Internal Medicine — Core of Discipline

C1 Assessing, diagnosing, and managing patients with complex or atypical acute medical presentations

Key Features:
- This EPA focuses on diagnosis and includes providing medical care to patients presenting with acute medical problems from initial presentation through and including appropriate follow-up.
- This EPA focuses on patients with high complexity, defined as those with: multiple conditions that co-exist and/or interact; a single condition with multisystemic manifestation; an atypical presentation of a common condition; management challenges due to social determinants of health and/or cultural complexities.
- At this stage, the trainee is entrusted with complex clinical presentations with uncertainty in diagnosis and/or management. The trainee is also entrusted to recognize when patients require subspecialty care.
- This EPA may be observed in the inpatient, outpatient, or emergency room setting.

Assessment Plan:

Direct or indirect observation by supervisor

Use Form 1. Form collects information on:
- Type of observation: direct; indirect
- Setting: ambulatory care; inpatient

Collect 18 observations of achievement
- At least 4 direct observations
- A mix of ambulatory and inpatient settings
- At least 6 different assessors

Milestones

• ME 1.5. Maintain a duty of care and patient safety while balancing multiple responsibilities

• ME 2.1. Consider clinical urgency and comorbidities in determining priorities to be addressed

• ME 2.2. Perform complete and appropriate assessment of complex clinical presentations, including consideration of competing treatment needs

• ME 2.2. Select and interpret appropriate investigations based on a differential diagnosis

• ME 2.2. Integrate and summarize information obtained through the clinical assessment and investigations

• ME 2.2. Generate and prioritize the differential diagnoses

• ME 2.2. Monitor the evolution of the clinical course and/or the patient’s response to treatment

• ME 2.4. Generate management plans that address on-going diagnostic uncertainty, address treatment needs, evolve with the clinical course, and incorporate best practice and evidence-based guidelines

• ME 3.1. Integrate all sources of information to develop a procedural or therapeutic plan that is safe, patient-centred, and considers the risks and benefits of all approaches

• ME 4.1. Establish plans for ongoing care, taking into consideration the patient’s clinical state, circumstances, preferences, and actions, as well as available resources, best practices, and research evidence

• ME 4.1. Determine the necessity and timing of referral to another health care professional

• COM 3.1. Provide information to patients and their families clearly and compassionately

• COM 5.1. Document clinical encounters to adequately convey clinical reasoning and the rationale for decisions

• COL 1.2. Work effectively with other health care professionals, including other physicians

• L 2.1. Demonstrate resource stewardship in clinical care

• S 3.1. Generate focused clinical questions relevant to patient diagnoses or management to guide literature searches

• S 3.2. Utilize point of care evidence-based resources

• S 3.4. Critically appraise relevant medical literature to make evidence informed medical decisions