(Based on a dissertation done by the American Board of Medicine through the Committee on Evaluation in General Medicine ? this document on Clinical Competence in Internal Medicine has been used as reference. The document is comprehensive and generally echoes the goals of the Department of Medicine Residency Training Program).

Philippine College of Physicians

 Clinical Competence of the Internist

At the conclusion of his/her training, the resident should have developed the attitudes and habits, interpersonal skills, skills in data gathering (history,physical examination) problem definition and render competent and appropriate medical care expected of an internist. The development of this kind of physician is merely a continuum of the task started during medical school and does not end with the completion of the resident's formal training. The resident may be called upon to demonstrate such skills, attitudes and habits.

Attitudes and Habits

The Internist should:

§      Have as his primary concern the welfare of his patients 

§      Provides comprehensive and continuing care to his patients, utilizing his and other sources of expertise as may be required to alleviate as much as possible all of his patient's health problems.

§      Be sensitive to the patient as an individual and to his emotional, cultural,social and physical needs. He must be able to accept the anxiety, fears,hostility and anger that his patients may exhibit and accept responsibility for the patient's care without bias or prejudice.

§      Be accessible to his patient and to provide coverage by peers when he is unavailable.

§      Recognize his limitations and be willing to consult with other physicians when necessary, making appropriate use of their advice. He should not undertake management of diagnostic or therapeutic procedure he is not qualified to do unless circumstances indicate all alternatives carry greater risk.

§      Accept responsibility for educating patients and/or their families regarding problems,management plans and decisions.

§      Use restraint by avoiding diagnostic and therapeutic measures which are unnecessaryor present undue risk.

§      Minimizethe cost of medical care to the patient

§      When acting as a consultant be appropriately thorough to identify the previously unidentified medical problems other than those for which the patient was referred.

§      When acting as consultant, accept the responsibility of maintaining appropriate communication with the referring physician and support the referring physician-patient relationship unless the patient's welfare is jeopardized.

§      Participate in the continuing education of students, residents, peers and other health personnel.

§      Participate according to his talents in the solution of health care problems in the community and society.

§      Devote the interest, time, and energy required to maintain and upgrade his clinical knowledge and skills.

§      Understand the limitations of current medical knowledge in explaining all aspects of a patient's problems.

§      Always display integrity, honesty and medical ethics above reproach. 

 

Interpersonal skills

 

The internist should have the interpersonal skills to:

·     Develop a strong relationship that inspires confidence in patients and convey a feeling of interest and concern.

·     Communicate with patients and patient's families information about diagnosis, prognosis and management.

·     Interact in a non-judgmental manner

·     Be alert to and interpret non-verbal clues of the patient.

·     Recognize and be sensitive to the patients? emotional needs and recognize their potential    influence on the symptoms and course of the illness.

·     Educate the patient in health maintenance.

·     Inspire cooperation with other members of the health care team.

·     Communicate effectively and tactfully with colleagues both as a consultant and as a member of the health care team.

 

Data Gathering-History

 

1.   Attitudes and habits

·     Develop the habit of completing and recording a complete history.

·     Be sensitive to symptoms or statements which suggest depression or psychosomatic illness.

·     Develop the habit of updating and supplementing historical data on follow-up visits.

·     Pursue with appropriate thoroughness all historical rules

2.   Interpersonal skills

·     Be able to establish rapport with the patient and other informants which makes possible the obtaining of a complete and accurate history.

·     Be able to recognize verbal and non-verbal clues of the patient and pursue the indicated lines of inquiry.

·     Be able to adapt language appropriately to ensure communication with persons ofdiffering ethnic cultural or nationality backgrounds.

·     Be able to adapt to patients who present a disjointed or disorganized history.

 

3.   Motorand Technical skills

·     Be able to utilize techniques such as body posture and eye contact that facilitate communication.

 

4.   Knowledge

·     Have depth of knowledge that allows thorough exploration of symptoms relating to thepatient's problem.

·     Have depth of knowledge that allows consideration of various etiologies to explainthe patient?s symptoms.

 

5.   Pathophysiology

·     Understand symptoms interms of altered structure and function of body systems.

·     Differentiate between symptoms that arise directly from a disease process and those that occur as aresult of the body's response to disturbed homeostasis.

 

6.   Organization

·     Approach the history in a logical directed way to ensure completeness.

·     Follow up medical clues in a directed logical pattern.

·     Organize and record the history completely in a fashion that will be understandable to all patients andusers of the record.

  

7.   Synthesis

·     While obtaining history,integrate symptoms into diagnostic hypothesis.

·     Recognize symptom patterns that suggest even low frequency diseases. As additional data are obtained, be able to formulate new or additional diagnostic hypothesis.

 

8.   Clinical Judgment

·     Assesses the reliability of the history obtained.

·     Separate approximately irrelevant from relevant information.

·     Identify information that seems incongruous with the clinical situation.

  

DATA GATHERING-PHYSICAL EXAMINATION

 

In performing a physical examination, the internist should:

 

1.   Attitudes and Habits

·     Develop the habit of performing a complete physical examination unless inappropriate to the clinical situation

·     Pursue appropriately all abnormal physical findings.

 

2.   Interpersonal skills

·     Be able to encourage the patients cooperation so that a complete physical examination is possible.

·     Undertake the physical examination with concern for the patient's comfort, privacy andsensitivity forewarning the patient of uncomfortable or unanticipated maneuvers.

 

3.   Motor and technical skills

·     Be able to elicit subtleas well as obvious physical findings by inspection, percussion, palpation orauscultation and be able to use appropriate instruments such as the ophthalmoscope,tonometer, sigmoidoscope.

·     Be able to modify physical examination procedures to adapt to particular medicalsituations.

4.   Knowledge

·     Know the range of normalvariation of physical findings.

·     Know alternative techniques capable of confirming abnormal findings.

 

5.   Pathophysiology

·     Understand the underlying rationale for indicated procedures.

·     Interpret the results that reflect homeostatic responses to disease as contrasted to those that reflect the effect of disease.

 

6.   Organization

·     Order laboratory studies in a logical sequence to avoid unnecessary procedures, cost and observe appropriate timing of procedures to avoid invalidation of test results.

 

7.   Synthesis

·     Accurately interpret test results.

·     Recognize patterns of diagnostic information.

·     Integrate data appropriately to confirm or refute diagnostic hypothesis.

 

8.   Clinical Judgment

·     Select from alternatives those diagnostic procedures with the greatest likehood of useful results taking into account risk and cost.

·     Make appropriate judgments from conflicting laboratory results.

·     Adapt diagnostic procedures to meet special requirements of the situation.

·     Discern when indicated procedures should be delayed (e.g., an emergency)

·     Judge the validity and reliability of laboratory studies in each clinical situation.

 

 

DIAGNOSIS OR PROBLEM DEFINITION

 

In reaching decisions about patients and their medical problems, the internist should.

 

1.   Attitudes and Habits

·     Develop the habit of relating as much as possible, the clinical situation of a patient to the total body of knowledge and experience in medicine.

·     Consider clinical explanations for all the clinical findings obtained.

·     Develop the habit of considering psychological disease as a possible explanation of a patient?ssymptoms.

·     Strive for the most definitive diagnosis for each problem.

·     Carefully consider diagnostic possibilities suggested by patients or other sources ofinformation.

 

2.   Interpersonal Skills

·     Be able to express clearly to patients and families facts about the diagnosis thatwill ensure their understanding and cooperation.

 

3.   Knowledge

·     Considerall the diagnostic possibilities that might explain the data obtained.

·     Possess knowledge of the manifestations of the likely etiologies of the patient?sdisease.

·     Be able to link the clinical findings to knowledge of the natural history ofdisease such as epidemiology, course, complications and prognosis.

 

4.   Pathophysiology

·     Express diagnosis in terms of altered structure and function where appropriate.

·     Be able to explain in pathophysiologic terms the relationship between diagnosisand the presence or absence of symptoms, signs and findings.

·     Be able to apply established and emerging concepts in the basic medical sciencesto clinical problem solving.

 

5.   Organization

·     Obtain and record data including appropriate negative information, knowledge of whichis indicated by the nature of the disease present.

·     Record diagnosis in a logical fashion in the medical record.

·     Discuss the patient?s diagnosis and problems in the medical record in progress notes inan organized and complete fashion.

·     Record all appropriate diagnosis and problems in the medical record to ensure adequatefollow-up.

·     Be able to present patient's problems to consultants or other personnel in an organized,logical fashion.

 

6.   Synthesis

·     Use knowledge of disease processes to integrate data obtained into diagnostic hypothesis.

·     Recognize clusters of signs and symptoms associated with particular disease entities.

·     Utilize all data in making final diagnostic decisions.

·     Recognize unusual or aberrant findings as they relate to diseases under consideration.

·     Recognize manifestations of psychologic disturbance.

·     Beable to diagnose the presence of multiple or complex interacting disorders.

 

7.   Clinical Judgment

·     Develop final diagnostic formulations by evaluating all available data and information.

·     Be able to make diagnostic decisions when necessary in the absence of compete data.

·     Utilize available data from the literature or other sources as an aid to assessing the importance of conflicting findings.

·     Be able to revise or suspend judgments when acute new complications or findings of illness occur.

 

 

MEDICAL CARE-IMMEDIATE AND CONTINUING

 

In prescribing medical care, the internist should     

 

1.   Attitudes and Habits

·     Provide comprehensive and continuing care to his patients whenever appropriate, takinginto account pertinent socioeconomic factors.

·     Accept the responsibility to see that all sources of expertise are utilized to ensurethe best outcome of all patient's health problems.

·     Refer to others the management of patients requiring technical therapeutic procedures which the internist may not be qualified to perform.

·     Resist patient demands for inappropriate therapy.

 

2.   Interpersonal Skills

·     Be able to educate patients and families adequately to ensure compliance withimmediate and continuing management plans.

 

3.   Motor and Technical Skills

·     Be proficient in those therapeutic procedures requiring technical skills.

 

4.   Knowledge

·     Know the most effective therapies available for the problems.

·     Know the correct procedures for instituting the indicated therapy.

 

5.   Pathophysiology

·     Have knowledge of interactions between drugs and the need to modify drug therapy inthe presence of specific organ dysfunction.

·     Understand the mechanisms of drug action and the acute and chronic side-effects.

 

6.   Organization

·     Document thoroughly all therapeutic plans.

·     Organize all available resources to ensure patient compliance and the results oftherapy.

·     Establish monitoring procedures to assess patient compliance and the results of therapy.

·     Inform and instruct all health professionals involved with the patient.

·     Arrange for long-term follow-up and care including rehabilitation.

 

7.   Synthesis

·     Devisea therapeutic plan which considers the patient?s active, treatable problems.

·     Recognize the signs and symptoms indicating adverse effects therapy.

·     Prescribe the correct dosage, timing and duration of therapy appropriate to the patient?stotal situation.

 

8.   Clinical Judgment

·     Make therapeutic decision in the light of potential benefits, risk and the expectedquality of life.

·     Take into account psychologic, environmental and socio-economic and religiousfactors in the formulation of therapeutic plans.

·     Develop management plans to prevent, minimize or delay the development of known complications of the clinical conditions present.

·     Be able to make therapeutic decisions when necessary in the absence of a confirmed diagnosis.

·     Be able to improvise therapeutic plans in an emergency utilizing available resources.

·     Be able to recognize those situations in which it is appropriate not to treat amedical problem or to treat it only symptomatically.

·     Be able to adapt therapeutic procedures to meet special or changing needs of themedical situation.

·     Be able to recognize when a patient?s illness has reached a point at which achievingan acceptable quality of life is unlikely and at that time be able to ensurethat the patient dies with comfort and dignity.