Entry requirements
7. Rotations in phase A
8. Contents of learning
Syllabus: Applied basic sciences
8.1.1. Anatomy course content
8.1.2. Physiology course content
8.1.3. Biochemistry and clinical chemistry course content
8.1.4. Pathology course content
8.1.5. Microbiology
8.1.6. Virology
8.1.7. Genetics & Immunology
8.1.8. Clinical Pharmacology
8.1.9. Statistics and (in phase B)
Syllabus: Clinical and procedural competencies
8.2.1. General clinical competencies:
8.2.1.1. History taking
8.2.1.2. Clinical examinations
8.2.1.3. Decision making and clinical reasoning
8.2.1.4. Therapeutics and safe prescribing
8.2.2. Symptom based competencies
8.2.3. Management of acute medical problems
8.2.4. System based competencies
8.2.4.1. Palliative care and End of Life care
8.2.4.2. Cardiology
8.2.4.3. Endocrinology and metabolic disorders including
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diabetes mellitus
8.2.4.4. Gastroenterology and hepatology
8.2.4.5 Hematology
8.2.4.6. Psychiatry/ Mental health disorder
8.2.4.7. Rheumatology / Disorders of Musculoskeletal
system
8.2.4.8 Neurology/ Disorders of neurological system
8.2.4.9. Nephrology/ Disorders of the renal and
genitourinary systems
8.2.4.10. Pulmonary Medicine/Disorders of the Respiratory
and sleep system
8.2.4.11. Dermatology/Skin disorders
8.2.4.12. Infectious diseases
8.2.4.13. Otolaryngology and ophthalmology
8.2.4.14. Oncology
8.2.4.15. Genetic diseases
8.2.5. Medicine throughout the lifespan/growth and
development
8.2.5.1. Manage common medical problems in pregnancy
8.2.5.2. Manage problems in the older patients/Elderly/
Geriatrics
8.2.5.3. Manage common problems associated with the
menopause/Women’s Health
8.2.5.4. Public Health Issues and Health Promotion
8.2.5.5. Evidence-Based Medicine (EBM)
8.2.6. Investigational competencies
8.2.7. Procedural competencies
8.3. Educational syllabus
8.3.1. Maintaining good medical practice
8.3.2. Professional behavior
8.3.3. Ethics and legal issues
8.3.4. Patients’ education and prevention
8.3.5. Team working and leadership
8.3.6. Teaching and educational supervision
8.3.7. Patients’ safety
8.3.8. Infection control
8.3.9. Clinical governance
8.3.10. Information technology, computer assisted
learning and information management
8.3.11. Research
9. Assessment strategy
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10. Trainee supervision and feedback

11. Curriculum implementation strategies
12. Curriculum review
13. Annexure

1. Introduction
1.1. About Internal Medicine (Ref. ACP)

What does "internal medicine" mean?

The term "Internal Medicine" comes from the German term Innere Medizin, a
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discipline popularized in Germany in the late 1800s to describe physicians who

combined the science of the laboratory with the care of patients. Many early 20th
century American doctors studied medicine in Germany and brought this medical
field to the United States. Thus, the name "internal medicine" was adopted. Like
many words adopted from other languages, it unfortunately doesn't exactly fit an
American meaning.

Doctors of internal medicine focus on adult medicine and have had special study and
training focusing on the prevention and treatment of adult diseases. At least three of
their seven or more years of medical school and postgraduate training are dedicated
to learning how to prevent, diagnose, and treat diseases that affect adults. Internists
are sometimes referred to as the "doctor's doctor," because they are often called upon
to act as consultants to other physicians to help solve puzzling diagnostic problems.

What's an "internist"?

Simply put, internists are Doctors of Internal Medicine. Doctors for Adults.® But
they are referred to by several terms, including "internists," "general internists" and
"doctors of internal medicine." But don't mistake them with "interns," who are
doctors in their first year of residency training. Although internists may act as
primary care physicians, they are not "family physicians," "family practitioners," or
"general practitioners," whose training is not solely concentrated on adults and may
include surgery, obstetrics and pediatrics.

Role of an internist: Caring for the whole patient

Internists are equipped to deal with whatever problem a patient brings -- no matter
how common or rare, or how simple or complex. They are specially trained to solve
puzzling diagnostic problems and can handle severe chronic illnesses and situations
where several different illnesses may strike at the same time. They also bring to
patients an understanding of wellness (disease prevention and the promotion of
health), women's health, substance abuse, mental health, as well as effective
treatment of common problems of the eyes, ears, skin, nervous system and
reproductive organs.

Role of an internist: Caring for patient’s life

In today's complex medical environment, internists take pride in caring for their
patients for life -- in the office or clinic, during hospitalization and intensive care,
and in nursing homes. When other medical specialists, such as surgeons or
obstetricians, are involved, they coordinate their patient's care and manage difficult
medical problems associated with that care.

Internal medicine subspecialties

Internists can choose to focus their practice on general internal medicine, or may
take additional training to "subspecialize" in one of 13 areas of internal medicine.
Cardiologists, for example, are doctors of internal medicine who subspecialize in
diseases of the heart. The training an internist receives to subspecialize in a
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particular medical area is both broad and deep. Subspecialty training (often called a
"fellowship" in USA) usually requires an additional one to three years beyond the
standard three year general internal medicine residency.
1.2 The Modern-Day Physician

No greater opportunity, responsibility, or obligation can fall to the lot of a human

being than to become a physician. In the care of the suffering, [the physician] needs
technical skill, scientific knowledge, and human understanding. . . . Tact,
sympathy, and understanding are expected of the physician, for the patient is no
mere collection of symptoms, signs, disordered functions, damaged organs, and
disturbed emotions. [The patient] is human, fearful, and hopeful, seeking relief,
help, and reassurance.

–Harrison's Principles of Internal Medicine, 1950

The practice of medicine has changed in significant ways since the first edition of this
book appeared in 1950. The advent of molecular biology with its enormous
implications for the biological sciences (the sequencing of the human genome),
sophisticated new imaging techniques, and advances in bioinformatics and
information technology have contributed to an explosion of scientific information
that has fundamentally changed the way we define, diagnose, treat, and prevent
disease. This explosion of scientific knowledge is not at all static as it continues to
intensify with time.

The widespread use of electronic medical records and the Internet have altered the
way we practice medicine and exchange information. As today's physician struggles
to integrate the copious amounts of scientific knowledge into everyday practice, it is
important to remember that the ultimate goal of medicine is to treat the
patient. Despite more than 50 years of scientific advances since the first edition of
this text, it is critical to underscore that cultivating the intimate relationship that
exists between physician and patient still lies at the heart of successful patient care.

1.3 The Science and ART of Medicine

Science-based technology and deductive reasoning form the foundation for the
solution to many clinical problems. Spectacular advances in biochemistry, cell
biology, and genomics, coupled with newly developed imaging techniques, allow
access to the innermost parts of the cell and provide a window to the most remote
recesses of the body. Revelations about the nature of genes and single cells have
opened the portal for formulating a new molecular basis for the physiology of
systems. Increasingly, we understand how subtle changes in many different genes
can affect the function of cells and organisms. We are beginning to decipher the
complex mechanisms by which genes are regulated. We have developed a new
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appreciation of the role of stem cells in normal tissue function and in the
development of cancer, degenerative disease, and other disorders. The knowledge
gleaned from the science of medicine has already improved and undoubtedly will
further improve our understanding of complex disease processes and provide new
approaches to disease treatment and prevention. Yet skill in the most sophisticated
application of laboratory technology and in the use of the latest therapeutic modality
alone does not make a good physician.

When a patient poses challenging clinical problems, an effective physician must be

able to identify the crucial elements in a complex history and physical examination,
to order the appropriate laboratory tests, and to extract the key results from the
crowded computer printouts of data to determine whether to "treat" or to "watch."
Deciding whether a clinical clue is worth pursuing or should be dismissed as a "red
herring" and weighing whether a proposed treatment entails a greater risk than the
disease itself are essential judgments that the skilled clinician must make many times
each day. This combination of medical knowledge, intuition, experience, and
judgment defines the art of medicine, which is as necessary to the practice of
medicine as is a sound scientific base.

1.4 The competency-based curriculum

A key trend in postgraduate medical education is a move to a model in which the
emphasis has changed to focus on the product and the expected learning outcomes.
In outcome based education, the learning outcomes are clearly specified and
decisions about the content of training and how it is organized, the educational
strategies, the assessment procedures, and the educational environment are made in
the context of the stated learning outcomes. A competency-based, outcome oriented
curriculum has become, to a large extent, the standard in postgraduate medical
education.

The new Internal Medicine curriculum reflects the changes in practice in hospitals
where “true” general medical wards and clinics are diminishing in number but also
recognizes that an increasing number of patients have complex medical problems
involving multiple problems. It is, therefore, expected that through this curriculum, a
trainee in Internal Medicine will acquire skills, knowledge and attitudes in broad
aspects of Medicine encompassing both acute and chronic illnesses.

2. Mission statement
The mission of the residency program in Internal Medicine is

i) To prepare the Internists who would be able to meet and respond to the
changing healthcare needs and expectation of the society
ii) To develop Internists who posses knowledge, skills and attitudes that will
ensure that they are competent to practice Medicine safely and effectively.
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iii) To ensure that they have appropriate foundation for lifelong learning and
further training in their specialty
 iv) To help them develop to be critical thinkers and problem solvers when
managing health problems in the community they serve

3. General objectives
The objectives of the Residency program in Internal Medicine are to
produce medical specialists who:

1. Can address all aspects of the healthcare needs of patients and their families
2. Have acquired and developed leadership and team working skills, especially
with other healthcare professionals, to deliver patient centred care
3. Maintain the highest standards appropriate in their professional field and
show themselves able to respond constructively to assessments and appraisals
of professional competence and performance
4. Are aware of current thinking about ethical and legal issues
5. Are able to act as safe independent practitioners whilst recognising the
limitation of their own expertise and are able to recognise their obligation to
seek assistance of colleagues where appropriate.
6. Are aware of the procedures, and able to take appropriate action, when things
go wrong, both in their own practice and in that of others
7. Will be honest and objective when assessing the performance of those they
have supervised and trained
8. Manage time and resources to the benefit of themselves, their patients and
colleagues
9. Can take advantage of Information Technology to enhance all aspects of
patient care
10. Can develop management plans for the “whole patient” and maintain a
knowledge in other areas of medicine which impinge on the specialty of
cardiovascular medicine
11. Understand that more effective communication between cardiologists and
their patients can lead to more effective treatment and care
12. Apply appropriate knowledge and skill in the diagnosis and management of
patients with cardiovascular disorders
13. Establish a differential diagnosis for patients presenting with cardiovascular
problems by the appropriate use of the clinical history examination and
investigations
14. Are competent to perform the core investigations and procedures required in
cardiovascular medicine
15. Develop clinical practice which is based on an analysis of relevant clinical
trials and to have an understanding of other research methodologies
16. Are able to apply the knowledge of biological and behavioural sciences in
clinical practice
17. Are able to identify and take responsibility for their own educational needs
and the attainment of these needs.
18. Have developed the skills of an effective teacher.
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4. Educational Objectives
At the completion of training, the resident will have acquired the following seven
roles of an ideal physician as described in The Can Meds framework: Annexure 2

5. Teaching and Learning Methods

Adults learn by

• Reflecting and building upon their own experiences

• Identifying what they need to learn
• Being involved in planning their education and training
• Evaluating the effectiveness of their learning experiences.

For Internal Medicine trainees to maximize their learning opportunities it is

important that they work in a ‘good learning environment’. This includes
encouragement for self-directed learning as well as recognizing the learning potential
in all aspects of day to day work. There should be a positive attitude to training with
learning from peers being encouraged. There should be active involvement in group
discussion as this is an important way for doctors to share their understanding and
experiences. A supportive open atmosphere should be cultivated and questions
welcomed. The bulk of learning occurs as a result of clinical experience (experiential
learning, on-the-job learning) and self-directed study. The degree of self-direct
learning will increase as trainees become more experienced. Lectures and formal
educational sessions make up only a small part of the postgraduate training in
Medicine.
The list of learning opportunities below offers guidance only. There are other
opportunities for learning that are not listed here. Trainees will learn in different
ways according to their level of experience. Trainees should regularly update their
personal portfolio to keep a personal record, and be able to present to others, the
evidence of the learning methods used.

Experiential Learning Opportunities:

1. Every patient seen, on the ward or in out-patients, provides a learning opportunity,
which will be enhanced by following the patient through the course of their illness.
Patients seen should provide the basis for critical reading around clinical
problems.
2. Every time a trainee observes another doctor, consultant or fellow trainee, seeing a
patient or their relatives there is an opportunity for learning.
3. Ward-based learning including ward rounds. Ward rounds should be led by a
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consultant and include feed-back on clinical and decision making skills.

4. Supervised consultations in outpatient clinics. Trainees should have the
opportunity to assess both new and follow-up patients and discuss each case with
 the supervisor so as to allow feedback on diagnostic skills and gain the ability to
plan investigations.
5. Trainees need to learn to make increasingly independent decisions on diagnosis,
investigations and treatment consistent with their level of experience and
competence and with maintaining patient safety. These decisions should be
reviewed with their supervisors.
6. There are many situations where clinical problems are discussed with clinicians in
other disciplines, such as multidisciplinary medical boards or meetings. These
provide excellent opportunities for observation of clinical reasoning.

Training in Practical Procedures: Undertaking supervised practical procedures

in different sub-specialty of Medicine with a consultant or more senior trainee,
including the care and counseling of the patient/carers before and after the
procedure, is the key method of gaining competence in these aspects of the
curriculum. Also with advances in technology the use of simulators will play an
increasing part in the training of practical procedures. As trainees gain experience
they will progress from observing to performing and from simple to more complex
cases. Trainees should maintain a logbook of experience. Where appropriate the
curriculum indicates the likely minimum number of procedures thought necessary to
encompass a sufficiently broad spectrum of clinical experience to define performance
or “does” in Miller’s triangle.

Small Group Learning Opportunities:

1. Case presentations and small group discussion, particularly of difficult cases,
including presentations at clinical and academic meetings. This should include
critical incident analysis.
2. Small group bedside teaching, particularly covering problem areas identified by
trainees.
3. Small group sessions of data interpretation, particularly covering problem areas
identified by trainees. Participation in audit meetings, journal clubs and research
presentations etc.

One-to-One Teaching:
1. Review of out-patients, ward referrals or in-patients with supervisor.
2. Review/case presentations with educational supervisor including selected notes,
letters and summaries.
3. Critical incident analysis.
4. Discussion between trainee and trainer of knowledge of local protocols.
5. Feedback following assessments provides excellent teaching opportunities.

Formal postgraduate teaching:

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Examples include:
i) Lectures both clinical and preclinical
 ii) Morning sessions- Journal clubs, case presentations, grand round s
iii) Joint specialty meeting
iv) Attendance in training program organized by deanery/ other academic body
v) Attending lectures on educational syllabus

Independent self directed learning

Trainees will use this time in a variety of ways depending upon their stage of
learning. Suggested activities include:
i) Reading, including web-based material
ii) Maintenance of personal portfolio (self-assessment, reflective learning,
personal
development plan)
iii) Reading journals
iv) Writing reviews and other teaching materials
v) Achieving personal learning goals beyond the essential, core curriculum

Teaching Others:
1. Teaching undergraduate medical students and students in allied health professions
and postgraduate doctors provides excellent learning opportunities for the teacher.
2. Presenting cases at grand rounds or similar clinical meetings provides the
opportunity to review the literature relating to the clinical case. This provides the
opportunity for in depth study of one clinical problem as well as learning important
critical thinking and communication skills.
3. Journal club presentations allow development of critical thinking and in depth
study of particular areas.

Community based/ community oriented learning: In future

Problem based learning (PBL): In future

Audit and Guidelines: In future

Participation in audit: trainees should be directly involved and expect, after
understanding the rationale and methodology, to undertake a minimum of one in-
depth audit every in two-years of training. Trainees should be involved in guideline
generation and review.

Research (In phase B)

Development of research competencies forms an important part of the curriculum as
they are an essential set of skills for effective clinical practice.
Undertaking research helps to develop critical thinking and the ability to review
medical literature. Clinical research also allows development of particular expertise
in one area of medicine allowing more in depth knowledge and skills and helping to
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focus long term career aims and interests. It is therefore highly likely that many
 trainees in Internal Medicine with the appropriate aptitude and desire will wish to
take the opportunity to spend extra time in research during the training period.

6. Entry requirements
i) Graduation from an accredited institute with MBBS or equivalent
ii) One year after successful completion of internship
iii) Registration with BMDC
7. Rotations in phase A
Total duration: 24 months

• Last 3 months (22nd,23rd & 24th month) of the part A: will be allotted for
Assessment
• The remaining 21 months will be divided into 7 BLOCKS each comprising of 3
months as follows:

BLOCK SPECIALITY DURATION

(months)
1 Internal Medicine 3
2 Cardiology 3
3 Rheumatology, Endocrine & 3
Respiratory Medicine ( 1 month each)
4 Gastroenterology or Hepatology 3
5 Neurology 3
6 Haematology, Nephrology 3

(1& ½ month each)

7 Dermatology, Psychiatry & ICU 3
( 1 month each)
8. Contents of learning
Competencies are defined as the ability to use knowledge, skills and appropriate
attitudes and personal qualities to solve clinical problems in professional, ethical,
and proficient way for optimal patient and societal outcome
This section lists the contents of the syllabus including applied basic medical
sciences, clinical rotations and generic skills.
Each stage/phase of learning in the curriculum has defined the competences to be
attained by the trainee within the domains of knowledge, skills and
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attitude/behaviors.
8.1. Syllabus: Applied basic sciences

8.1.1. Anatomy course content

i) Cardiology: conductive system of heart and accessory pathways, coronary
circulation, pulmonary circulation, cardiac valves, branches of aortic arch,
jugular veins
ii) Gastrointestinal tract: gross structure of GI tract, gastro-esophageal sphincter
iii) Gross structure of liver, porto systemic circulations, blood supply of liver,
portal vein
iv) Neuroanatomy: cerebral blood supply, gross structure of brain including
limbic system, basal ganglia, extra pyramidal system optic pathway, internal
capsule, corticospinal tracts, sensory tracts, course of cranial nerves &
phrenic, radial medial and ulnar, recurrent laryngeal nerve nerves, branches
of dermatomes of clinical significance, brachial plexus, ventricles of the brain
and CSF system
v) Structure of bone, joints, muscle and synovium with special emphasis on
synovial joint.
vi) Renal system: structure of kidney, nephron, glomerulus, male and female
genital tract
vii) Respiratory system: gross structure of lung including airways, broncho-
pulmonary segments, concept of anatomical dead space, thoracic duct
viii) Anatomy of thyroid and parathyroid glands

8.1.2. Physiology course content

i) Fluid & electrolytes: Physiology of body fluids, fluid and electrolytes
requirements in well and unwell patients, Acid base balance, contents of
commonly available replacement fluids.
ii) Pain: pathophysiology
ii) Regulation of body temperature
iii) Cardiology: production of heart sounds and murmurs in relation to
cardiac cycle, factors governing cardiac output, cardiac performances control
of blood pressure
iv) Hormones: Functions of hormones of hypothalamus, anterior and
posterior pituitary, thyroid hormones, adrenal glands, pancreas; hormone
receptors, feedback control of hormones, RAA system
v) GI tract: Control of gastric, pancreatic and intestinal secretions,
digestion of fat protein carbohydrate & absorption of end products of
digestion of fat, protein & carbohydrate, small and large intestinal motility, GI
hormones
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vi) Liver: blood supply in liver, functions of liver

 vii) Blood: structure of hemoglobin, control of hemopoesis, coagulation
cascades & fibrinolytic pathway, mechanism of homeostasis, mechanisms of
hemolysis, structure of spleen lymph nodes and other lymphoid tissues
viii) CNS: Neurotransmitters and neurotransmission
ix) Renal: Function of kidneys, Renal transport of sodium, potassium,
action of ADH, urine formation and its composition, site of action of diuretics,
principles of measurement of GFR, creatinine clearance
x) Respiratory system: Gas exchange, basic respiratory physiology to
interpret the lung function tests,
xi) Physiological changes associated with normal pregnancy and lactation
xii) Physiological changes associated with peri and post-menopausal period

8.1.3. Biochemistry and clinical chemistry course content

i) Metabolism: fat, protein, carbohydrate, Vitamin D, calcium: glycolytic pathway, TCA
cycle, gluconeogenesis, lactate production, pentose phosphate pathway, glycogenesis,
glycogenolysis, ketone body formation, cholesterol metabolism, lipolysis, lipid
transport & lipoproteins, Purine metabolism, prostanoid (eicosanide) metabolism,
disorders of globin synthesis, metabolism of haem.
ii) Fallacies in interpretations of biochemical reports

8.1.4. Pathology course content

i) Acute and chronic Inflammation, healing & repair
ii) Cardiovascular: atherosclerosis
iii) Cellular pathology: cell growth and aging, cell injury, death & apoptosis
iv) Molecular and cellular oncogenesis
v) Haemodynamic disorders: edema, thrombosis, embolism, infarction, shock
vi) How to preserve and transport histopathological specimens

8.1.5. Microbiology course content

i) Infection control: Universal precautions, hospital practices to reduce risk, isolation
procedures, hand washing
ii) General principles of microbial pathogenesis
iii) How to collect, preserve, transport microbiological specimens specially blood and
urine
iv) Gram positive and gram negative bacterial
v) Antimicrobial drug resistance
vi) Common pathogenic fungi, and their diagnosis

8.1.6. Virology course content

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i) General discussion of HBV, HCV, HIV

 8.1.7. Genetics & Immunology course content
i) Genetics of thalassemia
ii) Autoimmunity
iii) Hypersensitivity reactions
iv) Cells involved in the immune response
v) HLA system
vi) Structure of human gene, DNA, RNA
vii) Protein synthesis
viii) Human Genome project
ix) Defn of Polymorphism, mutation, trisomy, deletions, Philadelphia chromosomes
x) Principles of Mendelian, sex-linked, mitochondrial, polygenic inheritance
xi) Genetic basis of disease: genetic mechanism of disease, basic knowledge of the
common genetic disorders as well as understanding of commonly used genetic tests
including PCR
xii) Principles of gene therapy
xiii) Principles of blood grouping, blood transfusion, rhesus incompatibility
xiv) Transplant immunology including graft rejection and GVH reaction
xv) principles of Coomb’s test, CFT

8.1.8. Clinical Pharmacology ( linked to …………)

8.1.9. Statistics and……. ( in phase B)

i) Incidence, prevalence, accuracy, precision, predictive value, correlation
ii) Sensitivity, specificity
iii) Measures of central tendency
i) Frequency distribution
ii) Measures of dispersion
iii) Probability distribution
iv) Sampling
v) Hypothethesis testing and statistical significance
vi) Test of significance
vii) Protocol writing
viii) Writing of scientific paper

8.2. Syllabus: Clinical and procedural competencies

8.2.1. General clinical competencies: i) History taking, ii) clinical

examinations, iii) decision making and clinical reasoning, and iv)
Therapeutics and safe prescribing
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8.2.2. Symptom based competencies

 8.2.3. Management of acute medical problems

8.2.4. System based competencies

8.2.5. Medicine throughout the lifespan/growth and development

8.2.6. Investigational competencies

8.2.7. Procedural competencies

8.3. Educational syllabus

8.3.1. Maintaining good medical practice

8.3.2. Professional behavior

8.3.3. Ethics and legal issues

8.3.4. Patients’ education and prevention

8.3.5. Team working and leadership

8.3.6. Teaching and educational supervision

8.3.7. Patients’ safety

8.3.8. Infection control

8.3.9. Clinical governance

8.3.10. Information technology, computer assisted learning and information

management

8.3.11. Research

8.2.1. General clinical competencies

8.2.1. 1. History taking

The written history of an illness should include all the facts of medical significance in
the life of the patient. Recent events should be given the most attention. The patient
should, at some early point, have the opportunity to tell his or her own story of the
illness without frequent interruption and, when appropriate, receive expressions of
interest, encouragement, and empathy from the physician. Any event related by the
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patient, however trivial or seemingly irrelevant, may provide the key to solving the
medical problem. In general, only patients who feel comfortable will offer complete
information, and thus putting the patient at ease to the greatest extent possible
contributes substantially to obtaining an adequate history.

An informative history is more than an orderly listing of symptoms; by listening to

patients and noting the way in which they describe their symptoms, physicians can
gain valuable insight into the problem. Inflections of voice, facial expression,
gestures, and attitude, i.e., "body language," may reveal important clues to the
meaning of the symptoms to the patient. Because patients vary in their medical
sophistication and ability to recall facts, the reported medical history should be
corroborated whenever possible. The social history can also provide important
insights into the types of diseases that should be considered. The family history not
only identifies rare Mendelian disorders within a family but often reveals risk factors
for common disorders such as coronary heart disease, hypertension, or asthma. A
thorough family history may require input from multiple relatives to ensure
completeness and accuracy. However, once recorded, it can be readily updated. The
process of history-taking provides an opportunity to observe the patient's behavior
and to watch for features to be pursued more thoroughly during the physical
examination.

The very act of eliciting the history provides the physician with the opportunity to
establish or enhance the unique bond that forms the basis for the ideal patient-
physician relationship. This process helps the physician develop an appreciation of
the patient's perception of the illness, the patient's expectations of the physician and
the health care system, and the financial and social implications of the illness to the
patient. Although current health care settings may impose time constraints on
patient visits, it is important not to rush the history-taking since the patient may get
the impression that what he or she is relating is not of importance to the physician
and therefore may hold back relevant information. The confidentiality of the patient-
physician relationship cannot be overemphasized.

Learning objective: Elicit the history and obtain other relevant data.

Goal: To progressively develop the ability to obtain a relevant focused

history from increasingly complex patients and challenging
circumstances.

To rerecord accurately and synthesize history with clinical;

examination and formulation of management plan according to
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likely clinical evolution.

Knowledge

Recognize the importance of different elements of history

Recognize that patients do not present history in structured fashion

Know likely causes and risk factors for conditions relevant to mode of presentation

Recognize that history should inform examination, investigations and management

Recognize the different approaches of history taking as needed in various clinical

settings such as acute inpatient, emergency and ambulatory care

Recognize other potential sources of data (e.g., personal health records, medical
records, general practitioners, family physician, family members, carers, pharmacy
records etc)

Skills

Identify and overcome possible barriers to effective communication

Establish a rapport and professional relationship with patients, their carers and
relatives

Obtain a focused, efficient and accurate history

Records and presents accurate clinical history relevant to the clinical presentation

Elicit most important positive and negative indicators of diagnosis

Starts to ignore irrelevant information

Ability to obtain history in difficult circumstances e.g., angry or distressed patients/

relatives

Evaluate critically the history in light of the degree of functional impairment,

physical findings, and other data

Persist in seeking information to assist in clinical decision making

Revisit the history when clinical situation is not clear

Behaviors

Show respect and behave in accordance with Good Medical Practice

8.2.1. 2. Clinical examination

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The purpose of the physical examination is to identify the physical signs of disease.
The significance of these objective indications of disease is enhanced when they
confirm a functional or structural change already suggested by the patient's history.
At times, however, the physical signs may be the only evidence of disease.
The physical examination should be performed methodically and thoroughly, with
consideration for the patient's comfort and modesty. Although attention is often
directed by the history to the diseased organ or part of the body, the examination of a
new patient must extend from head to toe in an objective search for abnormalities.
Unless the physical examination is systematic and performed in a consistent manner
from patient to patient, important segments may be inadvertently omitted. The
results of the examination, like the details of the history, should be recorded at the
time they are elicited, not hours later when they are subject to the distortions of
memory. Skill in physical diagnosis is acquired with experience, but it is not merely
technique that determines success in eliciting signs of disease. The detection of a few
scattered petechiae, a faint diastolic murmur, or a small mass in the abdomen is not
a question of keener eyes and ears or more sensitive fingers, but of a mind alert to
these findings. Because physical findings can change with time, the physical
examination should be repeated as frequently as the clinical situation warrants.
Because a large number of highly sensitive diagnostic tests are available, particularly
imaging techniques, it may be tempting to put less emphasis on the physical
examination. Indeed, many patients are seen for the first time after a series of
diagnostic tests have already been performed and the results known. This should not
deter the physician from performing a thorough physical examination since clinical
findings are often present that have "escaped" the barrage of pre-examination
diagnostic tests.

Learning objective: Conduct an appropriate physical examination

Goals: To progressively develop the ability to perform focused and

accurate clinical examination in increasingly complex patients
and challenging circumstances
To relate physical findings to history in order to establish
diagnosis and formulate a management plan
Knowledge

Understand the need for valid clinical examination

Understand the basis for clinical signs and the relevance of positive and negative
physical signs

Recognize the limitations of physical examination and the need for adjunctive
functional/ screening test- mini mental state examination, GCS, depression score, 6-
minute walk tests etc

Skills
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Perform a through, accurate complete physical examination of new patients

Perform a focused clinical examination in selected settings

Tailors physical examination according to the patient’s history

Interpret physical signs accurately

Perform relevant adjunctive examination

Clearly documents examination findings

Behaviors

Considers patients dignity and the need for a chaperone for somer or all of the
examination

Demonstrate sensitivity to patients who are in pain, embarrassed or who are

vulnerable

8.2.1. 3. Decision making and clinical reasoning

Learning objective: Synthesize findings from history and physical

examination to develop a differential diagnosis
and management plan

Goal: To progressively develop the ability to formulate a diagnostic and

therapeutic plan for a patient according to the clinical information
available
To progressively develop the ability to prioritise the diagnostic
and therapeutic plan
To be able to communicate the diagnostic and therapeutic plan
appropriately
Knowledge

Define the steps of diagnostic reasoning: Interpret history and clinical signs,
Conceptualize clinical problem, generate hypothesis- test, refine, and verify
hypothesis, and develop action plan

Recognize how to use expert advice, clinical guidelines and algorithms

Know how relative and absolute risks are derived and the meaning of the terms
predictive value, sensitivity and specificity in relation to diagnostic tests

Knowledge reading normal values of different laboratory tests

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Skills
Interpret and integrate the history and physical findings

Formulate a complete and reasonable problem list with differential diagnoses and a
management plan

Priorities the problem list, particularly in patients with multiple medical problems

Priorities the urgency of individual investigations and treatment

Record history, examination findings, synthesizes, and plan for investigations and
management accurately and concisely

Develop provisional diagnosis (working diagnosis0, differential diagnosis on the

basis of clinical evidences

Institute appropriate investigation and therapeutic plan

Justify the diagnosis based on clinical information

Modifies working diagnosis based on new information or response to therapy

Provide instructions regarding frequency of observations, and clear instructions on

parameters for action

Elicit the co-morbities and other patients’ factors influencing the management plan

Apply quantitative data of risks and benefits of therapeutic intervention to an

individual patient

Communicate with the patient, their family and carers to develop a management
plan

Behavior

Recognize the difficulties in predicting occurrence of future events

Show willingness to discuss intelligibly with the notion and difficulties of prediction
of future events, and benefit/risks balance of therapeutic intervention

Be willing to facilitate patient choice

Show willingness to search for evidence to support clinical decision making

Demonstrate ability to identify one’s own biases and inconsistencies in clinical

reasoning

8.2.1. 4. Therapeutics and safe prescribing

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Learning objective: Prescribe appropriate and safe pharmacotherapy

Goal: To progressively develop ability to prescribe, review and monitor
appropriate medication relevant to clinical practice including
therapeutic and preventive indications.

Knowledge

Basic Science

Mechanism of drugs at the receptor and intracellular level

Principals of absorption, distribution, metabolism and excretion of drugs

Effects of aging, pregnancy, and lactation on pharmacokinetics

Importance of genetic alterations in drug metabolism

Pharmacological basis of drug interactions

Impact of organ dysfunction on pharmacokinetics and dose modification

Principles of prescribing

Recall indications, contraindications and dosage of commonly used drugs

Patient factors impacting on prescribing- allergy, age, pregnancy

Appropriate dose adjustment in disease, ageing, pregnancy

Categories of drug safety in pregnancy and impact on prescribing

Principles of dose titration

Legislation regarding prescribing and controlled and restricted drugs

Adverse drug reactions and interactions

Common and life-threatening drug interactions and common presentations of drug-

induced disease, adverse drug reactions

Common interactions between prescription and non-prescription and

complementary therapies

Report adverse drug reactions to appropriate authority

Therapeutic drug monitoring

Recall drugs requiring therapeutic monitoring and interpret results

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Quality use of medicines

Factors affecting adherence

Factors increasing risk of medication error

Technique for enhancing medication safety

Factors predisposing to polypharmacy and reasons for overprescribing

Delivery techniques for specific medicines

Skills

Basic Science

Applies basic science principles in prescribing

Prescribes appropriately with reference to specific patient factors including organ

dysfunction, allergies and adverse effects

Calculate loading dosed and maintenance doses

Calculate GFR, body weight. Body surface area

Principles of prescribing

Takes a complete drug history including history of use of complementary therapies

and over-the-counter medications

Consults pharmacist/MIMS/ similar database to obtain prescribing information

Take help of guidelines for prescribing

Writes a clear and unambiguous for prescription

Provides accurate medication list with all the necessary information on discharge

Adverse drug reactions and interactions

Identify presence of, or potential for, adverse drug reaction and drug interactions
and treats appropriately

Monitors for development of common adverse drug reactions, including selection of

appropriate laboratory investigations (e.g., monitoring of renal & hepatic function)

Therapeutic drug monitoring

Monitors drug levels and effects when appropriate and responds accordingly to
results

Quality use of medicines

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Practice regular medication review with appropriate adjustment of regimen and

avoidance of polypharmacy
Ceases medications where proven ineffective or no longer indicated

Engage patient in decision making, explaining drug therapy and monitoring and
following up verbal with written information where appropriate

Assess patient uses of delivery devices

Uses a range of strategies to enhance patient adherence

Behaviors

Recognize the benefit of minimizing number of medications

Recognize the importance of patient compliance

Recognize the importance of resources when prescribing

Ensure the sharing of prescribing information with the patient and caregivers

Remain up-to-date with therapeutic alerts and respond appropriately

Knowledge Skill

Analgesics Take a relevant pain history

Patho physiology of pain Identify source of pain

Measurement of pain Use common pain-scoring tools

Non-pharmacological approaches to Utilize non-drug approaches to pain

management of pain management

Classes of commonly available analgesics Prescribe appropriate analgesia with

with respect to mode of action, reference to cause, severity, co-
pharmacokinetics, potency and efficacy morbidities and co- medications
in various pain syndromes
Monitors efficacy of treatment and
Common adverse effects and drug adjusts regimen appropriately
interactions for drug class
Prescribe adjuvant therapy where
Principles of acute and chronic pain appropriate
management
Refers to pain team when appropriate
Principles of adjuvant therapy in pain
management

Anticoagulant therapy Initiate anticoagulation with appropriate

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agent at appropriate dose taking patient

Actions and indications of factor into consideration
anticoagulants, both prophylactic and
therapeutic Adjusts therapy to achieve target ranges
and monitors therapy appropriately
Drug interactions, adverse effects,
pharmacokinetics, monitoring of Manages over anticoagulation
anticoagulation

Corticosteroid therapy Uses steroid judiciously

Actions and indications of Recognize when steroids are not

corticosteroids; relative potencies; appropriate
monitoring, prevention of adverse effects
Escalate dose on sick days

Manages dose reduction/tapering

Minimizes and manages adverse effects if

steroid use unavoidable

Antimicrobial therapy
Initiate empiric antimicrobial therapy
Mode of action, antimicrobial spectrum, with appropriate agent at appropriate
adverse effects, interactions, dose taking patient factors into
pharmacokinetics of common classes of consideration
antimicrobials

Antimicrobial resistance and strategies

for prevention

Psychotropic medication Uses these medications judiciously,

carefully monitoring for side effects
Mode of action, adverse effects,
interactions, pharmacokinetics of Uses non-pharmacological approaches
antipsychotics, benzodiazepines, initially, where possible
antidepressants
Checks interactions to avoid the
seronergic syndrome

8.2.2. Symptom & Sign Based competencies/Management of

patients with undifferentiated presentations
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 Learning objective: competencies required to practice in
general internal medicine by listing the common ways in
which a patient can present

Goal: The patient usually presents with some symptoms and

exhibits some signs. It is the duty of a primary care physician
to assess the patient on first presentation, to formulate valid
differential diagnosis, investigate appropriately, initiate
management plan.
Knowledge Skills Behavior

Differential diagnosis,
Recall the common Recognize the
appropriate causes, pathophysiology
investigations, importance of
and initial management for of each of the symptom multidisciplinary
Recognize that patient
the common, approach including early
present with symptoms
undifferentiated clinical
or signs but it is the duty surgical assessment
presentations including: of a physician to find out when appropriate
the underlying cause
Fever, PUO Establishes a differential Involve other specialties
diagnosis and a when required
Night sweats
provisional diagnosis,
based on clinical history Display sympathy to
Chronic physical and mental
and physical
fatigue/Lethargy/Generalized response to specific
examination.
weakness Initiates basic symptom
investigations.
Syncope/collapse/loss of Recognize the anxiety of
Interprets investigations
consciousness to plan a further the patient or relative till
diagnostic process. a reasonable diagnosis is
Acute & chronic confusional Initiates management
state reached
on the basis of clinical
findings. Recognize the anxiety
Aggressiveness/disturbed Identifies acutely unwell
behavior and distress caused to
patients and initiates
appropriate patients or families and
Visual disturbances resuscitation and/or care givers by underlying
therapy. condition and admission
Substance dependence
Initiates symptomatic to hospital
Panic attack management of
problems
Dyspnoea such as pain, nausea,
dyspnoea etc.
Hemoptysis Engages in discussion
with supervisors and
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Hemetemesis patient
regarding when to stop
investigations.
Melena For any presentation the
Trainee recognizes the
Epistaxis possible contribution of
psychological factors,
Wight loss mental illness or
personality disorder to
Weight gain the clinical presentation.
Nausea

Anorexia/Loss of appetite

Vomiting

Anemia

Cyanosis

Jaundice

Edema

Hematuria

Abdominal pain

Chest pain

Back pain

Neck pain

Bodyache

Acute, chronic and recurrent

cough

Acute and chronic diarrhea

Constipation

Falls in the elderly

Fits /Seizures

Paresthesia and numbness

Headache

Polydipsia
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Polyuria
Pruiritus

Rectal bleeding

Oral ulcers

Skin blisters

Speech disturbances

Dysphagia

Limb pain

Palpitation

Rash

Purpura/ bruises

Physical symptoms in
absence of organic disease

Hepatosplenomegaly

Lymphadenopathy

Abdominal mass

Ascities

Dysuria/Burning micturation

Incontinence of urine

Micturation difficulties

Genital discharge

Genital ulcers

Head injury

Hoarseness and stridor

Involuntary movements

Joint swelling

Loin pain
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Chance/incidental findings

Medical Recognize a surgical Recognize the

problems/complications condition, provides importance of thrombo-
following surgical initial resuscitation, and embolic complications
procedures: baseline investigations and prophylaxis during
and refers appropriately acute illness and in post-
Goals: Surgical Assess patient with operative period
Presentations – define history and examination Recognize the
symptoms such as to form differential importance of measures
haematuria, rectal bleeding, diagnosis Investigation to prevent
and abdominal pain etc and management of complications: DVT
which are traditionally patients with common prophylaxis, effective
managed by surgical teams. peri-operative problems- analgesia, nutrition,
The reason that these sepsis, delirium, physiotherapy, gastric
symptoms appear in this thrombo-embolism, protection
curriculum is to recognise glycemic control, fluid Call for senior help when
that often a physician is balance, arrhythmia, appropriate
called upon to perform the unresolved pain. Respect opinion of
initial assessment of these Initiate treatment when referring surgical team
patients. These presentations appropriate in
frequently occur in the consultation with the
context of long-term medical surgical team
illness and as a complication Institute measures for
of medical illness. Also, the thrombosis prophylaxis
hospital-at-night team when appropriate
structure leads to physicians Encourage preventative
at all levels of training taking measures: thrombo-
responsibility for surgical in- prophylaxis,
patients. The role of the physiotherapy, adequate
physician in these situations analgesia
is not to take responsibility
for the full management of
these patients. However, a
physician is expected to
stabilize the patient as
necessary, perform initial
investigations and
management if urgently
required, and make a
referral to the appropriate
surgical team for a specialist
opinion in a timely manner.

Knowledge

The trainee will be able to

assess, investigate and treat
medical problems arising
postoperatively and during
acute illness and recognize
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importance of preventative
measures plan
Recall the common medical
complications occurring in
post-operative patients and
how they present
Recall the reasons for
medical problems frequently
presenting
atypically post-operatively
Pre-operative assessment of
cardiovascular and
respiratory risk
Causes of delirium in the per,
post operative period
Recall the investigations
indicated in different
scenarios: shortness of
breath, chest pain,
respiratory failure,
drowsiness, fever, collapse,
GI bleeding
Physical symptoms in Safely determine after Recognise the pattern of
absence of organic appropriate work up repetition that non-
disease that a patient is likely to organic presentations
have a non-organic can have
Goal: The trainee will be cause for their
able to assess and presentation Respect the distress the
appropriately investigate a mode of presentation
patient to conclude that Identify underlying may be causing
organic psychiatric disease: Adopt a non-
disease is unlikely, counsel psychosis, depression, or judgemental sensitive
sensitively, and formulate an anxiety attitude when engaging
appropriate management in counselling a patient
plan Formulate a over the likelihood of
management plan for non-organic disease
acute period of care
Knowledge Involve psychiatric
services when
Define and differentiate from appropriate
each other: somatisation Address security issues
disorders, malingering, where necessary
dissociative disorders, Recognise the
hypochondriasis, importance of the
psychogenic (or somatoform) Primary Care team in
pain disorders and factitious assessment and
disorders management
Recognise the phenomenon
of excessive symptoms in the Recognise the cultural
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context of established disease differences in

e.g. breathlessness in well somatoform disorders
controlled asthma Communicate with
 primary Care and other
health workers where
possible

8.2.3. Management of Acute Medical Problems

Learning objectives: Recognize and manage the critically ill patients

Goal: As general internist, it is important to understand the basic

principle of Critical Care Medicine. A general internist must be
able to recognize the unstable patient who is at risk for acute organ
failure. Upon recognition of this patient, the general internist must
be able to appropriately provide initial supportive management
and facilitate the transfer of these patients to the appropriate level
of care. The general internist should be familiar with the
multidisciplinary approach to Critical Care and the appropriate use
of consultants including a Critical Care specialist. The general
internist must have a basic understanding of the treatments unique
to the Critical Care setting such as invasive hemodynamic
monitoring, mechanical ventilation, and vesopressors. The general
internist must also have a basic understanding of the nature and
treatment of medical conditions commonly encountered in the
critical Care Unit. Most importantly, the general internist must
also recognize the importance of end of care issues in the Critical
Care setting.
Knowledge Skills Behavior

Basic cardiovascular Recognizes emergency Conveys to

physiology and situations and the families/carers the
hemodynamics critically ill adult. progress to date, likely
Pathophysiology of shock Determines rapidly the cause for situation,
Pathophysiology of sepsis clinical context and immediate therapeutic
Basic principles of sequence of events goals, expected outcome,
mechanical ventilation leading to the emergency. and any limits on
Principle of blood Conducts a rapid, escalation of care.
component therapy focused clinical Discusses the current
Physiology & pharmacology examination. situation within the
of vasopressors and Establishes a provisional broader context of the
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ionotropes diagnosis and orders trajectory of patient

Pharmacology of antibiotics appropriate initial illness and quality of life,
used in ICU setting investigations, including areas of
Basic respiratory Physiology determines severity of uncertainty.
Pathophysiology of organ dysfunction(s). Indicates when medical
hypoxemia and Initiates appropriate staff will review the
hypercapnoea emergency management, situation and/or meet
Principles of End of Life Care including summoning with family again.
Signs and symptoms of help, teamwork, team
impending leadership and urgent Demonstrate caring and
Cardio-respiratory arrest. referral to other services. respectful behaviors
Clinical features of serious Discusses the situation when interacting with
illness. with a more senior staff patients and their
Causes of acute airway member at earliest families
obstruction, respiratory appropriate opportunity
failure, shock and coma. and recognizes if
Principles of oxygen delivery transportation or
and assisted ventilation. retrieval to another
Principles of fluid facility is required.
resuscitation. Monitors patient’s
Principles of inotropic condition appropriately
support. and recognizes and acts
Principles and practice of on complications.
defibrillation. Anticipates patients in
Hospital emergency codes. whom there may well be
Location and contents of a rapid deterioration, and
hospital resuscitation reflects on indicators and
trolleys and their contents. actions to be taken in the
Principles of teamwork and management plan.
leadership in an acute Develops appropriate
emergency. care plans for patients in
Local indications and whom resuscitation or
contraindications for ICU. emergency escalation of
Basic Life Support. care is not indicated.
Advanced Life Support Conveys these plans in
the notes, and verbally, to
For the following relevant health care staff.
emergencies or potential Performs CPR and BLS
emergencies, the Trainee according to ILCOR
describes the clinical guidelines.
presentation, differential Performs ALS according
diagnosis, underlying to ILCOR guidelines.
patho physiology, initial
investigations, initial For each of these
management, and likely poisonings the Trainee
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complications: identifies symptoms and

• cardiac arrest signs of common
• stridor/airway obstruction poisonings and toxic
• acute difficulty swallowing syndromes, assesses and
• hypoxia, respiratory failure monitors for
• hypotension, shock – other serious
hypovolemic, septic, consequences of
cardiogenic, neurogenic, poisoning, initiates
anaphylactic emergency management
• arrhythmia including specific
• seizures Antidotes.
• acute Seeks specialist and ICU
paraplegia/weakness/rigidity advice in a timely
• painful red eye manner.
• Acute loss of vision Assesses suicidality
• acute agitation
• suicidal behavior
• severe acid base disorders
• Electrolyte disturbances
• hypoglycemia
• diabetic ketoacidosis
•Non Ketotic Hyperosmolar
Coma
• thyroid, adrenal and
pituitary crisis
• meningitis
• hyperthermia and
hypothermia
• Electrocution
• extensive skin blistering.

•Diarrhea & dehydration

Massive hemetemesis and

melena

Massive hemoptysis

Oliguria/Anuria

Severe hypertension

Severe headache

Acute abdominal pain

Coma
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Severe sepsis
Severe pneumonia

Acute coronary syndrome

COPD exacerbation

Acute severe asthma

Fever in ICU

Ventilator associated
pneumonia

Status epilepticus

Cardiac temponade

Severe pancreatitis

Near drowning

Nutrition in ICU

Pulmonary embolism

Venous thromboembolism
prophylaxis

Pneumothorax

Cardiovascular accident

Coagulopathy

DIC

Fulminant hepatic failure

The Trainee describes the

related pharmacology,
clinical presentation and
initial acute management
of the following common and
serious poisonings/
overdoses:
• paracetamol
• antidepressants
• antipsychotic drugs
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• alcohol
• amphetamines
• opioid drugs
• benzodiazepines
• anticholinesterases
• snake bite.

8.2.4. System Specific Competencies

Learning objective: Manage patients with disorders of organ systems

Goals: Learning to manage each mode of presentation does not avoid the need for a
trainee to have a solid grounding of knowledge in specific medical conditions.
It is also the case that patients very often already have a ‘diagnostic label’, for
example a GP referring ‘a breathless patient with heart failure’. In the age of
better patient education and patient involvement in their chronic disease
management, frequently today’s clinician needs to refer to disease-specific
knowledge earlier in the consultation.
Therefore, listing the specific disease conditions aims to advise the trainee on
the conditions that require detailed comprehension. The list also gives a
guide to the topics that will form the basis for formal and work-place
assessments.
A framework for the knowledge required for specific conditions arranged
alphabetically is set out below, and should continue to improve with time in
line with the principles of a spiral curriculum:
Definition
Pathophysiology
Epidemiology
Features of History
Examination findings
Differential Diagnosis
Investigations indicated
Detailed initial management and principles of ongoing management
(Counseling, lifestyle, medical, surgical, care setting and follow up)
Complications
Prevention (where relevant to condition)

8.2.4.1. Palliative care and End of Life care

Educational purpose: General Internal Medicine encompasses a variety of disorders
over a wide spectrum of ages in both sexes. A critical component to the
trainee of an Internal Medicine resident is the ability to care for patients
with acute and chronic pain and those with terminal illnesses. The goal
of this sorts of training is to strengthen a resident’s knowledge and
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ability to take care of patients with terminal illness, provide end-of-care,

and to manage both pain and other issues in terminally ill patients.
Knowledge
Define palliative care and Take an
terminally ill patient. history
Recognize the common
problems in terminally ill
patient: Pain,
Constipation,
Breathlessness, Nausea &
Vomiting, pressure sores.
Anxiety & depression
Pharmacology of major
drug classes in palliative
care: Opoids, NSAIDs,
agents for neuropathic
pain, anti-emetics,
bisphosphonates,
laxatives, anxiolytics
8.2.4.2. Cardiology
Skill Behavior
accurate pain Recognize the
psychological and social
issues surrounding
Recognize that the patients at the end of life
terminally ill patients
often present with Contribute to discussions
problems with multi- on decisions not to
factorial causes resuscitate with patient,
carers, family and
Recognize when palliative colleagues appropriately
care opinion is needed and sensitively ensuring
Recognize the dying phase patients interests are
of terminal illness paramount.
Develop proficiency in Effectively work with other
counseling patients on health care professionals
common symptoms and including social worker,
syndromes encountered at nurse
the end of life, as well as
be able to deliver “ bed
news” to patients and
family members.
Manage symptoms in
dying patients
appropriately
Practice safe use of
syringes drivers
Recognize importance of
hospital and community
Palliative Care teams
Recognise that referral to
specialist palliative care is
appropriate for patients
with other life threatening
illnesses as well as those
with cancer.
Assessment and
evaluation of brain death
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Educational purpose: The trainee should be able to provide primary and secondary
preventive care and initially manage the full range of cardiovascular
disorders.

Knowledge

A. Basic science

i) Anatomy of cardiovascular system

ii) Physiologic principles of cardiac cycle and cardiac conduction

iii) Blood pressure homeostasis

iv) Pathogenesis of Shock

v) Pathogenesis of atherosclerosis

vi) Laboratory markers of cardiac diseases

vii)Pharmacology of major drug classes: Beta adrenoceptor blockers, alpha

adrenoceptor blockers, ACE inhibitors, ARBs, Anti-platelet agents,
thrombolysis, ionotropes, calcium channel blockers, potassium channel
activators, diuretics, anti-arrhythmics, anti-coagulants, lipid modifying
drugs, nitrates, centrally acting anti-hypertensive.

B. Take a chronological problem-oriented history, including but not limited to:

i) Subjective description of complaints

ii) Past history of rheumatic heart disease and cardiac procedure

iii) Identify risk-factors for coronary artery disease

C. Perform an adequate physical examination, including:

i) Extra-cardiac signs

ii) Abnormalities in the pulse, blood pressure, and jugular venous pressure

iii) Detailed heart examination

iv) Mastering clinical signs of the various valve lesions

D. Evaluate and manage a wide range of cardiac disorders, including:

i) Coronary artery disease

a) Discuss risk-factors modification in primary and secondary prevention

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b) Manage stable and unstable angina and myocardial infarction

 c) Discuss the selection of medical therapy, percutaneous
revascularization and surgical therapy.

ii) Heart failure

a) Describe the signs, symptoms and etiology of right, left and

biventricular heart failure. Meanings of CCF

b) Discuss the selection of medical therapy

iii) Valvular and congenital heart diseases

a) Know the etiology, investigations, diagnosis and approach to

medical therapy and surgical therapies.

iv) Endocarditis

a) Know the classifications of native and prosthetic valve endocarditis, and

endocarditis in intravenous rug abusers.

b) Describe the clinical presentations and diagnosis

c) Know the microbiology.

d) Discuss the antimicrobial treatment, prophylaxis and surgical interventions

v) Pericardial disease

a) Know the etiology of pericarditis/ pericardial effusion

b) Know the clinical presentation of pericardial effusion and cardiac tamponade

c) Diagnosis and treatment of pericardial effusion and tamponade

d) Pathogenesis, presentations and management of constrictive pericarditis

vi) Arrhythmias with heart block

a) Describe the pathophysiology of recurrent ventricular and supraventricular

arrhythmias

b) Develop competence in using anti-arrhythmic drugs

vii) Cardiomyopathies

viii) Hypertension

ix) Dyslipidemia

x) Primary and secondary pulmonary hypertension

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xi) Dissection of aorta

 xii) DVT and PE

xiii) Cardiovascular manifestations of systemic diseases ( e.g., diabetes, thyroid,

renal, SLE)

Skill

Conducts a focused clinical examination and applies basic science knowledge to

interpret clinical signs. Applies basic science knowledge to interpret complex ECGs
and chest radiograph. Applies basic science knowledge to appreciate the significance
of and appropriately act on reports of echocardiograms, stress tests, myocardial
perfusion scans, angiograms, duplex ultrasound scans, ABI, arterial Doppler.

Applies knowledge to establish a provisional diagnosis, arrange appropriate

investigations, and can independently initiate appropriate medical management for
uncomplicated disease.
Recognize the need for and appropriate time for referral to cardiologist/ cardiac
surgeon.

If there are complications, or procedural intervention is required, the trainee

recognizes this, provides initial emergency management and refers appropriately and
timely

Learn the indications for:

i) Electrocardiogram, ETT, echocardiograms

ii) Cardiac catheterization
iii) Coronary angiography and angioplasty
iv) Cardiac nuclear mediocine studies
v) Electrophysiology
vi) Pacemakers
vii) 24-hour ECG monitoring
viii) Pericardiocentesis

Learn to interpret:
i) Chest X-ray
ii) ECG, ETT
iii) Hemodynamic studies

Behavior
Conduct interviews with patients, and their families in a compassionate, culturally-
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effective, and patient-centered manner

 Know how to obtain inform patients and obtain voluntary consent for the treatment
plan and specific diagnostic and therapeutic interventions

Counsel patients on risk factors for cardiovascular disease including smoking

cessations

8.2.4.3. Endocrinology and metabolic disorders including

diabetes mellitus
Educational purpose: The goal of the resident is to gain a general knowledge of the
major conditions specific to the endocrine system, be able to interpret
basic endocrinologic diagnostic tests, and be able to diagnose and
manage a variety of common endocrine disorders, making referrals
when appropriate. The trainees plays a key role in managing endocrine
emergencies, including diabetic keto acidosis and hyperosmolar
nonketotic coma, severe hyper-and hypocalcemia, and addisonian crisis.

Knowledge

A. Basic science

i) Structure and functions of hormones, hormone receptors, second messengers,

and hormone action

ii) Structure and function of hypothalamus, pituitary, thyroid, adrenals,

parathyroid, gonads, adipose tissues

iii) Secretion, transport, and feedback control of hormones

iv) Carbohydrate, protein and lipid metabolism

v) Pharmacology of major drug classes used: Insulin, OHA, thyroxin, Anti-

thyroid drugs, corticosteroids, sex hormones, drugs affecting bone metabolism

B. Diabetes mellitus

i) Understand the different etiologies, pathophysiologic process, and clinical

presentations of type 1 & 2, and secondary diabetes

ii) Understand laboratory diagnosis

iii) Understand specific therapeutic modalities, including oral agents and

conventional and intensive insulin therapy.

iv) Diagnose and manage acute complications: diabetic ketoacidosis,

hyperosmolar coma, hypoglycemia
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v) Diagnose and manage chronic complications: retinopathy, nephropathy,
neuropathy, dermopathy, arteriosclerotic vascular disease, infections

C. Thyroid disorders

i) Interpret thyroid function tests in thyroid and non-thyroid illness

ii) Describe the use of anti-thyroid medications and thyroid hormone

replacement therapy

iii) Diagnosis and different treatment options for thyrotoxicosis

iv) Discuss the use of radioactive iodine in the treatment of hyperthyroidism and
thyroid cancer

v) Evaluation and management of hypothyroidism

vi) Evaluation of patients with thyroid nodules

vii)Evaluation and management of sub acute and Hashimoto’s thyroiditis

D. Hypothalamic and pituitary diseases

i) Recognize and evaluate patients with pituitary tumors: prolactinomas,

Cushing’s disease, acromegaly, incidentilomas

ii) Understand the hypothalamic-pituitary-end organ function and interpret the

test measuring HPA axis

iii) Evaluate and treat patients with pituitary or hypothalamic hormone

deficiencies

E. Disorders of calcium and skeletal metabolism

i) List the etiologies, evaluation and management of hyper and hypocalcaemia

ii) Evaluation and management of metabolic disorders including

hyperparathyroidism, hypoparathyroidism, osteoporosis, osteomalacia.

iii) Interpretations of skeletal radiography and BMD

F. Endocrine hypertension

i) Evaluate for secondary causes of hypertension, including pheochromocytoma

and syndrome of mineralocorticoid excess

ii) Discuss the role of imaging studies in the diagnosis

iii) Discuss the medical and surgical therapies

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G. Adrenal disorders
i) Interpret hormonal testing in the evaluation of adrenal diseases

ii) Recognize the clinical presentations, differential diagnosis, and management

of Cushing’s syndrome

iii) Diagnose adrenal insufficiency, lists its causes, and initiate therapy

iv) Evaluate and mange congenital adrenal hyperplasia and virilizing disorders,
and adrenal masses

H. Hyperlipidemia

i) Categorize lipid disorders based on lipoprotein measurements, and recognize

their genetic & secondary forms

ii) Discuss the role of diet, exercise, and lipid lowering agents

iii) Describe the use of screening procedures

I. Reproductive endocrinology

i) List the differential diagnosis of hormonal causes of infertility

ii) List the causes of primary and secondary hypogonadism and discuss the
indications and use of hormone replacement therapy

iii) List the differential diagnosis, evaluation and treatment of amenorrhea

J. Hormone producing neoplasm

i) Understand the pathophysiology associated with hormone-producing tumors,

including, but not limited to carcinoid syndrome, multiple endocrine
neoplasia, pheochromocytoma, insulinoma, gastrinoma, and small cell cancer

ii) Identify imaging studies for suspected hormone producing neoplasm

iii) Diagnose and manage syndromes of ectopic hormone production

K. Disorders of growth and sexual development

i) Understand the impact of systemic diseases, nutritional factors, and endocrine

abnormalities

ii) Interpret dynamic endocrine testing in the evaluation of disorders of growth

and sexual development

L. Endocrine and metabolic manifestations of systemic diseases

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M. Endocrine emergencies
 myxedema coma, thyrotoxic crisis, Addisonian crisis, phaecromocytoma crisis,
diabetic coma

Skill

Conduct a focused clinical examination and applies basic science knowledge to

interpret clinical signs

Applies basic science knowledge to interpret basic endocrine tests

Conducts anthropometric assessment ( BMI, WHR, triceps skin fold)

Recognize the presenting illness, establish a provisional diagnosis, orders

appropriate investigations, and independently initiate appropriate management for
uncomplicated diseases.

If there are complications, the trainee recognizes these, and refers appropriately

Learn to interpret:

Dexamethasone suppression test

Short and long Synacthin test

Thyroid function tests, home blood glucose monitoring log

Thyroid and parathyroid nuclear scans

Behavior

Recognize the vital importance of patient education and a multidisciplinary approach

for the successful long-term care of diabetes

Communicate effectively and demonstrate caring and respectful behaviors when

interacting with patients and their families

Willingness to give basic dietary counseling for diabetes, hyperlipidemia, and obesity

Education for patients on the disease course of diabetes and rationale of treatment to
decrease blood glucose.

8.2.4.4. Gastroenterology and hepatology

Educational purpose: The general internist should have a wide range of competency
in gastroenterology and hepatology and should be able to provide
primary and in some cases secondary preventive care, evaluate a broad
array of gastrointestinal symptoms, and manage many gastrointestinal
and hepatic disorders. The trainee must be familiar with the indications,
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contraindications, and interpretations of GI procedures.

Knowledge
A. Basic science

i) Structure and functions of gastrointestinal system

ii) Structure of liver

iii) Hormone/enzymatic control of alimentary tract including control of acid and

pancreatic secretion

iv) Laboratory markers of hepatic and pancreatic functions and malabsorption

v) Bilirubin metabolism

vi) Macro and micronutrient absorption

vii) Pharmacology of major drug classes used

B. Dysphagia

i) Differentiate oropharyngeal from esophageal Dysphagia

ii) Know the general approach to esophageal dysphagia: rings, GERD, stricture
and cancer

C. Gastro esophageal reflux

i) Know the symptoms and complications: for example Barrett’s esophagus

ii) Know the treatment options

D. Peptic ulcer disease

i) Know the role of Helicobacter pylori, NSAIDs and acid hyper secretion

ii) Know the initial treatment of H. pylori and follow-up strategies

iii) Know the prevention and treatment of NSAID induced ulcers

iv) Know the diagnosis and management of acid hypersecteion (gastrinoma)

E. Upper GI bleeding

i) Know common causes

ii) Know resuscitation techniques and when endoscopy treatment is needed

iii) Know the primary and secondary prevention

F. Diarrhea
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i) Know causes and initial management of acute diarrhea

ii) Know the approach to chronic diarrhea: osmotic vs. secretary diarrhea

iii) Know the risk factors for secondary diarrhea: endocrine tumor, diabetes,
bacterial overgrowth, laxative abuse

G. Inflammatory bowl diseases (IBD)

i) Know the clinical presentations, including extra intestinal manifestations,

complications of Crohn’s disease and ulcerative colitis

ii) Know how to differentiate Crohn’s from ulcerative colitis using radiology,
endoscopy, pathology, clinical manifestations

iii) Know the appropriate medical therapy and surgicsal options

H. Irritable bowel syndrome (IBS)

i) Know differentiations from IBD and treatment options

I. Gastrointestinal malignancy

i) Know the use and limitations of colon cancer screening strategies: fecal blood
testing, flexible sigmoidoscopy, colonoscopy, barium x-rays

ii) Know the role of surgery, adjuvant chemotherapy and radiation therapy in
cancer stomach and colon cancer

J. Diverticular disease

i) Know the clinical presentation, complications, investigations and treatment

options

K. Pancreatitis

i) Know the common causes and clinical presentations of acute and chronic
pancreatitis

ii) Know the definition and use of Ranson and Apache criteria

iii) Learn about diagnostic tests: Role/time course of amylase/lipase, CT/MRI of

pancreas, ERCP, pancreatic function tests

iv) Determine the treatment options of acute and chronic pancreatitis

v) Know the diagnosis and management of complications of acute and chronic

pancreatitis

L. Gallstone disease
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i) Know the clinical presentations of biliary colic, acute cholecystitis and

choledocholithiais
 ii) Known the indications for abdominal ultrasound, CT, MRCP, ERCP

iii) Know the management strategies for cholangitis, common bile duct stones
and cholecystitis

M. Liver diseases

i) Know approach to abnormal liver function tests

ii) Know approach to jaundiced patients: acute, persistent intermittent

iii) Know the chronicity of virus B and C

iv) Know the hepatotrophic viruses

v) Know the diagnosis and management of acute hepatitis

vi) Diagnosis and management of chronic B hepatitis

vii) Management chronic asymptomatic B virus infection

viii) Diagnosis and management hepatitis C infection

ix) Know the clinical presentation, diagnosis and management of Cirrhosis of

liver including PBC

x) Know about the liver transplantation

N. Acute abdominal conditions

i) Know the diagnosis and initial work up and emergency management of acute
appendicitis, acute cholecystitis, intestinal obstruction, perforation of
hollow viscous.

O. Malabsorption

P. Nasogastric feeding

Q. Gastrointestinal manifestations of systemic disease (e.g., NASH)

Skill

Conducts a focused clinical examination and applies basic science knowledge to

interpret clinical signs.
Applies basic science knowledge to interpret clinical signs, abdominal X-ray,
abdominal CT scan, and laboratory tests (including LFTs, liver screen, viral serology,
coeliac serology, helicobacter testing, malabsorption tests, faecal microscopy and
culture and toxin testing).
Applies basic science knowledge to appreciate the significance of, and appropriately
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act on reports of, abdominal ultrasound, upper and lowerendoscopy, ERCP, MRCP,
MRA.
The Trainee recognizes the presentation of illness, establishes a provisional
diagnosis, orders appropriate investigations, and can independently initiate
appropriate medical (non-procedural) management for uncomplicated disease.
If there are complications or procedural intervention is required, the trainee
recognizes this, provides initial emergency management and refers appropriately.

Behavior

Conduct interviews with patients and their families in a compassionate, culturally

effective, and patient-centered manner
Communicate effectively with patients and other health care professionals
Discuss issues of palliation for GI malignancies, including blood transfusions,
enteral, and parenteral alimentation, and chemotherapy
Know how to inform and obtain voluntary consent for the treatment plan and
specific diagnostic and therapeutic interventions

8.2.4.5 Hematology
Educational purpose: The general internist should be competent in the detection of
abnormal physical, laboratory, and radiologic findings relating to the
lymphohematopoetic system; the assessment of the need for bone
marrow aspirate and biopsy and lymph node biopsy; the initial
diagnostic evaluation and management of the haemostatic and clotting
system; the assessment of the indications and procedure for transfusion
of blood and its separate components; the management of therapeutic
and prophylactic anticoagulation; the diagnosis and management of
neutropenia / immunosuppression.

Knowledge

A. Basic science

i) Structure and function of blood forming tissues, reticulorendothelial system,

and blood components
ii) Hemoglobin structure and function
iii) Process of coagulation
iv) Haemopoesis
v) Iron, Vit B12, folate metabolism
vi) Principles of transfusion and bone marrow transplantations
vii)Pharmacology of major hematinics and erythropoietin
viii) Genetics of thalassemia
ix) Evidences of hemolysis
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B. Describe the clinical presentations, differential diagnosis,

investigations, initial management, potential complications of
 the disease and its management for the following common and
important conditions:

i) Aplastic anemia/Bone marrow failure

ii) Bleeding disorders: Hemophilia, DIC
iii) Coagulation disorders including hypercoagulable state
iv) Thrombocytopenia including ITP
v) Anemias: Iron deficient, megaloblastic, hemolytic
vi) Hemolytic disorders
vii) Mylodysplastic syndrome (MDS)
viii) Acute and chronic Lekemias
ix) Lymphomas and lymphadenopathy
x) Plasma cell dyscrasia/Multiple myeloma
xi) Myeloproliferative disease
xii) Amyloidosis
xiii) Thrombophilia
xiv) Neutropenia
xv) Pancytopenia

C. Understand the basis of bone marrow transplantation, both

autologous and allogenic hemopoetic stem cell transplantation
and recognize complications like GVHD

D. Hematological manifestations of systemic diseases (anemia of

chronic disease, hemolysis, cytopenia)

Skill

Conducts a focused clinical examination and applies basic science knowledge to

interpret clinical signs.
Applies basic science knowledge to interpret clinical signs, full blood count and film,
coagulation profile, thrombophilia screens.
Applies basic science knowledge to appreciate the significance of, and appropriately
acts on reports of, bone marrow aspirate and trephine, cytogenesis
The trainee recognizes the presentation of illness, establishes a provisional diagnosis,
plans and arranges appropriate investigations, and independently initiates
appropriate management for uncomplicated disease.
If there are complications, the trainee recognizes these, and refers appropriately.

Behavior

Be able to provide genetic counseling to patients and family members when

appropriate
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Assists patients in decision making regarding treatment options, discharge planning,

and recognizing complications of treatment
Discuss the impact of hematological and oncologic disorders on patient’s quality of
life
Demonstrate integrity, respect, and exhibit compassion, kindness and empathy
Recognize potential problems that may have an impact on the treatment and
outcome, including compliance and social factors

8.2.4.6. Psychiatry/ Mental health disorder

Educational purpose: Internists will care for patients with diagnosed and
undiagnosed psychiatric disease. Patients may present to an internist
with complaints that are a manifestation of mental illness. Then
resident must be able to recognize those mental illnesses that can be
treated by the general internist and when a patient should be referred
for psychiatric cae. The resident must also understand the impact of a
patient’s mental illness on the provision of care for medical problems,
and learn methods for delivering care in these situations.

Knowledge

A. Basic science:

i) Structure and function of limbic system and hippocampus.

ii) Principles of neurotransmitters
iii) Principles of addiction and tolerance
iv) Pharmacology of major drug classes used: anti-psychotics, lithium, tricyclic
antidepressants, MAO inhibitors, SSRIs, Venlafexine, donepezil, drugs used
for addiction (bupropion, disulpharama)

B. Describe the clinical presentations, differential diagnosis,

investigations, initial management, potential complications of
the disease and its management for the following common and
important conditions:

i) Mood disorders
ii) Bipolar disorder
iii) Acute psychosis
iv) Schizophrenia
v) Personality disorders
vi) Anxiety and panic disorders
vii) Phobias
viii) Stress disorders
ix) Obsessive compulsive disorders
x) Grief reaction
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xi) Eating disorders

 xii) Substance abuse: the pattern of use, relevant pharmacology, detailed
management of acute intoxication, and secondary preventive strategies
xiii) Unsuccessful suicide attempt
xiv) Parasuicide
xv) Dementia
xvi) Unexplained physical symptoms which suggests somatization
xvii) Alcohol syndrome: alcohol dependence and alcohol withdrawal
C. Psychiatric manifestations of systemic disease

Skill

Conduct a focused clinical examination and applies basic science knowledge to

interpret clinical signs
Applies basic science knowledge to interpret mental status examination, and tests of
cognitive functions
The trainee recognizes the clinical presentation, establishes a provisional diagnosis,
plans and arranges appropriate initial investigations to rule out organic causes,
discusses broad therapeutic options, initiates appropriate emergency management
and involves other members of the team whenever appropriate and refers
appropriately.
If there are complications, the trainee recognizes these and refers appropriately
For any presentation the trainee recognizes the possible contribution of mental
illness or personality disorder to the clinical presentation
Recognizes withdrawal state of alcohol, opioids, benzodiazepines, nicotine and its
management
Evaluate suicide risk

Behavior

Recognizes role of community mental health care teams

8.2.4.7. Rheumatology / Disorders of Musculoskeletal system

Educational purpose: The trainee must be competent in the initial diagnosis and
management of wide range of disorders affecting musculoskeletal
system to prevent disability and death. He/She must also be proficient
in monitoring the effects of anti-inflammatory, immunosuppressive,
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and cytotoxic drugs

Knowledge
 A. Basic science

 Structure and function of bone, muscle and synovium

 Bone and mineral metabolism
 Purine metabolism
 Pharmacology of major drug classes used: NSAIDs, corticosteroids,
immunosuppressants, colchicines, allopurinol, bisphosphonates
 Describe the epidemiology, clinical presentations, differential diagnosis,
investigations, initial management, potential complications of the disease
and its management, preventive strategies for the following common and
important conditions:
• Rheumatoid arthritis
• Systemic lupus erythamatosus
• Spondyloarthropathies: ankylosing spondylytis, Reiter’s syndrome,
psoriatic arthritis, inflammatory bowel disease associated arthritis
• Systemic vasculitidies: polyarterirtis nodusa, Wegener’s
granulomatosis, giant cell or temporal arteritis, Takayasu’s arteritis,
cryoglubulinemia
• Crystal induced arthropathy: gout and pseudo gout
• Osteoarthritis
• Osteoporosis
• Dermatomyositis/polymyositis
• Anti-phospholipid syndrome (APLS)
• Sjogren’s syndrome
• Systemic sclerosis/PSS
• Fibromyalgia
• Septic arthritis

B. Approach to a patient with polyarthritis

C. Approach to a patient with acute monoarthritis

D. Musculoskeletal manifestations of systemic diseases

Skill

Conducts a focused clinical examination and applies basic science knowledge to

interpret clinical signs.

Applies basic science knowledge to interpret clinical signs, imaging (plain

radiographs, bone densitometry), laboratory tests of bone and mineral metabolism
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(Ca/PO4/PTH/VitD/ALP), investigations to monitor inflammation and disease

activity and to diagnose immunologically-mediated disease (ESR, CRP, RF, ANA,
ENA), synovial fluid analysis. Applies basic science knowledge to appreciate the
significance of, and appropriately act on, reports of specialised imaging of bones and
joints.

The Trainee recognises the presentation of illness, establishes a provisional

diagnosis, plans and arranges appropriate investigations, and independently initiates
appropriate management for uncomplicated disease. If there are complications, the
Trainee recognizes these, and refers appropriately.

Monitors for complications.

Recognizes the indications of the following:

Muscle biopsy

Minor salivary gland biopsy

EMG/NCV

Arthroscopy

Peripheral nerve (sural) biopsy

Muskuloskeletal X rays, MRI, CT scans

Angiography: cerebral, visceral, limb

Interpret the following:

Parameters of systemic inflammation: ESR, CRP

Auto antibodies: rheumatoid factor, ANA, ENAs, anti-dsDNA, Jo-1, La, Scl-70, C-
ANCA, p-ANCA, C3, C4,

Synovial fluid findings: Examination under polarized light microscopy and

identification of MSU and CPPD crystals

Imaging studies: X-rays of joints and other parts, MRI, BMD Page101
Behavior

Recognizes the importance of multidisciplinary approach to rheumatologic diseases

including physiotherapists, orthopedicians

Listen carefully and respond appropriately to patients’ concern

Understand the impact of chronic pain, fatigue, and cognitive disturbances on family
and workplace

Know when to involve other specialists to prevent or treat complications of

rheumatologic disease.

8.2.4.8 Neurology/ Disorders of neurological system

Educational purpose: Neurologic complaints are expected to increase due to an
increase burden of degenerative neurological disease in our aging
population. Residents should understand the management of emergent
neurologic problems, and when to obtain urgent consultation. Residents
should be able to perform a focused history on common neurologic
presenting syndromes. Emphasis will be on cultivating sound judgment
in diagnosis and management of neurologic disorders linking data,
coma, medical knowledge, and experience in coherent care plan.
Resident will develop proficiency in the neurologic exam with emphasis
on normal and abnormal neurologic and motor responses, mental status
exam, and sensory exam. Resident will use clinical knowledge on lesion
localization and differential diagnosis generation.

Knowledge

A. Basic science

Neuroanatomy including cerebral blood supply.

Electrical activity of the brain and nerve conduction.

Metabolism of the brain.

Neurotransmitters and neurotransmission (including ANS).

Sleep-wake regulation.

Concept of brain death.

Pharmacology of major drug classes used: anxiolytics, hypnotics, anti-epileptics,

anti-parkinson drugs
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Vision and hearing.

 B. Describe the epidemiology, pathophysiology, clinical presentation,
differential diagnosis, investigations, detailed initial management, principles
of ongoing management, potential complications of the disease and its
management, preventive strategies:

• Stroke and TIA

• CNS infections: Meningitis, encephalitis, brain abscess
• Epilepsy/seizures
• Headache including migraine
• Subarachnoid hemorrhage
• Raised intra-cranial pressure
• Peripheral neuropathy
• Bell’s palsy, Parkinson’s disease
• Guillan Barre syndrome
• Multiple sclerosis
• Motor neurone disease
• Myesthenia gravis
• Cerebellar disorders
• Coma
• Acute confusional state: Wernicke’s encephalopathy
• Dementia
• Tremors
• Vertigo
• CNS tumors: Pituitary, metastatic
• Retinopathies
• Visual disturbance
• Neurological manifestations of systemic disease( peripheral neuropathy,
paraneoplastic, seizure)

Skill

Learn the approaches to patient with neurologic disease: locate the lesion, define
pathophysiology, and establish etiological diagnosis

Take an adequate problem oriented history

Perform an efficient and complete neurological examination

Recognizes when a neurological consultation is apprppriatre

Participate in the care of seriously ill neurological patients , including those in the
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ICU, and those with traumatic injury of head and spine

Conducts a focused clinical examination and applies basic science knowledge to
interpret clinical signs.

Applies basic science knowledge to interpret clinical signs, and major abnormalities
on CT head.

Applies basic science knowledge to appreciate the significance of, and appropriately
act on reports of, EEGs, NCSs and EMGs, autonomic function testing.

Applies basic science principles to interpret clinical findings, reports of perimetry,

audiometry.

the Trainee recognises the presentation of illness, establishes a provisional diagnosis,

plans and arranges appropriate investigations, and independently initiates
appropriate management for uncomplicated disease.

If there are complications, or special intervention is indicated (e.g. thrombolysis for

stroke), the Trainee recognises these, and refers appropriately

Learn to interprete: CSF , Brain CT and MRI

List the indications for Lumbar puncture, Brain CT, MRI, PET Scan, Cerebral
angiography, EMG, NC studies, EEG, Evoked potentials. Muscle biopsy

Understand the steps of brain death diagnosis and its ethical issues

Behavior

Carefully approach to the relatives of critically ill patients

Discuss ethical issues that may face patients and their families, including Brain death
and resuscitation issues

Discuss appropriate management and discharge plan with patients and /or their
families who are distressed

Recognize potential problems that may have an impact on the treatment and
outcome, including compliance and social factors

Interact with social workers, nurses, and medical assistants to provide an effective
and comprehensive patient care

Apply evidence-based, cost-conscious strategies to prevention, diagnosis, and

management of disease
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8.2.4.9. Nephrology/ Disorders of the renal and genitourinary
systems

Educational purpose: Nephrology involves the diagnosis and management of

diseases of kidneys, and its contiguous collecting system, and its
vasculature. Commonly encountered conditions in Nephrology that the
resident should be competent and comfortable in assessment and
management of include disorders of fluid, electrolyte, and acid base
balance; acute renal failure, chronic kidney disease, nephrolithiasis, and
infections. Other problems include disorders involving the glomerulus,
asymptomatic urine abnormalities, tubulointerstitial disorders, renal
vascular diseases, tubular defects, renal disease in pregnancy; renal
transplantation, including pre-transplant, and post-transplant care; and
neoplasm of the kidneys, collecting system, and bladder. The resident
should also understand how systemic diseases affect the kidneys, and
recognize the potential toxicities of various therapeutic and diagnostic
agents. The resident must understand current strategies to delay or
prevent kidney disease.
The resident must be competent in managing patients with chronic
kidney disease who are not yet on dialysis and know indications for
initiating dialysis. The resident should also recognize when consultation
of a nephrologist is appropriate in the management of any of the
aforementioned conditions.

Knowledge
A. Basic science

i) Structure and function of the renal system and male and female genital tract
ii) Regulation of fluid and electrolyte status
iii) Acid base regulation
iv) Urine composition
v) Hormonal regulation ( ADH, rennin-angiotensin system)
vi) Measurement of renal function/ calculation of creatinine clearance and GFR
vii)Principles of renal replacement therapy- transplant and dialysis
viii) Pharmacology of major drug classes used
ix) Renal diet: what it consists and when to initiate it?

B. Describe the epidemiology, pathophysiology, clinical presentation,

differential diagnosis, investigations, detailed initial management, principles
of ongoing management, potential complications of the disease and its
management, preventive strategies:
i) Acute renal failure
ii) Chronic renal failure
iii) Glomerulonephritis
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iv) Nephrotic syndrome

v) Urinary tract infections
 vi) Polycystic kidney disease
vii) Acute tubular necrosis
viii) Interstitial kidney disease
ix) Renal cell carcinoma
x) Genitourinary malignancies (prostate, testicular, bladder,
uterine/cervical/ovarian)
xi) Obstructive uropathy

C. Adjustment of medications in patients with renal disease

D. List the indications, risks, and contraindications of renal biopsy

E. Renal manifestations of systemic disease

Skill

Conducts a focused clinical examination and applies basic science knowledge to

interpret clinical signs.

Applies basic science knowledge to interpret clinical signs, laboratory tests (renal
function, electrolytes, MSU, ABGs).

Applies basic science knowledge to appreciate the significance of, and appropriately
act, on reports of imaging (renal tract ultrasound, functional

renal scans, renal angiograms, urograms), renal biopsies.

Anticipates future need for dialysis or transplant refers for vascular access where
appropriate, and avoids cannulation of target vessels.

The Trainee recognizes the presentation, establishes a provisional

diagnosis, plans and arranges appropriate initial investigations, initiates

symptomatic therapy, discusses broad therapeutic options, and refers appropriately.

Dietary modification in renal failure

Management of anemia in chronic renal failure

Management of Fluid and electrolyte disorders

Management of Acid-Base disorders

Cauterization

Knowing when to refer or prescribe suppressive antibiotics for chronic indwelling

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bladder catheter
Demonstrate ability read a urine dipstick and recognize RBCs, WBCs, bacteria and
various types of casts

Behavior

Discuss with the patient likely outcome, progress of the condition and requirement of
long term follow up

Discuss the risks and benefits of renal replacement and its impact on quality life

Understand the ethical issues of organ donation and promote community awareness
of brain death and organ donation

8.2.4.10. Pulmonary Medicine/Disorders of the Respiratory

and sleep system
Educational purpose: The general internist is expected to understand the
environmental, immunologic, inflammatory, and genetic mechanisms
that usually maintain gas exchange but can sometimes lead to
disordered function. He or she is expected to apply this understanding
in the obtaining the history and examining and counseling the patient.
The general internist is also expected to understand the indications
and contraindications of diagnostic tests or interventions, to assess
validity of tests before interpreting them, and to know how to optimize
consultation with specialists in the care of one’s patients.

Knowledge

A. Basic science

i) Airway of lungs/airways
ii) Gas exchange
iii) Ventilation
iv) Ventilation perfusion matching
v) Acid base balance
vi) Applied respiratory physiology – to interpret basic pulmonary function tests
vii) Pharmacology of major drug classes used: bronchodilators, inhaled
corticosteroids , leukotriene receptor antagonists, immunosuppressents
viii) Occupational and environmental toxins ( cigarettes, asbestos)
ix) Inflammation of airways

B. Describe the epidemiology, pathophysiology, clinical presentation,

differential diagnosis, investigations, detailed initial management, principles
of ongoing management, potential complications of the disease and its
management, preventive strategies for the following conditions:
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i) Pneumonia
ii) Acute respiratory failure
 iii) Chronic respiratory failure
iv) Bronchial asthma
v) COPD and corpulmonale
vi) Pleural effusion
vii) Pneumothorax
viii) Tuberculosis
ix) Bronchiectasis
x) Diffuse parenchymal lung disease/ILD
xi) Lung cancer
xii) Bronchieactasis
xiii) Pulmonary hypertension
xiv) Pulmonary embolism
xv) Cystic fibrosis
xvi) Mycotic lung disease, including histoplasmosis and aspergillosis
xvii) Sleep apnea

C. Respiratory manifestations of systemic diseases

Skill

i) Take a complete problem-oriented history, including

a) Subjective description of the complaints
b) Previous chest X-rays
c) TB exposure including past history of anti-TB therapy
d) History of thoracic procedures
e) Occupational history, including exposures
f) Family history of specific pulmonary disease
ii) Conduct a focused clinical examination and applies basic science knowledge to
interpret clinical signs, imaging, pulse oximetry, blood gases, pulmonary
function tests
iii) The Trainee recognizes the presentation of illness, establishes a provisional
diagnosis, plans and arranges appropriate investigations, and independently
initiates appropriate management for uncomplicated disease.
If there are complications, the Trainee recognizes these, and refers appropriately.
Monitors for complications.
Understands the principles of safe oxygen therapy
Understands the principles of short and long term oxygen therapy
Understands the different delivery systems for respiratory medications
Understands the methods of smoking cessation of proven efficacy
Counsel patients in smoking cessation appropriately
Recognizes side effects of anti-TB drugs
Able to interpret Chest R-rays, CT scan of chest, pulmonary function tests, ABG, peek
flow rate, 6-min walk test, skin test for allergy, pleural fluid study reports, pleural
biopsy, V/Q scan
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Understands the indications, contraindications and limitations of the following

studies: Endotracheal intubation, BiPAP, bronchoscopy (including BAL, brush,
endo-vs transbronchial biopsy) , percutaneous lung biopsy, CT scan, lung scan,
pulmonary artery cathetarization, pleural biopsy, ventilation perfusion scan (VQ
scan), mediastinoscopy, video-assisted thoracoscopy, open lung biopsy

Behavior

Resident must communicate effectively and demonstrate caring and respectful

behaviors when interacting with the patients and their families:
i) Motivational interviewing for smoking cessation: 5A’s, set a quit date
ii) Asthma management plan
iii) Explain gang preparing for oxygen therapy
iv) Giving bed news regarding terminal illness (e,g., end-stage COPD, lung
cancer)
Resident must work effectively with other health care professional including those
from other disciplines, to provide patient-focused care:
i) Radiologists
ii) Allergists
iii) Otolaryngologists
iv) Cardiologists( distinguish pulmonary vs. cardiac cause of symptoms)
v) Psychiatry- depression in COPD, cancer
Utilize information technology to enhance patient care and patient education
Proper counseling of TB patients

8.2.4.11. Dermatology/Skin disorders

Educational purpose: The resident should be able to diagnose and manage a variety
of common skin conditions and make referrals when appropriate. He or
she should be proficient at examining the skin; describing the findings;
and recognizing skin signs of systemic disease, normal findings, and
common skin malignancies.

Knowledge
A. Basic science

i) Structure and function of skin, hair and nails

ii) Pigmentory, inflammatory, immune responses of the skin
iii) Pharmacology of major drug classes used: topical corticosteroids,
immunosuppressents
B. Describe the epidemiology, pathophysiology, clinical presentation,
differential diagnosis, investigations, detailed initial management, principles
of ongoing management, potential complications of the disease and its
management, preventive strategies for the following conditions:
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I) Infestations with scabies and lice

II) Dermatitis
 III) Fungal infections e,g tinea
IV) Psoriasis
V) Vasculitis
VI) Eczema
VII) Acne
VIII) Toxic epidermal necrolysis
IX) Erythema multiforme
X) Skin cancer: squamous and basal cell carcinoma
XI) Pitriasis Rosacea
XII) Erythema nodosum
XIII) Skin ulcers
XIV) Urticaria and angioedema
XV) Cellilitis and abscess, impetigo
XVI) Viral infections: Herpes simplex and herpes zoster infections
XVII) Bullous disorders
XVIII) Cutaneous drug reactions
XIX) Skin rashes
XX) Dermatomyositis
XXI) Scleroderma
XXII) Melanoma

C. Skin manifestations of systemic disease

Skill

Conducts a focused clinical examination and applies basic science knowledge to

interpret clinical signs.
Applies basic science knowledge to interpret clinical signs including description of
skin lesions
using standard nomenclature.
Applies basic science knowledge to appreciate the significance of, and appropriately
act on reports of, skin and lesion biopsy.
For these conditions, the Trainee recognizes the presentation of illness, establishes a
provisional diagnosis, plans and arranges appropriate investigations, and
independently initiates appropriate management for uncomplicated disease.
If there are complications, the Trainee recognizes these, and refers appropriately.
Monitors for complications.

Behavior

Counsel patients on preventive strategies for skin tumors (e.g., avoiding excess UV
exposure), and the diagnostic features for early detection of malignant melanoma
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Recognizes when a patient’s presentation heralds a systemic disease

Patient education on proper skin care for sensitive skin, infections, and chronic
pruiritic skin disorders.

8.2.4.12. Infectious diseases

Educational purpose: Infections lead to significant amount of morbidity and

mortality. Recently the emergences of new infections have made
management of communicable diseases a global issue. Infectious
disease medicine requires an understanding of the microbiology,
prevention, and management of disorders caused by viral, fungal, and
parasitic infections, including appropriate use of antimicrobial agents,
vaccines, and other immunologic agents. Important elements include
the environmental, occupational, and host factors that predispose to
infection, as well as basic principles of the epidemiology and
transmission of infection. It is important that residents be able to
provide appropriate preventive, diagnostic, and therapeutic care for
most infections. Residents should also be able to evaluate symptoms
that may be caused by a wide range of infectious disorders. Residents
must understand principles and systems of infection control for
individual patients and larger populations.

Knowledge

A. Basic science

i) Biology of common and important pathogens

ii) Host response to infection
iii) Principles underlying laboratory testing for infectious disease
iv) Principles of infection control
v) Immunasitation
vi) Pharmacology of major classes of drug used including pharmacology of
antibiotics

B. Describe the epidemiology, pathophysiology, clinical presentation,

differential diagnosis, investigations, detailed initial management, principles
of ongoing management, potential complications of the disease and its
management, preventive strategies for the following conditions:

i) PUO
ii) Septicemia, Complications of sepsis: shock, DIC, ARDSB
iii) Common community acquired infection: LRTI, UTI, skin and soft tissue
infections
iv) CNS infection: meningitis, encephalitis, brain abscess
v) Fever in the returning traveler
vi) HIV and AIDS including ethical consideration of test in Infections in
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immunocompromised host
vii) Tuberculosis
 viii) Common genitor-urinary conditions: non-gonococcal urethritis,
gonorrhea, syphilis
ix) Fungal infections e.g., asperogillus, pneomocystis, jirovecii infection
x) Lyme disease
xi) Viral infections: CMV, Herpes simplex, EBV, varicella zoster
xii) Endocarditis
xiii) Osteomyelitis, septic arthritis
xiv) Viral Hepatitis
xv) Diarrheal illness
xvi) Conjunctivitis
xvii) Malaria, kala-azar
xviii) Rabies
xix) Hydatid diseases
xx) Global outbreak: SARS, pandemic flue, avian influenza
Skill
i) Conducts a focused clinical examination and applies basic science knowledge
to interpret clinical signs.
ii) Applies basic science knowledge to interpret clinical signs, laboratory tests
(FBC, inflammatory markers, microbiology, virology, serology), basic imaging
(CXR, CT head, CT abdo/pelvis).
iii) Applies basic science knowledge to assess potential routes of
infection/transmission, secondary sites of infection.
iv) Applies basic science knowledge to appreciate the significance of and
appropriately act on reports of complex investigations – nuclear medicine
scanning, ultrasound scan
v) The Trainee recognizes the presentation of illness, establishes a provisional
diagnosis, plans and arranges appropriate investigations, and independently
initiates appropriate management for uncomplicated disease.
vi) If there are complications, the Trainee recognizes these, and refers
appropriately.
vii) Monitors for complications.
viii) Resident must know to interpret a laboratory’s antibiogram and use the
information for empiric antibiotic choice for clinical care
ix) Resident must understand the indications for and types of isolation
procedures
x) Resident must be able to obtain informed consent for HIV testing. Resident
must learn to protect them to minimize the risk of occupational exposure. If
an exposure does occur, must know how to seek appropriate evaluation and to
make appropriate notification
xi) Resident must learn to assess the clinical usefulness of new antibiotics
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xii) Learn to communicate with microbiology laboratory regarding culture and

sensitivity results
xiii) Know the local antimicrobial resistance pattern
 xiv) Know the local immunization and vaccination practice

Behavior

• Resident should be able to assess vaccine utilization in their patients

• Resident must utilize the skill when delivering HIV results, informing patients
of positive diagnosis of STDs

8.2.4.13. Otolaryngology and ophthalmology

Educational purpose: The general internist will see complaints related to the ear,
nose and throat during the care of patients. The resident must be
familiar with those complaints and problems that can be diagnosed and
treated by the internists, and which conditions need referral to an
otolaryngologists. The resident will also need to be able to recognize ear,
nose, and throat manifestations of diseases managed by the internist.

Knowledge
A. Basic science

i) Anatomy of ear, nose and throat

B. Describe the epidemiology, pathophysiology, clinical presentation,

differential diagnosis, investigations, detailed initial management, principles
of ongoing management, potential complications of the disease and its
management, preventive strategies for the following conditions:

i) Earache
ii) Ear discharge
iii) Ringing in the ear
iv) Sore throat
v) Sinusitis
vi) Epistaxis
vii) Hoarseness of voice
viii) Otitis media
ix) Otits externa
x) Cerumen impaction
xi) Hearing loss
xii) Laryngitis
xiii) Pharyngitis
xiv) Acute visual loss
xv) Diplopia
xvi) Nystagmus
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xvii) Opthalmoplegia
xviii) 3,4,6 nerve palsies
xix) Proptosis
 xx) Cavernous sinus thrombosis
xxi) Red eyes
xxii) Retinopathies including retinal hemorrhage: diabetes, hypertensive

Skill
Should be able to do examination of Ear, nose and throat and refer appropriately
Should be able to do fundoscopic examination and to interpret them and to act on as
necessary

Behavior
Become familiar with the appropriate referral services for hearing impaired
Must demonstrate respect, compassion, and altruism to those who are blind

8.2.4.14. Oncology

Educational purpose: Resident should be able to identify individuals at risk for

malignancy and counsel them regarding risk reduction and screening,
investigate clinical symptoms, and syndromes suggestive of underlying
malignancy, undertake the palliative care of patients with solid and
hematologic tumors, identify neoplasms with a potential for cure, and
manage appropriately

Knowledge

A. Basic science
i) cell growth and aging, cell injury, apoptosis
ii) molecular and cellular oncogenesis
iii) Principles of metastatic spread
iv) Principles of staging
v) Broad pharmacological principles of chemotherapy, radiotherapy, and
immunotherapy
vi) Principles of screening tests

B. For the following malignancies, the risk factors, clinical presentation,

natural history, broad therapeutic options and preventive strategies including
screening:

• lung
• breast
• gastrointestinal
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• prostate
• skin
• brain
 • carcinoma of unknown primary
• lymphoma
• multiple myeloma
• leukaemia
• potentially curable cancers.

C. The management of important acute complications of cancer:

• uncontrolled pain
• malignant hypercalcemia
• spinal cord compression
• SVC obstruction
• pericardial tamponade.

D. The management of important complications of cancer therapy:

• bone marrow suppression

• neutropenic sepsis
• tumour lysis syndrome
• mucositis
• Graft vs. host disease.

Skill

Conducts a focused clinical examination and applies basic science knowledge to

interpret clinical signs.
Applies basic science knowledge to interpret clinical signs, CXR, CT head, chest,
abdomen, bone scan, laboratory tests (e.g. tumors markers, cytology, body fluid
analysis).
Applies basic science knowledge to appreciate the significance of, and appropriately
act on, reports of more specialized imaging, predictive genetic testing
For conditions listed, the Trainee recognizes the presentation of illness, establishes a
provisional diagnosis, plans and arranges appropriate investigations, and
independently initiates appropriate management of presenting symptoms.
If a diagnosis of cancer is considered, the Trainee develops an appropriate
management plan in consultation with their supervisor.
If there are complications and/or procedural intervention is required, the Trainee
recognizes this, provides initial emergency management and refers appropriately.
Initiates management of complications including pain, neutropenic sepsis, tumour
lysis syndrome, mucositis, fluid balance disturbances, common chemotherapy side
effects.
Recognise the dying phase of terminal ilness
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Behavior

Recognizes the associated social and psychological problems

Break bed news to patient and family with cancer in sensitive and appropriate
manner
Contribute to discussions on decisions not to resuscitate with patient, carers, family,
colleagues appropriately and sensitively ensuring patients interest are paramount.

8.2.4.15. Genetic diseases

Educational purpose: Manage patients with common genetic disorders

Knowledge

A. Basic Science

• Structure and function of human cells, genes, DNA, RNA,and cellular

proteins.
• Principles inheritance: Mendelian, sex-linked, mitochondrial , polygenic
• Principles of mutation, polymorphism, trinucleotide repeat disorder
• Major cancer genetics.
• Basic principles of individualised medicine and pharmacogenetics.
• Principles of enetic testing techniques: PCR, FISH, gene sequencing.
• Awareness of genetic databases.
• Human Genome Project.

B. Describe the common genetic diseases, the inheritance, phenotype(s), clinical

presentation, natural history, complications and comorbidities principles of
ongoing management and appropriate referral:

• Trisomy 21
• Turner’s syndrome
• cystic fibrosis
• haemochromatosis
• Marfan’s syndrome
• Klinefelter’s syndrome
• Huntington’s disease
• Down’s syndrome
• Hemophilia
• Von Willebrand’s disease
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• Polycystic kidney disease

• Thalasemia
 • Familial cancers.
Skill

Conducts a focused clinical examination and applies basic science knowledge to

interpret clinical signs.
Applies basic science knowledge to collate an accurate family history.
Constructs and interprets a family pedigree.
Applies basic science knowledge to appreciate the significance of, and appropriately
act on reports of, genetic tests.
Recognize the importance the importance of skilled counseling in the investigation of
genetic susceptibility to disease
Recognize basic pattern of inheritance
Estimate risk for relatives of patients with Mandelian disease
If a genetic disease is present, or considered, the Trainee develops an appropriate
management plan in consultation with their supervisor

Behavior

Recognize the anxiety caused to an individual and their family when investigating
genetic susceptibility to disease
Recognize the implications of a genetic diagnosis to family

8.2.5. Medicine throughout the lifespan/growth

and development

8.2.5.1. Manage common medical problems in pregnancy

Educational purpose: The trainee will be competent in the assessment, investigation

and management of the common and serious medical complications of
pregnancy.

Knowledge

Demonstrate awareness of the possibility of pregnancy in women of reproductive

years
Outline the normal physiological changes occurring during pregnancy
Demonstrate awareness of the impact of long term conditions in relation to maternal
and fetal health e.g. diabetes
List the common medical problems occurring in pregnancy: jaundice in pregnancy,
renal disease in pregnancy
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Identify the unique challenges of diagnosing medical problems in pregnancy

Recall safe prescribing practices in pregnancy and post partum
Demonstrate awareness of pregnancy related illness, e.g. eclampsia
Skill

Recognize the critically ill pregnant patient.

Initiate resuscitation measures and liaise promptly with senior colleagues and
obstetrician.
Take a valid history from a pregnant patient.
Examine a pregnant patient competently.
Produce a valid list of differential diagnoses.
Formulate a management for acute period of care: pre-eclampsia, eclampsia,
suspected pulmonary embolism, infection, heart failure, diabetes mellitus, asthma,
epilepsy.

Behavior

Recognize interrelationships between maternal and fetal health.

Communicate with obstetric team throughout the diagnostic and management
process.
Recognize the anxiety of the family members regarding the outcome of pregnancy.
Discuss case with senior promptly.

8.2.5.2. Manage problems in the older patients/Elderly/

Geriatrics
Educational purpose: With the aging of the baby Boomers, internal medicine
residents can expect to be involved in the care large number of elderly
patients. Within the training program the trainee should acquire the
defined knowledge, skill, behaviors and attitudes needs to provide
comprehensive care for the geriatric patient in a variety of settings as
competent internists.

Knowledge

A. Basic Science

• Physiology of ageing – pharmacology, changes associated with ageing in major

organ systems.
• Cellular ageing, tissue growth and repair.
• Non-specific presentation of illness in the elderly.
• Normal laboratory values in older people

B. For the following common and important problems in older people the
Trainee describes the epidemiology, clinical presentation, differential
diagnosis, investigations, detailed initial management, principles of ongoing
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management, preventive strategies:

• polypharmacy and adverse drug reactions

 • falls
• Fractures
• delirium
• Acute confusion
• cognitive decline/dementia/memory loss
• Movement disorder including parkinsonism
• Stroke and TIAs
• Syncope
• incontinence, BPH
• constipation
• functional decline/detoriaration in mobility
• psychiatric presentations including depression, anxiety, mania.
• Osteoporosis
• Osteoarthritis
• Leg and pressure ulcer
• Insomnia
• Vertigo/dizziness
• Hearing loss
• Constipation
• Vision loss
• Malnutrion
• Sexuality and aging
• Glaucoma

Skill
Applies basic science knowledge to interpret clinical signs, laboratory tests, basic
imaging, tests of mental status examination, and tests of cognitive function.
The Trainee recognizes the presentation of illness, establishes a provisional
diagnosis, plans and arranges appropriate investigations, and independently initiates
appropriate management for uncomplicated disease.
If there are complications, the Trainee recognizes these, and refers appropriately.
Monitors for complications.

Behavior
Demonstrate interpersonal and communication skils that result in effective exchange
of information and collaboration with patients, their families, and health
professionals.
Recognize that “the elderly” are a diverse group with reguard to personalities, values,
functional levels and medical illnesses.
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8.2.5.3. Manage common problems associated with the
menopause/Women’s Health
Educational purpose: Manage common problems associated with the menopause

Knowledge

Physiological changes associated with peri-menopause and post-menopausal period.

Clinical presentation of menopause.
Risk factors for disease in post-menopausal female:
• osteoporosis
• cardiovascular disease
• neoplasia
• incontinence
• depression.

Evidence for interventions to detect and prevent post-menopause-osteoporosis,

cardiovascular disease

Skill

Detects symptoms of normal and abnormal menopause.

Appropriately examines and conducts investigations for post-menopausal female,
including breast and pelvic examination and screening investigations.
Appropriately examines and conducts investigation for early onset menopause.
Manages disease associated with menopause.
Detects symptoms of depression and recognizes psychosocial factors impacting on
presentation.
Counsels peri- and post-menopausal women regarding healthy lifestyle.
Promotes screening to detect early disease – breast, cervical, bone density for those
with risk factors, cardiovascular risk screening.

Behavior

Female patient will be treated with respect, compassion, integrity, and altruism
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8.2.5.4. Public Health Issues and Health Promotion
Educational purpose: To Recognize that the public health issues can impact on an
individual’s patient’s wellbeing. Also to recognize that the opportunities to be taken
for health promotion with the patient population that presents to hospital.

Knowledge

To progressively develop the ability to work with individuals and communities to

reduce levels of ill health, remove inequalities in healthcare provision and improve
the general health of a community.
Understand the factors which influence the incidence of and prevalence of common
conditions.
Understand the factors which influence health – psychological, biological, social,
cultural and economic especially poverty.
Understand the influence of lifestyle on health and the factors that influence an
individual to change their lifestyle.
Understand the purpose of screening programmes and know in outline the common
programmes available within the UK.
Understand the relationship between the health of an individual and that of a
community.
Know the key local concerns about health of communities such as smoking and
obesity
Understand the role of other agencies and factors including the impact of
globalisation in protecting and promoting health.
Demonstrate knowledge of the determinants of health worldwide and strategies to
influence policy relating to health issues including the impact of the developed world
strategies on the third world.
Outline the major causes of global morbidity and mortality and effective, affordable
interventions to reduce these.
Recall the effect of addictive behaviours, especially substance misuse and gambling,
on health and poverty.

Smoking
Outline the effects of smoking on health
Promote smoking cessation
Recognise the need for support during cessation attempts
Recognise and utilise specific Smoking Cessation health professionals

Alcohol
Recall safe drinking levels
Recognise the health and psychosocial effects of alcohol
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Recommend support networks for problem drinkers

Outline appropriate detoxification programme and methods to retain abstinence
Obesity
Recognize medical impact of obesity
Outline good dietary practices
Promote regular exercise
Recommend specialist dietician input as appropriate
Define principles of therapeutic interventions in morbid obesity
Recognize the public health problem of poor nutrition
Perform basic nutritional assessment
Identify patients with malnutrition and instigate appropriate management
Recognize importance of dietician input and follow-up
Define principles of enteral and parenteral feeding

Nutrition
Recognize the public health problem of poor nutrition
Perform basic nutritional assessment
Identify patients with malnutrition and instigate appropriate management
Recognize importance of dietician input and follow-up
Define principles of enteral and parenteral feeding
Outline the ethical issues associated with nutrition
Promote safe sexual practices
Recognize the health and psychosocial effects of substance abuse
Recommend support networks
Be able to define the levels of social deprivation in the community
Recognize the impact of social deprivation on health
Recognize the impact of occupation on health
Outline the role of Occupational Health consultants
Define the health benefits of regular exercise
Outline the ethical issues associated with nutrition

Sexual behavior
Promote safe sexual practice

Substance abuse
Recognise the health and psychosocial effects of substance abuse
Recommend support networks

Social Deprivation
Be able to define the levels of social deprivation in the community
Recognise the impact of social deprivation on health

Occupation
Recognise the impact of occupation on health
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Outline the role of Occupational Health consultants

Exercise
Define the health benefits of regular exercise
Promote regular exercise

Mental health
Recognise the interaction of mental and physical health
Recommend appropriate treatment and support facilities

Skill

Identify opportunities to prevent ill health and disease in patients.

Identify opportunities to promote changes in lifestyle and other actions which will
positively improve health.
Identify the interaction between mental, physical and social wellbeing in relation to
health
Counsel patients appropriately on the benefits and risks of screening
Work collaboratively with other agencies to improve the health of communities

Behavior

Engage in effective team-working around the improvement of health

Encourage where appropriate screening to facilitate early intervention

8.2.5.5. Evidence-Based Medicine (EBM)

Educational purpose: The BSMMU residency program believes that it is vitally
important that residents be able to incorporate the principles of Evidence-Based
Medicine (EBM) into their daily practices. EBM represents a new paradigm in the
ongoing evolution of the practice of Medicine. This paradigm emphasizes the use of,
when possible, systematic, reproducible, and unbiased observations recorded in the
medical literature to increase one’s confidence in the true prognosis, efficacy of
therapy, and utility of diagnostic tests as they apply to questions about one’s patients.
It de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic
rationale as sufficient ground for clinical decision-making and stresses the
examination of evidence from clinical research.
Knowledge

i) Understanding the application of statistics in scientiofic medical practice

ii) Understand the advantages and disadvantages of different study
methodologies (randomized control trials, case control study)
iii) Understand the principles of critical appraisal
iv) Understand levels of evidence and quality of evidence
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v) Understand the role and limitations of evidence in the development of clinical

guidelines
vi) Understand the advantages and disadvantages of guidelines
 vii)Understand the processes that result in nationally applicable guidelines (e.g.,
NICE & SIGN)

Skill
• Ability to search the medical literature including use of Medline, Cochrane
reviews and the internet
• Appraise retrieved evidence to address a clinical question
• Apply conclusions from critical appraisal into clinical care
• Identify the limitations of research
• Apply an open-minded, analytical approach to acquiring new knowledge
• Access and critically evaluate current medical information and scientific
evidence
• Apply an evidence-based approach to clinical problem-solving, clinical
decision-making, and critical thinking in the clinical setting.
• Contribute to the construction, review and updating of local and national
guidelines of good practice using the principles of EBM.

Behavior

a) Keep up to date with national and international reviews and guidelines of

practice (NICE & SIGN)
b) Aim for best clinical practice at all times, responding to evidence based
medicine
c) Recognize the occasional need to practice outside clinical guidelines
d) Encourage discussion amongst colleagues on evidence-based practice

8.2.6. Investigation competences

Diagnostic Studies

We have become increasingly reliant on a wide array of laboratory tests to solve

clinical problems. However, accumulated laboratory data do not relieve the physician
from the responsibility of carefully observing, examining, and studying the patient. It
is also essential to appreciate the limitations of diagnostic tests. By virtue of their
impersonal quality, complexity, and apparent precision, they often gain an aura of
authority regardless of the fallibility of the tests themselves, the instruments used in
the tests, and the individuals performing or interpreting them. Physicians must
weigh the expense involved in the laboratory procedures relative to the value of the
information they are likely to provide.

Single laboratory tests are rarely ordered. Rather, physicians generally request
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"batteries" of multiple tests, which often prove useful. For example, abnormalities of
hepatic function may provide the clue to such nonspecific symptoms as generalized
weakness and increased fatigability, suggesting the diagnosis of chronic liver disease.
Sometimes a single abnormality, such as an elevated serum calcium level, points to a
particular disease, such as hyperparathyroidism or underlying malignancy.

The thoughtful use of screening tests, such as low-density lipoprotein cholesterol,

may be quite useful. A group of laboratory determinations can be carried out
conveniently on a single specimen at relatively low cost. Screening tests are most
informative when directed toward common diseases or disorders and when their
results indicate the need for other useful tests or interventions that may be costly to
perform. On the one hand, biochemical measurements, together with simple
laboratory examinations such as blood count, urinalysis, and sedimentation rate,
often provide a major clue to the presence of a pathologic process. On the other hand,
the physician must learn to evaluate occasional abnormalities among the screening
tests that may not necessarily connote significant disease. An in-depth workup
following a report of an isolated laboratory abnormality in a person who is otherwise
well is almost invariably wasteful and unproductive. Among the more than 40 tests
that are routinely performed as screening, it would not be unusual for one or two of
them to be slightly abnormal. If there is no suspicion of an underlying illness, these
tests are ordinarily repeated to ensure that the abnormality does not represent a
laboratory error. If an abnormality is confirmed, it is important to consider its
potential significance in the context of the patient's condition and other test results.

The development of technically improved imaging studies with greater sensitivity

and specificity is one of the most rapidly advancing areas of medicine. These tests
provide remarkably detailed anatomic information that can be a pivotal factor in
medical decision-making. Ultrasonography, a variety of isotopic scans, CT, MRI, and
positron emission tomography have benefited patients by supplanting older, more
invasive approaches and opening new diagnostic vistas. Cognizant of their
capabilities and the rapidity with which they can lead to a diagnosis, it is tempting to
order a battery of imaging studies. All physicians have had experiences in which
imaging studies turned up findings leading to an unexpected diagnosis. Nonetheless,
patients must endure each of these tests, and the added cost of unnecessary testing is
substantial. A skilled physician must learn to use these powerful diagnostic tools
judiciously, always considering whether the results will alter management and
benefit the patient.

Learning objective: Plan and arrange investigations appropriately

Goal: To progressively develop to formulate first line and second line

investigations for an individual patient
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Knowledge

Clinical indications and contraindications of investigation

Relative cost of investigations

Risk of performing investigations

Impact of false negative and false positives on patients care

Sensitivity, specificity, positive & negative predictive value, likelihood ratio of

investigations

Skills

Rationally and effectively plans and arranges investigations based on findings from
history and physical examination

Adapts approaches to investigations taking into account patient factors and co-
morbidities

Weighs the costs and benefits of investigations in each clinical situation

Choose the most cost-effective investigation path

Applies diagnostic reasoning to minimize the number of investigation s used and

minimize harm from false positives

Recognize situations where it is appropriate to not investigate at all

Choose and order first-line investigation appropriate for a patients

Select second-line or specific investigation and formulate the criteria for their
selection

Avoid unnecessary repetition of investigations

Checks results of investigations in a timely manner and acts on results appropriately

Modify working diagnosis and treatment plan in response to investigation results

Behavior

The trainee should stop temptations in doing unnecessary investigations. Every

patient should be informed regarding the utility of doing the investigations, its costs-
effectiveness, risk and benefits.

8.2.7. Procedural competences

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Learning objectives: Prepare patient for procedure, performing the
procedures relevant to adult internal Medicine, providing care following
the procedures

Goals: The trainee is expected to be competent in performing the

procedures, recognize the indications, the importance of valid
consent, aseptic technique, and minimization of patient
discomfort (for complete list see in the appendix)

Knowledge Skills Attitude/Behavior

Preparing patient for Explain procedure to

procedure patient and obtains
informed consent
Indications,
contraindications, and Documents discussion
potential complications and informed consent
related to procedure
Prepare the patient,
Principles of informed carers, staff and
consent and environment for
documentation of consent procedure

Indications, Administers appropriate

contraindications, side local anesthetic, analgesia
effects of anesthetic agents and sedation where
and sedation required

Appropriate instruments
and environment
including infection control
measures and staffing
requirements required for
procedure.

Procedures Uses smart (automatic)

defibrillator
Emergency and
elective DC cardio Uses manual defibrillator
version
Perform as team member
Defibrillator function and as team leader
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Necessity of synchronized
shock
Starting voltage

Number of shocks

Pressure Measures CVP accurately

measurement and
care of central venous CV line monitored
line regularly

Desired position of CVP And maintained in good

line condition for as long as
necessary
Physiology of CVP
monitoring and strategies Complications are dealt
to ensure measurements with appropriately
are accurate

How to secure line and

maintain patency

Potential complications

Pleural and ascetic Punctures pleural /ascetic

fluid aspiration space

Anatomical landmarks Safe and successful

aspiration of fluid
Safe approach

Intercostal drain Perform safe blunt

insertion and dissection to pleural space
management and inserts intercostals
tube
Anatomical landmarks
Connects UWS and
How an underwater seal secures in place
functions
Maintenance of drain in
good working condition
until removal

Safe removal of the drain

Knee joint aspiration Safely punctures the joint Minimization of patient’s

at appropriate site discomfort
Anatomical landmarks
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Removal of sample

Lumbar puncture Safe and successful Minimization of patient’s

Anatomical landmarks puncture at appropriate discomfort
site
Appropriate timing of
procedure Measures CSF pressure

Non-invasive Fits masks Ventilation maintained

ventilation effectively for as long as
Prescribe pressure required
Principles of CPAP and
BiPAP

Principles of monitoring
and adjustment

Tracheotomy care and Recognize infection, Respond immediately to

immediate obstruction, dislocation open the airway
complication
management

Anatomy

Components and
functioning

Providing care Documents procedures

following procedures and provides clear
instructions related to
Potential complications of observations and
procedures’ management required

Provide appropriate
analgesia

Responds appropriately to
changes in observations
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9. Assessment strategy
a)Formative assessment at the end of each block

End of Block Assessment Guidelines

I. Objectives of the EOB Assessment:

• Formative assessment at the end of each block
• End of Block assessment will be organized by the Course Coordinators
• Assessment is to be completed within the last 7 days of each block
• Report must be completed within 7 days after Block Completion and be preserved by
the Parent Course Manager
• Debriefing / Feedback on Block activities / performance should be provided to the
Resident following assessment before they leave the training Department / Service
II. Content and Process
A. Written Examination:
Marks : 50; Time: 100 mm
Type of questions : Short Essay Question (SEQ)
Content : (a) Lectures /Tutorials/Journal Presentations, etc during the
block period in the respective discipline, (b) Applied Basic Medical
Sciences, and (c) Professional Qualities / Medical Humanities
Number of questions : 10 SEQs from the above mentioned components. No
component
should have less than two questions

B. Clinical Examination (OSCE / OSPE):

• Ten stations to be distributed among the following categories.
1) Case based focused history taking
2) Case based specific system clinical examination
3) Demonstration of clinical skill/procedure
4) Data interpretation covering disease covered during the block
5) Communication skill and patient education
6) Case scenario based management of common emergencies related to the block
7) Scenario based situation to assess the managerial cum leadership quality training
C. Medical Record Review (POMR focused assessment):
• Assessment is to be reported as follows:
Satisfactory : 81-100% satisfactorily completed
Unsatisfactory : <81% satisfactorily completed
D. Logbook Assessment:
• Assessment is to be reported as follows:
Complete :81-100% of the activities /Task were completed satisfactorily
Recoverable : 6 1-80% completed satisfactorily
Irrecoverable :<60% Completed satisfactorily
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E. Portfolio Assessment:
• Assessment is to be reported as follows:
 Uptodate : 8 1-100%, Complete and satisfactory
Deficient : <81% of the desired contents is complete; needs to revise the
contents
F. Global Rating of Resident’s Competence! Performance (EOBR Rating):
• Average rating (Rating scale I to 10)

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 End of Block Assessment Report (EBAR)

Resident’s name:………….……………………...………..RID NO. …….. Discipline:

………………….
Block Period:…………..………………………………………... Training Department/Service:
……............
Category of Assessment Assessment Scale (Score/Grade) Score/Grade
Achieved
Written examination Total marks 50
Clinical examination Total marks 100
Medical Record Review Satisfactory: 80-100% satisfactorily
(POMR assessment) completed Unsatisfactory : <80%
satisfactorily completed.
Logbook Assessment Complete :80-100% of the activities
/Task
were completed satisfactorily
Recoverable: 60 -79% completed
satisfactorily
Irrecoverable :< 60% Completed
satisfactorily.
Portfolio Assessment Uptodate: 8 -100%, Complete and
satisfactory Deficient: <80% of the
desired contents is complete; needs to
revise the contents.
Resident’s Work-based Average rating (Rating scale 1 to 10) a)……….
Competence Assessment: [ EOBR forms] b)…………
a) Clinical competency; c)…………
b) Communication skills; d)…………
c) Scholarship
d) Professionalism

Overall Comment*:

Feedback Summary:

…………………………………. ……………………………….
Coarse Co-ordinator Supervisor

* Assessment to be categorized as:

- ‘Outstanding’: Overall excellent performance

- ‘Expected’: Expected progress in all the areas of education and training; has clear
conceptions and competent in basic skills
- ‘Needs more effort’: has clear conception but lacks competency in basic skills; the
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weakness can be overcome by guided personal efforts

-‘Needs to repeat’: both conception and basic skills are unsatisfactory
 b) Summative assessment at the end of phase A

• Conducted by the University examination department

• Successful completion of eight blocks will be prerequisite for appearing in the
examination
• Examination format

- Written tests: SEQ

- Clinical examination:

a) OSCE: Ten stations to be distributed among the following categories.

1) Case based focused history taking
2) Case based specific system clinical examination
3) Demonstration of clinical skill/procedure
4) Data interpretation covering disease covered during the block
5) Communication skill and patient education
6) Case scenario based management of common emergencies related to the
block
7) Scenario based situation to assess the managerial cum leadership
quality training
b) Long case
- Viva-voce:

10. Trainee supervision, monitoring and

feedback
Monitoring methods:

i) POMR
ii) Log book: (Daily Training Record)

It provides trainees with a personal record of all procedural and

other training experiences, which are requirements for satisfactory
completion of the relevant training program.

iii) Portfolio: contents of the portfolio in each block: At least one best
case note based on POMR, one best referral note, one best discharge
summary, any one assignments (reflective essays, SDL plan, case
based learning exercise, problem-solving exercise, reflective case
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study/essay, critical incident report, one presentation in clinical

meetings/grand rounds/ journal clubs.
 iv) EOBR form evaluating Can Meds 7 roles of a physician.

11. Curriculum implementation strategies

A Medical Education Unit (MEU) should be established to provide logistic and
technical support for proper implementation of the curriculum and better
educational environment.

This unit in turn will support the following areas:

Developing study skill rooms

Audiovisual accessories

Effective and appropriate media selection and development

Preparing lesson plan for each session

Developing academic calendar

Preparing effective methods for respective individual teaching learning session

Faculty development

Staff training

For better assessment

- Selecting and developing valid and reliable assessment tools with model
answers when needed
- Development of question bank

12. Curriculum review:

- Ongoing monitoring should be done for proper implementation of
curriculum through checklist, questionnaire and from both formal and
informal feedback from the trainer, trainees and other stakeholders
- Course evaluation should be done for further improvement of the
curriculum continuously
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Annexure 1
Procedural competencies
The trainee should be competent and confidant to perform the following procedures
relevant to general medicine by the end of phases A training period.
•Venepuncture
•Cannula insertion, including large bore
•Arterial blood gas sampling
•Lumbar puncture
•Pleural fluid aspiration
•Ascitic fluid aspiration
•Intercostal drain insertion
•Central venous cannulation
•Pressure measurement and care of central venous lines
•Initial airway protection including insertion of an oral airway
•Basic and subsequently advanced cardio respiratory resuscitation
•DC cardio version
•Urethral catheterization-male and female
•Nasogastric tube insertion and checking
•ECG recording
•Supervision of Exercise ECG testing
•Knee joint aspiration
•Blood culture from peripheral and central sites
•Application of oxygen administration devices
•Inhaler devices
•Nebulisation
•Water seal drainage
•Minor suturing and debridement of wounds
•Dipstick urinalysis
•Blood glucose determination using capillary blood
•Bag and mask ventilation of unintubated patients
•Spirometry and peak expiratory flow rate determination
•Throat/pus/wound swab
•Cervical smear and swabs
•Nasal support ventilation (CPAP, BiPaP)
•Tracheostomy care
•Bone marrow aspiration
•Splenic aspiration
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•Collection, storage and transportation of pathological specimens with

accompanying notes.
Annexure 2 : CanMEDS Role : The seven Roles of
Doctor

Role 1: Medical Expert:

P
Definition: As medical experts, physicians integrate all of the CanMEDS Roles,
applying medical knowledge, clinical skill, and professional attitudes in their
provision of patient-centered care. Medical expert is the central physician role in the
CanMEDS framework.

Description: Physicians possess a defined body of knowledge, clinical skills,

procedural skills and professional attitudes, which are directed to effective patient-
centered care. They apply these competencies to collect and interpret information,
make appropriate clinical decisions, and carry out diagnostic and therapeutic

Medical exper
interventions. They do so within the boundaries of their discipline, personal
expertise, the healthcare setting and the patient’s preferences and context. Their care
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is characterized by up-to-date, ethical, and resource-efficient clinical practice as well

as with effective communication in partnership with patients, other health care

Good clinical care

providers and the community. The role of medical expert is central to the function of
physicians and draws on the competencies included in the roles of communication,
collaborator, manager, health advocate, scholar and professional.

Key Competencies: Physicians are able to :-

1. Function effectively as consultants, integrating all of the CanMEDS roles to
provide optimal, ethical and patient-centered medical care;
2. Establish and maintain clinical knowledge, skills and attitudes appropriate to
their practice;
3. Perform a complete and appropriate assessment of a patient;
4. Use preventive and therapeutic interventions effectively;
5. Demonstrate proficient and appropriate use of procedural skills, both
diagnostic and therapeutic;
6. Seek appropriate consultation from other health professional, recognizing the
limits of their expertise.

Role 2: Communicator:

Definition: As communicators, physicians effectively facilitate the doctor-patient

relationship and the dynamic exchanges that occur before, during, and after the
medical encounter.

Description: Physicians enable patient-centered therapeutic communication through

shared decision-making and effective dynamic interactions with patients, families,
caregivers, other professional, and important other individuals. The competencies of
the role are essential for establishing rapport and trust, formulating a diagnosis,
delivering information, striving for mutual understanding, and facilitating a shared
plan of care. Poor communication can lead to undesired outcomes, and effective
communication is critical for optimal patient outcomes. The application of these
communication competencies and the nature of the doctor-patient relationship vary
for different specialties and forms of medical practice.

Key Competencies: Physicians are able to....

1. Develop rapport, trust and ethical therapeutic relationships with patients and
families;
2. Accurately elicit and synthesize relevant information and perspectives of
patients and families, colleagues and other professionals;
3. Accurately convey relevant information and explanations to patients and
families, colleagues and other professionals;
4. Develop a common understanding on issues, problems and plans with
patients and families, colleagues and other professionals to develop a shared
plan of care;
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5. Convey effective oral and written information about a medical encounter.

Role 3: Collaborator:
Definition: As collaborators, physicians effectively work within a healthcare team to
achieve optimal patient care.

Description: Physicians work in partnership with others who are appropriately

involve in the care of individuals or specific groups of patients. This is increasingly
important in a modern multiprofessional environment, where the goal of patient-
centered care is widely shared. Such as a ward team, but also extended teams with a
variety of perspectives and skills, in multiple locations, It is therefore essential for
physicians to be able to collaborate effectively with patients, families, and an
interprofessional team of expert health professionals for the provision of optimal
care, education and scholarship.

Key Competencies: Physicians are able to:-

1. Participate effectively and appropriately in an interprofessional healthcare
team;
2. Effectively work with other health professionals to prevent, negotiate, and
resolve interprofessional conflict.

Role 4: Manager:
Definition: As managers, physicians are integral participants in the healthcare
organizations, organizing sustainable practices, making decisions about allocating
resources, and contributing to the effectiveness of the healthcare system.

Description: Physicians interact with their work environment as individuals, as

members of teams of group, and as participants in the health system locally
regionally or nationally. The balance in the emphasis among these three levels varies
depending on the nature of the specialty, but all specialties have explicitly identified
management responsibilities as a core requirement for the practice of medicine in
their discipline. Physicians function as managers in their everyday practice activities
involving co-workers, resources and organizational tasks, such as care processes, and
policies as well as balancing their personal lives Thus, physicians require the ability
to prioritize, effectively execute tasks collaboratively with colleagues, and make
systematic choices when allocating scarce healthcare resources. The CanMEDs
manager role describes the active engagement of all physicians as integral
participants in decision-making in the operation of the healthcare system.
Key competencies: Physicians are able to: -
1. Participate in activities that contribute to the effectiveness of their healthcare
organizations and systems;
2. Manage their practice and career effectively;
3. Allocate finite healthcare resources appropriately;
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4. Serve in administration and leadership roles, as appropriate.

Role 5: Health Advocate:

Definition: As health advocates, physicians responsibility use their expertise and

influence to advance the health and well-being of individual patients, communities,
and populations.

Description: Physicians recognize their duty and ability to improve the overall health
of their patients and the society they serve. Doctors identify advocacy activities are
important for the individual patient, for populations of patients and for
communities. Individual patients need physicians to assist them in navigating the
healthcare system and accessing the appropriate health resources in a timely
manner. Communities and societies need physicians special expertise to identify and
collaboratively address broad health issues and the determinants of health. At this
level, health advocacy involves efforts to change specific practices or policies on
behalf of those served. Framed in this multi-level way, health advocacy is an essential
and fundamental component of health promotion, Health advocacy is appropriately
expressed both by individual and collective actions of physicians in influencing
public health and policy.

Key competencies: Physicians are able to : -

1. Respond to individual patient heath needs and issues as part of patient care;
2. Respond to the health needs of the communities that they serve;
3. Identify the determinants of health of the populations that they serve;
4. Promote the health of individual patients, communities and populations.

Role 6 : Scholar:

Definition: As scholars, physicians demonstrate a lifelong commitment to reflective

learning , as well as the creation, dissemination, application and translation of
medical knowledge.

Description: Physicians engage in a lifelong pursuit of mastering their domain of

expertise. As learners, they recognize the need to be continually learning and model
this for others. Through their scholarly activities, they contribute to the creation,
dissemination, application and translation of medical knowledge. As teachers, they
facilitate the education of their students, patients, colleagues, and others.
Key Competencies: Physicians are able to :-
1. Maintain and enhance professional activities through ongoing learning;
2. Critically evaluate information and its sources, and apply this appropriately to
practice decisions.
3. Facilitate the learning of patients, families, residents, other health
professionals, the public, and others, as appropriate.
4. Contribute to the creation, dissemination, application and translation of new
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medical knowledge practices.

Role 7: Professional:

Definition: As professionals, physicians are committed to the health and well-being

of individuals and society through ethical practice, profession-led regulation, and
high personal standards of behaviour.

Description: Physicians have a unique societal role as professionals who are

dedicated to the health and caring of others. Their work requires the mastery of a
complex body of knowledge and skills, as well as the art of medicine. As such, the
professional role is guided by codes of ethics and a commitment to clinical
competence, the embracing of appropriate attitudes and behaviors, integrity,
altruism, personal well-being, and to the promotion of the public good within their
domain. These commitments from the basis of a social contract between a physician
and society. Society, in return, grants physicians the privilege of profession-bed
regulation with the understanding that they are accountable to those served.

Key Competencies: Physicians are able to:-

i) Demonstrate a commitment to their patients,
profession, and society through ethical practice;
ii) Demonstrate a commitment to their patients,
profession, and society through participation in
profession-led regulation;
iii) Demonstrate a commitment to physician health and
sustainable practice.

Common competencies- The common competences are those that should be

acquired by all physicians during their training period starting within the
undergraduate career and developed throughout the postgraduate career. The first
three common competences cover the simple principles of history taking, clinical
examination and therapeutics and prescribing. These are competences with which
the specialist trainee should be well acquainted throughout the training period.

Symptom Competences - define the knowledge, skills and attitudes required for
each level of learning for different problems with which a patient may present. These
symptoms are further broken down in to emergency, “top 20” and other
presentations. The top 20 presentations are listed together to emphasize the
frequency with which these problems are encountered in clinical practice, and are
based on medical admissions unit audit data including the “next 40” less common
presentations

Surgical Presentations – define symptoms such as haematuria, rectal bleeding,

and abdominal pain which are traditionally managed by surgical teams. The reason
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that these symptoms appear in this curriculum is to recognize that often a physician
is called upon to perform the initial assessment of these patients. These
presentations frequently occur in the context of long-term medical illness and as a
complication of medical illness. Also, the hospital-at-night team structure leads to
physicians at all levels of training taking responsibility for surgical in-patients. The
role of the physician in these situations is not to take responsibility for the full
management of these patients. However, a physician is expected to stabilize the
patient as necessary, perform initial investigations and management if urgently
required, and make a referral to the appropriate surgical team for a specialist opinion
in a timely manner System Specific Competences - define competences to be attained
by the end of training, and also lists the conditions and basic science of which the
trainee must acquire knowledge.

Investigation Competences - lists investigations that a trainee must be able to

describe, order, and interpret by the end of training.

Procedural Competences - lists procedures that a trainee should be competent in

by
the end of training.

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Annexure 3: List of lecture to be delivered in the
department of Medicine
(List will be upgraded)

Evaluation of patients with

1. Palpitation
2. Upper abdominal pain
3. low back pain
4. Diffuse abdominal pain
5. Neck pain
6. Headache
7. Lateral wall chest pain
8. Chronic polyarthritis
9. Acute polyarthritis
10. Pain in single joint (Monoarthritis)
11. Generalized aches
12. Shoulder pain
13. Knee pain
14. Upper limb pain
15. Foot and ankle pain
16. Hip pain
17. Acute fever
18. Prolonged pyrexia
19. Headache and fever
20.Dizziness
21. Generalized weakness
22. Tremor
23. Involuntary limb movement
24. Paraesthesias
25. Acute confusional state in the elderly
26. Unconscious patient
27. Recurrent loss of consciousness
28.Slurred speech
29. Loss of memory
30.Daytime somnolence
31. Insomnia
32. Unpleasant sensation in lower limbs
33. Ptosis
34. Diplopia
35. Proptosis
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36. Facial palsy

37. Hemi facial pain
38.Involuntary movement of face
39. Recurrent convulsions
40.Imbalance of gait
41. Periodic paralysis
42. Proximal muscular weakness
43. Paraplegia
44.Hemiplegia
45. Oral ulcers
46.Acute breathlessness
47. Shortness of breath on exertion
48.Chronic cough
49.Chest pain on exertion
50.Acute central chest pain
51. Hypertension assessing secondary causes and target organ damage
52. Haemoptysis
53. Bilateral pedal edema
54. Unilateral limb edema
55. Shock
56. Dysphagia
57. Anorexia
58. Nausea
59. Early satiety
60.Vomiting
61. Gaseousness in abdomen
62. Chronic diarrhea
63. Chronic constipation
64.Upper GI bleeding
65. Lower GI bleeding
66.Acute abdominal pain
67. Lower abdominal pain
68.Heartburn
69.Dryness of mouth
70. Weight loss
71. Steatorrhea
72. Ascites
73. Jaundice
74. Asymptomatic abnormal LFTs
75. Dysuria
76. Urethral discharge in male patient
77. Haematuria
78. Pyuria
79. Polyuria
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80.Proteinuria
81. Incontinence of urine
82.Oliguria and anuria
83.Erectile dysfunction
84.Hisutism and virilisation
85. Infertlity
86.Pruritis
87. Urticaria
88.Facial rash
89.Blisters and bullae
90.Purpuric spot
91. Alopecia
92. Papules and nodules
93. Leg ulcers
94.Raynaud’s phenomenon
95. Claudication
96.Tight and thick skin
97. Dark skin
98.Anemia
99.Iron deficiency anemia
100. Gum bleeding
101. Splenomegaly
102. Hepatomegaly
103. Hepatosplenomegaly
104. Lymphadenopathy
105. Evaluation of ST-T changes in ECG
106. Errors in interpretation of ECG
107. Polycythemia
108. Pancytopenia
109. DVT
110. Solitary thyroid nodule
111. Asymptomatic abnormal thyroid function test results
112. Thyrotoxicosis
113. Hypothyroidism
114. Short stature
115. Loss of libido
116. Gynecomastia
117. Cushing’s syndrome and disease
118. Weight gain
119. Spontaneous hypoglycemia
120. Night sweats
121. Evaluation of HPA axis
122. Evaluation and monitoring of a diabetic patient
123. Medically unexplained somatic symptoms
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124. Depressed mood

125. Unexplained raised ESR
126. Fever with drowsiness
127. Genital ulcers
128. Asymptomatic abnormal urinary findings
129. Malabsorption
130. Acute agitation
131. Spontaneous hypoglycemia
132. Common pulmonary infections in immunocompromised patients
133. Carcinoma of unknown primary origin
134. Adult patient with dyspnoea in emergency department
135. Bleeding disorders
136. Hypogonadism
137. Acute tubular necrosis
138. PUO
139. Metabolic syndrome
140. Thyroid swelling
141. Acute paralysis
142. Hoarseness voice
143. Renal tubular acidosis
144. Empty sella syndrome
145. Jaundice in pregnant woman
146. Dyslipidemia
147. DPLD
148. SLE and pregnancy
149. Adrenocortical insufficiency
150. Osteoporosis
151. Pulmonary hypertension
152. Rheumatoid arthritis and pregnancy
153. Patient presenting with erythema nodosum
154. Galactorrhroea
155. Hypertensive urgencies and emergencies
156. Anxiety disorder
157. Fall in elderly
158. Painless cervical lymhadenopathy
159. Recurrent fracture
160. Right iliac fossa lump
161. Unexplained raise of ESR
162. Bruising and spontaneous bleeding
163. Hypothermia
164. Hyperthermia/heat stroke
165. Severe anemia
166. Acute new onset headache
167. Deliberate self harm
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168.
Management of
1. Steven – Johnson syndrome & TEN
2. Nutropenia and fever
3. Withdrawal of steroid
4. Hyperosmolar coma
5. Diabetic coma
6. Newly diagnosed type II diabetes
7. OPC poisoning
8. Methanol poisoning
9. Snake bite
10. Heat injuries
11. Management of obesity
12. MOF & SIRS
13. Acute circulatory failure
14. Acute respiratory failure
15. Chronic respiratory failure
16. OPC poisoning
17. Snake bite
18. Palliative treatment of cancer patients
19. Uncomplicated Tuberculosis: pulmonary and extra pulmonary
20.Complicated tuberculosis
21. MDR TB
22. Leprosy
23. Pneumonia
24. Malaria
25. DHF
26. Prevention and management osteoporosis
27. UTIs
28.Atrial fibrillation
29. Supraventricular tachycardia
30.VES
31. Stable angina
32. Unstable angina
33. Acute coronary syndrome
34. Management of hypertension
35. Management of HTN in special situation
36. Management of Rheumatic valvular diseases
37. Management of congenital heart diseases
38.Hypertrophic cardiomyopathy
39. Management of heart failure
40.Management of septic arthritis
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41. Management of hyperglycemia in Diabetes with end stage renal failure

42. Managing patients at the end of life
 43. Management of glycemic control in acute illness
44.Peripheral vascular disease
45. Management of important complications of cancer therapy
46.Mx of diabetes in ESRD
47. Mx of patient at the end of life
48.Management of glycemic control in acute illnesses
49.Mx of patient with HBV infection in carrier state
50.Emergency management of bronchial asthma
51. Step care management of bronchial asthma
52. Mx of psoriasis
53. Mx of IBD
54. Mx of IBS
55. Mx of crystal arthropathy
56. Mx of polymyelgia rheumatic and giant cell arterirtis
57. Mx of nephritic syndrome
58. Mx of GN
59. Principles of Management of CRF
60.Mx of COPD
61. Mx of pulmonary hypertension
62. Mx of Obstructive sleep apnea syndrome
63. Mx of acute pulmonary embolism
64. Mx of Acute renal failure

Evaluation and management of

1. Heel pain
2. Evaluation and General management of the poisoned patient
3. Acute diarrhea
4. Urethral discharge in male
5. Chronic tubulointerstitial diseases
6. Asymptomatic hyperuricemia
7. Evaluation and treatment of acute diarrhea
8. Acidosis
9. Alkalosis
10. Hyponatremia
11. Hypokalaemia
12. Hyperkalamia
13. Hypocalcaemia
14. Hypercalcemias
15. Deep fungal infection
16. Pericardial effusion
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17. Anti-phospholipids syndrome

18. Miliary tuberculosis
19. TBM
20. Patient with vasculitis
21. Avascular necrosis
22. Infective endocarditis
23.

Miscellaneous
1. Principles of antimicrobial therapy
2. Diagnosis and management of HIV infection
3. Complications of steroid and their prevention
4. Lung function tests
5. Risk factors for thromboembolism and indications for thromboprophylaxis
6. Methods of delivery of oxygen and ventilation
7. Components of blood products and indications, contraindications and adverse
effects of the use of the blood products
8. Principles of acute and chronic pain management
9. Common an life threatening drug interactions and common presentation of
drug induced disease
10. Mechanical ventilation
11. Renal manifestations of systemic disease
12. Gastrointestinal manifestations of systemic disease
13. Hematological manifestations of systemic disease
14. Musculoskeletal manifestations of systemic disease
15. Neurological manifestations of systemic disease
16. Respiratory manifestations of systemic disease
17. Cardiovascular manifestations of systemic disease
18. Dermatological manifestations of systemic disease
19. Common pulmonary infections in immunocompromized patients
20.Potentially curable cancers
21. Interstitial kidney disease
22. Bone marrow failure-potential causes and complications
23.
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Annexure: 4
For Phase - A
• List of symptoms that a trainee should learn to evaluate

• List of self-limiting conditions curable or treatable on one-step basis

• List of very common chronic condition for which intern should acquire to
offer best evidence-based longitudinal care

For Phase – B
• List of uncommon emergency

• List of less common chronic condition that needs best evidence-based

longitudinal care

• Non-interventional longitudinal care of patients with multiple problems e.g.,

patient with IHD, DM, dyslipidemia or patient with bronchial asthma,
hypertension, RA & CAD

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 Note

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