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Overview of the Programme 1.1 GENERAL OBJECTIVE To produce competent and safe internal medicine specialists who

are capable of managing common medical conditions and emergencies independently

are compassionate and guided by ethical principles in decision-making

can recognize their limitations and will seek proper consultation

Are capable of developing their interest and further training in medical subspecialties

demonstrate critical thinking and self-directed learning in continuing education

demonstrate leadership skills in managing the services and the team in the medical unit

Programme Master of Internal Medicine

Degree to be awarded A candidate who has successfully completed all the courses in the programme and passed all

the course examinations, will be awarded upon recommendation of the Senate, a:

MASTER OF MEDICINE (INTERNAL MEDICINE)

Type of award Masters Degree

Field of Study Internal Medicine

Language of Instruction: English

Mode of Study: Full-time

Duration of Study 4-years. Maximum duration is 7 years.

Mode of delivery Lecture/tutorial/lab/clinical/research

Occupation of graduates: General Physician

Estimated date of first intake: June and December each year

Projected intake: 30 per year

Awarding Body: Universiti Kebangsaan Malaysia

1.2 PROGRAMME STRUCTURE The programme consists of 4 years aimed at progressive mastery of knowledge, skills and attitude, increasing responsibilities and independence. It is divided into three phases: Phase I - Year I Phase II - Year 2 and 3 Phase III - Year 4 Year 1 The general objective is to enable candidates to acquire knowledge of the basic principles of Basic sciences and Internal Medicine and to applying them in the clinical problem solving and decision-making process involved in the management of patients under supervision.

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Candidates will be posted for 12 months in the general medical wards and Coronary Care Unit where ever relevant. Year 2 and Year 3 The general objective is to enable candidates to acquire knowledge, skills and attitude appropriate for the managing patients in the various medical subspecialties which will be useful in their general medical practice. They will manage patients under supervision at the level of the junior registrars. The candidates must undergo 8 rotations of 3 months each from the following: Cardiology, Endocrinology, Neurology, Nephrology, Gastroenterology, Respiratory, Haematology and Rheumatology/Dermatology/Infectious Diseases. Rotations of these posting can be undertaken in an accredited institution/department/subspecialty unit locally or overseas under the supervision of a consultant. The candidates are also required to write 4 case reports during this period. Year 4 The general objective is to enable the candidate to function as the registrar of the medical unit. Managing patients as well as assisting the consultant to manage the unit, candidates will also be able to develop skills in the subspecialty area they have an interest in. Candidates are posted for 6 months in general medicine and 6 months elective in a subspecialty of interest. 1.3 CANDIDATE ASSESSMENT & EXAMINATIONS PART I ASSESSMENT Continuous asssessment Continuous assessment of a candidate will be based on: a) Reports from the supervisors using the Trainee’s Assessment Form every 3 months. Each

candidate must pass the continuous assessment as a prerequisite to proceed to the Part 1 examination.

d) Satisfactory filling up of the Log book Prerequisites for sitting for Part 1 examination All candidates must pass all the components of the continuous assessment PART 1 EXAMINATION Part I examination will be conducted in two separate exams conducted twice a year at six monthly intervals (in April/October and May/November respectively). The exam consists of two components: Theory and Clinical. The examination will be hosted alternately between the various universities of the Conjoint Examination Board. Only candidates who pass the theory examination will be allowed to proceed to the clinical examination. The clinical exams will be held approximately 1 month after the theory examination

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CLINICAL DURATION MARKS (%)

OSCE / Short Cases

(4 cases x 15 minutes).

1 hour

40 %

Criteria for Passing MMED Part 1 Examination 1. Candidates must pass BOTH Theory and Clinical components

2. Candidates must achieve at least 50% of the overall marks in the OSCE/Short cases

3. Candidates must pass at least 2 out of 4 short cases / OSCE

PART II ASSESSMENT Continuous Assessment Continuous assessment will be based on: a) Progress reports from supervisors from all postings based on attitude, integrity, attendance,

clinical competence and theoretical knowledge recorded in the Candidate Assessment Form (Appendix 3).

b) Satisfactory filling up of the Log book c) Four satisfactory case reports (each one achieving a pass mark of ≥ 50%) submitted during

the 4 years of the course as a pre-requisite to sit for the MMED Part II Examination. All case reports must be of publishable quality according to the Indexed journal and must be submitted at least 2 months before the theory examination date.

Prerequisites to sit for Part II examination a) A thesis proposal presented to the department’s MMed Committee and submitted to the

ethics committee is required as a prerequisite to sit for the MMED Part II Examination at

THEORY DURATION MARKS (%)

OBA (One Best Answer)

(100 OBA questions are divided into 2

papers : OBA I and OBA II)

50 OBA in 1.5 hr

(OBA I) And

50 OBA in 1.5 hr (OBA II)

35 %

Problem Solving

(10 questions x 12-15 minutes).

5 PS in 1.5 hr

And 5 PS in 1.5 hr

25 %

TOTAL MARKS

60 %

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least 1½ months before the theory examination. Proof of submission of the proposal to the ethics committee must be handed in to the department.

b) All candidates must pass all the components of the continuous assessment. PART II EXAMINATION Part II examination will be conducted in two separate exams conducted twice a year at six monthly intervals (in April/October and May/November). The examination will be hosted alternately between the various universities of the Conjoint Examination Board. The exam consists of two components: Theory and Clinical. Only candidates who pass the theory examination will be allowed to proceed to the clinical examination. The clinical exams will be held approximately 1 month after the theory examination

THEORY DURATION MARKS (%)

One Best Answer (OBA)

(100 OBA questions are divided

into 2 papers : OBA I and OBA II)

50 OBA in 1 ½ hr

and

50 OBA in 1 ½ hr

20 %

Modified Essay Questions

(MEQ)

1 ½ hours

(2 MEQ x 45 minutes)

10%

Objective Structure Practical Examination (OSPE)

2 hours

(24 x 5 minutes)

10 %

TOTAL MARKS 40%

CLINICAL DURATION MARKS (%)

One Long Case

1 ½ hours(1 hour for clerking and 30

minutes for discussion)

25%

Four Short Cases

1 hour

(4 x 15 minutes*)

25%

Viva-voce

(2 stations : Evidence-based medicine & Communication Skills)

20 minutes 10%

TOTAL MARKS 60%

*15 minutes = 7 minutes examination + 3 minutes presentation + 5 minutes Q&A

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Criteria for passing MMED Part II Examination 1. Candidates must pass BOTH Theory and Clinical components

2. Candidates must achieve at least 45% in the Long Case

3. Candidates must pass at least 2 out of 4 short cases

4. Candidates must NOT attain less than 4/10 marks in any of the short cases

Examination Results The students are informed of the examination results by the Head of Department after the Board of Examiners meetings at the department and faculty level. PART III ASSESSMENT& EXAMINATION The criteria for passing the Part III examination and the award of the MMED degree will be based on: i) Satisfactory report(s) from supervisor(s) ii) Satisfactory evaluation of dissertation The dissertation will be assessed in 2 methods:

1. Submission of a hard copy of the dissertation (formatted according to the UKM Style Guide)

2. Oral presentation followed by a viva

Assessment of the dissertation will be performed by an external/internal examiner appointed by the supervisor. The dissertation will be marked either as: -Pass without corrections -Pass with minor corrections -Major corrections requiring re submission 1.4 CRITERIA FOR PROMOTION

Dissertation A candidate is to conduct a research project during the programme. This is to introduce the candidate to research methodology and data analysis. The candidate is not expected to conduct in-depth study of a subject equivalent to an M.D or PhD thesis. Research projects proposals for the purpose of dissertation for Phase III (Year IV) must be presented at the department level and submitted to the IEC/IRB in year 2 or beginning of year 3. The approved project proposal must be submitted to the MMed Coordinator 1½ month before the Part II examination. The dissertation must be about 20,000 words (excluding diagrams, tables and references) with at least 40 % allocated to discussion.

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Redeemable Failure All examination results are final. A candidate is not allowed to make any redemption once the examination results have been announced. Repeat Examination 1) Candidates who fail the Theory examination will not be allowed to proceed to the clinical examination for both Part I and Part II. This will be considered as one attempt. 2) Candidates who pass the Theory but fail the Clinical examination will be allowed to proceed

to repeat the clinical examination after 6 months. If the candidate fails again he/she will be allowed to sit for another clinical examination after 6 months.

3) A candidate will be allowed a maximum of 3 attempts at the Theory examinations and a maximum of 3 attempts at the clinical examination. However, if the candidate still fails, he/she will be dismissed from the programme. 4) If a candidate passes the repeat examination, he/she will be allowed to continue with the programme. 1.5 LEAVE OF ABSENCE i) Work leave

Work leave include sick leave, vacation, maternity leave, holiday and family and medical

leave. Candidates are allowed a total of 14 days per year.

ii) Deferment from the program

Candidates can apply for deferment from the programme for one semester (6 months)

based on acceptable reasons. Candidates are allowed to defer for only twice throughout

the duration of the course. The total period of deferment must not be more than twelve

months.

1.6 GRADUATION A candidate is certified for graduation once he/she pass the Part III examination

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Specific Objectives by year of study

Year 1 The general objective is to enable candidates to acquire knowledge of the basic principles of Medicine and to apply them in the clinical problem solving and decision-making process involved in the management of patients under supervision. Candidates will be posted for 12 month in the general medical wards or certain subspecialty wards wherever relevant. Specific Objectives: At the end of Year I, candidates will be able to demonstrate their ability to: 1. Apply knowledge of basic medical sciences and the principles of Medicine in the clinical reasoning process of diagnosis and management of medical conditions 2. Provide appropriate care based on basic medical principles by: a) Taking a thorough history and performing a complete physical examination to derive provisional and differential diagnoses b) Instituting initial management with relevant investigations c) Planning further management of the patient in consultation with senior colleagues d) Arranging for further confirmatory investigations and consultations e) Performing ward procedures under supervision 3. Apply rules of evidence to clinical, investigational and published data in order to determine their applicability and validity in journal club, critique of scientific writing, case presentation and mortality/morbidity conference 4. Identify areas of deficiency in their performance, find appropriate educational resources, use the new knowledge and skills in the care of patients and evaluate their own learning progress.

Year 2 and 3 The general objective is to enable candidates to acquire knowledge, skills and attitude appropriate for the management of patients in the various medical subspecialties which will be useful in their general medical practice. They will manage patients under supervision at the level of the junior registrar. The candidates must undergo 8 rotations of 3 months each from the following:

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Cardiology, Endocrinology, Neurology, Nephrology, Gastroenterology, Respiratory, Rheumatology & Immunology, Dermatology & Infectious Diseases, Hematology and Oncology.

NEPHROLOGY

By the end of the Nephrology rotation the candidate should be able to: 1. Apply the knowledge of the natural history of renal disease and the principles of treatment

in the clinical reasoning process of diagnosis and management of renal conditions

2. Provide appropriate care to patients based on basic principles of Medicine by:-

a) Taking a thorough general and renal history, performing a complete physical examination to derive the provisional and differential diagnoses

b) Assessing clinically the effects of the disease on the physical, mental and social well-being of the patient

c) Instituting initial management with routine and other relevant investigations

d) Planning, in consultation with senior colleagues, the further management of the patient with particular attention to the principles involved and the role of the multidisciplinary team

e) Arranging for further confirmatory investigations and consultation

f) Perform urinalysis by dipstick, light microscopy and phase contrast microscopy and interpret renal function tests, basic renal histopathology and organ imaging techniques

3. Apply rules of evidence to clinical, investigational and published data in order to

determine their applicability and validity in reviewing various aspects of renal disease

4. Participate in audit, current ongoing projects or conducting short-term studies leading to scientific writing and publication. (Candidates who select a dissertation project in Nephrology will be supervised by the Lecturer/supervisors of the formulation of the research proposal, collection and analysis of data and the drafting of the dissertation)

5. Participate as a junior registrar in the renal team with responsibility for the day-to-day care

of patients in the ward and clinic, including educating patients and their families, presenting and discussing cases that have been clerked, assessed or reviewed, presenting at x ray conference, assisting in special procedures, performing tests, doing call duties, writing discharge summaries, attending follow-up and referral and participating in the academic activities of the unit.

6. To identify the areas of deficiency in their performance, to find appropriate educational

resources, use the knowledge and skills in the care of patients and to evaluate their personal learning progress.

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Core Knowledge Candidates are expected to possess adequate core knowledge about nephrology as listed below. To assist in the acquisition of knowledge a short series of lectures on basic practical nephrology will be given (Wednesday 12.30pm). In addition, an annual seminar on Nephrology is organized in conjunction with the Malaysian Society of Nephrologists. 1. Anatomy and physiology of the kidney 2. Glomerular diseases: IgA, Minimal change disease, FSGS, Membranous nephropathy,

pathogenesis, pathology, clinical features, diagnosis and management 3. Systemic diseases: SLE, vasculitides affecting the kidney (Wegener’s granulomatosis),

myeloma kidney 4. Interstitial disease: Interstitial nephritis, analgesic nephropathy, reflux nephropathy, urinary

tract infection, renal tubular disorders, cystic disease, urinary calculi 5. Renal failure: Acute renal failure, chronic renal failure, dialysis modalities and

complications, transplantation 6. Miscellaneous: Fluid and electrolyte disorders, the kidney in pregnancy, hypertension and

the kidney, drugs and the kidney, diabetic nephropathy. Nice to Know i) Use of immunosuppressive agents, therapeutic drug monitoring, side effects and

complications ii) Technical aspects of Hemodialysis and Peritoneal dialysis iii) Extra renal lupus SUGGESTED REFERENCES: a) Harrison’s Principles of Medicine – Renal Section b) Oxford handbook of Hypertension and Nephrology c) UpToDate d) Hypertension, Dialysis & Clinical Nephrology Website (HDCN.com)

ENDOCRINOLOGY By the end of the rotation in Endocrinology the candidate should be able to: 1. Apply the knowledge of the natural history of endocrine diseases and principles of treatment in the clinical reasoning process of diagnosis and management of most endocrine disorders 2. Provide appropriate care to patients based on basic principles of Medicine by:

a) Taking a through history and performing a complete physical examination to derive the provisional and differential diagnoses

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b) Assessing clinically the effect of the disease on the physical, mental and social well-being of the patient

c) Instituting initial management with routine and other relevant investigations d) Planning, in consultation with senior colleagues, further management of the patient

with particular attention to the principles involved, the role of the multidisciplinary team and judicious use of the facilities available

e) Arranging for further confirmatory investigation and consultation f) Perform common diagnostic and therapeutic procedures and interpret the results of

investigations with understanding the indications, contraindications, limitations as well as complications:

For example: Anterior pituitary function test, Fine needle aspiration of thyroid nodule 3. Apply rules of evidence to clinical, investigational and published data in order to determine their applicability and validity in reviewing various aspects of the discipline of endocrinology in reputable journals. 4. Carry out audit, simple clinical research or participate in current ongoing projects leading to scientific writing and publication (Trainees who select a project in Endocrinology will be supervised by the lecturer/supervisors of the unit with regards to the formulation of the research proposal, collection and analysis of data and the drafting of the dissertation) 5. Participate as a junior registrar in the endocrine team with responsibility for the day-to-day care of patients in the ward and clinics, presenting and discussing cases that have been clerked, assessed or reviewed, writing discharge summaries, assisting in special procedures, doing call duties and participating in academic activities of the unit 6. To identify the areas of deficiency in their performance, to find appropriate educational resources, use the new knowledge and skills in the care of patients and to evaluate their personal learning progress. Core knowledge 1) Basic concepts in endocrinology Concept of homeostasis and its regulation by hormones, the types of hormones, organization of the endocrine system, hormone action, nature of endocrine disorder, physiologic basis of endocrine testing (screening and dynamic tests) and principles of radioimmunoassay 2) Basic sciences of various endocrine systems or glands Clinical anatomy of hypothalamus, pituitary, thyroid, parathyroids, adrenals, endocrine pancreas and gonad 3) Physiology and biochemistry of the clinically important hormones secreted by the above

organs. Able to appreciate and integrate the roles of these hormones in growth (somatic

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and sexual),reproduction, metabolism of fuel and calcified tissues and the maintenance of intra and extra cellular milieu that are life sustaining

4) Common endocrine disorders Pathogenesis, causes, clinical features, diagnosis, treatment, complications and natural history where applicable, the following common endocrine disorders Hypothalamus : Syndrome of hypothalamic disorders Anterior pituitary: Syndrome of pituitary insufficiency, functioning pituitary, Tumours (prolactinoma, Cushing’s and acromegaly and non-functioning pituitary tumour) Neuro hypophysis : Syndrome of polyuria, Cranial diabetes insipidus, Syndrome of inappropriate secretion of anti diuretic hormone Thyroid:Syndrome of hyperthyroidism, Grave’s disease, Thyrotoxic Crisis, Syndrome of hypothyroidism, Myxedema coma, Thyroid nodules and carcinoma Adrenal cortex :Primary hyperaldosteronism, Adrenal Cushing’s, Congenital Adrenal hyperplasia Adrenal medulla:Phaeochromocytoma Pancreas:Diabetes Mellitus (including diabetes during pregnancy, undergoing surgery and diabetic emergencies) Parathyroids and metabolic bone disease: Syndrome of hypercalcemia (emphasis on primary hyperparathyroidism and malignancy associated hypercalcemia), Syndrome of hypocalcemia (emphasis on hypoparathyoidism), Osteoporosis, Osteomalacia Reproductive endocrinology: Testis: Primary and secondary testicular failure, (emphasis on Klinefelter’s syndrome

and isolated gonadotropins deficiencye.g. Kallman’s syndrome), Testicular feminizing syndrome Ovaries :Primary and secondary ovarian failure (emphasis on Turner’s Syndrome,premature menopause and gonadotropins deficiency), Polycystic ovary syndrome

Infertility:Endocrine assessment of the infertile couple Growth and sexuality Syndrome of delay in growth and sexual development, sexual precocity, intersexuality, hirsuitism 5) Multiple endocrine disorders: Multiple endocrine neoplasia, Multiple endocrine failures (autoimmune) A candidate is expected to attend at least one short course on endocrinology during the duration of the programme.

Assessment methods 1. Supervisor’s evaluation report (Appendix A) 2. 1 Case write-up 3. Audit report and presentation (optional)

Suggested references

Textbook

1. Williams textbook of endocrinology (latest edition)

2. Fundamentals of clinical endocrinology (latest edition)Eds. Hall R. Anderson J. Smart GA &

Besser M

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3. World book of diabetes in practice (latest edition) Eds. Krall LP. Albert KGMM & Turtle JR

4. Biochemistry. Ed. Stryer (latest edition)

5. Review of medical physiology (latest edition) Ed. Ganong WF

Journals

Lancet

New England Journal of Medicine

Journal of Clinical Endocrinology and Metabolism

Journal of Clinical Endocrinology

NEUROLOGY By the end of the posting in Neurology, candidates should be able to: A) Apply the knowledge of the natural history of neurological diseases and principle of

treatment for the various disorders in the clinical reasoning process of diagnosis and management of most neurological disorders

B) Provide appropriate care based on basic principles of Medicine to patients by

i) Taking a through history and performing a complete physical examination with attention to the nervous system, to derive to the provisional and differential diagnoses

ii) Assessing clinically the effect of the disease on the physical, mental and social well-

being of the patient iii) Instituting initial management with routine and other relevant investigations iv) Planning in consultation with senior colleagues, the further management of the

patient with particular attention to the principle involved, the role of the multidisciplinary team and judicious use of the facilities available

v) Arranging for further confirmatory investigations and consultation vi) Demonstrating skills in the diagnostic investigations at the level of competency

indicated, with understanding of the indications, contraindications, limitations as well as complications.

C) Apply rules of evidence to clinical, investigational and published data in order to determine

their applicability and validity in reviewing various aspects of the discipline of neurology in reputable journals

D) Carry out audit, simple clinical research or participate in current ongoing projects leading to

scientific writing and publication (Candidates who select a project in Neurology will be supervised by the lecturer/supervisors of the unit with regards to the formulation of the research proposal, collection and analysis of data and the drafting of the dissertation)

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E) Participate as a junior registrar in the neurology team with responsibility for the day-to-day

care of patients in the ward and clinics, including educating patients and their families, presenting and discussing cases that have been clerked, assessed or reviewed, presenting at radiological conferences, assisting in special procedures, performing tests, doing call duties, writing discharge summaries and study protocols, attending follow-up and referral, and participating in the academic activities of the unit

F) To identify the areas of deficiency in their performance, to find appropriate educational

resources, use the new knowledge and skills in the care of patients and to evaluate their personal learning progress. 1. In-patient Clinical training include managing patients in the following places:

a. Medical/ non-medical wards b. Referral cases

2. Out-patient Clinical training:

a. Neurology clinics: Follow-up clinic (every Monday/ Wednesday mornings) New case clinic (every Thursday morning)

b. BOTOX clinics: every 1st and 2nd Fridays of the month

3. Procedures:

Observe Perform Interpret

Lumbar Puncture √ √

CSF examination √ √

EEG √ √

EMG √ √

Nerve conduction √ √

Evoked Potentials √ √

Carotid Doppler & Ultrasound √ √

MRI brain & spine √ √

Cerebral CT scan √ √

4. Activities

a. Neurology Team Meeting for stroke patients (every Tuesday 9 am) b. Neuroradiology conference (every Tuesday 1 -2 pm) c. Journal Club (every Friday) d. GWR (every Friday)

5. End-posting Assessment

I. 1 Case write-up II. Supervisor’s Evaluation

III. Presentation- Journal club and CME IV. Audit

6. Feedback:

a. The candidates will be given feedback regarding their performance b. The supervisors will ask for feedback from the candidates at the end of the

posting regarding all aspects of the posting

7. Topics to be covered during the posting:

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Core Knowledge 1. Cerebro-vascular disorders Transient ischaemic attacks Cerebral thrombosis-arterial & venous Cerebral embolism Cerebral haemorrhage Acute stroke management 2. Epilepsies Partial epilepsies Generalized epilepsies Status epilepticus 3. Coma Pathophysiology of coma Metabolic/Toxic encephalopathies Structural lesions producing coma Approach to comatose patient Brain death

4. Infections Meningitis-bacterial, viral, fungal Encephalitis limbic encephalitis, paraneoplastic Brain abscess Tuberculosis Neurosyphilis Slow viral infections Parasitic infections 5. Tumours Meningioma Neurofibromas Gliomas Ependymoma Choroid plexus papilloma Pinealoma Medullo blastoma Secondary metastases 6. Cranio cerebral trauma Cerebral concussion Cerebral contusion Haematomas - extradural - Subdural - cerebral

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7. Degenerative Disorders Parkinsons Plus-Lewy Body Disease, Progressive supranuclear palsy, multisystem atrophy Dementia -Alzheimer’s disease, vascular cognitive impairment Spinocerebellar degeneration Motor neuron disease Huntington’s Chorea 8. Demyelinating Disorders Post infectious - radiculopathy - myelopathy - encephalopathy Multiple sclerosis Neuromyelitis optica 9. Movement disorders Parkinson’s disease Dystonia Wilson’s disease 10. Disease of spine and spinal cord Syringomyelia Cord compression Cervical spondylosis Lumbar disc prolapse Spinal trauma Cranio vertebral anomalies 11. Cranial Nerve Disease Bell’s palsy Acoustic Neuroma Painful ophthalmolegia Multiple cranial nerve palsies Optic neuritis Trigeminal Neuralgia 12. Peripheral Neuropathies Metabolic-diabetes, uraemia, prophyria Toxic-lead, arsenic Vascular-polyarterities nodosa, SLE Nutritional Leprosy Guillain Barre Syndrome Hereditary 13. Muscle Diseases Muscular dystrophies Endocrine/metabolic myopathies Polymyositis Myasthenia Gravis Mitochondrial myopathies

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14. Sleep Disorders Insomnia Hypersomnia Dysomnias REM sleep behaviour disorders Restless Leg Syndrome

15. Headache Cranial pain Migraine and related disorders Tension headache Cluster headache REFERENCES: Textbooks

Patten J (ed). Neurology Differential Diagnosis 2nd ed. Springer, New York 1996.

Walton J (ed). Brain’s diseases of the nervous system. Oxford Univ Press, Oxford 1997.

Bradley WG, Daroff RB, Fenichel GM, Marsden CD (eds). Neurology in Clinical Practice. Butterworth-Heineman, Boston 1996.

Journals

Annals of Neurology

Neurology

Archives of Neurology

Brain

Journal of Neurology, Neurosurgery, & Psychiatry

Movement Disorders Journal – (access userid 12612, password: nibrahim)

eMedicine

Journal Watch Neurology

GASTROENTEROLOGY

By the end of the Gastroenterology rotation, the candidate should be able to: 1. Apply the knowledge of the natural history of gastrointestinal diseases and principles of treatment in the clinical reasoning process of diagnosis and management of most gastrointestinal disorders 2. Provide appropriate care to patients based on basic principles of Medicine by

a) Taking a thorough history and performing a complete physical examination to derive at provisional and differential diagnoses

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b) Assessing clinically the effects of the disease on the physical, mental and social well being of the patient

c) Instituting initial management with routine and other relevant investigations d) Planning, in consultation with senior colleagues, the further management of the

patient with particular attention to the principles involved, the role of the multidisciplinary team and judicious use the facilities available

e) Arranging for the further confirmatory investigations and consultation f) Perform or assist common diagnostic and therapeutic procedures and tests with

understanding of the indications, contraindications, limitations as well as complications, for example: Nasogastric tube insertion Liver biopsy blind/ultrasound guided Abdominal paracentesis Stool examination-ova/cyst/leucocytes Sigmoidoscopy/proctoscopy Endoscopy ERCP

g) Interpreting the results of investigations:

Liver function tests Hydrogen breath test Gastric acid measurement Organ imaging techniques-plain film, barium studies Basic histopathology Proctoscopic and sigmoidoscopic findings Basic upper gastrointestinal endoscopic and colonoscopic findings Basic ultrasonography of hepatobiliary and pancreatic system 3. Apply rules of evidence to clinical, investigational and published data in order to determine their applicability and validity in reviewing various aspects of the discipline of gastroenterology in reputable journals 4. Participate in audit, current ongoing search projects, or carry out short-term studies leading to scientific writing and publication or review various aspects of gastrointestinal diseases (Trainees who select a project in gastroenterology will be supervised by the lecturers/supervisors of the with regards to the formulation of the research proposal, collection and analysis of data and the drafting of the dissertation) 5. Participle as a junior registrar in the gastroenterology team with responsibility for the day- to-day care of patients in the ward and clinics, including educating patients and their families, presenting and discussing cases that have been clerked, assessed or reviewed, presenting at x ray conference, assisting in special procedures, performing tests, doing call duties, participate in the weekly audit of the unit, writing discharge summaries and study protocols, attending follow-up and referral cases, and participating in the academic activities of the unit

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6. To identify the areas of deficiency in their performance, to find appropriate educational resources, use the new knowledge and skills in the care of patients and to evaluate their personal learning progress Core Knowledge 1. Anatomy and physiology of the gastrointestinal and hepatobiliary system 2. Esophagus - dysphagia-classification/causes - gastro-esophageal reflux - carcinoma of the esophagus - motility disorders of the esophagus - oesophageal candidiasis - oesophageal varices 3. Stomach/duodenum - dysphagia-classification/causes/management

- vomiting-classification/causes - hematemesis-classification/causes/management - peptic ulcer disease - non-ulcer dyspepsia - carcinoma of the stomach, GIST, MALT lymphoma - Dieulafoy lesions - Angiodysplasia

4. Small intestine

- malabsorption- classification/causes/management - tropical sprue & coeliac disease - lactase deficiency

5. Large intestine

- Diarrhea (acute.chronic)- classification/causes/management - Constipation-classification/causes/management - Lower gastrointestinal bleeding- classification/causes/management - Inflammatory bowel disease - Colonic polyps - Diverticular disease - Irritable bowel syndrome

6. Liver

- Jaundice- classification/causes/management - Liver failure- acute, hyperacute, subacute - Acute hepatis- causes/management - Cirrhosis of the liver - Portal hypertension- classification/management - Hepatic encephalopathy - Ascites and spontaneous bacterial peritonitis - Hepatorenal syndrome - Drug induced liver disease - Alcoholic liver disease - Hepatic tumours

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7. Gallbladder - Cholangiocarcinoma

8. Pancreas

- Acute pancreatitis - Chronic pancreatitis - Carcinoma of the pancreas - Pancreatic cysts

9. Others

- Acute abdomen - Nutrition including total parenteral nutrition (TPN)

Assessment methods 1. Case Write-up: Sufficient standard to be published in a local or international medical journal 2. Case presentation Journal club presentation 3. Supervisor’s Evaluation Report 4. Audit report and presentation (optional) 5. Competence in performing sigmoidoscopy and liver biopsy

Suggested References Textbooks 1. Sherman DJC, Finlayson NDC Diseases of the Gastrointestinal Tract and Liver.Churchill

Livingstone. Edinburgh (latest edition) 2. Sherlock S. Diseases of the liver and biliary system. Blackwell Scientific Publication, Oxford

(latest edition) 3. Bouchier IAD-Textbook of Gastroenterology. Bailiere Tindall, London. (latest edition) 4. CV Williams. Practical gastrointestinal endoscopy. Blackwell Scientific Publication. Oxford

(latest edition) 5. Schiller KF. R. Cockel R. Hunt RH-A colour atlas of Gastrointestinal endocopy. Chapman

and Hall. London (latest edition) Journals

Gut

Gastroenterology

American Journal of Gastrointerology

Hepatology

RESPIRATORY By the end the Respiratory rotation, the candidate should be able to: 1. Apply knowledge of the natural history and principles of treatment in the clinical reasoning

process of diagnosis and management of most respiratory disorders, in particular common local respiratory illnesses.

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2. Manage patients with respiratory diseases appropriately by:

a) Obtaining a thorough medical history, paying particular attention to important clues respiratory diagnosis and performing a complete physical examination to derive provisional and differential diagnoses.

b) Assessing the effect of the disease on the physical, mental and social wellbeing of the patient.

c) Instituting initial management with routine and other relevant investigations

d) Planning the further management of the patient in consultation with senior colleagues, with particular attention to the principles involved, the role of the multidisciplinary team and judicious use of available facilities.

e) Arranging further confirmatory investigation and consultation

f) Performing common diagnostic and therapeutic procedures and tests with understanding of the indications, contraindications, limitations as well as complications:

- Basic resting lung function tests (unaided) - Intradermal sensitivity test - More advanced lung function tests - Bronchoscopy

Candidates who have decided to specialize in Respiratory Medicine are expected to learn competent bronchoscopic examination g) Interpreting the results of respiratory investigations: Basic lung function test, arterial blood gases, chest imaging, full lung function tests, sleep study, lung biopsy specimens

3. Apply rules of evidence to clinical, investigational and published data in order to determine

their validity and applicability when reviewing aspects of respiratory medicine in reputable journals

4. Participate in audit, current ongoing research projects or carry out short-team studies leading to scientific writing and publication or review. (Candidates who select a project in Respiratory Medicine will be supervised by the lecturer/supervisors of the unit with regards to the formulation of the research proposal, collection and analysis of data and the drafting of the dissertation)

5. Participate as a junior registrar in the respiratory team with responsibility for the

day-to-day care of patients in the ward and clinics, including educating patients and their families, presenting and discussing cases that have been clerked, assessed or reviewed, presenting at radiology conference, assisting in special procedures, performing tests, doing call duties, writing discharge summaries and study protocols, attending to follow-up and referral cases and participating in the academic activities of the unit.

6. Identify and address areas of deficiency in their knowledge and performance, by finding appropriate educational resources; to use the new knowledge and skills in the care of patients; and to continually evaluate their personal learning progress.

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Core Knowledge

1. Common Respiratory Emergencies

Acute respiratory failure Acute cor pulmonale /pulmonary oedema Respiratory arrest Status asthmaticus Stridor, laryngeal edema and vocal cord paralysis Tension pneumothorax/mediastinum emphysema

2. Common Chronic Respiratory Illnesses

Asthma Bronchiectasis Chronic bronchitis Common pneumoconiosis Emphysema Lung abscesses Lung cancers Pleural effusion/empyema Pulmonary collagen vascular diseases Pulmonary fibrosis

Tuberculosis

3. Common Acute Respiratory Diseases Acute bronchitis Acute exacerbation of chronic lung diseases Lobar and bronchopneumonia Pneumothorax Pulmonary embolism Upper respiratory tract infection

4. Less Common Respiratory Diseases Bronchial adenoma Eosinophilic lung diseases Fibrosing alveolitis Fungal infection of the lungs

Idiopathic interstitial pneumonias Parasitic diseases of the lungs Pulmonary angiitis and granulomas Pulmonary hemosiderosis Sarcoidosis

Assessment Methods 1. Case write-up 2. Supervisor’s evaluation report: Ward case presentation and discussion

Clinic case discussion Daily clinical work and patient care Assistance in respiratory procedures 3. Participation in ongoing research 4. Journal reviews and publication 5. Audit report and presentation (optional)

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SUGGESTED READING 1. Global Initiative for Asthma Guidelines 2. Global Obstructive Lung Disease Guidelines 3. Malaysian Clinical Practice Guidelines on COPD 4. Malaysian Clinical Practice Guidelines on Tuberculosis 5. Crofton and Douglas’ Respiratory Diseases, 5th ed. John Crofton & Andrew Douglas. 6. Harrison Principles of Internal Medicine, 18th ed. 7. Pulmonary/Respiratory Therapy Secrets, 3rd Edition Polly Parsons, John Heffner. 8. A Primer on Reading Pulmonary Function Tests. Joshua Benditt, M.D. 9. Radiology Assistant - Website of the Netherlands Radiology Society

RHEUMATOLOGY

By the end of the Rheumatology rotation the candidate should be able to: 1. Apply the knowledge of the natural history of rheumatic diseases and principle of treatment in the clinical reasoning process of diagnosis and management diagnoses 2. Provide appropriate care based on basic principles of Medicine to patients by:

a) Taking a thorough history and performing a complete physical examination with attention to the musculoskeletal system to derive the provisional and differential diagnosis

b) Assessing disease activity, the drug response and the effect of the disease on the physical, mental and social well-being of the patient

c) Instituting initial management with routine and other relevant investigations d) Planning in consultation with senior colleagues, the further management of the

patient with particular attention to the principles involved, the role of the multidisciplinary team, side effects of medication and judicious use of the facilities available

e) Arranging for further confirmatory investigations and consultation f) Perform common diagnostic and therapeutic procedures and tests with

understanding of the indications, contraindications, limitations as well as complications: Aspiration and examining joint fluid for microscopy and crystals Ultrasound Musculoskeletal

g) Interpreting the results of major serological investigations: Rheumatoid factor Anti - CCP LE cell phenomena Antinuclear factor

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Anti DNA Extractable nuclear antigen Anti smooth muscle antibodies HLA antibodies Other autoantibodies 3. Apply rules of evidence to clinical, investigational and published data in order to determine their applicability and validity in reviewing various aspects of the discipline of rheumatology in reputable journals 4. Participate in audit, current ongoing research projects, or carry out short-term studies leading to scientific writing and publication or review various aspects of rheumatic diseases (Candidates who select a project in Rheumatology Medicine will be supervised by the lecturer/supervisors of the unit with regards to the formulation of the research proposal, collection and analysis of data and the drafting of the dissertation) 5. Participate as a junior registrar in the Rheumatology team with responsibility for the day-to-day care of patients in the ward and clinics, including educating patients and their families. Presenting and discussing cases that have been clerked, assessed or reviewed, presenting at x ray conference, assisting in special procedures, performing tests, doing call duties, writing discharge summaries and study protocols, attending follow-up and referral and participating in the academic activities of the unit 6. To identify the areas of deficiency in their performance, to find appropriate educational resources, use the new knowledge and skills in the care of patients and to evaluate their personal learning progress. Core knowledge 1. Rheumatoid Arthritis 2. Systemic lupus Erythematosus 3. Progressive Systemic Sclerosis and its variants 4. Mixed Connective Tissue Disease 5. Dermatomyositis 6. Crystal Deposition Arthropathy (Gout/Pseudogout) 7. Polymyositis 8. Seronegative Spondyloarthropathy 9. Osteoarthritis 10. Cervical and Lumbar Spondylosis 11. Prolapse Intervertebral disc 12. Infective arthritis (septic, tuberculous, gonococcal) 13. Polymyalgia Rheumatica and Giant cell arteritis 14. Primary vasculitis 15. Soft tissue rheumatism 16. Fibromyalgia and psychogenic rheumatism 17. Osteoporosis/Osteomalacia 18. Radiographic positive spondyloarthropathy 19. Regional Syndrome

a) Backache b) Pain in the neck c) Pain in the shoulders

20. Arthritis of systemic illness a) Viral e.g. rubella b) Rheumatic

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c) Serum sickness 21. Aches and pain in the elderly Assessment methods 1. 1 Case Write-up 2. Viva session for 15 minutes by two lecturers 3. Radiographic interpretation 4. Supervisor evaluation form 5. Journal club presentation 6. Paper publication on cases (if done) 7. Audit report and presentation (optional) SUGGESTED TEXTBOOKS AND JOURNALS 1. Rheumatology. John H Klippel & Paul and Dieppe Mosby

2. Oxford Textbook of Rheumatology. Madison, Isenberg and Woo Oxford Medical Publication

3. Textbook of Rheumatology. John Klippel & Paul a Dieppe Mosby.

4. Radiology of Arthritides- A Clinical Approach. Adam Greenspan & M Eris Gersham. Gower

Medical Publishing

5. Rheumatic Diseases Clinic of North American Saunders

6. Current Opinion in Rheumatology

7. Lippincott-Raven WWW: http:/ www.Irpub. Com

HAEMATOLOGY

By the end of the Haematology rotation the candidate should be able to: 1. Apply the knowledge of the natural history of haematological diseases and principle of treatment in the clinical reasoning process of diagnosis and management of most haematological disorders and haematological manifestation of other systemic disorders 2. Provide appropriate care based on basic principles of Medicine to patients by

a) Taking a thorough history and performing a complete physical examination with attention to the clues of hematological disorder musculoskeletal system to derive the provisional and differential diagnosis

b) Assessing disease activity, the drug response and the effect of the disease on the

physical, mental and social well-being of the patient c) Instituting initial management with routine and other relevant investigations

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d) Planning in consultation with senior colleagues, the further management of the patient with particular attention to the principles involved, the role of the multidisciplinary team, side effects of medication and judicious use of the facilities available

e) Arranging for further confirmatory investigations and consultation f) Perform common diagnostic and therapeutic procedures and tests with

understanding of the indications, contraindications, limitations as well as complications:

Bone marrow aspiration Bone marrow trephine Infusion of cytotoxic drugs g) Interpreting the results haematological investigations and recognizing laboratory

errors and reference ranges: Full blood count and peripheral blood films Bone marrow aspirate and trephine biopsy Other hematological investigations

3. Apply rules of evidence to clinical, investigational and published data in order to determine their applicability and validity in reviewing various aspects of the discipline of haematology in reputable journals

4. Participate in audit, current ongoing research projects or carry out short-team studies

leading to scientific writing and publication or review and present various aspects of haematology diseases

(Candidates who select a project in Haematology Medicine will be supervised by the lecturer/supervisors of the unit with regards to the formulation of the research proposal, collection and analysis of data and the drafting of the dissertation)

5. Participate as a junior registrar in the hematology team with responsibility for the day-to- day care of patients in the ward and clinics, including educating patients and their families. Presenting and discussing cases that have been clerked, assessed or reviewed, presenting at x ray conference, assisting in special procedures, performing tests, doing call duties, writing discharge summaries and study protocols, attending follow-up and referral and participating in the academic activities of the unit 6. To identify the areas of deficiency in their performance, to find appropriate educational

resources, use the new knowledge and skills in the care of patients and to evaluate their personal learning progress.

Clinical Training

1. In-patient clinical training include managing patients in the following places:

a. Hematology medical wards

b. Pusat Pemindahan Sum-Sum Tulang (PSST) Maybank ward

c. Referral cases (from HUKM and from other hospitals in Malaysia)

d. On-call (Separate Call list for MO and Consultants),

i. On-call MO required to do rounds in PSST ward during Public Holidays

ii. On-call MO required to see selected patients in Hematology/ other wards

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iii. On-call MO to pass over selected cases to registrar on-call if required

iv. On-call MO to discuss problem cases with consultant

2. Out-patient clinical training:

a. Haematology clinics: New cases (every Monday: 200 pm), Follow-up clinic (every

Thursday: 2 pm)

b. Haematology Day care (every day except Public Holidays)

c. HSCT clinic (every Wednesday: 10 am)

d. MyPAP clinic (every Wednesday: 9 am)

3. Procedures:

a. Bone marrow aspiration and trephine biopsy

b. Central line insertion

c. Lumbar puncture and Intrathecal chemotherapy

d. Venesection

e. Leukapheresis

f. Stem cell harvesting

4. Case presentations

a. Journal club (every Monday: 11 am) Combine with Hemato Pathology unit)

b. Mortality (Once a month: Friday: 1 pm)(Coordinator : Dr. Rafeah Tumian

c. CME (on rotation, Thursday)

d. GWR (on rotation, Tuesday)

5. Clinical bed-side teaching

a. Grand ward round: Every Monday: (after slide session) & Thursday : 2 pm

6. Interpretation of bone marrow and peripheral blood film slides (every Tuesday : 9.30 am)

(supervisors : Prof Dr. Cheong Soon Keng / Prof Dr. Leong Chooi Fun)

7. Psychosocial skills: Coordinator: SCT Counsellor

a. Breaking bad news

b. Counselling patient and family for stem cell transplantation

c. Patient support groups : Lymphoma, CML

8. Palliative care (Coordinator: Dr. Hayati Yaakub):

a. Pain management

b. End of life care

Core Knowledge

i) Approach to patients with Febrile neutropenia ii) Approach to patients with Cytopenias iii) Approach to patients with Lymphadenopathy iv) Approach to patients with Hyperleukocytosis v) Approach to patients with Bleeding disorders and Coagulopathy vi) Approach to patients with Thrombophilia vii) Work-up of patients with newly diagnosed hematological malignancies: Clinical Staging, Histological grading, Risk assessment

Observe

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viii) Principles of treatment of hematological malignancies: treatment modalities & strategies, principles of chemo regimen, response assessment ix) Prevention and treatment of Acute tumors lysis syndrome x) Types of Cytotoxic chemotherapy and management of side-effects xi) The haemoglobinopathies and thalassaemic syndromes xii) Blood transfusion good practice xiii) Haemolytic anemias xiv) Anemias associated with other systemic disease xv) Aplastic anemias xvi) Immune thrombocytopenic Purpura xvii) Malignant lymphomas (Non Hodgkin and Hodgkin) xviii) Acute leukemias xix) Chronic leukemias xx) Paraproteinemias xxi) Management of Cancer pain xxii) Fundamentals of Hematopoietic stem cell transplantation

Nice to Know

iv) Graft vs Host Disease

v) Myeloproliferative disorders

vi) Iron metabolism and its disorders

vii) Role of Radiation therapy in hematological malignancies

Assessment methods

i. End-posting Assessment (Total 100%).

This must be done before CA can be completed by Supervisors

(Coordinator: Cik Siti Noor Fatimah):

a. Continuous assessment CA (30%)

b. Case Report (10%)

c. End posting examination (60%):

i. MCQ (30 questions),

ii. Data interpretation (2 questions)

REFERENCES:

a. Chemotherapy Protocol: 3rd Edition, Dec 2009, Cell Therapy Center, UKMMC. Fadilah SAW, Rafeah T, Hiok Seng T, Hayati Y.

b. The EBMT Handbook: 5th Edition 2008, European school of Haematology. Apperly J,

Carreras, E, Gluckman E, Gratwohl A, Masszi T. c. Fundamentals of the Management of Non Hodgkin Lymphoma, 2009, Medical Journal

Malaysia. Fadilah SAW d. The A-B-C of Haematopoietic Stem Cell Transplantation, 2009, Medical Journal Malaysia.

Rafeah T, Fadilah SAW

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e. Fundamentals in The Management Of Multiple Myeloma, Dec 2010, Medical Journal Malaysia. Fadilah SAW

f. Management of Cancer pain: Malaysian CPG July 2010 g. Management of ITP: Malaysian CPG August 2006 h. CML: Malaysian CPG 2011 i. Blood Cell-A Practical Guide: 2nd Edition Bain BJ, 1995 j. Journals: Blood, British J Haematology, Bone Marrow Transplantation, J of Clinical

Oncology, Blood Reviews

CARDIOLOGY By the end of the Cardiology rotation (include General Cardiology and Coronary Care Unit) the candidate should be able to: 1. Apply the knowledge of the natural history of cardiovascular diseases and principles of treatment in the clinical reasoning process of diagnosis and management of most cardiovascular disorders, recognizing and appropriate institution of management of important though uncommon cardiovascular diseases and common and important cardiovascular emergencies 2. Provide appropriate care based on basic principles of medicine to patients by:

a) Taking a thorough history and performing a complete physical examination with attention to the clues of cardiovascular system to derive the provisional and differential diagnosis in relation to the anatomic, pathologic and aetiologic diagnosis as well as the functional status and underlying pathophysiologic mechanisms

b) Assessing disease activity, the drug response and the effect of the disease on the

physical, mental and social well being of the patient c) Instituting initial management with routine and other relevant investigations and

manage common and important cardiovascular emergencies d) evaluate management options and planning in consultation with senior colleagues,

the further management of the patient with particular attention to the principles involved, the role the multidisciplinary team, judicious use of the facilities available with awareness of the costs of cardiac care and investigations

e) arranging for further investigations and consultation f) Performing common diagnostic and therapeutic procedures and tests with

understanding of the indications, contraindications, limitations as well as limitations and complications unaided or under the supervision of a specialist:

Resting 12 lead ECG :interpret and report

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24 hours ambulatory ECG (Holter): perform at least 2 and report at least 5 with a cardiologist

Chest x-ray: interpret Echocardiography: observe at least 25 and perform at least 5 together with

a cardiologist/cardiac technician Exercise stress test: observe at least 5 and perform and interpret at least

20 Doppler echocardiography: observe 10 and perform at least 5 with a

cardiologist/cardiac technician Ambulatory BP monitoring: perform at least 2 and report at least 5

together with a cardiologist Transesophageal echocardiography: observe on 5 patients Cardiac catheterization: do the necessary pre-cath workup, prepare a cath

list and look after the patients post-catheterization, observe at least 5 of various disorders being performed (includes both right and left heart catheterization), interpret and discuss the results of these 5 patients with the cardiologists

Temporary cardiac pacing: observe/assist in at least 3 each from the following routes, interpret and manage the data obtained: internal jugular vein, subclavian, femoral vein

Demonstrating knowledge of the equipment required, the routes avaiable3 (subclavian, internal jugular, femoral and cubital veins) and the necessary precautions

Swan-Ganz pulmonary artery catheterization: observe/assist in at least one and interpret the basis data obtained

Intra-arterial line: perform at least one demonstrating knowledge of the indications, routes available and complications and manage the line once set up

Electrophysiological and pacing studies: observe Implantation of permanent pacemakers: observe Nuclear medicine/cardiology: observe the procedure on at least 2 patients Percutaneous transluminal coronary angioplasty and percutaneous

valvuloplasty: observe

3. Apply rules of evidence to clinical, investigational and published data in order to determine their applicability and validity in reviewing various aspects of the discipline of cardiology in reputable journals 4. Participate in audit, current ongoing research projects or carry out short-team studies leading to scientific writing and publication or review and present various aspects of cardiovascular diseases (Candidates who select a project in Cardiology will be supervised by the lecturer/supervisors of the unit with regards to the formulation of the research proposal, collection and analysis of data and the drafting of the dissertation) 5. Participate as a junior registrar in the cardiology team with responsibility for the day-to-day care of patients in the ward and clinics, including educating patients and their families. Presenting and discussing cases that have been clerked, assessed or reviewed, presenting at x ray conference, assisting in special procedures, performing tests, doing call duties, writing discharge summaries and study protocols, attending follow-up and referral and participating in the academic activities of the unit 6. Attend and pass the Basic Life Support Course (cardiopulmonary resuscitation) and Advanced Cardiac Life Support Course

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7. To identify the areas of deficiency in their performance, to find appropriate educational resources, use the new knowledge and skills in the care of patients and to evaluate their personal learning progress. Core knowledge 1. Epidemiology, Physiology & Pathophysiology relevant to cardiovascular medicine 2. Symptoms and sign in cardiovascular disease 3. Heart failure and pulmonary edema 4. Shock, hypotension, syncope 5. Cardiac arrhythmias 6. Pulmonary hypertension 7. Systemic hypertension 8. Congenital heart disease in adolescents and adults 9. Rheumatic fever and rheumatic heart disease 10. Infective endocarditis 11. Valvular heart disease 12. Coronary artery disease - Stable Angina - Unstable angina - Variant angina - Myocardial infarction - Ischemic cardiomyopathy - Biology and Pathology of Atherosclerosis 13. Cardiomyopathies and myocardities - Pericardial effusion & tamponade - Acute pericarditis - Constrictive pericarditis - Cardiac tamponade 14. Diseases of the aorta - Dissection of the aorta - Aneurysms of the aorta - Primary arteritis 15. Pulmonary thromboembolism 16. Pregnancy and cardiovascular disease 17. Systemic disease and the heart - Collagen vascular disease - Endocrine disease - Neurological disease - Haematologic and oncologic disease - Nutritional disease 18. Psychological aspects of heart disease 19. General principle of cardiac surgery 20. Cardiac arrhythmias 21. Cardiovascular pharmacotherapy 22. Noncardiac surgery in patients with cardiac disease 23. Cardiac myxoma 24. Trauma and the heart 25. Cardiological techniques and procedures

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Assessment methods 1. Case presentations (frequent and regular, ongoing) 2. 1 Case Write-up 3. Journal club presentation 4. Supervisor’s evaluation report on continuous assessment based on ward and clinic work, patient care records, discharge summaries, procedures, etc. 5. Production of a paper for presentation or publication (where applicable) 6. Audit report and presentation (optional) Recommended references: 1. Braunwald E.: Heart Diseases – A Textbook of Cardiovascular Medicine, W.B. Sauders

Company (latest edition)

2. Hurst, J.W.: The Heart, Arteries and Veins, McGraw Hill Book Company (latest edition)

3. Figenbaum, Harvery: Echocardiography (latest edition)

4. Berne, R.M. and Levy, M.N.: Cardiovascular Physiology, C.V. Mosby Company (latest

edition)

5. Constant, J.; Bedside Cardiology, Little, Brown and Company (latest edition)

6. Constant, J.: Learning Electrocardiography – A Complete Course; Little, Brown and

Company (latest edition)

DERMATOLOGY

By the end of the Dermatology rotation, the candidate should be able to: 1. Apply the knowledge of the natural history of dermatological diseases, correlate the clinical and histopathological features of common dermatoses and apply the principles of management in the clinical reasoning process of diagnosis and management of most dermatological disorders 2. Provide appropriate care based on basic principles of medicine to patients by:

a) Taking a thorough history and performing a complete physical examination of the skin to derive to the appropriate provisional and differential diagnosis

b) Assessing the activity of major skin problems and its effect on the physical, mental

and social well being of the patient c) Instituting initial management with routine and other relevant investigations d) In consultation with supervisor(s), evaluating management options and planning

further management with particular attention to the principles involved, response to therapy, management of the medication side- effects, role of multidisciplinary team and facilities available

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e) Arranging for further confirmatory investigation and consultation f) Performing common diagnostic and therapeutic procedures with understanding of

the principles, indications, contraindications as well as limitations and complication, under the supervision of a specialist:

o Skin scraping or nail clipping for fungus o Swabs for bacteriological studies o Tape test o Skin biopsies for histopathology and/or immunofluorescence staining including punch, excisional and incisional biopsy o Currettage and cauterization for certain skin malignancies o Cryotherapy o Administration of intralesional steroids o Trichloroacetic acid application o Milia extraction o Wet wraps for eczematous conditions o Prick tests o Patch tests o Electrocautery o Iontophoresis o Botulinum toxin injections for hyperhidrosis

3. Apply rules of evidence to clinical, investigational and published data in order to determine their applicability and validity in reviewing various aspects of the discipline of dermatology in reputable journals 4. Participate in audit, current ongoing research projects or carry out short-team studies leading to scientific writing and publication or review and present various aspects of dermatological diseases. (Trainees who select a project in Dermatology will be supervised by the lecturer/supervisors of the unit with regards to the formulation of the research proposal, collection and analysis of data and the drafting of the dissertation) 5. Participate as a junior registrar in the dermatology team with responsibility for the day-to- day care of patients in the ward and clinics, including educating patients and their families. Presenting and discussing cases that have been clerked, assessed or reviewed, presenting at x ray conference, assisting in special procedures, performing tests, doing call duties, writing discharge summaries and study protocols, attending follow-up and referrals and participating in the academic activities of the unit 6. To identify the areas of deficiency in their performance, find appropriate educational resources, use the new knowledge and skills in the care of patients and to evaluate their own personal learning progress. Clinical training

In-patient clinical training

Management of patients in:

1. The medical wards

2. Referred cases from other departments in PPUKM, including Pediatrics and other hospitals

3. Dermatology ward rounds

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Out-patient clinical training

1. Dermatology clinic: Tuesdays, Thursdays (9.00am- 1.00pm)

2. Procedure clinic: Fridays (9.00am- 1.00pm)

3. Case presentations:

Continuous medical education (CME) – according to rotation, Thursday 8.00-9.00am.

Grand ward rounds (GWR) - according to rotation, Tuesday 8.00-9.00am.

Mortality - according to rotation, Friday 8.00-9.00am

Histopathology – Tuesdays in the last week of each month, 8.00-9.00 am

4. Clinical bed-side teaching

Dermatology ward rounds: Tuesday and Thursday pm

Dermatology grand ward round: Friday pm

Research

Research may be conducted as a student’s dissertation, as part of the requirement for MMed (Int

Med).

Pharmaceutical linked research are also conducted.

Core Knowledge/ must know

i. Description of skin lesions.

ii. Psoriasis

iii. Eczema

iv. Infections:

a) Superficial pyogenic infections

b) Superficial fungal Infections

c) Viral Infections

d) Mycobacterial infections including leprosy

v. Bullous diseases

vi. Cutaneous malignancy

vii. Cutaneous manifestations of systemic diseases

viii. Acne

ix. Drug reactions

x. Erythroderma

xi. Scabies

xii. Dermatopharmacology: potency of topical corticosteroid, isotretinoin, acitretin

Nice to know

Cutaneous lymphoma

Urticaria and angioedema

Pigmentary disorder

Hair and nail diseases

Photodermatoses

Sexually transmitted infections

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Assessment Methods

1. Case Write-up

2. Case presentations

3. Continuous assessment based on ward, clinical clerkship, patient care records and

discharge summaries

Recommended references

1. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology. 6th Edition 2010.

2. Clinical Dermatology. Weller, Hunter, Dahl. 3rd Edition 2002.

3. British Journal of Dermatology

4. Journal of American Academy of Dermatology

INFECTIOUS DISEASE Specific Objectives By the end of the Infectious Disease rotation, the candidate should be able to: 1. Apply knowledge on the natural history of infectious disease and the principles of treatment

in the clinical reasoning process of diagnosis and management of infectious disease conditions

2. Provide appropriate care to patients based on basic principles of Medicine by

(a) Taking a thorough infectious disease history and performing a complete physical

examination to derive the provisional and differential diagnoses

(b) Assessing clinically the effects of the disease on the physical, mental and social well being of the patient

(c) Instituting initial management with routine and other relevant investigations.

(d) Planning, in consultation with senior colleagues, the further management of the

patient with particular attention to the principle involved and the role of the multidisciplinary team

(e) Arranging for further confirmatory investigations and consultation

3. Apply rules of evidence to clinical, investigational and published data in order to determine their applicability and validity in reviewing various aspects of infectious diseases

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4. Participate in audits, current ongoing projects or conducting short-term studies leading to scientific writing and publication. (Candidates who select a dissertation project in Infectious Diseases will be supervised by the Lecturer/supervisors of the formulation of the research proposal, collection and analysis of data and the drafting of the dissertation)

5. Participate as a junior registrar in the infectious disease team with responsibility for the day-

to-day care of patients in the ward and clinic, including educating patients and their families, presenting and discussing cases that have been clerked, assessed or reviewed, presenting at x ray conference, assisting in special procedures, performing tests, doing call duties, writing discharge summaries, attending follow-up and referral and participating in the academic activities of the unit.

6. To identify the areas of deficiency in their performance, to find appropriate educational

resources, use the knowledge and skills in the care of patients and to evaluate their personal learning progress.

Core Knowledge Candidates are expected to possess adequate core knowledge about infectious disease as listed below: Management of HIV/AIDS among adults.

Management of General Infectious Diseases o Infections caused by Multiresistant organisms (MROs) o Specific Endemic Tropical Infectious Diseases eg. typhoid, dengue leptospirosis, typhus,

melioidosis, malaria,syphilis etc. o Complicated infections eg. endocarditis and other vascular infections, non-resolving

pneumonias, o Management of infections in immunocompromised hosts o Providing antimicrobial consultations in other organ-specific infections

Management of Nosocomial Infections o In the Intensive Care Units (ICU): Nice to know Infection Control Measures o Management of infectious diseases requiring barrier isolation o Implementing Infection Control measures in the department and hospital through the

Hospital Infection Control Committee o Antibiotic Surveillance and audit through the Hospital Infection Control Committee

Management of Post-occupation biological exposures among healthcare workers (HCW) in the hospital o Counseling and testing of HCW concerned o Reviewing results of index patient and HCW concerned o Providing PEP and other necessary post-exposure interventions (including monitoring of

treatment & vaccination) o Compiling and analyzing PEP data of the hospital

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o Recommending further infection control measures if necessary Assessment Methods 1. Case Write-up: 2. Case presentations 3. Journal Club presentation 4. Continuous assessment based on ward, clinical clerkship, patient care records and

discharge summaries

Recommended references 1. Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases

2. HIV online journals: http://aidsinfo.nih.gov

3. Malaysian and WHO Dengue Guidelines – online CPGs

4. Harrison’s Infectious Diseases by Dennis Kasper and Anthony Fauci

PALLIATIVE MEDICINE Specific Objectives By the end of the Palliative Disease rotation, the candidate should be able to acquire these additional skills:

Social skills

To demonstrate sensitivity when dealing with patients, families and staff To communicate clearly with patients, families and staff To work as a member of the Interdisciplinary Team

Theoretical skills

To increase general medical knowledge To increase knowledge of palliative medicine, especially

To recognize when a patient’s treatment philosophy changes from curative to palliative

To recognize when a patient is dying

To control symptoms by both pharmacological and non-pharmacological methods

How to access the resources of the hospices and other NGO such as Hospice Malaysia, Kasih Hospice, Assunta Hospice etc

How to conduct a family meeting

How to do bereavement simple counseling

Organizational skills

To plan and organize the discharge of patients

Responsibility

To demonstrate motivation and initiative in

* Being responsible for patient care

* Self-education

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Outcome/Core Knowledge:

At the end of this term, candidates are expected to have basic knowledge in:

1. Principle of drug used in Palliative care 2. Basic pain management 3. Indications of opioids, able to prescribe appropriate opioids, side-effects and their

management 4. Management of various symptoms in end stage disease i.e.

a. GI symptoms b. Cachexia, anorexia and fatigue c. Respiratory symptoms and others

5. Acute emergencies in palliative care 6. Recognition of dying process and management of patient at terminal stage 7. Communication and bereavement 8. Hospice principles and NGO contribution of palliative care in community

Others/nice to know:

1. Management plan and treatment options for patient who diagnosed with solid organ cancer

: lung, breast, colorectal, prostate and liver

Day 1 : Report to Head of Unit in medical Department at 9 am

Briefing session

Unit’s operations and clinic

Medical officers responsibilities

Clinical privileges

You will be given the induction handouts, timetable and log book.

2. Weekly Timetable

DAY TIME ACTIVITIES VENUE

MON

0900-1300 Specialist Ward round PPUKM

1400-1700 Referral

TUE 0900-1300 Specialist Ward round PPUKM 1400-1600 Workshop in symptoms management

WED 0830-1700 Oncology grand ward round/Selayang PCU grand ward round/UMMC Hospital Journal club

PPUKM/Selayang Hospital/UMMC

THURS 0900-1400 Specialist ward round/referral HUKM

1500-1700 Pain Clinic (acute/chronic pain)

FRI 0900-1300 Palliative medicine clinic

PPUKM

1400-1700 Specialist Ward round/referral

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3. Log Book

4. Assessment:

a. 50% attendance/participation

b. 50% quiz at end of attachment

Recommended references

Oxford textbook of palliative medicine, 3rd Ed, 2004

Palliative Medicine 4th Ed, 2004 (Roger Woodruff)

Management of advanced disease 4th Ed 2004 (Eds Sykes, Edmonds &Wiles)

Palliative Care Formulary 2nd Ed, 2002 (Twycross, Wilcock Charlesworth & Dickman)

Therapeutic Guidelines – Palliative Care 2nd Ed 2005

Palliative Medicine Induction for Medical Officers (Appendix 1)

Year 4

The general objective is to enable the candidates to function as the registrar of the medical Unit. Candidates are expected to participate in patient management as well as assisting the consultant to manage the unit. Candidates should also begin to develop skills in the subspecialty area they have an interest in. Candidates will be posted for 6 months in general medicine and 6 months in a subspecialty of interest. Specific Objectives 1. Apply the knowledge of basic medical science and the principle of Medicine in clinical problem solving and decision-making and in providing care and emergency coverage to patients with competent skills and appropriate attitudes 2. Perform the following procedures under supervision in the subspecialty (refer procedure list in Year 2 and 3) 3. Be a role model in teaching and training junior doctors and other health personnel 4. Assist the consultant in performing managerial duties of the ward: ward rounds, maintains discipline and unit cohesiveness, arranges duty roster and wherever relevant ensures academic activities are conducted: journal club, X-ray conference, mortality conference, case presentations at CME, grand ward rounds, histopathology, conference, CPC etc 5. Apply rules of evidence to clinical, investigational and published data in order to determine their applicability and validity in the research project and dissertation, case write-ups, other scientific writing and audit 6. To identify the areas of deficiency in their performance and to find appropriate educational resources, evaluate their personal learning progress and to use the new knowledge and skills in the care of patients (self audit)

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Assessment methods 1. Supervisor’s Evaluation report 2. Paper presentation/publication

Supervision and Role of the Supervisor Supervision is the dynamic process in which the supervisor encourages and participates in the development of the candidate. Supervision is fundamental to the educational process and an imperative in the Open learning program. The two major roles of supervision are: 1. Objective evaluation of candidate’s performance using appropriate methods of assessment 2. Establishing a relationship that will help the candidate to self-actualize and become self- directed learners and highly motivated individuals Thus it is the responsibility of the supervisor to:

Have a good understanding of and commitment to the programme to facilitate learning by the candidate

Assist the candidate in monitoring his/her progress and to be prepared for assessments

Ensure that the candidate satisfies all requirements of the programme

Be a good role model and to continue upgrading his/her skills in relevant areas Accreditation of consultant/specialist Accreditation is based on commitment to teaching, evidence of teaching activities at department and hospital levels. To be supervisor phase I, the consultant/specialist must possess M.Med (Internal Medicine) degree or its equivalent for at least 2 years. To be a supervisor in Phases II dan III, the consultant/specialist must have at least 3 years experience in a subspeciality after M.Med (Internal Medicine) or its equivalent (please also refer to Prospectus Master of Medicine (Internal Medicine), Report of the specialty (Internal Medicine) subcommittee meeting) Role of head to department The head of department is responsible for the smooth implementation of the programme in their units. The supervisor’s are nominated for appointment by the head of department and a copy of their names as well as the candidate supervised by them is sent to the UKM department of Internal Medicine. The head of department is also responsible for conducting regular meetings with the supervisors to assess the progress of the trainees and to make appropriate recommendations for promotion to the department of Medicine, UKM Under the Open System there will be five types of supervisors:

Course supervisors (or programme supervisor or course coordinator)

Candidate supervisor

Clinical supervisor

UKM liaison supervisor

Clinical Coordinator

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Course Supervisor or Programme Supervisor (Department of Medicine) A Course Supervisor (or Programme Supervisor) is a senior member of the department of medicine Tasks: 1. To schedule lecturer and clinical postings 2. To conduct and attend to matters pertaining to examination 3. To collect clinical supervisor’s reports, all case reports, audit reports and thesis dissertation 4. To approve candidates leave 5. To be a member of the Selection Board 6. To represent the Department at the Postgraduate Board Meetings 7. To be the mentor/academic advisor to the candidate 8. To be the Secretary to the Board of Examiners for the course 9. To be a liaison officer for the course 10. To participate in programme evaluation Programme Supervisor (Government Department) Some hospitals may leave several candidates and supervisors in the medical discipline. In such cases there will be a programme supervisor appointed from amongst the supervisors who will ensure that the candidates are given an all round general medical training and appropriate experience in the subspecialties. Tasks: 1. Arrange the rotations for the candidates as required by the programme 2. Ensures reports of candidates are submitted to UKM through the head of department 3. Liaise with the universities in programme implementation 4. Provided assistance to trainees and candidate supervisors 5. Participates in programme evaluation Candidate Supervisor (Academic or Government Department) A candidate Supervisor must be a consultant/specialist with at least 3 years experience after M.Med (Internal Medicine) or its equivalent. A candidate Supervisor can only supervise 2 candidates at one time Tasks: 1. To act as a mentor/academic adviser to the candidate in matters pertaining to academic performance 2. To act as a liaison officer between the candidate and the course supervisor 3. To be advisor to the candidates pertaining to career development 4. To be the candidate’s supervisor for dissertation/research project 5. To participate in programme evaluation Clinical Supervisor (Academic, Government or Private Department) A clinical supervisor shall be a member of an academic, government or private institution which is accredited. A clinical supervisor can supervise not more than 4 candidates at any one time.

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Tasks: 1. To supervise the candidate’s clinical work 2. To ensure that the candidate keeps up with the literature, attends hospital teaching activities (e.g. CPC) and maintains a professional attitude toward patients 3. To ensure that candidate complete the case reports satisfactorily 4. To submit reports regarding candidate’s clinical compete 5. To encourage and assist the candidate to write papers and attend seminars/conferences Clinical Supervisor’s Terms of Reference 1. Candidates A clinical Supervisor can be assigned a maximum of 4 candidates, 2 from phase I and 2 from phases II and III from any phase of the M.Med. Programme. 2. Arrangement of activities The supervisor shall arrange the activities of the candidates in the department regarding: i) Ward duties and on-call duties ii) Clinics iii) Referrals iv) Procedures (laboratories, investigative, therapeutic) v) Clinical meetings and educational activates vi) Tutorials and lectures The supervisor is to submit to the Candidates Supervisor a representative time-table stating the weekly activities of the department(s)/candidates 3. Case write-up and reviews The supervisor shall advise and assists the candidates regarding the case write-up, review, audit reports or short-term studies. All studies and write-ups are to be completed by the end of the posting. The supervisor shall be promptly mark and grade the write-ups and the mark/grading shall be recorded in the supervisor’s report. 4. Log book Each candidate must have a log book for each subspecialty posting. At the end of the posting, the clinical supervisor will assess and comment on log book entries. 5. Progress report It is advised that the supervisor meet the candidate at least once a month to review the candidate’s progress. Problems should be identified early to allow appropriate remedial measures to be taken 6. Disciplines The clinical supervisors shall report immediately to the candidate’s supervisor if: i) a breach of discipline relating to the University, Hospital or Government regulations has been incurred ii) Malpractice or criminal intent has been proven UKM Liaison Supervisor

For each hospital, a UKM academic staff in Internal Medicine will be appointed as the liaison supervisor which comprise of members at The Masters of Internal Medicine Committee, Department if Medicine, UKM

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Tasks: To make site visits at least once a year in order to: 1. Assess the progress of the candidates together with the candidate and programme supervisor 2. Assess the activities carried out in the unit and to identify problems in implementation 3. Discuss the implementation of the programme with the candidates 4. To make recommendations in consultation with supervisors and clinical coordinator on ways to improve the implementation 5. To report to the head of internal medicine, UKM The names of the UKM liaison supervisors are as follows:

NAMA PENSYARAH

HEMATOLOGI

Prof. Dr. S. Fadilah Abd Wahid

Prof. Madya (K) Dr. Wong Chieh Lee

Dr. Nor Rafeah Tumian

Dr. Wan Fariza Wan Jamaluddin

ENDOKRINNOLOGI

Prof. Dr. Nor Azmi Kamaruddin

Prof. Dr. Norlela Sukor

Prof. Madya Dr. Norlaila Mustafa

Prof. Madya Dr. Rohana Abdul Ghani

Dr. Norasyikin A. Wahab

Dr. Suehazlyn Zainudin

NEUROLOGI

Prof. Dato’ Dr. Raymond Azman Ali

Prof. Datin Dr. Norlinah Mohamed Ibrahim

Prof. Madya.Dr. Tan Hui Jan

Dr. Wan Nur Nafisah Wan Yahya

Dr. Ramesh Sahathevan

Dr. Shahrul Azmin Md. Rani

Dr. Rabani Remli

Dr. Law Zhe Kang

RESPIRATORI

Prof. Dr. Roslina A. Manap

Prof. Madya Dr. Roslan Harun

Dr. Andrea Ban Yu-Lin

NEFROLOGI

Prof. Madya Dr. Abdul Halim Abdul Gafor

Dr. Rozita Mohd

Dr. Rizna Abdul Cader

Dr. Ema Juliaty Jamaluddin

Dr. Kong Wei Yen

Dr. S. Ravih A/L Subramaniam

Dr. Rizawati Rizal Isfahani

Dr. Ruslinda Mustafar

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Clinical Coordinator Each training hospital will have a clinical coordinator who will be responsible for ensuring that all postgraduate programmes are implemented smoothly in the hospital The clinical coordinator is a member of the Hospital Postgraduate Committee. If not already present and active, each accredited hospital must form a new committee or activate existing ones. The committee is chaired by the Pengarah Hospital. Other members include the programme supervisors and representatives of the universities. Tasks: 1. Ensures the hospital fulfill all the requirement of accreditation 2. Reviews the number of training positions 3. Keeps a register of candidates and supervisors 4. Provides information to the National Coordinating Committee regarding candidates and placements, transfers of candidates and supervisors, through or with the knowledge of the State Pengarah 5. Coordinates the training programmes in the hospital and assists in its evaluation 6. Provide the necessary assistance to facilitate the programmes 7. Provide adequate support system for candidates and supervisors.

KARDIOLOGI

Prof. Madya (K) Dr Oteh Maskon

Dr. Masliza Mahmood

Dr. Hamat Hamdi B. Che Hassan

Dr. Osama Ali M. Ibrahim

Dr. Choor Chee Ken

DERMATOLOGI

Dr. Adawiyah Jamil

Dr. Mazlin Mohd Baseri

Dr. Norazirah Md. Nor

RHEUMATOLOGI

Prof. Madya Mohd Shahrir Mohamed Said

Dr. Sakthiswary A/P Rajalingham

Dr. Syahrul Sazliyana Shaharir

GASTROENTROLOGI

Prof. Madya (K) Dr. Hamizah Razlan

Prof. Madya (K) Dr. Shanthi A/P Palaniappan

Dr. Ngiu Chai Soon

Dr. Wong Zhiqin

Dr. Raja Affendi Raja Ali

Dr. Jeevinesh Naidu A/L Aplanaidu

PALLIATIVE MEDICINE

Dr. Hayati Yaakup

INFECTIOUS DISEASE

Dr. Petrick @ Ramesh K. Periyasamy

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Responsibilities of the Candidate Welcome: First of all we wish to welcome you as a colleague in the discipline of internal medicine Values There are values which candidates must develop and possess right from the start of the programme. While acknowledging that the candidates have specific learning needs, the candidates nevertheless must develop a sense of belonging to the unit they are attached to and to be committed to the programme organized by Universiti Kebangsaan Malaysia and function as an effective apprentice to the supervisor. Candidates must accept that they have an obligation to provide service as part of their training in the MMed programme to the nation while undergoing and after graduating from the in-service programme Training Objective Candidates are responsible for their learning. Learning is defined as the process that results in a relatively permanent change in behavior because of the acquisition of new knowledge, skills and attitudes. The supervisors’ role is to facilitate and guide and not to spoon-feed. Tasks: Each candidate is expected to: 1. Provide holistic and comprehensive patient care appropriate to the level of training, with full commitment and appreciation of the patient as human beings with feeling, families and other responsibilities 2. Appreciate cost of care by appropriately selecting investigations and treatment 3. Be directly responsible to the senior colleagues and consultant in patient care and other duties 4. Be aware and acknowledge the limitation in providing care and to seek and respect the guidance and consultation in the performance of duties from all members of the medical team 5. Develop effective interpersonal skills and mutual respect in the relationship with all members of the medical team 6. Participate actively in all activities of the unit (CPC, journal club, morbidity/mortality, quality assurance) 7. Continue learning as self-directed learners who are stimulated by problems presented by patients 8. Satisfy course requirement according to schedule and to constantly assess their own progress with the supervisor every month 9. Develop professional qualities of responsibility, trustworthiness, availability, caring etc as described in the supervisor evaluation form.

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Organizational Support and Linkages There are several parties involved in the Open System: * the Conjoint Board * the University Academic Departments and academic staff * the Joint UKM/MOH Medical Implementation Committee * the MOH National Coordinating Committee * the Hospital Postgraduate Committee * the MOH unit and its programme supervisor and candidate supervisors * the Postgraduate Secretariat The organizational linkages suggested for the implementation of this Open System are concerned with OPERATIONS: i.e the smooth and efficient execution of the programme including monitoring, evaluation, feedback and further improvement. It is not concerned with decisions about the academic programmes, assessment and accreditation, which are the functions of the Conjoint Board or academic departments. Good communication at the operational level is the basic foundation for the success of the Open System. Therefore, it is strongly recommended that bureaucracy is minimized at the operational level and that formal as well as informal linkages or channels be hospital postgraduate committee as well as the medical unit, the programme and candidate supervisors and the candidate themselves. To facilities communication and better working relationships, it is recommended that Fellowship activities be conducted regularly between the universities and the MOH specialists. Conjoint Board Consists of head of department and programme supervisor of the department of internal medicine of the local universities and representative from Academy of Medicine and Ministry of Health National Coordinating Committee At the pinnacle of the implementation of the Open System in the MOH is the National Coordinating Committee. The members consist of the deans of the medical schools and the hospital and training divisions of the MOH. Functions: * Decide on the equitable placement of candidates vis-à-vis supervisors, with minimal disruption to the service * Inform and liaise with the State Pengarah and Hospital Pengarah to ensure the smooth Transfer of candidates (interstate, within the state, within the hospital and with the universities) * Ensure that the supervisors are fully committed to the programme and are aware of the needs of the programme (training, supervision, monitoring, assessing, providing feedback and counselling) and the needs of the candidates * Ensure that the accredited hospitals fulfill the accreditation criteria (physical facilities, equipment, books and journals, postgraduate secretariat and committees, etc)

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* Ensure needs of the supervisors are met: Updated information on the programme Opportunities for CME with reimbursement (e.g once a year for local programmes, once in 2 years for ASEAN region) computers and electronic links/network facilities for literature search postgraduate centre with secretarial facilities academic recognition training in research methodology, teaching methods, assessment techniques, computer literacy management suitable remuneration and incentives * Ensure that the needs of the trainees are met Minimum disruption to family life caused by transfers for placements a conducive Environment for learning (culture of learning and scholarship, Rest room and study area etc) Proper library accommodation for short-term rental time to reflect, study and discuss opportunities to present paper network with each other loans and allowances, mileage claims, call allowances, course fees, book allowance Hospital Postgraduate Committee If not already present and active, each accredited hospital must form new committees or activate existing ones. The committee is chaired by the Pengarah Hospital, and consists of the clinical coordinator and programme supervisors with representatives from the unit universities. Functions * Ensure the hospital fulfill all the requirements of accreditation * Reviews the number of training positions * Keeps a register of trainees and supervisors * Provides information to the National Coordinating Committee regarding candidates and placements, transfers of candidates and supervisors, through or with the knowledge of the State Pengarah * Coordinates the training programme in the hospital and assists in its evaluation * Provides the necessary assistance to facilitate the programme * Provides adequate support system for candidates and supervisors

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Learning in the Open System Self – directed learning (SDL) As postgraduate students you are expected to continue learning as motivated self-directed learners. SDL is essential for the following reasons: * learning can become a lifelong process utilizing every available resource: * learning becomes efficient and effective, so that people take initiatives in their own learning, retain more of what they learn and make use of this knowledge longer: * provides equality of opportunity, so that each person can go as far as his/her aptitude

will permit in fundamental skills and knowledge; they are then motivated to continue their own self-development;

* Enable people to cope with initiatives in education, so that they can deal successfully with the nontraditional study programmes such as distance learning, external studies, etc. Underlying SDL are the assumptions that firstly an individual would have the capacity for “self-initiative, self-discipline, resourcefulness, productivity and self-evaluation” (Beggs and Buffie, 1965); secondly that the natural orientation for learning is task or problem-centered; and thirdly, that values such as individualism, democratic participation, personal authority and responsibility and freedom of choice are held to apply to students as well as to the general population. On the basis of these assumptions, SDL requires a climate where students can be motivated to take on more responsibilities for their own learning and progress at their unique rate and creating a more desirable relationship between teachers and students. Indeed SDL would result in teachers not having to push students to study, complete their projects, etc because they make their own plans to do so. Dressel and Thompson (1973) has defined self-directed learning (SDL) as “the student’s pursuit of academic competence in as autonomous a manner as he/she is able to exercise at any particular time “As autonomous a manner as he/she is able to exercise” implies learning which is independent or in isolation without the help of others, or in association with teachers, tutors, mentors, resource people and peers. To facilities SDL, you should aim at developing the following skills: * Perceptive skills in detecting ambiguity, gaps in knowledge, ability, etc * Skills of inquire: knowing what, how and where to look for information. This includes kills in managing information technology. The sources for information include people (consultation, discussion, teleconference, lecture, tutorial, etc), books, journals, internet, drug literature * Analyzing skills: ability to break up problems in component parts, interpret new information and evaluate the usefulness * Synthesizing skills: integrating new information to meaningfully fit into the memory store

of knowledge and generalizing to new situations The most difficult skill is the skill in perceiving or recognizing your deficiencies. This is because most doctors solve problems according to the solutions they already have and most times. These solutions do not give rise to problems. But problems due to inadequate knowledge or skills may exist without them being detected. Therefore you must make an active effort to detect these deficiencies. Various techniques can be used:

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* Reflection – look back at the patients you have seen for the day and think about how their management could have been different. * Active challenge by others such as in case presentation, journal club, seminars, teleconference * Performing self assessment test * Chart stimulated recall * Practice profiling * Audit * Problem-based learning * self-learning package and computer-aided instruction * Teaching others Chart Stimulated Recall This is a simple technique which you can do with your peers. Chart stimulated recall (CSR) is a learning experience through a discussion which is stimulated by events or records derived from a real chart (patient’s record). It is entirely educational. It can be done on a one-to-one basic or in small groups (3-5) people. The process involves someone going through the case notes of a patient managed by you and he/she then asked you for clarification on certain decisions and actions taken. Some of the aspects that could be highlighted through CSR include: * deficiencies in knowledge, skills etc * opportunity to discuss a rare or unusual presentation of a problem * record keeping problems e.g. Inaccurate entries of time and date * communication deficiencies For it to be effective CSR must remain purely educational for patient care improvement and not used for administrative purposes and that there must be access to properly documented medical records with confidentiality within the unit. CSR also facilities the development of skills in giving and receiving feedback, interpersonal communication skills and critical appraisal. Most importantly, it helps to identify student’s areas of strength and weakness for further improvement. In distance learning, it is possible and indeed to be encouraged, to practice CSR through teleconferencing. Copies of the case notes (make sure patient confidentiality is maintained) are distributed to the entire center. One of the trainees is asked to do CSR on the colleagues who clerked that case. Practice Profiling Analysis of practice can be performed by the individual doctor. It shows what you actually do and provided evidence of deficiencies that need correction. For example, there was the case of a doctor who was interested in cardiovascular diseases and was mainly attending lectures and talks on the associated problems. When he began analyzing his practice he found that the majority of his patients actually suffered from depression and he had not been paying much attention to this problem. The discovery of this fact was a powerful stimulus for charge in his continuing education behaviour. A study of 94 physicians in the US has shown that practice profiling (with regards to prescriptions) followed by learning packages is a powerful method of improving physician

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behaviour. The learning packages addressed the problems encountered, such as inappropriate indications, wrong dosages, high frequency prescriptions and potential drug interaction. A 30% change in prescribing practice was achieved. The comparison group, without the package, only showed a 3% change. The Codmans Medical Outcome Model can also be used to analyze practice. Each patient is studied to determine the quality of the care given and fixing responsibility for any problem. Was the failure due to the:- Doctor who is responsible for treatment Organization carrying out the details of treatment Disease or condition of the patient Personal and social conditions preventing the patient’s cooperation Valuable information can be gained to allow the doctor to obtain further education relevant to improving his on her own practice. Two methods of studying a practice are suggested: a) Index charts by condition You can file your patient records according to names however index them according to Conditions e.g. diabetes, bronchial asthma etc which can be used to analyze your experience and build up a profile of patients presenting with a condition. You can also use the records to review your management of the cases with an expert in the area. This personalizes the education. b) Record lessons learned on instructive patients. 3x5 inch cards are used to record the brief experience gained or useful lessons learned from the patient and subsequently use these cards to review or teach from the experience. Computers are useful in practice profiling. Minimum data required to study a personal medical practice include: * Risk factors encountered The sex and age distribution of patients would indicate which patient groups are involved and what should be emphasized. For example, if a doctor is seeing a large number of women in the forty age-group, she/he might want to know more about breast cancer * diagnoses (an index of diagnosis would indicate the common conditions seen) * drugs prescribed * laboratory studies * procedures ordered * complications encountered

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Evaluation Tools

There are values which candidates must develop and possess right from the start of the programme. The candidate must develop a sense of belonging to the unit they are attached to, be committed as an integral part of the service and function as an effective apprentice to the supervisor. The service they perform is an essential and integral part of learning. Apart from learning how to care for the medical patients, they must also develop professional qualities, managerial and leadership skills as well as demonstrate the ability to be self-directed learners who are motivated to continually improve their performance. Thus the assessment of practice is a very important component of the progress evaluation. The tools used in the assessment emphasize the links to practice. Candidates are encouraged to meet and discuss their performance regularly with their supervisors and mentors to obtain early feedback and to subsequently take the initiative to search for the relevant information to improve themselves. The tools used are aimed at assessing different competencies:

- Case write-ups - Supervisors report - Dissertation - Medical audit

How to do Case-Write-up Satisfactory completion of case write-ups is a criterion for promotions. Please refer to the objectives of the relevant year for the number of case write-ups to be submitted. 1. Select the case you wish to write on. The criteria to help you select the cases include: presence of an interesting feature such as unusual manifestation of a common problem, rarity, problem in management. 2. Write a summary of the case and make sure all relevant data such as X-ray and other investigations are available. 3. Review the literature regarding the problem, making an annotated bibliography. 4. Write the case using the following format:

An abstract of not more than 200 word stating the type of case to be presented and the aspect of management to be discussed

An introduction which should contain the objectives of write-ups

The body which should describe the relevant history, clinical findings, diagnosis, investigations, treatment and follow-up

Discussion of 1-2 aspects of the problem critically reviewing, analyzing

And synthesizing evidence from the literature to draw your own conclusions.

A reference of at least 5 articles

A length not exceeding 1000 words using precise language 5. Show the first draft to the supervisor. The corrections should be returned within 2 weeks 6. Modify the write-ups as suggested and re-submit until the supervisor in satisfied that the Case-write-up

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7. Case-write-up will be given marks by examiners which contribute to the final marks for continuous assessment 8. Final submission to the department of Medicine UKM after doing the necessary corrections suggested by the examiner for the academic year. Guideline for dissertation Candidates will be given the opportunity to participate in a workshop on Research Methodology where they will develop skills in writing a research protocol, to conduct the research project and to report the findings. 1. By the end of the first 6 month of Year 2, identify suitable topics for the research project. Discuss the topics with your supervisor. 2. Review the literature on the topic, keeping an annotated bibliography 3. Develop a research proposal with guidance from the supervisor 4. Present the proposal to the department prior to submission for approval by the hospital research committee.

5. Once the protocol is approved by the ethics committee, you should start data collection as early as year 2. 6. The dissertation must be submitted 6 weeks before the Part 3 examinations. The length

should not exceed 60,000 words and should contain the following: -abstract of not more than 300 words -introduction -material and methods -results -discussion -conclusion -acknowledgement -references Supervisor’s Evaluation Report All candidates will be closely observed by the supervisor throughout the posting. The competencies and qualities to be observed as well as the criteria for evaluation are described in the evaluation form. With the guidance from this checklist, trainee should endeavour to develop the competencies and qualities listed, aiming for excellence in all dimensions. The candidate is encouraged to use this evaluation form as a guideline to informally discuss his/her progress with the supervisor throughout the posting. The supervisor is also expected to provide continual formative feedback to the trainee based on this evaluation form. At the end of the posting the supervisor will fill out the evaluation in duplicate. Both copies are to be sent to the Programme Supervisor Department of Internal Medicine, UKM. The department of Internal medicine will send a copy to the Postgraduate Secretariat, UKM. (Updated 1082012) Next review August 2017